For more than 15 years, Cmdr. Tim Fuentes has worked at Austin-Travis County Emergency Medical Services, despite the agency's shortcomings — and because of its great success.
Working 24-hour shifts, as many paramedics do, takes a toll on the body. On a typical day, Fuentes said, a paramedic in Austin might respond to 16 calls and take just one hourlong nap.
It wasn’t always that way.
Since Fuentes started as a paramedic in 2008, the population of Austin has nearly doubled. EMS has not, and for years, the agency has struggled.
Emergency medical services across the country have faced challenges, especially in the aftermath of COVID-19.
“When you look at the health care system nationally and you ask, 'Is this working?' The answer is no,” Fuentes said. “A lot needs to change.”
Austin-Travis County EMS’s comorbidities include chronic short-funding and understaffing. The agency estimated its unmet budgetary needs totaled $8.6 million in June, according to a report provided to the American-Statesman. And out of 689 full-time positions, EMS counted 127 as unfilled in July — an 18% vacancy rate.
The Austin city manager’s proposed budget for the next fiscal year went public Friday. It included an additional $2 million above the $10 million increase EMS was expecting. Those extra funds, EMS Association President Selena Xie said, could go to adding ventilators and medicine pumps to Austin ambulances.
“But we know that there still are extremely important gaps in service,” Xie said.
Shortage of ambulances, staff
Some of Austin’s busiest downtown areas lack ambulances, Xie explained. On weekend nights, trucks from surrounding neighborhoods must answer calls in the entertainment district, spreading the already-stressed system ever thinner.
EMS’s communications department has faced similar challenges. Since 2014, the agency tracked a 25% increase in 911 call volume, but it hasn’t been able to increase its minimum staffing levels, according to data provided to the Statesman.
For some paramedics, the conditions at EMS are too dire to stay. Last year, the Statesman reported on high rates of EMS personnel leaving the agency due to burnout and low pay.
For others, the draw of working at one of the country's leading EMS agencies keeps them in Austin.
Innovating as the nation’s biggest third-service agency
Serving more than 1,300 square miles, including all of Travis and parts of Williamson and Hays counties, Austin-Travis County EMS is the largest stand-alone EMS agency in the country.
Most emergency medical services in the United States are coordinated through fire departments. That means EMS funding filters through another organization, and paramedics must also be part-time firefighters.
Austin is different. As a "third-service" agency, Austin-Travis County EMS can focus solely on prehospital emergency care. And it has always been that way: The first stand-alone EMS station in the country was built in Austin in 1982.
If that seems recent, it’s because the field of EMS is young compared with other public safety disciplines. Emergency medical services didn’t take shape in their modern form until the mid-1960s during Lyndon B. Johnson’s presidency.
There are half a dozen different organizational models for EMS, including services attached to fire stations, attached to hospitals, run by private companies or nonprofits.
“Here,” Fuentes said, “the city’s taken a stand to keep us public and a third-service agency.”
Despite its challenges, Austin’s stand-alone status enables it to innovate in ways and at scales that few others can.
Austin-Travis County EMS began providing whole blood transfusions in the field in 2022. Now, the agency’s become the highest user of whole blood across the 10-county network served by We Are Blood Bank.
In hospitals, transfusions using component blood are the standard. That could be a combination of separated plasma, red blood cells, white blood cells or platelets. Whole blood, on the other hand, goes straight from donor to patient without separation into parts.
According to Chief Deputy Medical Director Heidi Abraham, it's the “magic juice” of emergency medical care.
Abraham works for the Office of the Chief Medical Officer, a team of physicians responsible for oversight of the Austin-Travis County EMS medical practice. When she serves in the field once a week, Abraham helps paramedics respond to the most acute calls.
On one call, she remembered, a 7-year-old girl with severe bleeding seemed on the cusp of death. Whole blood brought her back.
“It’s a huge lift,” Abraham said: “Essentially, an organ transplant.”
Protocols like whole blood make traditional emergency medical care more effective. But sometimes innovation at Austin-Travis County EMS means a fundamental change to the system.
New programs: Spare an ambulance, save a patient
Cmdr. Gabe Webber heads Austin-Travis County EMS’s Collaborative Care Communication Center, or C4 for short. With 10 paramedics, the program connects less acute and high-frequency 911 callers with services that are more effective than an ambulance and emergency room visit.
The program is meant to diverge from the EMS “you call, we haul” method, Webber said, in which anyone who calls 911 gets an ambulance and most go to the emergency room, even for minor issues. The strategy comes from a well-intentioned abundance of caution, but it also means many ambulances waste time on nonemergency calls.
At C4, “we connect people to more appropriate resources than the ER,” Webber said. “That could be a primary care doctor, or an urgent care, or even helping someone call an Uber to the pharmacy.”
The program preserves system capacity, so EMS can provide more care with fewer ambulances, as it has been forced to do in recent years.
The program began during the pandemic, when EMS sought strategies to ease COVID-19’s shock on the health care system.
C4’s footprint was small but effective. The infrastructure already existed, and it was cheap: With just a desk, a computer and a few monitors, a C4 paramedic call taker can save dozens of vehicles.
“When all you ever have are hammers, then everything looks like a nail,” Webber said. “Now we’re adding new tools to our toolbox.”
Today, C4 runs from 7 a.m. to 10 p.m. seven days a week. More funding could make the successful program a 24-hour service.
Many of C4’s patients come from Austin’s most vulnerable populations: elderly persons, chronically ill patients and homeless people. They’re also some of the most challenging EMS patients because, as less acute cases but high 911 users, they reside in a gray area of care.
Providing new forms of care to Austin’s homeless
Capt. Amber Price has worked as a paramedic in Austin for 20 years, most recently as a member of the Community Health Paramedic team.
Since its inception in 2006, the program has grown to a full-time staff of 32, and, according to the agency, nine more paramedics are scheduled to join the program this year.
Price's workplaces, many days of the week, are the forgotten lots and litter-strewn enclaves that most Austinites never see.
On Thursday, she maneuvered her cruiser down a rough dirt path on an undeveloped lot in Southeast Austin. Makeshift shelters of tarps and trash appeared in the underbrush.
She was visiting the camp off Ben White Boulevard to help a patient obtain an ID; she’d met the man a year before and helped him through cancer treatment.
Price specializes in providing Austin’s homeless residents with medical care, so they don’t have to call 911 in the first place. In partnership with local organizations, she gets them food, water, personal hygiene products, over-the-counter medicine, Narcan, bus passes, IDs and health insurance.
“You name it, we do it,” Price said as she walked the encampment, which at first had seemed deserted. Now Price’s patients emerged slowly from the woods.
One of them, a lifelong Austinite named Richard Castro, lost his home when his mother died and the bank foreclosed on her house. That was two years ago. Since then, he has mostly lived outside. Because of his attention-deficit/hyperactivity disorder, Castro said, he struggles to get along in shelters.
Price gave him a premade baggie of food and a cold bottle of water. As half a dozen others emerged, she began handing out more food, medicine and bus passes. For new patients, she took down information and dispersed health insurance. In half an hour, she got insurance for four people.
“They can go to Seton now and get primary care,” Price said. “They have bus passes to get there. And after that they can get their prescriptions filled.”
For her first 13 years as a paramedic, the "revolving door" of patients constantly in and out of the ER baffled Price. Before the Community Health program, there were few solutions in EMS that met their needs.
"The undone work is the problem," she said.
Responding to trauma patients in record time
Whereas the Community Health Paramedic team focuses on keeping patients out of ambulances, initiatives like the EMS Counter Assault Strike Team, or CASTMED, work to get gunshot and stabbing victims the fastest care possible.
Started in 2018, CASTMED is a joint task force that partners tactically trained medics with Austin police officers. They respond to calls faster than any other EMS program because they don’t have to wait for the scene to be declared safe by police.
In Austin’s entertainment district, where EMS struggles to have ambulances, CASTMED teams averaged 94-second response times after injury in 2023. Sometimes they arrive so quickly, an active shooter is still close by.
It’s a dangerous job. These paramedics wear bulletproof vests. But for Ross Copland, cutting-edge initiatives like CASTMED are why he chooses to work at Austin-Travis County EMS.
CASTMED paramedics are volunteers who sign up for overtime in addition to their weekly shifts. The program only operates part time on Friday and Saturday nights downtown and during special events.
Full-time positions for CASTMED paramedics are chief among Austin EMS’s unmet budgetary needs.
“Shootings don’t just happen on the weekends,” Copland told the Statesman during a ride in June.
Sticking it out
Not only do Austin-Travis County EMS programs improve patient care, Fuentes said, they’ve grown as hiring and retention incentives.
That’s part of why Fuentes stayed at the agency all these years: the opportunity to pursue a dynamic career.
For 11 years, he worked as a tactical paramedic, like Copland, and for three years after that he was a special operations commander. It hasn’t been easy.
“I’ve come really close to quitting this job two times before,” he said. “But I’m really glad I stuck it out.”
This article originally appeared on Austin American-Statesman: Austin-Travis County EMS attempts to fill gaps in service: ‘The undone work is the problem’
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