In order to speed up responses to 911 calls, Multnomah County has agreed to temporarily relax a requirement that ambulances be staffed with two paramedics.
The county contracts with a private ambulance company, American Medical Response (AMR), to respond to 911 calls. In its 2018 contract, AMR committed to respond to at least 90% of life-threatening calls within eight minutes. But the ambulance provider has missed that target every month since March 2022 and has accrued $7.1 million in county fines for missing the target.
According to a May 2024 report by the Multnomah County Ombudsperson’s office, AMR is chronically out of compliance with the response time requirement. Portland Fire Fighters’ Association president Isaac McLennan told the Labor Press ambulances are often late to scenes or totally unavailable.
Austin DePaolo is secretary-treasurer of Teamsters Local 223, which represents Multnomah County paramedics and emergency medical technicians (EMTs). He says AMR has failed to hit the target for a number of reasons:
Call volumes to 911 exploded during the COVID-19 pandemic, contributing to a national shortage of paramedics.
It’s common for Multnomah County residents to call 911 when they’re only seeking general health care.
The Bureau of Emergency Communications often dispatches ambulances to healthy patients, which stretches AMR’s pool of paramedics thin.
And first responders constantly are called to drug overdoses and behavioral health crises, which have risen dramatically in recent years.
DePaolo said many paramedics have burned out on the job. AMR says it needs 275 paramedics in Multnomah County and is short about 40.
AMR told the county it could meet its response time target if it’s allowed to send ambulances to emergency calls with one paramedic and one EMT. Like Seattle, Houston, Boston, and some other major cities, Multnomah County requires that ambulances responding to life-threatening calls are staffed by two paramedics, who can perform intubations and other procedures that EMTs cannot.
Paramedics receive two years of training, compared to 120 hours (three weeks) for EMTs. Paramedics are trained to respond to life-threatening calls such as heart attacks, strokes, and seizures. They can perform tracheostomies, electrocardiograms, and other vital procedures.
Commissioners Sharon Meieran and Julia Brim-Edwards agreed that AMR should be allowed to have ambulances staffed with one paramedic and one EMT. Chair Jessica Vega Pederson wanted to keep the two-paramedic requirement, and commissioners Jesse Beason and Lori Stegmann leaned that direction too, according to DePaolo. Behind the scenes, DePaolo lobbied commissioners to keep the two-paramedic requirement, but Teamsters was not part of the county’s negotiations with AMR and did not propose alternatives.
After four months of private negotiations, AMR and Multnomah County announced a new agreement on Aug. 1. The settlement temporarily relaxes the two-paramedic requirement and offers to waive millions of dollars in fines the county has imposed on the company for failing to meet the response time — if AMR improves its response times now.
Under the agreement, AMR can send teams of one paramedic and one EMT to some life-threatening calls. The deal still requires that AMR staff at least 20 of its ambulances with two paramedics. (The company operates between 34 and 44 ambulances daily.) AMR will also be able to send ambulances with two EMTs to lower-level emergencies, provided they respond to 85% of such calls, in order to free up paramedics.
If AMR meets that target each month, dispatches more two-paramedic teams than the minimum of 20, and ramps up investment to recruit and retain staff, the county will waive the entire fine amount in increments, the agreement says.
The company also stands to spend considerably less on wages for each EMT that replaces a paramedic. A starting paramedic earns $73,000 per year under Local 223’s contract, compared to about $49,000 for a new basic EMT.
The agreement would take effect in November and last one year, and the two-paramedic rule would go back into effect in November 2025. Temporarily eliminating the two-paramedic rule must be approved by the county commission. Meieran expects that vote to take place in August or September. The rest of the agreement didn’t require a vote by commissioners.
How to deal with poor ambulance response times was a deeply divisive topic on the county commission. For more than a year, Meieran blasted Vega Pederson for defending Portland’s two-paramedic model. Meieran says that standard slows response times. But Vega Pederson — like DePaolo — expressed concern about poor care when EMTs respond to calls they’re not adequately trained for. So has Dr. John Jui, Multnomah County’s EMS medical director, who has said for months that skilled paramedics are the best first responders to dispatch when a patient could die.
The parties appeared dug in just a few months ago.
Meieran told the Labor Press that she’s disappointed that Vega Pederson didn’t forge an agreement faster.
“The underlying logic, the desperate need, and the clear evidence that this model is safe haven’t changed,” she said. “The only change that has occurred over the past almost year and a half is the political pressure on the chair to get this done. The outcome was inevitable.”
Vega Pederson pushed back in an emailed statement.
“For me, this has always been about preserving survival rates and good outcomes for the people who live here. Changes to ambulance staffing have been informed by a thorough, thoughtful process to avoid unintended consequences that could impact system partners or patient safety,” she said.
Teamsters Local 223 represents about 200 medics and 60 EMTs in Multnomah County. DePaolo supports the settlement agreement, even though he publicly opposed changes to the two-paramedic model earlier this year in op-eds and statements to the media.
“In a perfect world, we wouldn’t have a paramedic shortage. This is a way we can get more ambulances on the streets,” DePaolo said.
However, he’s concerned that the county will permanently remove the two-paramedic model after the one-year agreement times out. That could put patients at risk, he said.
Northwest Oregon Labor Council Executive Secretary-Treasurer Laurie Wimmer told the Labor Press she also supports the compromise. So does McLennan, the Portland fire union president. McLennan said the issue needed urgent attention.
“We just need ambulances. It doesn’t matter who is on them, necessarily,” McLennan said.
A spokesperson for AMR did not respond to a request for comment. “AMR will now be able to invest in putting more ambulances on the road, supporting our goal to provide the right care at the right time,” said regional director Rob McDonald in a company press release.
DePaolo said AMR deserves credit for investing more in recruitment and retention in recent years — initiatives that the county will likely reimburse under the new agreement. For example, AMR says it is fully paying the costs of certification for EMTs and paramedics-in-training who are “racial-ethnic minorities.” It’s also offering up to $5,000 for potential employees who are willing to relocate to Multnomah County, according to a press release.
AMR is Multnomah County’s sole ambulance provider. In March 2022, the county commission extended its contract with AMR to August 31, 2028. AMR is a subsidiary of Texas-based Global Medical Response.
