January 29, 2016 To: Mayor Muriel Bowser ‘Through: Deputy Mayor Kevin Donahue Public Safety and Justice Mayor Bowser, thas been nearly seven months since I assumed my position as EMS Medical Director/Assistant Fire Chief for DC Fire and EMS. I was confirmed on November 3, 2015 with the humbly accepted endorsement from EMS professionals across the nation, Emergency Medicine colleagues, former employers and the local medical community. ‘The last six months have been filled with trying to understand exactly what has plagued this department for decades and to better comprehend wiy people die needlessly in the District of Columbia. The answers are clear, as I will share below. First, the eulture of the DC Fire and EMS Department is highly toxic to the delivery of any semblance of quality pre-hospital patient care. EMS reform, even attempts to make basic changes, are met with resistance from the top down. ‘The Department refuses to measure true performance beginning with response times. ‘They persist in providing incomplete measurements and elaborate graphs resulting in inaccurate and flawed information creating a “feel good” atmosphere that is not based in reality. You cannot fix what you do not measure honestly and this is one main reason the system continues to fail the people we are here to serve. A lack of accountability at all levels has created a workforce that is undisciplined and unchecked. Major infractions result in virtually no discipline and the “practice of medicine” is “overseen” by people with no authority, no medical expertise or teeth to drive change. Yet, itis that very “practice of medicine” for which this Department is so infamously known to be deficient. ‘The organizational chart and the lines of authority are not reflective of the work that is done daily. Over 80% of what DC Fire and EMS does daily is prehospital care and there are three people on the EMS “leadership side;” only two have any significant experience in the practice of prehospital emergency medicine. Only one (me), has ever reformed a failing system. However, I have no authority, no direct EMS provider reports and no ability to make policy change that would ensure the immediate improvement in patientcare, Ultimately, I have no ability to hold our providers accountable for the care they deliver. asked when I arrived to be able to assess the competency of at least the ALS providers in the Department. It was initially supported by the Chief, who has little to no experience running an EMS system, but as soon as the Local 36 warned that it would not happen as it would cause “undue stress” on its members (some were studying for a fire promotional exam to be given in April of 2016), the formal assessment was pushed to the side. ‘You cannot fix something if you have no idea where your baseline competency exists and you cannot improve that which you do not measure. I am now being asked to verify for the National Registry of Emergency Medical Technicians and the D.C. Department Of Health the “skill competency” of over 700 medics, including both basic EMTs and Paramedics. This means attesting to their ability to perform by placing my name and license on the line. In an attempt to hold this system accountable, lawyers have sued the last several medical directors over the providers’ lack of competency, lack of training and poor medical decision-making. Not only can I not verify competency, there is no valid indication that they have received any form of real training or continuing education. There is no indication that anyone can attest to the competency of these medics, least of all me as their Medical Director -- under whose license they operate. It would be unethical for me to attest to competency when I have not even been involved in any training or education. [ have never even met most of the providers, and my attempt to assess them has been blocked The Training Academy, while well intentioned, is not staffed with the proper number of quality educators necessary to assure that our providers are “competent.” I have said this from the beginning and stand by this statement. Again, the sense of this being a top priority seems to be overshadowed by other issues. When I arrived, I quickly observed how making simple deployment changes would alleviate much of the “emergency” that exists in the Districts’ provision of EMS. Holding providers accountable for answering their radios and not “disappearing” while at hospitals would dramatically increase the number of units available and, perhaps, buy us more time to train and educate our medics. When I suggested that we needed to hold ‘crews accountable for these “disappearing acts,” I was told that this is the way it has always been and that the middle management was not willing or able to hold them accountable. People are dying needlessly because we are moving too slow. Every time we send scarce resources to low level calls, we deplete our resources and prolong response times to true emergencies.‘The latest example is a young man stabbed to the chest Wednesday around 10 am. He suffered a potentially survivable injury, but it took more than 18 minutes for a transport ambulance to reach the 35-year-old man on 37" Street S.E. We failed that young man and it did not make the news. While some of our needless deaths have made headlines, tragically people die needlessly quite frequently and the majority of them don’t make the news. Thave been told in no uncertain terms that I am here for “medicine” and not policy or operational input. EMS is not an area of medicine where policy can be separated from practice. Itis all encompassing. Every policy decision should be driven by solid science and medicine to improve the care of every patient we touch. EMS includes everything from how we receive a call, how long it takes us to go in route (still twice as long to a ‘medical call as a fire call after 12 years), to the units we ride in, the equipment we carry, and the compassion we show. I have no authority or ability to improve any of these. If nobody holds the rank and file (or middle management) accountable for everything from answering a radio, to calling in sick repeatedly because they don’t like their assignment, the cycle will continue. It is worth noting that all of this takes an incalculable cost on our citizens. You hired me to reform EMS in the District of Columbia alongside Chief Gregory Dean. I trust you vetted me and saw my record and chose me because you felt I was the right person for this daunting task. I also understand I am an outsider which has its pluses and minuses, but what it does for sure, is give me a clear, unbiased lens through which to view the current “emergency situation.” It has become clear that answering to this Fire Chief and being philosophically not aligned are incompatible. I have tried repeatedly to communicate, but my concerns seem to fall on deaf ears. My experience has been that true leaders know their knowledge deficits, surround themselves with experts and listen to those experts. That is definitely not occurring at DC Fire and EMS. This is not what the District’s residents and visitors expect, nor what they deserve, from a public safety agency. Watching EMS policy, deployment and practice decisions made in ways that negatively impact the delivery of medicine, are not medically sound or scientifically driven, and are not tolerable for me when a clear alternative exists. Sending fire apparatus on every call to stop an imaginary clock that has no basis in medicine, science or patient outcomes (and in fact is operationally risky and dangerous) has placed this department in the “emergency” it is currently experiencing. Will giving $12 million to a private ambulance company fix this? It is as unlikely to fix the situation as placing a Band Aid on a gushing artery. ‘What is worse, it will temporarily distract from the real problem -- the lack of commitment to EMS and the lack of focus and attention to high quality prehospital emergency care at the DC Fire Department.‘The situation is grim and without immediate changes that include EMS medical leadership with teeth and authority, EMS will continue to be plagued by serious -- but fixable -- issues that result in the continuous, unnecessary loss of life. Thave given you my honest assessment, unwavering service and presented you with a truthful and hard reality from which to pivot. This is a lot to take in, but as I said in every interview, my sole focus is giving a voice to the voiceless, protecting and providing the citizens and visitors of DC with the best possible prehospital emergency care, and assuring that our providers are given the best opportunity for success each and every day. Each of these stakeholders deserves this and it can be done through difficult, but necessary, changes to a system that is not receptive to change. Alternatively, EMS ambulance response can be reconfigured and given its own internal structure and authority reporting to you directly. T suggest you create a separate division/department for the provision of advanced life support care. The fire department must continue to provide first response to the medical emergencies where rapid first response has been shown to make a difference in outcomes. With someone to hold it accountable for true response times, pethaps the fire department's first response system can be fixed. No system can be reformed without the strong and unwavering support of your leadership, a department's executives and their experts. understand if you are unable to make these changes. I must weigh in now. My sense of urgency is admittedly different than the Fire Departments’ and I do not apologize for that. When I see something that can make a difference between life and death, and yet it is ignored, I must distance myself from that system. Complicity kills and I will not be a party to that behavior. Regardless of how you choose to proceed, I respect you and your decision-making process and wish you and your constituents well. I would be honored to serve you now and again in the future. Please accept this as my two-week notice of resignation as Assistant Fire Chief for DC Fire and EMS. My service to you and the citizens in this capacity will end on February 13, 2016. Should you wish to discuss this I am, as always, happy to meet with you to provide more details to assist you moving forward. As the District of Columbia’s trusted leader, you can save many lives. With respect, Cpritettes| Soaps Oca