Where’s the Medic?

By KEVIN JOHNSON

I spent 26 years with a large department outside of Atlanta, Georgia. When I started as a paramedic in 1983, the fire department did it all. EMS was new to the community and was spawned out of a need for prehospital care. In fact, the community was begging for an emergency service that could do it all. Thus, Fire and EMS merged, and the fire department of today was born. The only roadblock to this great concept was that the growing EMS culture was at odds with the heritage and foundation of the fire service’s philosophy and mission. Fire had tradition, and EMS had call volume and heavy demand for a different nature of medical service for the sick and injured.

In 1984, the departments split and polarized management along borders, claiming that EMS missions were different and the demands were high while the fire service enjoyed low volume and high budgets. As the bell rang for community help, the two services combined forces and worked as a well-oiled machine even though their rank structure and true organizational missions varied to some degree. Seventeen years later, in 2001, these two departments merged again and have since attempted to make these two separate entities function as one.

Merging Fire and EMS is often touted as providing a community with the efficiencies of one-stop shopping. Public safety needs a vast array of individuals who can do many things all at once—the jack-of-all-trades, master of none. This evolution in fire rescue services has many reviewing the successes and failures of what some believe is the best model for service delivery. In Fire/EMS mergers, the dilemma of operational readiness can pose unintended consequences. Fire service leaders must exercise situational awareness to ensure that the public’s needs continue to be met. The pros and cons of merged systems remain a topic of conversation at firehouse kitchen tables around the country. Yet, when the alarm sounds, what are the operational dilemmas that need priority consideration?

Let’s consider a scenario for a working residential fire in a crowded neighborhood. For this scenario, I will call our moderately sized department “ABC Fire Rescue” (ABC), which will be operating on “Main Street.” As we review the initial 911 call, we must first examine the department itself. The scrutiny we place on this department is as important as the pending call itself. After all, how any department anticipates handling the real calls takes a high priority in its daily training operations and even one step beyond. Simply talking about independent roles is crucial. If the premerger fire department and local EMS services responded to this emergency call, their roles would be defined by training, by mission, and even by policy.

As smoke billows from the roof, the first fire engine from ABC pulls onto Main Street. This working fire evolves like many others. The officer-in-charge (OIC) eyes the environment as his apparatus nears the address. The radio is keyed up, and the usual size-up begins. “I’ve got a one-story, single-family structure; wood frame; about 1,400 square feet. Moderate smoke showing. Now establishing Main Street Command.”

All incoming units know the plan, and soon their assignments will unfold. The local EMS unit also is responding, but at this point it has no assignment. As command is established, the fire officer jumps off the truck and begins his 360° assessment, but a radio transmission then reports: “Engine 7, be advised that the caller is still trapped inside and just dropped the phone. Consider a valid entrapment.” All units, already at high peak stress, now know that life and death are in the balance; the situation has gone from a working fire to a live rescue. The crew breaches the door; fire rolls out, telling the firefighters that the property and the lives inside may not be salvaged.

The second team in begins a right-hand search around the walls as the primary unit holds off the flames with its attack lines. The members push forward, knowing the likely places a victim might be found. The third team in heads for the bedrooms, as smoke is thick and visibility is minimal. With flashlights on, they feel their way about their path; the crews push open the door to the master bedroom in the C/D corner. Crawling and feeling through the doorway to the room, their hand search reveals their target—a potential victim. Their pulses rise. The sweat inside their masks makes it impossible to see, but the team leader knows what is before him. “Team three, team three. Victim found in the back bedroom. Coming out. Conditions worsening.” Command acknowledges the radio traffic and then informs EMS: “Victim unconscious; vitals unknown. Be ready … coming out through the A side.”

These two separate departments function together, and the local EMS service and its field supervisor know that in moments their part of the job comes to bear. The medics were outside the structure, not wearing fire gear but ready and waiting for their part of the final outcome. Although the firefighters inside took up the challenge and made the grab, the second phase of their victim’s life was still undetermined. Now it was time to apply EMS to the equation.

The firefighters drag a lifeless female victim in a nightgown out of the house into the front yard and into the open arms of the waiting medics. The medics quickly assess the victim and find faint vitals; the grab was just in time. The victim’s unconscious state may in fact have saved her life: Hypoxia caused her to collapse on the floor away from the deadly heat and fumes, pushing her down to the floor for a few last gasps of cooler air before she passed out.

Our victim may or may not have survived in this scenario, and yet the variables will change. Although in ABC’s town they talk of merging Fire and EMS, no decision or plan has been formalized. For today, on Main Street, the two services wear different patches and have different rank structures. They answer the same calls, serve the same public, and love their duties as described by policy.

Tomorrow may yield a different result. The next time the bell goes off for the next house fire on Main Street in ABC’s town, the stars may no longer align as they did the day before. Yesterday, two groups, knowing their jobs and their missions, met to define who lives and who dies. ABC and local EMS arrived and dictated their roles so the medics did not have to go in to fight the fire. The medics instead waited in the yard with their gear spread among them, standing ready for the victim.

Tomorrow, the alarm can go off, and things may be different; two departments could merge overnight and their missions, although proclaimed to be the same as the day before, really are not. For example, the EMS unit, now a vital part of ABC and also en route to a new fire, has a medic and an EMT onboard—the same crew as yesterday, but today they are trained firefighters with a different role.

Now, Medic One is third in behind Engine 7 and Truck 3. Engine 7’s first officer jumps off and conducts his 360° size-up, just as yesterday, to ensure that fire is not showing from the rear. During this time, Medic One’s crew meets Truck 3’s crew at the door, fully dressed out in bunker gear, and assumes the search and rescue position. Everyone enters the house and is now on hands and knees with ax in hand and masks on “breathing air.” Today, they rush in and dash into the bedroom; they all know that victims try to hide in their comfort zones.

Medic One is feeling lucky; today could be the day that it makes a good grab on a victim. Truck 3 breaks left to the side bedroom, and Medic One heads to the master bedroom, feeling through the thick black smoke for any sign of life. They feel the walls, which are hot, and peer through the particles with their flashlight. The shadow by the bed could be a pillow or a fallen citizen. The crew crawls along the wall until they reach a woman’s lifeless body. The radio keys up and transmits the same report as yesterday: The grab is made, and the A side is near. Medic One has defeated the odds and drags the victim to the front yard. Today, in a merged department, however, they are the medics, the EMS unit, the ambulance, the box, or the bus all rolled into one. They had a different job and did it well, without hesitation, because that is what they are trained to do. This merged system does many things. Today, ABC and the EMS unit carried firefighters to the scene to fight fire.

Even if incident command is not acutely aware of the value of EACH piece of equipment, the victim may be brought out to an empty front yard. The two missions of these two groups can be the same, but they MUST be different. With several units on scene, the ambulance can become blocked in because the box will be crowded. The victims may not be able to be driven off the scene, and the two most highly trained individuals present who can still provide lifesaving skills have used up all their energy and effort performing the grab in phase one.

If incident command was not keenly aware of the role of each unit and its crew, this tragedy could easily have taken place in a merged system. Although the emphasis is on training all medical personnel to fight fire, it still cannot overshadow the EMS unit’s job. The crews assigned to the EMS unit must be positioned for egress and be prepared to respond to the needs of potential victims inside the fire building or even a member of Truck 3. If the EMS operators are inside, they cannot be expected to perform fire skills and then come to the street to perform medical skills; you cannot have two primary missions. In the tactical EMS scenario, we face the same situation. Role confusion is potentially deadly for all involved.

One crew cannot be both the truck company and the nozzle team at the same event. A command team cannot also do overhaul. Medics cannot also be firefighters. If you force crews to anticipate both sets of variables [grabbing victims and dragging them to the street and then providing advanced life support (ALS) care], then they will not be able to do either job well.

Merged systems depend on everyone being able to do all things. Although this is widely accepted in this system, fireground members must each have an assignment. The incident commander (IC) must anticipate injuries and have the resources in place to respond to those needs. EMS personnel can make great firefighters, and vice versa. No matter what their role, the crew must be conditioned and trained to perform their specific tasks.

Incident command is crucial and the OIC must anticipate the needs of the event before they happen. Too many times, the first-in EMS unit arrives right behind the engine and dresses out to attack the fire. If you think this approach is acceptable and that you can just call another medic unit to the scene to provide care, just wait until that crew falls through the floor and sounds a Mayday. Pull them free from the fire and look to the street to see the ambulance in tight behind the engine. Key your radio begging for the medics to come to the A side to save a life, only to find them pulling hose around the back.

Planning for victim extrication at a working fire is a high priority. A plan on how and when to use your ALS medical team for firefighting will cost lives if not done right. If your service is merged and fully integrated, it is appropriate to dictate job functions based on apparatus.

If you do not train and then enforce each crew’s roles for a response, then the above situation can occur. It happens all the time, as staffing gets shorter and each person becomes trained in many disciplines. I come from a merged service, and I believe in the ability of these departments to provide multiple layers of service.

Medics can indeed become firefighters, and firefighters most certainly are excellent care providers. On the fireground, it is crucial to have truck placement in the very first minute each unit arrives. All too often, a transport unit is blocked in and the crews are unavailable to respond. The IC—even before that call goes out—must ensure that those units know what is taking place and what their job will be when the Mayday goes out. Don’t expect the team that is dragging out a victim to provide concise medical care. It’s unreasonable to expect the same members carrying out a victim to doff their gear and become the transport crew as well.

Have crews at the ready—EMS included—when the call goes bad. Using up your medical crew to fight fire may give you staffing at the front of the call but could catch you short on the back end when you may need it the most. Role designation is important for a mission’s success. Whether treating a civilian or a crew member, medical care is provided by those in place and ready to do so. Resource allocation is the job of incident command; these officers must be taught the importance of having a medical team on the property and ready to go.

Training for merged systems is crucial in today’s public safety market. As traditional fire services merge with EMS services around the country, it becomes apparent that a mission can explode and become all encompassing. With that in mind, Fire field commanders are usually already at the battalion chief level or higher and may lack years of prehospital medicine as their primary background. For the merged department, setting the stage for how and when medical crews will be used in firefighting is crucial to the outcome.

KEVIN JOHNSON has been a Georgia paramedic and firefighter since 1983. He retired from Dekalb County (GA) Fire Rescue in 2009 after 26 years of service and is chief of EMS in Newton County, Georgia. Johnson has a master’s degree in fire service leadership and is a consultant for EMS, fire, and tactical events.

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