Many of the patients treated by fire service EMTs and paramedics also represent the segments of the population at greatest risk of injury or death from fire.
Just a couple of decades ago, many people questioned the fire service’s role in emergency medical services (EMS). Today, the value of providing advanced prehospital care to improve the survival of victims of traumatic injury and acute health crises, such as cardiac ailments and respiratory distress, is almost universally accepted and acknowledged.
As the stature of fire service EMS has risen and its role has become more secure, an awkward paradox has emerged: Many fire service agencies, burdened with burgeoning demand for their services, now have a questionable commitment to fire prevention.
Recognizing the increasing demand for EMS and the disproportionate toll fire takes among the most vulnerable in society, fire departments should take another look at the services their paramedics, emergency medical technicians (EMTs), and first responders provide. A few fire departments have already recognized the need to proactively manage EMS by promoting injury prevention and providing free health-monitoring services in their communities. These efforts cannot afford to overlook ways EMS providers can contribute to the core mission of the fire service: preventing fire-related deaths and injuries.
The skills and procedures EMS personnel use to help their patients can be applied to promoting fire prevention and fire safety. Even the busiest EMS providers can integrate fire safety activities into their existing routines by recognizing opportunities to help patients prevent fires and take precautions to prevent injury or death if a fire occurs. These efforts can extend beyond the incident to include promoting efforts by other healthcare providers, social welfare agencies, and concerned citizens to prevent fire-related injuries and deaths.
For better or worse, the fire service has become the principal supplier of EMS in most communities. Today, many fire departments find that EMS represents 70 to 80 percent of their emergency response workload. With so many calls flooding into fire department communications centers, many fire service agencies have found themselves forced to prioritize incoming calls and often face a backlog of calls awaiting in-service resources to respond. Even when fire service resources are available, emergency rooms are often so clogged with patients that responders face rotating emergency room blackouts and must transport the ill or injured to distant treatment centers rather than to the closest or preferred provider.
These problems have forced agencies to expand the role of their firefighters and firefighting units to include delivery of first responder services. Many departments now routinely dispatch a firefighting company to every EMS call regardless of severity or availability of EMS resources. Some agencies have expanded firefighters’ roles further, staffing all of their units with cross-trained firefighters qualified as EMTs or paramedics. (A few states have even begun requiring all firefighters to hold EMT or EMS first responder qualifications.) As a result, the role of triage-surveying and segregating cases into groups according to the severity of their conditions as a means of prioritizing treatment-has expanded beyond the scene of mass-casualty incidents to encompass virtually every decision made within the EMS system.
Triage ensures that the cases requiring the most urgent attention get addressed first. In an ideal situation, triage also ensures that every case receives the type and level of attention it deserves by preventing the EMS system from becoming overwhelmed before additional or specialist resources arrive. As specialist skills or additional resources arrive at an incident, first responders step into the background or undertake treatment of less critical cases.
With more and more first responders skilled as firefighters, fire departments should not overlook the opportunity to assess conditions that can affect the future demand for services. Many of the patients treated by fire service EMTs and paramedics also represent the segments of the population at greatest risk of injury or death from fire.
In recent years, public health professionals and epidemiologists have come to recognize fire as a leading cause of traumatic injury and death that disproportionately affects the poor, the infirm, the elderly, and young children. People in these same target groups also request EMS for traumatic injuries and chronic health conditions more often than most other groups in our society.
The National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, has studied the role of fire as a cause of unintentional injury and death. Its findings that fire and burns are among the leading causes of suffering and death among the very young and the elderly come as no surprise to fire safety professionals. What’s worth noting, though, is that health providers represent a significant source of support for getting the message to the people who need it most.
Public health professionals recognize that preventing illness and injury is among the best ways of controlling the public and private costs of providing healthcare. As such, most public health agencies send their practitioners into the homes of people in their target audiences to render services. Like the fire service, though, these professionals’ workloads often leave them with little time to tend to issues beyond the scope of their patients’ immediate needs. Still, many find the time because the benefits are so great.
Fire service EMS providers not directly engaged in patient assessment or treatment should be trained and directed to assess the patient’s environment to identify factors that influence the health, safety, and welfare of the patient and others who may be present. Such procedures routinely accompany other treatment protocols in the forms of searching for patient medications in the case of an unconscious patient, identifying or assessing the mechanism of injury in traumatic injury cases, and identifying ingested agents in poisoning and drug overdose cases.
The primary assessment of patients starts with checking their airway, breathing, and circulation and continues with a detailed physical examination. What fire safety signs should you, as fire service EMTs and first responders, look for when attending patients in their homes? Start by checking conditions and items that could start a fire or become involved in a fire, taking into account how they might come in contact with one another. After these fire hazards are identified, continue the assessment by considering occupants’ capabilities and how they might respond in a fire.
What heat sources can contribute sufficient energy to start a fire? Anything that generates temperatures high enough to produce visible light can start a fire. The glowing ash from a cigar or cigarette, a naked lightbulb, a candle flame, the incandescent element of an electric heater or electric range, and the arc from a defective lamp cord are all potential ignition sources.
During the fire safety assessment, ask yourself, Does someone in the household smoke? How is the home heated? What types of cooking appliances are present? Are enough electrical outlets provided for the appliances present? Are candles, incense, or other naked flames used?
EMS personnel should be aware of the close links between health risks and fire risks. Smoking-a leading cause of lung, throat, and oral cancers; a wide range of respiratory illnesses; and cardiovascular disease-is associated with the cause of nearly a quarter of all fatal residential fires in the United States.
Cooking fires, many involving frying or cooking with oils that contribute to obesity, hypertension, and cardiovascular diseases, are the leading cause of fires in the home. Heating fires often afflict the elderly and others with weakened circulatory or immune systems who rely on portable heaters and electric blankets to supplement inadequate home-heating systems.
Next, consider the things that could be ignited by these heat sources. Furnishings, bedding, loose-fitting clothes, draperies and decorations, foodstuffs, flammable and combustibles liquids, newspapers, and rubbish are among the most common fuels first ignited in dwelling fires.
Consider also factors that influence the ease with which a fire will start, the speed with which it will spread, and the intensity of any fire that results. The quantity, location, and arrangement of fuel sources like those listed above can dramatically affect the speed and severity of a fire. Even when the contents of a room are sparse enough to suggest that a relatively small fire would result from their ignition, the location or proximity of furnishings to one another, to walls, and to windows and doors may influence the nature and extent of the resulting fire. Fires that do not involve the entire room (reach flashover) can still kill.
EMS providers should also recognize that the use of oxygen by patients with advanced respiratory disease increases the fire hazard of clothing, bedding, and furnishings, particularly if the patient still smokes. Don’t laugh. Many victims of fires started by careless use or disposal of smoking materials had already contracted respiratory illnesses; a significant number were using home oxygen systems at the time.
The consumption of alcohol or other drugs, including many prescription medications, can significantly affect fire safety. Any substance that affects motor skills or level of consciousness has the potential to affect the user’s ability to safely use or control heat sources like cigarettes, matches, lighters, candles, and cooking and heating appliances. Alcohol and sedatives may also prevent people from responding in time if a fire occurs.
Some studies suggest that as many as half the adults who die in fires started by the careless use or handling of smoking materials were under the influence of alcohol. A University of North Carolina, Chapel Hill, study suggested that the consumption of alcohol was the leading risk factor influencing the likelihood of a fire resulting in injury or death regardless of cause and may be a factor in as many as 40 percent of all fire fatalities.1 Interestingly, not all of the victims of such fires were intoxicated, let alone habitual alcoholics. Alcohol has the effect of stimulating the rapid onset of deep sleep, making those who consume even moderate quantities more difficult to wake. These delays can prevent escape even when the victim does wake up.
Housekeeping provides a good indication of how fire-safe a home is. A dirty or disorderly home may provide more opportunities for heat and fuel sources to come in contact with one another. Household clutter, accumulations of rubbish, and the disposal of debris from fireplaces and solid-fuel appliances in cardboard boxes or paper bags may result in a serious fire even when the home otherwise appears tidy.
The home’s condition or arrangement may also suggest the influence of the residents’ conditions on their activities and their ability to protect themselves should a fire start. Households with disabled or elderly residents may use rooms for purposes other than those for which they were originally intended. This is particularly true in homes with more than one floor level, where residents with mobility impairments avoid the use of stairs. In some cases, a resident may rearrange the home to permit all of his normal activities to occur in one or two rooms with minimal movement.
Newborns and infants will often sleep in the same room and even the same bed as their parents. Other children may sleep alone or together in bedrooms near their parents. Older children and other relatives may sleep in rooms constructed in the basement or attic. All of these arrangements involve special considerations.
Young children, particularly in homes where the parents smoke, may have access to matches or lighters. Most children will exhibit curiosity about fire between the ages of three and eight. Often, they will experiment with fire when parents are asleep or otherwise occupied about the house. Always take signs of inappropriate fireplay or firesetting seriously. Many fire service agencies now employ trained specialists who conduct intervention programs designed to help families address this serious problem appropriately and constructively.
Adults and children respond differently to fire. Still, adults and children both underestimate fire dangers such as the likelihood of a fire’s starting, the speed with which fire spreads, and the effect of smoke and heat on their senses. To a large extent, this is because adults are familiar with controlled forms of fire as a source of heat, light, and convenience. Children often lack a sophisticated appreciation of fire’s danger because they lack experience with it and have little understanding of the physical world. This is often exhibited by an inability to clearly distinguish between what’s real and what they imagine. Adults often overestimate their ability to manage fire or the amount of time available to respond when a fire occurs. Children frequently believe that things they cannot see will not hurt them. As a consequence, they may hide when confronted with a fire instead of fleeing or alerting grown-ups.
In the field, patient care usually involves managing symptoms and stabilizing the situation rather than remedying the underlying cause of injury or illness. The frustration of seeing the same simple things result in needless pain and suffering over and over has moved many EMS agencies to become more active in injury prevention and health monitoring to help reduce the demand for emergency intervention. The same motivation and approach should apply to home fire hazards.
Although smoke alarms will not prevent fires, their low cost and ease of installation make them the first line of defense when a fire occurs. Smoke alarms can be purchased for less than $10 and installed in less than 10 minutes. Reliable estimates from a number of sources indicate that about 90 percent of American homes already have at least one smoke alarm.
For those cases where responders find a home without a smoke alarm or discover that the smoke alarms are not working, every fire department should carry a half dozen or so smoke alarms and replacement batteries on every firefighting and EMS vehicle for free distribution to the public. To make installation even easier, affix a few square inches of some heavy-duty, adhesive-backed, self-closing strips or other hook-and-loop fastener fabric to the back of each device. A good old-fashioned toilet plunger makes an ideal installation tool. If your agency can’t find a local sponsor to pay for a cache of smoke alarms, city officials should make the investment; distribute a postage-paid collection envelope with each one. You will be surprised at how many people will make a small donation to help defray the cost.
Those households without smoke alarms are also those at the highest risk of experiencing a fire; these fires are more likely to result in injury or death. No one can dispute the value of installing smoke alarms in the home, but their value should not be overestimated. With increases in the number of households protected by smoke alarms, the number of people dying in house fires has fallen steadily, but the number of people dying in fires in homes with smoke alarms has risen steadily, too.
Because smoke alarms are so inexpensive and easy to fit, the value of fire prevention is often overlooked today. Many homeowners are simply unaware of the hazards in their homes that are likely to cause them harm.
In most cases, identifying home fire hazards and helping people eliminate them take only a few seconds. Something simple like moving a space heater and leaving a brochure on home heating hazards can save a life just as surely as administering the Heimlich maneuver in time.
In addition to a supply of smoke alarms, carry brochures or pamphlets describing home fire safety hazards and how to correct them on all fire service and EMS vehicles. They should address the most common situations found in the home.
If the situation during an EMS incident does not facilitate on-the-spot fire safety intervention, fire or EMS providers should consider returning to the scene after completing the call to take corrective action. In extraordinary circumstances, fire safety officers or fire inspectors should be asked to follow up as well.
(Note: Unlike actions taken while in attendance at an emergency, returning to the scene to inspect fire safety deficiencies often requires the consent of the property owner or occupant in control of the premises. If your actions could result in application of legal remedies, such as issuing notices to secure compliance with building and fire codes or a summons to appear in court, you should obtain the owner or occupant’s permission or a search warrant to inspect the premises.)
Where responsibility for correcting a hazard rests with the landlord, make tenants aware of the risk even if they are not responsible for correcting it. Follow up with efforts to identify and contact the owner about the conditions observed. In most cases, fire safety or fire prevention officers or the local building official should handle this.
REMOVAL AND TRANSPORT
The most seriously ill and injured patients attended by EMS will require transport to hospitals or trauma centers, where physicians and other medical specialists can provide advanced treatment. Likewise, fire hazards that cannot be removed or remedied immediately may require the attention of fire safety specialists. In extreme circumstances, it may be necessary to remove occupants from a building until the fire hazard has been corrected.
At each call firefighters, first responders, and EMTs attend, they should look for fire hazards and unsafe conditions that require immediate action to prevent loss of life. These conditions include the following:
- an inadequate number of exits;
- locked or blocked exits, including windows fitted with security bars, grilles, or shutters;
- indoor storage of dangerous goods or hazardous materials, except in small quantities in approved containers stored away from heat sources2;
- use of gasoline or other low flash point liquids indoors for cleaning or repairs;
- indoor use of LPG for heating or cooking;
- use of defective or unvented heating appliances (other than approved kerosene heaters);
- inappropriate use of cooking appliances as a heat source;
- use of torches or open flames to remove paint from combustible surfaces;
- frayed or broken electrical cords, makeshift electrical wiring, and electrical fixtures installed too close to combustible finishes, decorations, and furnishings; and
- disposal of fireplace debris or smoking materials with other combustibles or in combustible rubbish containers, particularly if the containers are located indoors.
The mere existence of one of these conditions may not warrant evacuating the premises until the problem is corrected, but take action to remedy the situation without delay.
If a fire hazard observed at an EMS incident would almost certainly result in a loss of life if left uncorrected, EMS providers should call for a fire safety specialist and consider evacuating residents from the premises. Staff from other local government agencies, such as the building department, community housing, or power authority, may also have an interest in remedying such conditions. Fire service staff should seek assistance from officials of these agencies when appropriate.
Fire service agencies should develop close contacts and protocols for working with social welfare agencies and organizations in their communities to ensure that people displaced from their homes because of fire hazards receive emergency assistance comparable to that available to those victimized when a fire occurs.
A CONTINUUM OF CARE
Despite the doubts of skeptics, the fire service has become an important part of the continuum of care assisting critically injured and ill patients. The role of fire service EMS providers has expanded in recent years as injury prevention programs have started to emerge as a way to manage demand for EMS. Today, fire service EMS stands prepared to play an important role in managing the fire threat as well.
By recognizing ways to leverage their access to target audiences who experience increased risks for fires, fire service EMS providers can lessen the burden of fire on themselves and their communities. Building partnerships with public health agencies and other organizations concerned with the health and welfare of these segments of our communities can ensure that we do not work alone in this enterprise.
Many public health agencies already recognize the devastating effects of fire and actively promote fire prevention and fire safety. In some communities, public health nurses deliver, install, and test smoke alarms during perinatal visits, to prevent infant mortality in fires. Some check tap water temperatures and water heat settings to prevent scalds. Others provide fire safety advice to users of home oxygen systems. Is your community one of these?
With outpatient surgery and managed care becoming more common, similar programs could be set up with private healthcare providers. Today, many hospitals distribute smoke alarms to new mothers and other patients convalescing at home. Training home health nurses to assess the patient’s fire safety situation during their visits can ensure that smoke alarms are working; more importantly, they ensure that hazards that could start a fire or prevent someone from escaping are identified and eliminated.
Opportunities to improve fire safety and awareness of home fire hazards among vulnerable communities abound. How many fire service agencies work with the local Meals on Wheels program to reduce the incidence of cooking fires among the elderly or infirm? How about joint efforts to promote local utility company programs aimed at subsidizing home heating costs for the elderly, ill, and poor, to reduce reliance on portable heaters, electric blankets, and other makeshift arrangements like leaving the oven or stove on? Such programs already exist in many communities, and many already enjoy the support and encouragement of the local fire department.
Many businesses will get involved, too, if you only ask them. Those businesses that cater to our target groups in the community have a vested interest in promoting fire safety to their customers. Pharmacists, supermarket and convenience store clerks, newspaper carriers, bankers, and others can all be recruited to assist the cause by inquiring about the fire safety of their customers and providing fire service-supplied written advice about how to manage home fire hazards.
If your fire department has a Web site, consider adding a link to the CDC’s SafeUSA fire safety page on the Internet at http://www. cdc.gov/safeusa/fire/firesafe.htm. It provides excellent tips on fire safety and is part of a larger on-line safety resource containing information about other injury prevention topics. The CDC also operates a toll-free safety hotline at 1 (888) 252-7751 to answer fire safety and other injury prevention questions 24 hours a day.
The added value to the fire service for assuming responsibility for delivering EMS is proven every day. Expanding the continuum of care by looking beyond the current role of first responders, EMTs, and paramedics will extend that value even further. Engaging fire service EMS providers in efforts to prevent fires, manage home fire hazards, and promote community outreach is just one more way we can help reduce pain and suffering by keeping our community residents healthy and safe.
- Marshall, S.W, C.W. Runyan, et al., “Fatal Residential Fire: Who Dies and Who Survives?” Journal of the American Medical Association, 279 (20), May 1998, 1633-1637.
- Such materials include smokeless or black powder, fireworks, pool chemicals, muriatic acid, pesticides, certain fertilizers, LPG and other fuel gases, gasoline, mineral spirits, lacquer thinner, acetone and similar solvents, and solvent-based coatings in quantities greater than that required for normal household maintenance or use.
MARK CHUBB is the assistant fire region commander (fire safety) for the New Zealand Fire Service, Transalpine Fire Region, headquartered in Christchurch. He is a postgraduate student in public policy at Victoria University of Wellington (NZ) and has a bachelor of science degree in fire science and urban studies from the University of Maryland. Chubb is a member of the Institution of Fire Engineers and a certified building official. He has served on the Fire Engineering editorial advisory board since 1996.