Good Riddance to Paramedics Afraid of Accountability
Colorado paramedics are taking demotions in the wake of Elijah McCain's death. We don't need them.
Disclaimer: the author is a career firefighter/paramedic and a former member of the IAFF. All commentary contained herein refers to regional and international leadership—in my experience, local officers have prided themselves on enforcing accountability.
Second disclaimer: this was partly written in a very remote area with limited connectivity; later editions may feature better sourcing than what appears in your inbox.
Former Aurora (Colorado) Fire Department paramedic Peter Cihuniec is free. Citing “unusual and extenuating circumstances,“ Judge Mark Warner vacated his prison sentence for the negligent killing of Elijah McClain, instead imposing four years of probation.
As I mentioned in a footnote to my last post, I’m pretty agnostic as to what accountability looks like for misconduct in healthcare. It’s frustrating that no one on the scene of Elijah McClain’s death will face the kind of punishment mass incarceration fans propose for far more benign and even imaginary sins, but it’s hard to argue with the judge’s contention that Cichuniec poses no risk to the community—his license, without which the crime couldn’t have happened, is long gone. That said, I’m also not a huge fan of the judge’s reasoning that Cichuniec is less culpable because he merely supervised the injection of ketamine; as we’ve discussed before, the only thing Elijah McClain couldn’t have survived that night was negligence.
However, one little detail noted in previous coverage caught my eye, and suggests that the judge may be correct that the deterrent effect is already working: Aurora paramedics are quiet quitting.
According to data from March, 10% of Aurora’s paramedic workforce took voluntary demotions to the EMT level, forgoing raises and promotion potential in exchange for a decreased scope of practice and accompanying scrutiny. The difference is hard to encapsulate in brief, but generally, EMTs are focused on assessment, transport, and the simplest (but most vital) interventions; paramedics perform a far wider range of emergency medicine, including dozens of IV medications, airway management, electrical cardiology—and, important for our purposes here, sedation.
A Brief History of the “Fire Medic”
Fire and EMS have a more complicated history than it might look on TV—or even among the majority of fire-based paramedics. When “emergency medical services“ simply meant a ride to the hospital, it was generally outsourced to anyone with a vehicle someone could lay down in, from fire trucks to funeral homes. With the publication of Accidental Death and Disability in 1966, governments at all levels began to realize that the ability to treat patients in situ and stabilize their condition before or during transport might play a huge role in outcomes, and EMS as a profession was born.
From there, fire departments found their way into running ambulances1 in a variety of ways. Some built out EMS divisions in response to the newfound need; some merged with or cannibalized existing ambulance services; others started adding ambulances to justify their budgets as revolutions in fire prevention and public education wiped out structure fires.
It’s not hard to see the appeal of cross-staffing ambulances and fire apparatus, at least on paper. Local governments are understandably reluctant to pay full-time salaries for work that pops up a half-dozen times per year, the services share a lot of logistics and skill sets, and dangling the carrot of a childhood dream job allows them to fill positions amid persistent shortages2. There are real advantages for patient care, too: linking up with the fire service allows a soft landing for senior medics in a profession where career progression usually means getting off the street, and fire-service reliability standards imposed by insurance organizations apply to EMS as well3. Anecdotally, I’ve also seen merger with the fire service protect EMS agencies from privatization, which is a disaster for both employees and patients.
The merger also opened up a line of perverse incentives. Gatekeeping firefighter jobs, significant raises and promotion potential opens the door for paramedics who get the upgraded patch without any interest in the work. Hard data on EMS system effectiveness is elusive, and the only suggestion fire-based EMS is systemically worse requires multiple thinly drawn inferences4, but firefighter-based lobbies have repeatedly fought efforts to upgrade EMS from Big Red Taxi to healthcare. When paramedic trade associations proposed increased education for paramedics, the International Associations of Fire Fighters and Fire Chiefs released a letter denouncing the idea, as they did when EMS organizations proposed a Federally Registered Practitioner designation for paramedics5. And when Rhode Island was hit with an epidemic of misplaced ET tubes, an IAFF lobbyist defended the state’s lower standard for intubation privileges, incredibly saying, “we’re the experts…not doctors.”
Similarly, IAFF International President Ed Kelly said of Cichuniec’s resentencing, “we will always advocate for the public’s safety and our members’ ability to do their jobs without fear of ill-conceived criminal prosecution.”
Elijah McClain is Dead Because A Paramedic Didn’t Do His Job
The problem is, “doing their job” isn’t what happened here. If Elijah McClain had only been mistakenly given ketamine, he’d have gone home that night. As I’ve highlighted, the ketamine dose was too high by EMS standards but well within safe parameters, they were close to the hospital, and the complications of ketamine overdose are manageable. The problem is that neither of the paramedics on scene ever bothered to assess him until he was already dead.
The fire lobbies aren’t, in general, wrong about the nature of the work. This job involves quick decisions from an encyclopedic body of knowledge, often in abominable conditions. I don’t trust a paramedic who doesn’t have at least a close call with a serious medical error, and we need to meet good-faith mistakes with education and encouragement rather than punishment. What happened to Elijah McClain wasn’t that; it was two paramedics who listened to police without even speaking to the patient and not doing the due diligence required of a stubbed toe patient while giving a dangerous drug. We stop people’s hearts and shock them with electricity and still —despite Cichuniec’s best non-efforts—put them to sleep. And we’re already having to resort to riskier drugs as the public understandably loses faith in us to use ketamine responsibly—and as more Elijahs keep coming. If you’re afraid of what happened to Cichuniec happening to you, that patch didn’t belong on your shoulder in the first place, and you won’t be missed.
A 2008 pilot study found this represented around 40% of 911 ambulance services. Anecdotally, these are primarily staffed with cross-trained firefighter/EMTs or paramedics, though many municipalities staff ambulances with single-role personnel.
I once heard a third-service paramedic talk about the time her ambulance froze over and couldn’t be run to a cardiac arrest; the International Standards Organization offers lowered homeowner’s insurance premiums for compliance with its fire department guidelines, which include heated bays.
This study suggests that cardiac arrest survival rates were better in settings more likely to have independent, or “third service,“ EMS coverage. It did not differentiate between fire-based and third-service EMS systems generally or within that setting, and cardiac arrest survival is not a great proxy for the quality of an Advanced Life Support provider because it’s far more strongly correlated to effective Basic Life Support techniques.
Note: in both cases, they were joined by EMS management (not patient care) organizations.