By AARON DEAN and MICK MESSOLINE
Does your fire department provide emergency medical services (EMS)? In communities with populations of 100,000 or more, 97 percent of U.S. fire departments provide some level of EMS.1 Some fire departments provide emergency medical treatment at the basic life support (BLS) level, using emergency medical technicians (EMTs), while others may provide care at the advanced life support (ALS) level using paramedics.
Does your fire department transport? Fire department-based EMS transport systems are becoming increasingly common in today’s fire service. The rise of EMS transport has generated much discussion in the firehouses and capitol buildings across America. Fire suppression and prevention are now only two of the numerous duties a fire department must carry out.
EMS originated in the early 1960s. After World War II, many good-hearted, well-intentioned, but poorly trained civilian rescue and ambulance squads began providing service in the United States; they were typically unsophisticated and often unorganized groups trying to do the right thing. In 1966, President Lyndon Johnson signed Public Law 89-563, the “National Traffic and Motor Safety Vehicle Act,” which was the first attempt on a national level to address improving critical failures in these developing EMS systems.
Also in 1966, the National Academy of Sciences published the landmark development paper Accidental Death and Disability: The Neglected Disease of Modern Society, more commonly known as “The White Paper.”2The National Research Council Committees on Trauma and Shock concluded that both the public and the government were “insensitive to the magnitude of the problem of accidental death and injury in the United States.”
Furthermore, the paper validated that ambulance services were diverse in nature and “most ambulances used in this country [were] unsuitable, having incomplete … equipment, inadequate supplies, and manned by untrained attendants.” The White Paper suggested that to decrease the mortality rate of trauma victims, personnel would need proper (1) training, (2) communications, and (3) medical oversight. Today, personnel, equipment, and vehicles are highly specialized, technologically advanced EMS components. Private ambulance companies use single-skilled technicians to provide transport; fire departments use cross-trained personnel for transporting victims. In some areas, there exists a combination of the two.
In the private sector, system status management (SSM) projects where units should be positioned to address the public’s emergency and nonemergency needs. Private ambulance companies often provide for interfacility, nonemergency, and 911 calls. Fire department-based EMS transport systems typically use medic units only for 911 calls, responding from firehouses located strategically throughout the community. The fire department’s redundancy system, which uses cross-trained personnel, ensures that all aspects of emergency dispatch are handled (an “all-hazards” approach).
Private sector SSM vs. the redundancy of the fire department—what is the best cure for an ailing EMS system? It may seem like an easy question; yet, there are many aspects to determine how to best provide for the public’s needs. In 2008, medical aid calls for service by fire departments accounted for nearly twice that of all other service calls combined. Unlike firefighters, single-role EMS providers treat patients primarily during transport. This, too, has extenuating implications.
The fire service can deliver prehospital 911 EMS in many ways. The following are the three most typical ways this is done in the United States:
- Fire service-based using cross-trained/multirole firefighters: Firefighters act as all-hazard responders and are prepared to handle any situation that may arise at a scene, including patient care and transport.
- Fire service-based using employees who are NOT cross-trained as fire suppression personnel: Single-role, EMS-trained responders accompany firefighter first responders on 911 emergency medical calls.
- Combined system, which uses the fire department for emergency response and a private or “third service” (police, fire, EMS) provider for transportation support: Single-role EMTs and paramedics accompany firefighter first responders to emergency scenes to provide patient transport in a private or third-service ambulance.
“The reality today [is] that the fire service has become the first-line medical responder for critical illness and injury in virtually every community in America.”(2) On activation of 911, the fire department responds without question to any and all requests, including some law enforcement-led activities. Responding to all types of 911 incidents requires the fire department to not only provide EMS but also to do so under difficult or unusual circumstances.
The fire service responds to and mitigates incidents in addition to providing medical care. Such instances may include fire suppression victims; downed firefighters; high-angle rescues; elevator entrapments; over-the-bank to low-angle rescues because of motor vehicle accidents (MVAs) with entrapment; multicasualty incidents (MCIs) such as with vapor or toxic fume releases; swiftwater or ice rescues requiring resuscitation; or environmental hazards such as floods and earthquakes.
The fire service provides incident stabilization using the incident command system to manage and deploy resources effectively and safely. Some fire departments proclaim to be “all-risk,” meaning that the department is staffed, trained, and equipped to provide public service without assistance from neighboring agencies through mutual-aid agreements. The department is staffed sufficiently with on-duty personnel for larger incidents such as multiple-alarm fires, MCIs, and technical rescues.
Although private, single-role EMS providers perform transport and treatment, treatment usually requires being in close proximity to the patient. Unfortunately, not all patients are accessible without additional personnel training. Do these private or for-profit ambulance companies have the necessary equipment and training to provide this service? Or, do they have enough personnel to adequately respond on demand without callbacks or page-outs?
To accurately evaluate each service provider and the means by which it delivers service necessitates an uncomplicated analysis and comparison. There is similar value in the fire service’s cross-trained human resources and third-service providers’ “specialist” approach. Follow a modified compare-and-contrast model.
The fire service has expanded its reach greatly in the past several years. The average fire department now employs multiple specialties and expanded duties to provide timely community service from strategically located firehouses equipped and staffed with a variety of resources and equipment.
Fire departments that transport with ambulances can generate significant revenue. Some fire agencies have sole propriety for their region, while others may share propriety with a third-service provider. One proponent for fire department-based transport is the number of available and staffed units. A full ALS fire department has multiple stations throughout the jurisdiction, thereby reducing treatment and transport time.
The fire service also offers greater resources, equipment, and safety gear than other providers. It also has multiple specialized resources such as truck or rescue companies for auto extrication and similarly trained on-scene personnel, which offers redundancy in trained personnel and equipment. Additionally, an all-risk organization provides personal protective equipment (PPE) such as turnout gear, helmets, and self-contained breathing apparatus for all personnel, making each company member more interchangeable at an emergency scene.
One downside to fire department-based EMS transport is the “jack of all trades, master of none” claim often heard from the medical community. Medicine is a very dynamic field requiring constant training and improvement. Some contend that the fire service falls short of meeting this standard because of the time, training, and certification these specialties require.
Another potential negative to fire department transport is the cost of delivery. Although unionized firefighters offer a high degree of skill in many areas, they are expensive to employ and train. Specialized equipment is also expensive to purchase and maintain. Yet, since the fire department responds at least in first responder mode, why not transport, too? Also, if the fire department does not specialize in rescue, swiftwater, hazmat, and so on, who does? The need is present.
TRANSPORTING WITH NONFIRE PERSONNEL
Although it is more common to use cross-trained personnel, costs decrease when using limitedly trained or nonfire personnel. However, this could create a culture clash and cause human resource issues. Dana Kristin Maine’s article regarding the Fair Labor Standards Act, “When Are Firefighters Truly Firefighters?”3identified concerns controlled by lawmakers when firefighters perform EMS duties. Are they operating under the 80/20 Rule in the 29 Federal Code of Regulations, Section 553.212? In other words, legally, which labor codes apply to nonfire, single-resource emergency providers working in the same agency as sworn fire personnel?
Another aspect of intermingling yet dissimilar 911 personnel is the culture of the operational unit. In the fire service, firefighters eat, train, and sleep as a family. In EMS, members may be coupled with another individual on a moment’s notice because of scheduling, never having worked with that person before. Independent action is encouraged over teamwork, and the medical model favors individual over team responsibility for outcomes (positive or negative). This belief is contrary to that of the firehouse culture.
Philip Weiss’s September 1998 Fire Engineering article, “Fire/EMS Merger: An Examination of Cultural Differences,” examined the problems the Fire Department of New York encountered trying to incorporate EMS as a stand-alone division. This article validated many similar experiences field responders have had with cultural and operational issues of 911 emergency response. With regard to human resources, conflict will lead to union representation. This can also become costly, thereby affecting the notion of cost savings.
Private providers. Private ambulance providers are medicine-specific agencies that provide service to a given area. The authority to deliver service is usually awarded by contract. The “privates” are profit-driven companies, and transport is their biggest source of income. Their employees come with a wide variety of credentials; most meet the industry standard of cardiac and pediatric ALS and some variety of trauma-specific certifications. Continuing education generally is the employee’s responsibility. The employer provides additional mandatory agency-specific courses. A private provider’s most common staffing model features one paramedic and one EMT; this is the most cost-effective model for a for-profit operation that wants to maintain the standard ALS level of care.
A benefit of the private provider model is its desire to provide transport for incidents such as 911 emergency response, interfacility transfers, and nonemergency calls within its transport area. The provider’s financial bottom line is maintained by the number of transports; passing on a call for service means losing revenue. Usually, a surplus of physical resources on the street keeps the privates from missing any calls. Private provider employees have two related roles—patient transport and patient care. Having limited or no additional areas to focus on allows private providers more time to study and master principles of patient care and transport.
A negative of the private provider model is the difficulty in maintaining staffing levels. Occasionally, a limited quantity of hirable personnel can result in less talented patient care providers, thereby jeopardizing the initial patient care. Training and increasing an employer’s skill take time, experience, and patience.
The emergency resources that private companies provide are limited because of cost (including all equipment), maintenance, and training. Also, because of the cost of specialized safety gear, private companies will often restrict personnel from operating in environments that would require expensive PPE rather than equipping them properly. Such PPE includes turnouts or reinforced safety uniforms, helmets, and safety gloves. The lack of PPE as well as knowledge of and experience with scene management can hinder access to patients in fire and rescue situations, including vehicle accidents, high- and low-angle rescues, hazmat incidents, and other fire-related situations.
Hospital-based ambulances. Third-service ambulances can be lucrative to hospitals that need help meeting their bottom line. Training in hospital-based agencies seems to be at a slightly higher level than the industry standard because it is operated from a hospital. There is a greater opportunity for advanced-level instruction in many aspects of medicine. Hospitals have a vested interest in ambulance service and may provide regular physician-based education, which results in more polished employees. The higher the expectations placed on the provider, the more focused that provider’s education must be, which can only benefit the patient.
Two negative aspects of third-service providers include dynamic dispersal styles of dispatching and limited physical resources. Increasing resources during peak times and then lowering them during off-peak times can extend response times and may impact patient outcome negatively; SSM is educated guessing at its best. Also, third-service agencies lack the same training opportunities offered in the fire and rescue services. Storing equipment is also an issue; there is limited space to store forcible entry tools, extrication equipment, and PPE, all of which take a backseat to the storing of medical equipment.
Further complications of EMS delivery are now appearing, such as increased volume and 911 misuse and abuse. In the 40+ years of EMS, no one sector of 911 response has taken a leadership role to solve the problems of today or tomorrow. We simply survive the best way we know how in our own communities.
Therefore, the question is, considering the convoluted aspects of this complicated EMS system, which delivery method is your community’s best option? The question is not easily answered and actually creates more questions.
Which EMS delivery method best meets the community’s needs, and what other emergency response needs does the community require? Who provides the resources needed for rescue, hazmat, or swiftwater? Can your response team effectively rescue a civilian from a bread-and-butter residential structure fire? Which system provides the quickest treatment to a downed firefighter? Do you use a rapid intervention crew? Who best provides patient care during auto extrication? Who supplies additional personnel on an immediate-need incident such as an MVA that becomes an extrication and MCI?
Firefighters and EMTs/paramedics alike will have some sort of opinion on these issues, or they would not be true 911 responders. Everyone has an opinion, but whose opinion is correct?
1. www.nfpa.org/assets/files/pdf/needsassessment.pdf, pg. 57.
2. Accidental Death and Disability: The Neglected Disease of Modern Society. Division of Medical Sciences, Committee on Trauma and Committee on Shock; Washington, D.C.: National Academy of Sciences-National Research Council. September 1966. View this at http://www.nap.edu/openbook.php?record_id=9978&page=2.
AARON DEAN is a 21-year fire service veteran and a firefighter/paramedic for the Sacramento (CA) Fire Department (SFD). He has a master of science degree in emergency services administration from California State University-Long Beach and received his paramedic training from the Stanford Prehospital Care Program. Dean is the coordinator for the Every 15 Minutes program at SFD, which teaches high school students the consequences of drinking and driving.
MICK MESSOLINE is a 26-year fire service veteran and a firefighter/paramedic and EMS educator with the Sacramento (CA) Fire Department (SFD). He previously served with the Fairmount (CO) Fire Protection District and spent several years with the Denver (CO) Paramedics before joining the SFD. Messoline is also a National Registry of Emergency Medical Technicians paramedic.
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