Clerk general Public Comment. Members of the public may address the commission for up to three minutes on any matter within the commissions jurisdiction and does not appear on the agenda. Speakers shall address their remarks to the commission as a whole and not to individual commissioners or Department Personnel. Commissioners are not to enter into debate or discussion with a speaker. The lack of a response by the commissioners or Department Personnel does not necessarily constitute agreement with or support of statements made during Public Comment. President nakajo madam secretary, at this time, is there any member of the general public that wish to make Public Comment, please step to the podium. Seeing none, Public Comment is closed. Secretary. Clerk item number 3, discussion and possible action to approve meeting minutes. Minutes on regular meeting on october 23, 2019. President nakajo thank you very much, madam secretary. At this particular point of the agenda, approval of the minutes, i will call for Public Comment. Any member of the public wishes to address Public Comment, please approach the podium at this time. And madam secretary, can you please note that commissioner veronese has joined us at 9 03. Clerk discussion and possible action to approve a new memorandum of understanding between the Fire Department and city college of San Francisco. President nakajo i was reminded by the good commissioner cleaveland that i did not take a motion for approval of the minutes, is that correct . So i will turn to that item and ask the commissioners for any comments or questions or for a motion. So moved. Seconded. Very much, commissioner cleaveland. Thank you for reminding the president. Thank you commissioner for your second. All in favor, say aye . Approved. Thank you very much. Madam secretary, 4 . Clerk item number 5 . Update on e. M. S. 6 program. President nakajo madam secretary, i have item 4 for the directors report, after the memorandum of understanding. Clerk i have that as item number 4. Im sorry. President nakajo okay. Well call item 4. May i interject for a moment . I have to go to a mayors meeting, so i was wondering if i could give my report prior to item 4. President nakajo well make that adjustment. Clerk directors report. Report from jeanine nicholson. Report on the activities of the Fire Department since october 23, 2019 including special activities, outreach and changes to other Government Policies and the public. Good morning, commissioners, command staff and everyone else. Thank you for being here. Chief jeanine nicholson. This is my report since the last Fire Commission meeting and thank you for making an adjustment in todays calendar. I do have a Department Head meeting with the mayor at 9 30 downstairs. Weve been continuing our visits. I visited station 52. I visited station 51 a week and a half ago, and were getting good feedback, im getting good feedback from the folks in the field on those visits, and then last night, we had a town haul at station 49, and our very own mayor, london breed, was in attendance, and that was really, really great and really you could feel the good energy in the room, the morale of folks just sort of lifting up. And our people got to see that our mayor understands you know, understands our challenges, and she was really supportive, so that was really great. We met with the controller and the Mayors Office regarding performance metrics in e. M. S. , so we have all the data that we need when we go forward with this years budget, so we can be on point with all our ducks in a row. So were continuing to work with the mayors and Budget Office and continuing to work internally. We met with the Police Department chaplains. As you all know, we will be losing father john green, who is one of a kind, so we are looking to other models such as the Police Department the Police Departments model, and we are continuing conversations with them. They have numerous chaplains, and they are also starting a program for basically Community Chaplains to have people on call all the time, so were looking at that, seeing if we can jump on board with them. We met with lieutenant Dwayne Eckert who volunteers with meeting with the Fire Department in safety education. Were ramping up that again and we asked for one volunteer from at least each station to volunteer and go out and teach kids about fire safety. We had a meeting inhouse about special events. The mayor has interdepartmental meetings going on about inhouse events and how to sort of smooth the process there. Weve been making our voice there in terms of if you need an e. M. S. Plan, you need to check with us before signing off on things, for one. And also, we are looking at sort of the budget capture from within because we are working with more and more special events, and we are being asked to do more and more, it does have an impact on our budget. And so whether we get asked for tactical medics or an e. M. S. Stand by or even the event action plans that chief cochran works on, these are all action plans of ours, so we want to make sure we include that in the budget. Speaking of the budget, we attended a budget 101 meeting with mark corso. Gave us the nuts and bolts of the budget. Were starting on the budget earlier than normal with the Fire Department. So we did that a couple weeks ago, and that was super helpful in helping us understanding what our budget was. But we are ramping up on the budget right now, so we are ready to go come january 1. Chief bell and myself went up to the folks who deployed on mutual aid on the kinkade fire. Got to check in on them, bring them some goodies, and see how they were doing. So we did that on the 29th. We did have our academy to e. M. T. Pinning bump up, so kathy, can you make sure you let everyone know . Clerk yes. Its next friday. I had a meeting with sheryl davis of Human Rights Commission regarding opportunities for human rights for all, looking at in summer 2020 hopefully doing something similar to e. M. S. Corps, which is in the east bay and other places, hopefully somewhere in the city. So were looking at that, coming up with plans, and hoping to make that a reality in the nottoodistant future of next summer. And if you dont know, e. M. S. Corps is a program for youth who may be at risk, and it gives them an opportunity to take an e. M. T. Class, as well as it gives them trauma counseling and life skills and the like, so were looking at being part of that. We had the emergency firefighting water supply hearing at board of supervisors. Supervisor mar had a resolution, so its very similar, pretty much the same as what weve been talking about the last few months about the efws. Then, theres been the power safety public power safety public shutdowns. Weve had Treasure Island experiencing that, but weve had our generators up and running, so were ahead of the ball game on that. Chief nicosio attended a response to wild fires that was attended by supervisor mandelman. There was a lot of concern out there, so we were working with them and the parks on how to best address some of those issues. Phoenix Society Dinner was last week. I want to thank the command staff for attending. It was to honor several retirees, and i also want to thank the command staff for going out to the veterans day parade. We had a good showing, and that concludes my report. Im available for any questions. President nakajo thank you very much, chief nicholson. At this particular point, we will ask for Public Comment on the chiefs report first, then well ask for questions or comments from the commissioners. Any member of the public wishes to give Public Comment on chief nicholsons report, please indicate and approach the podium. Seeing none, Public Comment is closed. Commissioners, on the chiefs report, any comments or questions at this time . Thank you very much, chief nicholson. Give our salautations to the mayor in your meeting. Ill be here for a few more minutes. President nakajo we are going to go back to item 4, and then, after we have item 4, well have item 6. Madam secretary, item 4. Clerk item 4. Memorandum of understanding between city college and the Fire Department of San Francisco. A new memorandum of understanding between city college and the Fire Department of San Francisco. President nakajo good afternoon, chief. As you may recall back in january of this year, the Commission Approved a oneyear m. O. U. With city college. That encompassed training and Work Experience through the sffd, and that transferred into city College Course curriculum and resulted in actual city College Course credits for people going through the program. But this was a oneyear Pilot Program as the arrangement we had with city college, although it was a plan we had discussed for years and years, but we never had a plan until this last year to move forward. We were very pleased with how its worked out so far. The january 19 and Current Academy that began in october were the first two programs that went through this Pilot Program. Weve enjoyed our relationship with city college. As a result, both parties are looking at expanding the scope and agreement going forward. The m. O. U. Before you is a fiveyear agreement to enter into a contract with city college. Were working with city college to expand the scope to a variety of other training and other different courses, and that can be added at a later date being an addendum. The department believes this is a winwin for all parties. Both the city college and the department see benefits from this. Its a Revenue Source for the department, and members get access through no cost to them to city college, and they get College Credits to continue their education if they so choose. So this will be before the college in december. There are a few staff from city college here. So with that, happy to open up any questions or allow them to come up and say a few words. President nakajo could the representatives from city College Please approach the podium and participate in this memorandum of understanding item . Hi. Thank you. Im dr. Edith cuepar, the instructional director for city college. We have enjoyed or relationship through the m. O. U. , and during this time, weve deepened it [inaudible] and will be active on january 1. So anyone whos currently going through can get that certificate of achievement after january, they can apply for it. We will continue to work closely with our friends in the Fire Department and continue to deepen the relationship through many, many ways. Any questions about this partnership, id be glad to talk about that, but i also want to leave time for my colleagues. President nakajo please do, chancellor, and please remain until your team completes the presentation. Please. Good morning, chief. Jim connors, retired Fire Department, and director of instructional fire science. So chief corso described to us this contract. One thing that i would like to comment on, last january, president nakajo referred to whats called continuous professional training. Its complicated with the firefighters work schedule and trying to equate hours to units, so were diligently working on that. I have retired captain ed moy whos really good with numbers. Hes identified in several ranks hours of training over the hours, so now, the piece is going to we have to finish working on is how do we equate that to hours and units that meet the ed code requirements. And the only quick comparison ill give you is how convoluted our training schedules are. In the Fire Department, they detail their training schedule in the Police Department, they detail their training schedule to the training department. We send our people in shorter increments that dont equate to t. I. Were working on getting that in longer hours. I sent an email to the state and asked them if anyone has Instructional Service agreements, how do they address inservice training, so were working on it. President nakajo thank you very much, captain connors. The preference would be for you to verbalize, as well. Good morning. Im monique pascual, director of service agreements, so i v been working with chief corso, making sure that we run the process as smoothly as possible. It has been running smoothly, and im excited for the next five years. President nakajo very good. Were going to ask for questions or comments from the commissioners at this point, and if there are any questions or comments, please respond to them. Vice president covington. Commissioner covington thank you, mr. President. Thank you, mr. Corso, and the city college team. Have we gone through a complete calendar year under the trial . We have not gone through a complete calendar year. That would be in early january. Weve gone through a complete academy, which was the january 2019 h20 academy. Commissioner covington and were there any things that were changed from the initial m. O. U. To the fiveyear extended m. O. U. That we have before us . I do not believe that there were any changes in the language. There were mainly just addressing the dates, and as i mentioned, at a later date, we may be able to address some additional courses, but the scope is still consistent. Commissioner covington okay. And you referenced this being a Revenue Source for the department. Can you talk more on that . Absolutely. On the last page, page 7, it discuss discusses hourly reimbursement for training hours, so working closely with miss pascual, we pay for all members kind of enrollment fees, anything related to that, so our members do not have any costs that theyre forced to bear. As a result of that, we work with city college and bill them and get reimbursement on an hourly basis for the number of hours of instruction. So based on that, we see additional revenue come into the department that have been returned back into the training program. Commissioner covington all right. And what level of funds are we talking about them . So for example, for the initial h2 academy in january that has already concluded, the Department Took in a net of approximately 70,000 in revenues, and that would continue for future academies as well as the additional Work Experience course. Commissioner covington so that 70,000 goes back into the program itself. Is that to expand the program or purchase equipment or what . So the intent of that program is to go back into the Fire Departments initial training, be it more classes, equipment or what have you, but thats for the department to prioritize. Commissioner covington okay. Very good. I love a funding source. Absolutely love it. Okay. I had another question, and thats im not sure who on the college team will answer this, but the certificate of achievement and continuous professional training, what is required for you to receive that certificate . So for the certificate of achievement commissioner covington thank you thank you. Oh, yes. Hes much taller than i am. So for the certificate of achievement, what they need to complete is the academy plus their onthejob training. And at that point, they will get the certificate of achievement. These courses actually also apply to an a. S. In fire science at city college, so theyre in addition, while theyre going to the academy, theyre working towards their degree. Commissioner covington mmhmm. Their associates degree. Their associates degree. Commissioner covington okay. Thank you very much, doctor. President nakajo okay. Thank you, Vice President covington. Chief nicholson . I just want to say thank you, chief corso. Were happy with this relationship, were happy with this program, and i dont know if you know this, but that man over there, jimmy connors, was my very first boss in the Fire Department. Thank you. Thank you. All right. Im going to tap out right now. Thanks. President nakajo thank you very much, chief nicholson. Commissioner cleaveland . Commissioner cleaveland id just like to commend this program and move that we support this fiveyear memorandum of understanding. Commissioner covington second. President nakajo okay. Theres a motion by commissioner cleaveland and second by commissioner covington, but theres a comment by commissioner alioto veronese. Commissioner veronese commissioner cleaveland beat me to it, but this is a great program, and i wholeheartedly support it. President nakajo okay. Thank you, commissioner alioto veronese. Okay. Theres a question on the table. All in favor . Opposed . Motion passes. Okay. I have to say, class of 65, and i wish we were both 65. Thank you very much. Madam secretary. Clerk item number 5, update on e. M. S. 6 program. Dr. Clement ye and simon pang to provide an update on the e. M. S. 6 program. President nakajo okay. Welcome, dr. Ye and dr. Pang. Thank you, commissioners, chief wyrsch. Im clement ye, director for the department. Im joined by simon pang and paramedic captain april sloane. So were very excited to provide an update to the Commission Regarding the e. M. S. 6 program which i believe has been very successful and helped many people in the city. So kathy there we go. Thank you. So a few things before i i begin into the slide deck, i just want to say first of all, i just personally am very grateful to the commission for all your support and all your input in this program. I think this is something that we as a department, as a city should be very proud of being innovators and pushing the envelope and providing some i think necessary aid for helping a lot of our citizens and visitors in San Francisco here, so im very, very grateful. And then also, i understand that the commission has been receiving regular updates in their monthly packets recording e. M. S. 6 operations, and i know ive provided a few updates in the past about this program. I dont want to rehash that, i want to give a little bit different perspective. My plan is im going to give a brief overview of the program and then hand it over to my copresenters. We know youve been getting some data on the program. Were going to give you some other data. Were also going to provide you some depatientized stories. Also, we had a client who was interested in giving you their perspective, and we have a video at the end, with their permission, of course. Also, id just like to remind the commission that this Program Began in earnest back in january 2016. And this is a really robust collaboration between multiple departments in the city, primarily between the San Francisco department of public health, the San Francisco department of homelessness and Supportive Housing and of course the San FranciscoFire Department. We are really the primary driver of this, but it takes a village, and one of the great lessons in this is to motivate the great resources that are readily available to motivate some of the gaps in care. Just as a technical detail, we have been a Pilot Program with the state e. M. S. Authority as well as oshpod, which is a statewide Health Workforce development program, and hopefully this is going to spur some policy change to allow programs like this to exist permanently outside of a pilot process. So id also just like to sort of broad level highlight a few things that i think are real Core Competencies of this programs and real strengths. The real fundamental activity that we undertake, and chief sloane can address more about this is direct patient engagement. As part of the Emergency Health care responder system, we represent a safety net. This is about meeting people where theyre at, figuring out where the gaps are, what the unmet needs are, and then using this as a safety net to bring folks out of a state where they require a safety net all the time and hopefully stablize them. With that, weve been able to forge a lot of partnerships with a lot of multiple agencies. As youll hear from our case studies, what it really takes to get someone housed and off the street to where theyre not requiring 911 calls all the time takes quite a lot. While many remark that this seems like a remarkable amount of work and effort, i would also make the counter effort that having several dozen or hundreds of emergency responses in an effective way is really also a lost opportunity and also very costly from a resource standpoint. And then, finally, what we realize in looking at the absolute numbers and community numbers of this program, e. M. S. Really supports this program. This strengthens our ability to have a safety net, have what we anticipate are more typical responses. What we mean by that is when we have a client who has several hundred responses for a particular unmet problem, when we can get them sort of taken care of and stablized, it allows our Emergency Care system and responders to focus on other emergencies that they can be more ready to respond to. So those are kind of a few things that at a broad level i wanted to highlight, our strengths and Core Competencies and also to provide a little bit of a face and some stories to go with the numbers and results that youve been seeing on a monthly basis. So with that, id like to turn it over to section chief simon pang to take it from here, and i will return to answer questions and have some follow up comments. Simon . President , commission, chief wyrsch, thank you for the opportunity to speak today. Id like to begin with a case study. A person that was homeless in San Francisco for nearly 20 years, a person that could upend an emergency room with their disruptive behavior and shockingly sharp tongue. Three years ago, i remember being asked by her primary care doctor to talk her into going to hospice. Ga gaunt, frail, with acute respiratory needs, you can see she was at end of life. You can see well, you cant see how she was because of the words, but you can see her inability to provide food and shelter for herself. In the first half of 2018, in the first six months, she had already surfaced her entire utilization from the year before, and was on pace to increase her utilization by 200 . With someone in her state, you cannot just tell her they have a room at a shelter. They will never make it there. You have to take them there, escort them to their assigned bed, stay with them until they have a plate of food in front of her. We did this for her repeatedly. Eventually, with the help of the shelter team, she developed a plan, and she stablized. She moved into her own apartment in june of last year, and since then, she has only utilized our ambulances twice. The mission of e. M. S. 6 is to help Vulnerable People find the care they need. Someone becomes a frequent 911 utilizer because they need help, but an ambulance and emergency room dont provide solutions to the root causes of their predicament. By connecting them to the system that best suits their needs, such as primary care, primary Mental Health care, housing or shelter stablization, we reduce the dependency of the e. M. S. System. You have to be compassionate and motivated to create change. Fortunately, the team have those attributes, and we have also greatly benefited from the dedication of our medical director, dr. Yang. By march of 2020, we hope to be fully staffed at 7 e. M. S. Captains, all seven e. M. S. Captains, all trained at emergency paramedics. Our planned hours of operation will be 7 00 a. M. To 2 00 a. M. Seven days a week, and at our height, we will have four units in concurrent operation. We focus our efforts on individuals that have ten or more calls in a year, four or more calls in a month, or two or more in one day. Based on this threepart definition, on average, there are just over 600 frequent 911 utilizers in San Francisco. Those individuals account for over 1,000 calls per month. Measured qualitatively, we have helped people reconnect to housing, helped into housing, help people reduce harm or find sobriety. We fill the gap, helping people that are too disregulative to be able to schedule an appointment. We track the top 20 users with whom we have had contact. On average, since our inception in 2016, we have affected a monthly decrease in utilization of 35. 3 . We have created a panel of managed clients, individuals chosen due to their very high utilization rates or high rates of vulnerability. We convene meetings of the patients primary providers and create a hospital action plan. The action plan identifies the best action for each client in the event of a 911 activation. Sometimes, the best resource is an emergency room, but sometimes it is the medical staff at a Navigation Center or a visit to our primary care doctor. The bottom line is we help the individual get the care they need. Research authored by dr. Mary mercer of ucsf and General Hospital show our approach resulted in a 19 reduction in emergency room visits. For the same managed client panel, the Health Departments whole person care team is also studying our approach. Whole person care is a statewide grant that the Health Department received to approve the delivery of care to homeless adults. This stop light graph of the first seven managed clients demonstrates the effect of our prehospital action plan. This is an analysis of the individuals resource utilization four months before our action plan and four months after our action plan. The red bars indicate undesirable resource use, 911 calls, and e. D. Visits. The orange, yellow, and green bars represent a continuum towards stablization. As you can see by the arrows, there is a downward trend of red services and upward trend of green, yellow, and orange services. Now if you look at the services above the bars, they represent an average number of resource utilization per person. So for 911 calls, thats actually a decrease of seven up to four months. Not too impressive, but the second bar, e. D. Visits, is actually a reduction of e. D. Visits by 70. And if you look at the yellow graph for stabilizing health overnights, there is an increase in ought will utilization of overnights, what we mean by that is a stay at hummingbird, stay at residential detox, residential treatment. It is being promoted statewide by the whole person care team to be emulated by other cities. One additional aspect of our managed clients is well, the challenge for e. M. S. 6 is being able to arrive on the scene of the 911 call. Given the small size of our team, its not always possible. However, our internal data shows that when e. M. S. 6 does arrive on the scene, we have effected a 40 e. R. Diversion rate. I would like to turn it over now to captain april sloane who will walk us through a few case studies. Good morning, commissioners, chief wyrsch. I would like to present a few case studies of clients that weve worked with over the years, client number one is a good example of a positive outcome from a longterm engagement. He was consistently directed to sobering, and we have many tools around selfharm. We observed a sharp spike in his utilization of Emergency Services and his risk taking behavior. Our relationship with him allowed him to confide in us that he was actually suicidal, and we worked with street medicine. He was placed on a 5150. While he was in treatment, we supported him, and he entered detox, residential treatment, and then transitioned over to a nav center where he was awaiting housing. Our second case study is also another long engagement. We engaged him for several years. He made several attempts to detox and consistently began to voice his goal of reuniting with his family. Sobering and e. M. S. 6 encouraged him to follow this path, and they had some conversations with him by phone. They wanted to see him, and he went to detox, engaged in residential treatment, and after that, got on a bus and was reunited with his family. Client number three, this client became paraplegic and was on the street in a wheelchair. He was unable to care for himself and was often found sitting in his own feces. This caused the skin to erode way and caused several large lesions. He frequently left the hospital before completing treatment. E. M. S. Advocated for an involunta involuntary commitment so he could receive treatment for his wounds, and hes still in treatment. I guess everyone is following along so you can see the decrease in utilization from year to year, and after our intervention, the dramatic decrease in these individuals utilization. I want to point out that we chose these case studies to show the different outcomes that can result. So the first case study was about someone who got housing. The second was someone who gained longterm sobriety. The third, someone who was reunited with family, and this last one, someone whos benefiting from a conservatorship. From the beginning, we recognize the importance of collaborating with the Homeless Outreach team. We benefit from their experience and access to resources. Building on that for a combined total of 25 hours per week. We now have a psychiatrist, a psychiatric nurse practitioner, and a social worker riding with us. These advanced clinicians are members of the Health Department street medicine team. They are especially helpful with our patients that have Behavioral Health needs, and their participation is planned to increase to seven days per week in the very near future. E. T e. T. 3 is a medicare Pilot Program that could aid the sustainability of Community Programs such as ours. It stands for emergency triage, treatment, and transport. We submitted our application to participate about a month ago with director corsos help. We are waiting to see if we are accepted, and if we are accepted, it means the Fire Department would be reimbursed for serviced rendered by e. M. S. 6. We are not the only city agency that has identified individuals that are exceptionally vulnerable. There is so much overlap of these vulnerable individuals that it makes sense for us to work together, and we are collaborating with the department of homelessness and Supportive Housing to identify the most atrisk people in the city and help them on the pathway to housing. The Methamphetamine Task force was convened by supervisor mandelman to address the increasing use of meth in the city. It was my privilege to attend the task force and to lend our bootsontheground perspective to challenges to methamphetamine users. The recommendations of the task force have been released and the number one recommendation is the opening of a methamphetamine Sobering Center, similar to the alcohol Sobering Center that we have in the city. The conservatorship is a sixmonth conservatorship that we have for individuals that because of Mental Illness who are unable to care for themselves on the street and who have refused repeated offers of detox, treatment, and housing. The conservatorship is a fiveyear project, introduced by senator scott wiener, signed by governor brown, that guarantees permanent Supportive Housing at the end of the conservatorship. Because of our experience in working with individuals that would benefit from such a conservatorship, i have been appointed by mayor breed to the conservatorship board who helps with the law. With that, id like to turn it over for some final comments. We look forward to ongoing operations. I really hope that this would allow us to have an ongoing dialogue as well as provide a bit more of a perspective on the actual narrative and what the team encompasses. One last thing with your permission, we had a particular patient who was interested in sharing their experience, and if the commission would indulge us, id like to cue up a video that mr. Rocco flamio was willing to talk about his experience with e. M. S. 6. [video] so thank you very much, and wed be happy to take any questions. President nakajo thank you very much. We appreciate it very much. Were going to ask for Public Comment at this point, then well ask for questions or comments from the commissioners at this point. Any member of the public wishing to give Public Comment . Seeing none, Public Comment is closed. Commissioners, at this point, commissioner hardeman . Commissioner hardeman im supposed to be sitting here, i guess, but thank you for your report. It seems like these few cases you identified can take care of the whole 19 success rate here. The idea that we allow this as a society is crazy, that someone can take an ambulance 200 times, and we just dont care well, we care. Maybe after the 20th time, we can say were going to keep you in here for a day or so, but thats not the way to treat people. But in San Francisco, well continue this pattern, but maybe another city would be more common sense and say 20 might be the limit in a year, and then, were just going to keep you in. Some of the behavior was so bad as to be considered criminal, and they could probably incarcerate them, but we dont do that, either. Any way, congratulations on your success. Hopefully in a year, we can get the report back from you on these particular cases, and thats all worked out well and has paid dividends to everyone. Thank you. Thank you, commissioner hardeman. Commissioner hardeman thank y you. President nakajo thank you, commissioner hardeman. Commissioner veronese . Commissioner veronese i remember i went along on a ride along with you, and i dont know if you remember this, but roc rocco utilized us, and i got to interact with him and he answered a couple questions. After my ride along, i professed my love for this program. I have a statement, and its not directed at you, but at other departments. I strongly believe that this program exists because other departments are failing us. With that, i strongly believe that youre doing gods work. A couple of questions. I know we had some new hires coming out of the last budget, and that just goes to show the good job that youre doing. Im curious as to why each of the hires are captains. I wouldnt be doing my job if i didnt ask the obviously question that why everybody thats being hired into this program is a captain person . I can answer that and then ill hand it over to chief pang. One of the important design aspects is we need people to ask as supervisors when they arrive on scene with e. M. S. 6. If we have a unit out there, and there is a mass casualty incident, or a cardiac arrest, we have an additional unit that can respond. There are many other benefits, and i think that if you look at other programs in other jurisdictions, theres a lot of different approaches as to, you know, how you provide the service. I think that we saw the need for having a supervisory interaction for someone who can have that guidance and experience on there. And chief pang, you want to add on . I can think of three reasons. Dr. Yates mentioned the first two already. Because we are clinical supervisors for 911 medical emergencies. We are in proximity to a call, well go on it. If were the closest one to a cardiac arrest, well go. We feel thats our obligation and were a fully loaded a. M. S. Rig. The other one mentioned, i think it takes a supervisor on the scene of these calls. When were interacting with our own crews, not only our own crews, but members of Law Enforcement because a lot of times, theres a lot of chaos on scene and other city agencies dont want the scene to unfold the way we want it to go, so the fact that we are an officer in the Fire Department has a lot of weight, and thats very helpful. When were trying to convince an officer of the police force that we really want someone to be placed on hold, we feel that theyre greatly disabled, we feel that theyre a hazard to the community, but that officer doesnt want to do it, it helps tremendously to be a captain. The third one is we interact with our clients, our patients, with our crews, with members of Law Enforcement, but also with social workers, nurses, doctors, and also with agency directors. And its just a little bit more of course its not a symmetric relationship with an agency director, but if youre a captain of a Fire Department, its more weighty than if youre not, and its helped us tremendously. Commissioner veronese okay. Thank you very much. I think the command authority is a good enough reason it could be for me. Is it captain . I was recently promoted. I am now the section chief of e. M. S. 6. Commissioner veronese congratulations. I know you as captain, but congratulations, section chief. Its well earned. If you could expand on one topic that you just mentioned. We talked about it after the ride along. If you could talk about it to the other commissioners they werent there that day and saw what we saw. If you havent done a ride along, i would highly encourage you to do that. But if you could expand on the relationship that you guys have with the Police Department in regards to what youre talking about, the holds. Now, the holds, im assuming youre referencing the health and safety code, the references code for 5150. Yes. Commissioner veronese if you could give us an idea what that looks like, first of all, and what is your relationship between you and Law Enforcement and how does it come up in your job . Well, first of all, paramedics are not authorized to place people on a 5150 hold. A 5150 hold is is for an individual who is either a potential harm to themselves or to others or who are unable to provide for food or clothing or shelter for themselves as a primary result of Mental Illness. The police and social workers, doctors and psychiatrists are able to place those holds. Now as you guys know from Walking Around in our city, there are people that are vulnerable and gravely disabledisabled on our streets that are still on our streets. And when we come upon them, there are times that we simply feel that something must be done. So one route of placing them on hold wouldi be special calling of Police Officers. Police officers are quick to place someone on hold that are a harm to themselves. But disabled is another, and Police Officers in my opinion are not the best agency to do