Some Paramedics Beef About New System : Impersonal Work Under Trauma Center Rules Not Like the Old Days

It was a classic “scoop and haul”--a paramedic’s stock in trade.

A motorcyclist had driven into the back of a bread truck and was wedged beneath it. The collision opened the man’s chest and tore a piece of the right atrium of his heart. When Sonny Hilliard pulled up with a fellow paramedic, firefighters were freeing the victim.

“From the time we got him to the time we got him to the hospital, it was 10 minutes,” Hilliard remembered with satisfaction last week. The hospital took over from there. The man lived.

“We can’t do that no more,” Hilliard said sadly, pondering the changes in his job under San Diego County’s new trauma system. “Given the same call with the present system, we would have gotten to the scene and gotten him in the ambulance. Then we would have sat there.”

The progressive new trauma plan, with its meticulous processes and protocols and systems and reviews, has left some paramedics feeling edgy and uncomfortable, chafing against the rules like a starchy set of clothes.

They find the system rigid and intolerant of individual initiative--in a field that attracted them with its promise of decisive action. Drawn by the desire to make a personal contribution, they find the new way impersonal and politically charged.

No one who expressed unhappiness with the new trauma system could point to any cases in which they felt they could show that patient care had suffered. But it has been an unhappy lesson in the politics of progress.

“It’s a much more uncomfortable atmosphere. We’re not with friends and neighbors anymore,” said Mike Mathai, an Oceanside paramedic. “It’s not to say the system can’t work when there are faceless persona on either side of the radio. It just makes it a little more difficult--and a lot less fun.”

In the past, paramedics say, their role was clearer: They were to get trauma patients to the closest hospital as quickly as possible. Time at the scene was held to a minimum. In some cases, they wouldn’t begin intravenous feeding until the patient was en route.

They worked with the same doctors and nurses day after day, over the two-way radio and at the local hospital. They learned the fate of their patients and felt that the nurses and doctors trusted them. Questions about job performance were handled on an in-house basis.

Under the new countywide trauma system, paramedics are part of a complex network. They check the patient, radio a base hospital and wait for instructions. If the case is serious, they may be instructed to wait again, while a helicopter flies in, takes on the patient and flies away.

In the North County, the system requires the paramedics to work by radio with one of the county’s trauma centers some distance away and with nurses and doctors they haven’t met. Some say they never know the fate of their patients. They fear that questions about their performance will go straight to county officials.

“It’s like being under a microscope now: You had one person looking at you before, and now you have 10,” said Jerry Boosinger, an Oceanside paramedic. “When your boss is teed off, you’re going to be taking some smaller steps. You almost feel inhibited doing things you would have normally done in the past.”

North County paramedics feel their worst fears came true earlier this month when county health officials temporarily suspended the certification of Oceanside paramedic David Snyder after he violated a county rule in order to adhere to a city ordinance.

Snyder refused a doctor’s order to take an accident victim to a trauma center 30 minutes away. Instead, he took the patient to Tri-City Hospital in Oceanside, under city orders not to leave the city unprotected by taking ambulances outside city limits.

The county, which certifies paramedics, withdrew his certification--without ever raising the case with Snyder. The city, which hired and pays Snyder, defended his action. Four days later, the county reinstated Snyder pending an investigation.

To many, the case seemed to epitomize what they perceived as their new status--pawns.

“The paramedics weren’t to blame for what happened,” said a fire official from another department. “They get their checks from the city of Oceanside, and their boss, who pays them, told them not to go outside city limits. The county sought revenge against the guy who had no protection. That’s the stuff that revolutions are built on.”

The county’s year-old system for handling trauma cases is widely viewed as one of the nation’s best. Observers say the emergency medical service system is more coordinated, integrated and standardized than systems set up almost anywhere else.

In particular, the county managed to designate six trauma centers--a core of hospitals equipped to handle the most severe cases. Few areas have overcome the political barriers to designation, said William F. Bedwell Jr., a federal auditor studying systems nationwide.

(However, Tri-City narrowly missed selection as a trauma center and has gone to court to overturn the designations and get admitted to the trauma system.)

Also unusual is the county’s communications system, which gives hospitals direct contact with the paramedics in the field, Bedwell said. Once accepted, he said, such a system improves any emergency-care system, making the paramedics truly the doctors’ “eyes and hands.”

“Any time you develop something more sophisticated, you end up with people having to be more knowledgeable about what they’re doing,” Bedwell said. “It’s just like the CPA using generally accepted accounting practices: They grow every year as things become more sophisticated and complicated.”

Paramedics here tend to be in their 20s and early 30s, many of whom are former lifeguards, firefighters and emergency medical technicians. They embarked upon the 1,000 hours of training for certification because they admired paramedics’ knowledge, decisiveness and ability to help.

They like the job’s pressure and unpredictability, and the rush of saving a life. They say they aren’t in it for the money--$11.30 an hour for Sonny Hilliard, a 35-year-old firefighter-paramedic with eight years in his department and 15 in emergency medical service.

“I’ve had the opportunity to save quite a few lives, and that gives you a degree of satisfaction,” said Victor Reed, an Escondido paramedic. “These are the kind of people that don’t look for an ordinary nine-to-five job.”

Much of the new unhappiness is in North County, where paramedics blame the absence of a trauma center for many of their problems. Paramedics in Oceanside, Carlsbad and Escondido spoke openly, but Bill Toon, director of safety services for Poway, refused to give out the names of paramedics.

“As the chief of the fire department, I am fully aware of what my paramedics’ attitude is to the trauma system,” said Toon, who added that they feel the system works well. If any different perceptions exist in the department, Toon said, “Mine’s the right one.”

For Hilliard, the greatest source of frustration is the waiting.

Hilliard, who served as an Army medic in Vietnam, said the thrust of all of his training is to get a patient to a hospital. For some trauma patients, the only hope for survival is a surgeon. And it goes against paramedics’ instinct to sit and wait for instructions or for a helicopter to arrive.

“My instinct as a paramedic is, I don’t want anyone dying in my ambulance,” Hilliard said. “All we can do is sit and watch these people get worse. Because of the delays, we end up doing that quite often. It’s very nerve-racking and frustrating and irritating to do this.”

In Oceanside, where the helicopters and trauma centers are a significant distance away, paramedics recalled a recent shooting victim who they say could have been taken to a local hospital in 20 minutes.

But the victim had to go to a designated trauma center under the county system because the injuries were severe. The paramedics were instructed to wait for a Life Flight helicopter. They recall waiting almost 20 minutes for the helicopter to arrive.

Asked what happened to the man, a paramedic on the case said, “I heard two stories, one that he died and one that he didn’t.”

Battalion Chief Richard Thompson said it is no longer easy to find out what happens to patients after the helicopter picks them up.

“Here, we know all the nurses by first names. Not that it should make any difference, but they do tend to trust your evaluations,” said paramedic John Bruce, comparing the paramedics’ dealings with Tri-City Hospital to their dealings with remote trauma centers. “Now you’re talking to someone who has never seen you or met you,” Bruce said. “You’re trying to be their eyes and hands over the radio. There’s no trust yet.”

Many paramedics are afraid that same lack of trust will extend to the system’s “quality assurance” program--which auditor Bedwell praised as one of the system’s most impressive and unusual attributes.

In the past, officials say hospital emergency-room doctors and paramedic coordinators did the quality assurance, in what Richard Blacker, Escondido’s paramedic coordinator, characterized as “a very constructive form--it’s immediate, personal and non-persecutory.”

Now the county is considering handling deviations from normal protocols. Reports and documentation of questionable performance would go straight to the county, which could impose penalties up to and including decertification.

It is not yet clear which types of cases will be handled by the local hospital and which types will be handled by the county. But already paramedic coordinators and others have begun to object.

“What we’re saying is that if this policy was adhered to as strictly as it was written, there would be a lot of morale problems and possibly some legal problems in that people would say, ‘You took away my civil rights,’ ” Blacker said.

Paramedic Reed of Escondido said, “I think paramedics like the idea of going into the hospital and talking to doctors and paramedic coordinators, realizing that none of us are perfect and we all will make certain mistakes.

“I think what’s bad is when the paramedic has to be brought out in front of everyone in the county, even when it’s a little mistake. He feels like he’s under pressure to perform perfectly every time.”

Others say this is particularly worrisome at a time of proliferating paramedic rules and regulations from the state. Rapid advances in medicine cause the guidelines to change constantly, accumulating in documents several inches thick.

“The effort on the part of the county to put everything into writing has failed to recognize the fact that emergency care is as much art as it is science,” said one official involved in the system, who asked not to be named. “It’s virtually impossible to cover every contingency in writing; there are many areas open for interpretation.

“The medics tend to see this as a double-edged sword. The protocols can be read to indict them. Or, if they were to defend their actions on the basis of protocols, the regulatory agency could see fit to read them the other way.”

As to patient care, paramedics in Oceanside and Carlsbad have statistics suggesting that helicopter flights to trauma centers take longer than ambulance rides to local hospitals. But few disagreed with the principle that the most severe cases may get better care at the designated trauma centers.

In many cases, their complaints were personal--in some cases, almost a regret for the passing of an era. Over time, they concede they will grow accustomed to the new system. Several said the kinks will be worked out.

Hilliard recently applied to work part time for Life Flight--the most high-tech corner of paramedic work, where he believes paramedics have more autonomy. He knew helicopters from Vietnam, remembering them with a certain fondness and awe.

“To the ground forces, helicopters were the angels of death and the angels of mercy: They were the ones that bailed us out, one way or another,” he said. “I wanted it a little bit for that--like the Bruce Springsteen song, ‘Glory Days.’ I wanted to get back to that and be around the choppers.”

But Life Flight took Hilliard’s partner instead. Now Hilliard is taking the fire captain’s test, and watching the trauma system work out its kinks.

“I think 90% of the problem here is hurt egos, as far as not having the system up here (in North County), and the politics involved. And a lot of it is resistance to change,” he said.

The system will improve, he said with confidence. But in the meantime, “It’s hard for us at this point to conduct even the most routine call and not have somebody mad at us. I can’t recall one yet where we’ve done everything to please everybody.”