I started my career in the smallest of EMS “systems.” Back then it was really an answering service, a Cadillac ambulance that would go really fast, and two ambulance attendants. Not much of a “system,” but I loved what I did and took pride in my work. I could only imagine what it must be like to work in a big, busy system.
I soon moved on to bigger systems, and eventually to managing very large EMS organizations. I loved the challenges of the larger and more complex systems and proud of the work I was doing.
I remember attending a retirement party for a board member at the top of the Petroleum Club in Fort Worth, Texas, some twenty stories up. As I stood there looking out over the vast expanse that you can see in Texas, I was talking to Doug Key who worked with me running the MedStar system. I commented, “Doug, do you realize that if anyone as far as we can see needs ambulance services tonight, we’re responsible for it?” We talked about that enormous responsibility and the difficulty that surrounded the job.
Once one works in a large, complex system, it may be easy to forget the challenges of the “small” EMS system. Recently, I was reminded of the small system challenges and what it means to work on a smaller but no less difficult scale.
Last summer my family and I were on vacation and spent seven days in the Northwest where the temperatures didn’t exceed 62 degrees – quite a change from the triple-digit heat that had been beating us to death in Texas. We spent time with my Mom and Dad, ate too much home cooking, went to the county fair, and generally just relaxed.
Tim, my little brother (he really isn’t “little” anymore - just younger), lives there as well. Tim is a Commander with the local Sheriff’s Department, where he has been employed for over twenty years. This department is in a county that has seen its share of economic downturns, layoffs, and cutbacks. The department has shrunk, but those who remain keep on faithfully providing the best law enforcement they can.
The county is over 1,200 square miles and home to only 28,000 people. It is the very definition of “rural America” and small scale. During the day there are only two Sheriff’s cruisers, two or three city police vehicles, and one or two CHP officers on duty – and even less at night. That’s not many resources for a county that size.
My brother is always in his unmarked, fully equipped police car, and is always “on call.” He came to Mom’s house after work one night, still in uniform. Sitting at the dinner table, my brother’s radio goes off and the dispatcher asks for a response to a “911 hang up” at a house where the resident has an outstanding warrant. Tim recognizes the address and says, “I’m pretty close. I need to go. Do you want to come with me?” What adrenaline junkie wouldn’t say yes to that? I jumped at the chance – and off we went.
As we drove through the county, it became clear how much ground these guys have to cover. We arrived at the scene and immediately had a brief but ugly conversation with a young man who was already handcuffed by another officer.
A ticket for “failure to appear” was given, the husband was un-cuffed, and left with his unhappy wife to explain why he was arrested several months ago (she didn’t know exactly) and why he chose to ignore the court date – trust me , it was getting uglier by the minute.
On the way back, driving through this sparsely populated county, my brother searched and cleared a building after a silent alarm and made the rounds of the area’s homeless to ensure there wasn’t any trouble brewing. I was impressed and a little surprised when I heard cops and ruffians alike call him “Commander Athey.” I realize that is his title, but to me he is just my “little brother.” Standing a head taller than me and far younger, he cuts an impressive figure in a community where everyone seems to know him.
On the way back to Mom’s for a late dinner, he found himself closest to an “assault in progress,” and with lights and sirens turned on, off we went, followed closely by the two on-duty Sheriff Officers and an available CHP unit. No one had to look up the address, everyone knew this guy and his somewhat violent past record. Dispatch notified everyone that the “assault” had stopped, but the actor was still on the scene; all the units arrived at about the same time. We drove down a narrow dirt road overgrown with berry bushes and “keep out” signs posted every few feet. The dust kicked up by the four vehicles hadn’t yet settled when all the law enforcement officers piled out of their cars and sprinted toward the din of multiple people yelling and fighting. I had to stay in the car and lost sight of most of the action as they rounded the corner of bushes, but it all became very real when the CHP officer who was still in my sight suddenly tensed and put his hand on his service weapon ready to “clear leather.” It suddenly got very quiet.
In less than a minute, a young man in handcuffs was being led to the back of an officer’s car. After a few minutes of discussion with the remaining family members, all the police cars left, one car on its way to the jail and everyone else to their next assignment. My brother seemed completely nonplused about the call, but I peppered him with questions about what just happened.
Here’s what he told me. When the police cars all screeched to a halt in the driveway, the young man (who by then had stopped assaulting his victim) ran into the house and locked the door. Maybe there were weapons inside and maybe there was someone else in the house…no one knew for sure. The responding officers covered the front and the back of the residence, “removed” the front door, and “dragged him out.” Here is where I had my epiphany: if this call would have occurred in LA, Chicago, Dallas, or any other “large city system,” there is great chance that when the man locked himself in the residence the multiple officers on the scene would have retreated, surrounded the house, and called in a SWAT team and/or negotiators. Helicopters would have circled overhead, news crews would have arrived, and the event could have taken hours or days to resolve itself instead of just a few minutes. When I asked my brother about that, he said, “Yeah Steve, we don’t have “backup” – and we ARE the SWAT team.” One approach is not “more right” than the other, but it illustrates the difference between large and small systems and the simple matter of resources.
We got to Mom’s house and she warmed dinner up for us (it was “taco night”). I thought a lot about my perceptions regarding small system EMS – and now “small” police systems. Smaller systems mean fewer resources, more area to cover, and a lower margin for error. I used to know this because, after all, my first ambulance job was in that county with over 1,200 square miles and only 28,000 people. I thought back about the one-hour transport times, a single ambulance on duty, and the “on-call system” for the next crew to handle (God forbid) consecutive calls. I remember being lowered on a rope down a cliff to check out a vehicle that had been forced off the road during a mudslide on Last Chance Grade – all without a high-angle rescue team, rappelling training, or special equipment. Hell, I guess I WAS the high-angle rescue team.
System sophistication has improved dramatically since my days in the street, but in small rural areas all across the country, the lack of available resources may not have changed. Providers in these systems have to “improvise” to get the job done, and their challenges are real. Somewhere along the way I have forgotten the real challenges that “small” presents, and it took a cool night in a small town and a potentially dangerous situation for the “local” and small police departments to remind me. Thanks to all of them for putting up with me, however, I now worry a little bit more about all of you. Be safe.
