WASHINGTON -- Greg Maddock knew it was time to quit his job as a District of Columbia firefighter-paramedic when he was called to the home of a woman in labor with twins and he was the only person who could help. The second child was stuck in the birth canal, coming out feet first. After Maddock delivered her, she wasn't breathing.
"I had two babies and a mom, and the second baby I had to do CPR on for two minutes," Maddock said. "I had a roomful of firefighters and me, and I was the only paramedic on scene. That gets to you. You're like, 'I'm done. I can't do this my whole career.'"
Maddock left the D.C. Fire and EMS department in July 2011, after less than two years. The department has lost more than 40 paramedics since 2011, and just two have been hired. The attrition rate is just one of many problems in a department struggling to keep up with the city's growing population and a rapidly increasing number of emergency medical calls.
A shortage of ambulances, inadequate training and a poor strategy make the district "one of the worst EMS systems in the country when compared to other major metropolitan areas," said Lori Moore-Merrell, assistant to the general president of the International Association of Firefighters.
Detroit's EMS system, she said, "is in dire straits too, but it has no money. D.C. doesn't have that problem, but it seems no one's trying to fix anything."
Staffing and response time data collected by The Associated Press show the district is attempting to make do with less than half the paramedics employed by similar departments.
During his two-plus years on the job, Fire Chief Kenneth Ellerbe has yet to implement any major reforms, stonewalled by the firefighters' union and a skeptical D.C. Council that has questioned his competence. Mayor Vincent Gray hired Ellerbe and has consistently defended him.
Problems have mounted. This year, a police officer seriously injured in a hit-and-run had to wait nearly 15 minutes for an ambulance from Maryland because no vehicles from the city's fleet were available. A man died while waiting for an ambulance on New Year's Day, when dozens of firefighters called in sick. And on Monday, an ambulance that was supposed to travel with the president's motorcade ran out of gas at the White House because of fuel gauge problems.
The department hasn't increased the number of ambulances in four years, even though the city's population swells at a rate of 1,000 people a month. The council recently rejected a plan by Ellerbe that would have left the city without a single paramedic riding an ambulance in the overnight hours. This summer, the department contracted private ambulance companies to staff events at sports venues because too many city ambulances were breaking down.
Kenneth Lyons, president of the union that represents EMS workers, said residents with medical emergencies are better off finding their own ride to the hospital.
Successful urban fire and EMS departments tend to follow one of two models. One is where firefighters are trained as paramedics, and vice versa, so that they can respond to any emergency. In the other, the ambulance service is separate and employees are more specialized.
The District of Columbia has combined aspects of both systems into an unwieldy whole.
In 2007, a task force recommended firefighters be trained as paramedics following the death of New York Times reporter David Rosenbaum, who was beaten and robbed. He did not get the urgent care he needed because the responding emergency medical technicians thought he was drunk. He was never treated by a paramedic.
Nearly six years later, the department has about 200 paramedics among its 1,800 employees. Just 96 of those are firefighters.
A review by The Associated Press of data from 30 urban departments -- including call volumes, response times and deployment strategies -- paints a dire picture for the district. In 2011, the fire department received 130,000 emergency medical calls. At any given time, the city has 39 ambulances on duty, but only 14 are staffed with a paramedic. It also has 21 fire engines with at least one paramedic on board.
The department aims to have a paramedic on the scene within 8 minutes and an ambulance within 12 minutes. The National Fire Protection Association calls for a paramedic within 6 minutes and an ambulance within 10.
Many cities with similar call volumes have two to three times as many paramedics on duty at a given time.
"We can put a paramedic on the scene of any emergency within about 4 minutes," Memphis Deputy Fire Chief Gary Ludwig said. "We're starting to say Memphis is the safest place to have a heart attack."
Memphis has about 500 firefighter-paramedics, and 1,100 firefighters are also EMTs. Since 2008, every firefighter hired by the department has been required to become a paramedic.
Phoenix began cross-training its firefighters as paramedics in the 1970s, and more than one-third of its 1,750 firefighters are paramedics.
"We recruited people into the fire department that were inclined to be paramedics," said Dennis Compton, a former assistant chief in Phoenix and former Mesa, Ariz., fire chief. "The other thing we did is pay them for it."
In Washington, there is no internal paramedic training program, and Ellerbe has not made a major push to recruit paramedics, although the department says a few will be hired by the end of the month. The chief believes he can solve much of what ails the department with a radical change to firefighters' work schedules -- moving from 24-hour shifts to 12-hour shifts.
Ellerbe wants firefighters to spend more time on the job, saying they'll be more focused and will have more opportunities to train. He'd also prefer they live in or closer to the district. Some firefighters live as far away as West Virginia, New Jersey and North Carolina.
The union has strongly resisted the proposal, which is now in arbitration. Union leaders and rank-and-file firefighters say working several consecutive 12-hour shifts, and switching nearly every week between days and nights, would lead to mass burnout, regardless of where firefighters live.
"He's setting himself up for failure with the local," said William Bryson, a former fire chief in Miami and Miami-Dade County. "I'd really want to have a good plan with labor so that they have bought in. Everything I read about D.C., I see (union president) Ed Smith saying one thing and I see Chief Ellerbe saying almost the opposite. That's really not good."
The chief concedes that the department's problems are his to solve.
"The challenges and the things that don't look so great, I take those. The successes, the things that really make us shine, we give those to the employees," Ellerbe said. "I don't ride a fire truck. I don't ride an ambulance. But I take the responsibility if one of those units isn't where they're supposed to be in a timely manner."