If you’ve ever had to call an ambulance or ridden in one, it was probably one of the scariest moments of your life. But to the ambulance workers who sped to the scene, it was one of many calls during another busy day on the road.
Last year, ambulance workers in California were focused on the seemingly simple question of what, for them, constitutes a break.
The debate became a ballot initiative: Can the emergency medical technicians and paramedics who work for private companies be on call and on break at the same time?
Many EMTs thought the answer could make all the difference in their demanding field.
I reached out to a California paramedic who set the scene.
“We all know it’s messed up,” he said, asking me not use his name to protect his job. “Everybody who’s worked in private EMS for more than a couple of years gets somewhat jaded about it. There’s just this expectation of, ‘I’m going to get screwed, and that’s just the way it is.’ ”
When you call 911, the ambulance that responds could be government-run, typically a part of a fire department. Or it could be owned by one of a myriad of private, for-profit ambulance companies that contract their services to towns and counties.
The California paramedic I spoke to works for American Medical Response, or AMR, the nation’s largest private emergency medical service, with more than 6,000 ambulances across 41 states.
He described his first day, when he went in to sort out his work schedule.
“The person … I talk to is like, ‘Oh, but you know, if you work these kinds of schedules, you know, you can pick up a lot of overtime because you work nights and then you can pick up the days,’ ” he said. “The expectation usually is that if you are trying to actually make a living doing this, you work a lot of overtime in EMS.”
Working 12-hour shifts, you may get down time here and there, he said, but often, it’s relentless.
“If we’re running 10, 12, 13, 14 calls, they might be trying to pull you from the hospital, you’re getting paged: ‘Uh, hey, can you clear, we need you to clear. We have a call.’ ”
Which means: He’s still dropping off one patient in the emergency room, but dispatch needs him to move on to the next one.
“They might even just dispatch you without even asking. And then you have to go try to get your paperwork signed, run out, back to the truck, and run the next call,” he said.
He spends almost his entire shift on the road. When he gets time to go the bathroom, he said, it’s usually at a convenience store or behind a bush.
And, he explained, there’s no telling when exactly his shift will end because of hold-over calls. Essentially, that’s when you’re supposed to get off at 10, but maybe a call comes in at 9:45. That can stretch your 12-hour tour out to 14 or 15 hours.
“You almost always worked multiple consecutive days, which means if you do get held over two or four hours, it’s impossible to get sleep,” he said. “I’ve had partners where I’m like, ‘No man, pull over. I’m driving. This is not safe. You can’t do this.’ ”
That late call could be easy, a rolled ankle. Or it could be something more more critical, a call that requires serious concentration: a pedestrian struck at high speed, for example.
“More than once, it’s been like, OK, you know, I’m on hour 13, 14 … and now I have a traumatic code,” he said. “You know, and this person’s only chance of surviving is me doing my job right.”
The EMS professionals I spoke with say a couple years ago, it looked as if working conditions might be getting a bit better for California’s private ambulance workers. It all had to do with break times. They’re mandated by California law.
But ambulance workers don’t really get breaks the same way a barista might. EMS workers never know when the next call will come in, that heart attack or that kid with asthma. So they have to be at the ambulance, monitoring the radio, ready to respond immediately, at all times.
The paramedic I interviewed said the closest thing he gets to what you might consider a break is something called a “code 7.”
“We don’t really get breaks, those don’t exist anymore,” he said. “They still use the term ‘code 7,’ but it usually just means I’m going to stop at a gas station on my way from point A to point B, and I’m just telling you that’s what I’m doing.”
In 2016, the California Supreme Court ruled on-call breaks are illegal when it comes to security guards. Basically, the court said, the guards are on the radio during their breaks, so they’re on duty. That’s not really a break.
And how you define “break” is important. California law says if you don’t get one, you get paid an extra hour’s wages.
EMTs and paramedics hoped the ruling would apply to them, too. They had filed similar lawsuits in the past.
“The idea of ‘Wow, we’re supposed to get a break’ was pretty powerful, I think, to a lot of people,” the California paramedic said. “The idea of like, hey man, you know, the law actually does do something for us.”
Ambulance workers told me that, really, the debate was about more than just break times. They were excited about what having real breaks might lead to: better overall staffing and better pay.
If breaks were to become protected for ambulance workers, they figured private companies would have to hire more people to cover for units on break, keep more ambulances in service per shift. The companies would have to stop getting by with what workers say feels like the bare minimum.
The paramedic I spoke with said he hoped companies would pay out missed break pay more often. It’s pay he said he’s never gotten.
“There’s gonna be a bunch of back pay, people were excited about that, and then about what it might mean moving forward,” he said.
But then AMR, the big private company he works for, pushed back. It funded Proposition 11, a ballot initiative that essentially sought to keep things the way they had always been.
When I asked AMR about its break policies and working conditions, an AMR spokesperson said in a written statement that workers have plenty of down time, and that the company supported Prop 11 out of concern for patients.
That concern was the through-line in TV commercials supporting the ballot initiative.
An ambulance speeds down a street with lights and sirens blaring. A voice-over begins: “In an emergency, minutes can mean the difference between life and death. Proposition 11 saves lives by ensuring medical care is not delayed in an emergency.”
The TV ad ends with: “Vote yes on Prop 11 to make sure 911 is there when you and your loved ones need it.”
The message many voters heard was: You have a heart attack. Without Prop 11, the closest ambulance crew could be unavailable — on break, with the radio off. That could cost you your life.
Spots like that blanketed the airwaves ahead of the vote. AMR spent nearly $30 million pushing Prop 11.
Ken Jacobs is a labor specialist at the University of California, Berkeley. He did a deep dive into the private EMS industry.
“Had I not done any of the research and the work in advance, I would have heard these Prop 11 commercials like everyone else and thought, ‘Oh, that’s terrible. Of course people can’t have a break while I’m waiting to get my ambulance,’ ” he said.
Jacobs said he found Prop 11 wasn’t really about keeping response times as low as possible. It was about keeping labor costs down.
He said private-sector EMTs barely make minimum wage in parts of California.
“A third of EMS workers earned less than $13.63 an hour; overall, the median hourly wage was about $16.59 in the state. So we’re talking low wages, and those wages have been falling,” Jacobs said.
Low wages contribute to a serious retention problem, he said. Jacobs found that the average private ambulance worker stays with a company about four years.
“One of the common sort of job trajectories is go in, get trained, get some experience, then use that as the basis for applying for a firefighter job,” Jacobs said. “And so lots of people are going in with the hopes of getting out and getting into a better-paid job elsewhere.”
By elsewhere, he means public EMS operations, usually fire departments.
Those services are exempted from the break-time labor law, which means their workers don’t get traditional break time either. Both public and private ambulances have to pick up whoever calls, regardless of ability to pay. But the operations are very different.
A public-sector service doesn’t need to make a profit, relying on taxes. Workers there can make up to 40 percent more, and they’ve got access to firehouses.
Jason Brollini is a union leader for private EMS workers in Santa Clara County, California. He said the public side is just as busy as the private, but overall working conditions are far better.
“So if you look at a city like San Jose, they’ve got 32 stations, full kitchens, bathrooms, sleep rooms,” Brollini said. “That’s a stark difference to private EMS.”
Techs and medics employed by private companies typically just have their trucks and their street corners.
Every time fire stations have job openings and the public system opens up recruitment, the same thing happens, Brollini said: “There’s a mass exodus from the private side to the public side. We’ll go through these periods where staffing is so low that we ended up getting forced back to work.”
In other words, the techs and medics at private companies get called in on their days off because so many workers have quit all at the same time to go public.
“I don’t blame them for jumping ship,” Brollini said. “I mean, it’s very hard mentally and physically to make a career on the private side.”
In California, most 911 calls are fielded by private ambulance companies, not public-sector emergency medical services.
Decades of consolidation mean that a handful of companies control the lion’s share of private ambulances in California and nationally. They offer towns a cheaper alternative to the public system, and operate in rural areas no one else covers.
But industry experts say there’s a cost. Brollini said tougher working conditions, lower pay, and the higher turnover he described all add up to a system that’s making it more likely the medic responding to an emergency is exhausted, and a rookie.
“When I started, your average provider that showed up at your house had anywhere from 15 to 25 years’ experience,” said Brollini, describing the situation a couple decades ago, when private EMS was less consolidated. “And those are the people that you want showing up. Now, with this turnover, we’re lucky if it’s eight.”
Much of the nuance of working conditions for ambulance workers was missing from the Prop 11 debate. In fact, it wasn’t much of a debate at all. By voting day, nearly every major California newspaper had endorsed Proposition 11, calling it sensible public-safety policy.
In the end, it was a landslide, and nearly 60 percent voted yes. Prop 11 passed, confirming that on-call breaks are legal for EMS workers.
Medics and techs I spoke with weren’t exactly surprised.
“You could teach a semester course on all of the intricacies of an EMS system,” said Brollini. “But, you know, it’s very easy to boil down to a 30-second sound bite … instilling the fear that grandma’s going to have a heart attack and there’s not going to be an ambulance to respond because they’re taking a break.”
Scary commercials, the California Supreme Court decision, and the ballot box aside, something else really troubled the ambulance workers I spoke with — that there were people, lots of them, who believed EMTs and medics would prioritize their coffee breaks over the call of duty.
“There’s not one provider that I represent that would say, `No, I’m not responding to that call because I need to eat,’ ” said Brollini. “Not one. We would have always shown up. We have always shown up, and we will continue to show up.”
That unnamed AMR paramedic, he said people know they need men and women like him, but they don’t really know much about him.
“They just want to see the flashy lights when they need help,” he said.
Did this whole thing change the way he looks at his patients, the voters who passed Prop 11?
“I never let it affect kind of the way that I view them or treat them. When you’re in my ambulance, you’re my patient and I’m going to take care of you,” he said. “You stop cursing, you put on your gloves, and you go, ‘So what’s going on today?’ ”