Imagine it, the worst possible scenario: You're having a heart attack, your breath stopping, the life trying to escape from your body. Or you're a broken mess on the highway, wreckage jammed around you, blood choking you.
It can't get worse. And then it does.
The ambulance takes a long time to arrive, much longer than it ought to. And if you're not dead by the time it gets to you, the people responsible for keeping you alive until you reach the hospital--the people who insert a tube in your throat, give you an IV or try to start your heart beating again--may not have slept for 24 hours, and are being paid $5 an hour.
The history of ambulance services in Maricopa County is sordid. Private companies, competing for business, have acted like organized criminals. Ambulance drivers have lied about their locations, pretending to be closer to the scene of an emergency than they were. Dispatchers have alerted their own ambulances to an emergency before making an official dispatch over the open frequency. Money, not life, has been the bottom line.
And it still is.
Joe works for Southwest Ambulance. He started as an emergency medical technician, at $5 an hour. Now he's a paramedic. He gets $7.50 an hour. "On average, in order to make my bills, I work between 80 and 100 hours a week."
He works 24-hour shifts, so he at least manages to get a couple of days off to recuperate. "I do this because I like the work. I'm not in it for the money. Unfortunately, I have to work those hours to make ends meet. It's a very rewarding job, but, when you consider the training we go through and the educational qualifications that we have, we're underpaid."
As understatements go, that one is astounding. Paramedics undergo a year of training. Before that, they must be emergency medical technicians, which involves a semester at college and at least 1,000 hours' work in the field. EMTs get the same starting salary as a worker at McDonald's.
But wages are not the only problem, according to Joe. "We don't have enough ambulances, especially in the east parts of the Valley--Tempe, Chandler and Gilbert. The EMT who's driving the ambulance might have been driving for 36 hours straight, which is dangerous."
If you're not obviously wealthy, you may not get an ambulance in time to save you. "We have several units at any time of the day which Bob Ramsay, our CEO, keeps out of the system exclusively for what we call interfacility transports--taking people from nursing homes to hospitals and back. Even though an accident may happen across the street from those ambulances, and they could be on scene and rendering treatment immediately, he will not dispatch that ambulance. He will have an ambulance come from as far as five, six, seven miles away. No matter how serious the accident is--somebody could be dying--the ambulance right there can't treat the patient, because they need to stay available. It's a money issue--a guaranteed payment for interfacility transport, which is preauthorized by the insurance company, while in an emergency situation there's no guarantee of payment--we just have to hope they have insurance." Proving again his mastery of understatement, Joe adds, "It's immoral."
Other workers are less laconic. Martin and Chris, both EMTs, joined Southwest less than a year ago, and they're already at the end of their ropes. "Bob Ramsay only cares about what makes money," says Martin.
"They tell us this is a right-to-work state," adds Chris. "So if we don't like it, we don't have to work there. But they don't have the right to exploit. . . . We don't have good equipment, we don't have good ambulances, but you can bet he's [Ramsay] getting his money."
When they're on duty, Southwest staff members are required to be in their ambulances at all times. You take it in turns to leave the vehicle long enough to do what you have to do. If you need to eat, drink or relieve yourself at any time in a 24-hour period, you run out, do it and get back as fast as possible. For $5 an hour, the company owns your time.
So why do they do it? Both give the same answer, and it's the answer Joe gave, too--they love the work, which is just as well because they have little time for any life outside of it.
But their compassion is finite--it stops at their boss. Both Martin and Chris have the same dream: that Bob Ramsay has an emergency, and no ambulance shows up to save him. They laugh with relish as they talk about it.
When you consider the chilling pep talk that Martin claims Ramsay gave at orientation, it's hard not to feel that the hatred is justified. "He came in and he said, 'I understand that you guys are here to save lives and everything, but I want you to know that the most important thing you do on a scene is get the insurance information. I don't care what else happens--you've got to make sure the insurance papers are correct so we can bill them.'"
Did Chris have the same experience? "Absolutely the same."
"Ramsay and his mouthpiece, Roy Ryals, are in it for different reasons than their employees," says Tony, a paramedic. "We're in it to save lives, and they're in it to make dollars."
Ironically, Tony believes that things got worse for Southwest employees when they unionized five years ago. "If employees look for a union, they're collectively saying that they think they're getting a raw deal. Ramsay didn't like that, and ever since then we have paid the piper day after day."
Like his colleagues, Tony claims that he does it for love of the job. Inspiring though such altruism might be, it's hard to believe that all ambulance workers are candidates for sainthood. All of the ones I spoke to were intelligent, articulate people. If their vocation is in health care but their working conditions are so horrible, what's stopping them from undergoing further training, becoming registered nurses?
"Some do," says Tony. "But you miss the ambulances. You miss being out on the street, the emergency calls. I can't imagine wanting to do anything else but this."
Pat Cantelme, president of United Phoenix Firefighters union, dismisses Tony's claim that things have worsened since Southwest unionized. "Nothing could be further from the truth," he says. And he feels that complaints about low pay are exaggerated. "I'm not sure what they're paid specifically, but the first thing you have to take into consideration is that the hourly wage is a little bit lower than it would normally be because their employer is required to pay them time and a half after 40 hours. So a normal work week would have what they call scheduled overtime."
Joe scoffs at this. "Yeah, so we get overtime. We'd still get more money making Burrito Supremes."
Southwest has just been bought by Rural/Metro, the subject of a state investigation in 1994. As New Times reported at the time, the investigation dried up in January 1995.
Cantelme doesn't expect the sale to affect Southwest, at least in the short term. "Long term, it could have a pretty profound effect. But there's really no way to predict--will Southwest affect Rural/Metro, or will Rural/Metro affect Southwest? My guess is there will be some differences in the next three to five years, but I don't know which culture is going to affect which."
Bob Ramsay will remain in charge of Southwest. Ramsay's employees may revile him, but Cantelme has nothing but praise for him. "Ramsay puts a high premium on service delivery, and sometimes that requires people to work harder than they may feel that they should work. But I've never known him to be unfair or malicious."
Ramsay is elusive--he was permanently in a meeting when I tried to contact him. But Roy Ryals, executive director of emergency medical services at Southwest, had plenty to say. "I routinely speak to the orientation groups, and categorically I can tell you no one has ever been told that interfacility transport is more important than 911."
As to allegations that Ramsay said a patient's insurance is the most important thing, "Categorically untrue. We don't even request that our personnel get information until after they've arrived at the hospital."
Ryals has little sympathy with the complaints about low pay. "Our pay is what's required by the union contract," he says smugly. He denies that employees are forced to work unreasonably long hours. When it's suggested that they have to do it to make enough to pay their bills, he responds, "Well, I don't know what their bills are." It doesn't seem to occur to him that, on $5 an hour, any bills are a problem. But then, executive directors don't have to live on $5 an hour.
He points out that if a worker has a grievance, he or she can take it to the union. But Joe claims that Southwest rules by fear. Everyone interviewed asked that their names be changed. When I paged Joe's union rep, he called me right away, not knowing who he was calling. When I identified myself, he asked if he could call me back. He never did, and never responded to further paging.
I did have the pleasure of speaking to Jim Hayden. A former president of the United Emergency Medical Professionals of Arizona, he's now the union's business manager and is responsible for handling all employees' grievances with Southwest. This is disturbing, because Hayden the unionist is the company boy's company boy, even more pro-management than the management.
Although Hayden didn't manage to convince me that life is wonderful for the staff of Southwest Ambulance, he did reaffirm my belief in true love. Before I die, I hope to find a person who loves me as much as Jim Hayden loves Bob Ramsay.
Most of the time, Hayden's manner is that of a Mormon missionary. He talks in a soft, lecturing, condescending tone, inserting your first name in the middle of every third or fourth sentence. But, when he talks about Bob Ramsay, he sounds like a Scientologist talking about L. Ron Hubbard.
When I asked him about Ramsay supposedly saying that ambulance staff had to make insurance information a priority, you'd have thought I'd insulted his mother. "Bob Ramsay would never say something like that. Never. He is not that kind of person. He is not that kind of man. He's a very humble, religious man.
"Bob Ramsay stopped coming to orientation when I was no longer president. While I was president, for four years, every time we had orientation--except for one or two times--Bob Ramsay came in with me. He never said that. I've been in orientation hundreds of times, I've seen hundreds of employees go through orientation. And what Bob Ramsay does say is, 'We are not a management-oriented company. We are not an employee-oriented company. We are not a financial-oriented company. We are a patient-oriented company.' Ramsay's philosophy, which he started in this company in November of 1982, is that we're a patient-oriented company."
Hayden knows all about Ramsay, but, for a union man, he knows surprisingly little about condition for his members. When I asked him about the low pay, I had to tell him how much it was--he didn't know. "I'm not positive. Are starting wages $5 an hour for EMTs?"
When I repeated that this was indeed the case, he said, "I would like wages to be higher. However, the wages that are set today are the wages that two thirds of our employees voted to accept."
He complains that the employees I've talked to constitute about 2 percent of the Southwest workforce. Asked why 2 percent of employees hate the company so much, he says, "They're disgruntled employees." Asked what they're so disgruntled about that they'd approach a newspaper with what Ryals and Hayden claim are lies about a great man like Ramsay, he says, "I'm not sure. These employees are potentially creating their own problems." Why would they do that? "I don't know. There are disgruntled employees in any business."
But few people have any illusions about working at McDonald's. And I'd like to believe that those responsible for saving my life were happier in their jobs and better rested than those responsible for making me a quarter-pounder.
So: Bob Ramsay, visionary, entrepreneurial saint or greedy, unscrupulous profiteer? It's hard to say--his defenders are as staunch as his detractors, and the former are willing to have their names printed.
But it doesn't really matter. Ramsay isn't the problem. He could retire right now and things wouldn't improve, or get worse. A sneering company boy like Ryals isn't the problem, either. If Ryals stepped aside, he would be replaced by a fat executive just as arrogant as he is. A management toady like Hayden isn't the problem. There are many more careerists waiting to toe the company line.
And Southwest isn't the problem. The most shocking aspect of this story is that Southwest is perhaps the best ambulance company to work for or to be treated by. State officials familiar with its record say there have been no major complaints against Southwest, and the company has responded quickly to minor ones, taking steps to rectify its mistakes. "They're the best employer in the state," says Cantelme.
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What is the problem? It's the sheer barbarism of a system that allows health care to be administered by private companies, companies whose very reason for existing is to make a profit. Effective health care isn't profitable--and never can be, because poor people get sick or have accidents as often as the wealthy. When people's lives hang in the balance, and you put profit first, people must die. When it comes to health care, capitalism has no acceptable face. In the case of Southwest Ambulance, it doesn't matter who's right; the bottom line is that the focus isn't where it should be--on the sick and injured.
The solution isn't difficult. Other countries have understood that for years. In Scotland, where I grew up, health care is nationalized, paid for across the board with public money. It has been that way for decades. It's simple and effective.
The same must happen here. The profit motive must be entirely removed. Care of the sick and injured should not be the main concern--it should be the only concern.
Contact Barry Graham at his online address: firstname.lastname@example.org