# Serious Question: Why Does Fire-based EMS sometimes produce such low results?



## RocketMedic (Oct 20, 2017)

*Disclaimer: This isn't a slight against firefighters, and it's not necessarily targeting the high-functioning fire departments out there that do the right things, or even the fire-medics that actually do their jobs the right way. 
*Disclaimer 2: I'm not a firefighter, not particularly interested in being a firefighter.

So we hear a constant stream of anecdotes from across the nation, mostly from larger cities with big fire-based EMS systems, and there's a pretty common thread- systems operating at the limits of their operational capacity constantly, long shifts, provider and patient abuse, and terrible medical practice. So, why is this happening?


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## VentMonkey (Oct 20, 2017)

Because John Q. Public is still reeling over September 11th, and what many fire departments seem to continuously do is bank on this fact.

I too, am no firefighter and have no interest in it. I agree there are certainly departments that actually take things seriously when it comes to what they do most- provide medical aids. I have seen and learned from some well-to-do dual roles, but they’re far outnumbered and conformity seems a whole lot easier than greasing the ol’ firehouse wheel. 

What the general public will never understand is the “behind the scenes” politics, and quite frankly ugliness that goes into budget allocations at this level. When you’re willing to do whatever it costs to justify your existence—to include pretending to want to expand into the realm of prehospital care—but have no real intentions of making good on your efforts, your citizens will suffer. What makes it sad, and highly unfortunate is that, like many glossed over facades, the taxpayers cannot (will not?) see past the fluff. 

The flipside, however, could include the fact that, like any large urban system, their resources are taxed; single or dual-role, yet another example of how fractured healthcare in the U.S. is.


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## DesertMedic66 (Oct 20, 2017)

I can only speak for my area but 100% of the daily training they do is based on fire and rescue training. The only time they cover EMS is when they are forced to take a BLS CPR, ACLS, and yearly mandatory meetings by the EMS system. 

We were a training center for the fire department however when we found out they were allowing their medics to recertify in BLS CPR, ACLS, and PALS in one 8 hour day, we quickly stopped being the training center for them.


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## EpiEMS (Oct 20, 2017)

RocketMedic said:


> So, why is this happening?



@VentMonkey hit it on the head - #1 is because fire departments are politically untouchable...most of what they do is EMS response, but we can't rebalance resources to EMS because, you know, who wants to be the politician taking away money from firefighters?

#2 - they, by and large, don't want to do EMS. Not wanting to do EMS means not doing it well.


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## akflightmedic (Oct 20, 2017)

Having worked in several counties which underwent mergers and speaking from a FL perspective....there is also the fact that being a Paramedic is nothing more than a promotion. The majority of FFs here become paramedics to get the $7500 salary bump, have points for promotion, and do their time on the box and transfer to an engine as quickly as possible thereby preventing themselves from having to do all the EMS stuff and get to have all fun by responding in an engine, few cool skills and then hand off to transport medic.

There is Medic saturation in Florida, but that is mostly due to the IAFF selling a bill of goods to the public and the ignorant public thinking 2-8 paramedics on every call is better than 1-2.


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## akflightmedic (Oct 20, 2017)

Statistically there was a title change many years ago....however, I long for the days when we make it official and say.....

No, I do not work for a Fire Based EMS system....I actually work for an EMS based Fire Dept.


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## TXmed (Oct 20, 2017)

Youre either a half *** firefighter or a half *** paramedic the way i see it.


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## VentMonkey (Oct 20, 2017)

TXmed said:


> Youre either a half *** firefighter or a half *** paramedic the way i see it.


What if you’re a half *** paramedic who wants to be a half *** nurse, or half *** pilot for half of their half *** pay?


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## TomB (Oct 20, 2017)

RocketMedic said:


> *Disclaimer: This isn't a slight against firefighters, and it's not necessarily targeting the high-functioning fire departments out there that do the right things, or even the fire-medics that actually do their jobs the right way.
> *Disclaimer 2: I'm not a firefighter, not particularly interested in being a firefighter.
> 
> So we hear a constant stream of anecdotes from across the nation, mostly from larger cities with big fire-based EMS systems, and there's a pretty common thread- systems operating at the limits of their operational capacity constantly, long shifts, provider and patient abuse, and terrible medical practice. So, why is this happening?



Maybe this could be moved to the EMS Lounge or Children With Nothing Better To Do forum.


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## DesertMedic66 (Oct 20, 2017)

TomB said:


> Maybe this could be moved to the EMS Lounge or Children With Nothing Better To Do forum.


I think it is a completely valid question to ask and get differing view points.


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## RocketMedic (Oct 20, 2017)

TomB said:


> Maybe this could be moved to the EMS Lounge or Children With Nothing Better To Do forum.



I see someone didmt get his nap and snack...


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## VentMonkey (Oct 20, 2017)

My own snark aside, I agree that it’s a valid question. @TomB perhaps you can enlighten us? Most of your posts are articulate, informative, and carry weight on this forum. To me this proves you’re a good fit for a debater on the other side of this fence.

I have to openly admit that the fire-based culture in my state (no idea what The Carolinas do) is chocked full of such buzzwords and catchphrases as “tradition”, “the bravest”, and “brotherhood”. They seem to be spoon fed to the public so much so that at least, here, the fire-based EMS systems can do no wrong. The fact is, many of them are doing wrong, very wrong.

Again, are there articulate, well-honed firefighter/ paramedics among them? Absolutely, but these types where I am are often drowned out by cultures that lower the standards for EMS-driven fire culture, and not the opposite.

And before this thread is chocked full of pot shots (yeah, yeah, me too), I realize how many lowly, burnt out, non-con-ed-driven single roles there are. That is why this forum offers myself, and others like me—and you—reprieve.


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## NPO (Oct 20, 2017)

My paramedic textbook specifically cited Johnny and Roy as a major contributing factor to why modern EMS is often run by the FD and why the public is okay with it. 

My belief is that the FD-EMS problem is multi-tiered. Most often, I think it's a budget problem. FDs adopt EMS as a revenue stream, and a way to justify larger budgets, both for self-preservation and for growth of the dept. Larger depts yield more weight for local and regional issues and elections. 

The same depts also have a habit of forcing their firefighters to become paramedics and/or require shifts on an ambulance. Anytime you force someone to do something, they won't do it as well as if it was voluntary. I personally would make a very half-assed firefighter; it's not where my passion lies.

I'll close with the same thing the OP said, this is not exclusive to all FDs and FFs.


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## DrParasite (Oct 20, 2017)

hmmmm, where to start.... how about in most combined fire/EMS systems, EMS takes up 80% of the call volume, yet gets 20% of the budget?

Or if you have a civilian medic in the FD, the civilian medic who might need a year or two of education to get certified as a medic, will make nowhere near what the zero to hero FD makes on the engine, when the FF went through a maybe 6 month academy before being put on the engine?

many years ago I worked part time as a part time EMT for a FD that had an ambulance.  every month, one full time member of the FD (who were all EMTs and one or two were few paramedics) was taken off the engine and assigned to the ambulance, and paired up with a part timer.  They were paid twice as much as every part timer, had great benefits, didn't take a paycut when they were on the ambulance, and were absolutely miserable.  When they took vacation time, they always did it during their EMS month.  They wanted to be firefighters.  And when the opportunity presented itself for them to outsource the ambulance, they jumped on it.

Lets talk about staffing..... in general terms, most urban EMS systems are understaffed.  All things being equal, most 100% career FDs are pretty well staffed.  They rarely have all their units on calls, and while sometimes they do run, most do get some down time during a shift.  For rough numbers, any given area should have as many BLS units as engines, and ALS units as ladders.  With those numbers, you wouldn't need to send all the suppression units on EMS calls, which consists of 80% of their call volume.

Let talk about budgets.... Fire departments are, historically, a black hole for money.   millions of taxpayer dollars are spent, and they will never turn a profit.  EMS, however is expected to make money.  they bill for everything.  so the budget of EMS get cut when they don't generate enough revenue.  we won't put another ambulance on, if it won't be profitable.  and a fire engine is seen as an insurance policy; it's there in case it's needed.  an ambulance is only worth having if it's goin on a call and making money.

There are some great firefighter/paramedics.  more often than not, they started as paramedics, worked as ambulance paramedics for several years, before getting hired by the fire department.  some even continue to work part time as ambulance paramedics.  most firefighter paramedics that I know are firefighters who got their paramedic for reasons other than to be good healthcare providers on the ambulance.   they are firefighters who do just enough con ed to maintain their medic cert; and they want to be on the suppression units saving lives, not being on the ambulance.

if you force someone to be something they really don't want to do, if you treat them poorly compared to their suppression counterparts, if you don't give them the resources or direction to do the job right, and if you have accepted substandard and half-assed providers for so long, does it really surprise you that you get low results?


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## StCEMT (Oct 20, 2017)

I don't necessarily have a problem with fire based EMS under one circumstance. There are FD's that run both and keep them separate. STLFD is an example of that. If I could work for a FD, get that FD money, and basically never touch a firetruck I absolutely would. Those are not the norm, but they exist and in that case I don't see an issue with it.


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## VentMonkey (Oct 20, 2017)

StCEMT said:


> I don't necessarily have a problem with fire based EMS under one circumstance. There are FD's that run both and keep them separate. STLFD is an example of that. If I could work for a FD, get that FD money, and basically never touch a firetruck I absolutely would. Those are not the norm, but they exist and in that case I don't see an issue with it.


Right, but back to Rocket’s question- Does this mean that they’re producing desirable results, or are overall efficient? I truly don’t know. I have never been part of a fired-based EMS system like STL, of FDNY, or Philadelphia Fire, etc. 

Are their EMS divisions truly focused on doing the best with what they have, and are their cadres, and medical director(s) clinically, and EBM-driven? 

Are they spearheading trials, and do they remain sought after by single-roles throughout the country for their reputations as systems on the whole, versus, the benefits? IIRC, there’s a pretty well-respected EMS third service in the state capital of Texas which is slowly rebuilding its reputation as a solid EMS-only system after some tumultuous times.

Will they provide an actual career-ladder for EMS-only driven folks who truly want to only do EMS their entire career from their 20’s well into their 50’s?

Let us also not forget the paramedics who got their paramedic just to get on with a department, and see themselves as “stuck” at an ambulance service until their time comes. And even worse, what if it doesn’t? What kind of cop, nurse, etc. will they make?


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## CALEMT (Oct 20, 2017)

In regards to a post on here you get halfassed people regardless where you are in a career. Fire, EMS, LEO, nursing, accountants, etc... Does the majority of FFPM's get their p-card just for a job? Yeah, nobody is going to ******** that EVERY FFPM is Jesus with a stethoscope saving the world one cardiac arrest at a time. But then again not every private EMS paramedic is a excellent provider either. The wheel turns both ways. 

I don't necessarily believe that John Q taxpayer is still reaming over the events on 9/11. I think its more PR than anything. I mean think about it, the FD has fill the boot, regularly holds community events, and shows up at community events. The PD/SO has coffee with a cop, shop with a cop, and will also hold community events. Now what does AMR or any other private EMS agency have for PR? A Facebook account where most of it's followers are it's own employees. EMS has little to no community PR and thats where it fails. Just think if private EMS did the PR that a FD or PD/SO did, I personally think there would be more public push for private EMS. But then again private EMS is just that... private, not a government agency. So in theory private EMS will pay less, have worse benefits, and have a worse retirement than any government agency. 

Do I think the FD should completely do away with anything EMS related? Personally no. I must be one of the few who loves the fire suppression side and has a passion for expanding my knowledge in regards to EMS. Are you going to hire every FFPM who strives to be the best paramedic and the best firefighter? No, ain't gonna happen, but you do get those who do have a passion for both aspects of the job. So why are there crappy providers at every FD in the nation? Same reason theres crappy providers at private EMS companies and crappy cops, nurses, accountants, etc.


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## VentMonkey (Oct 20, 2017)

CALEMT said:


> I don't necessarily believe that John Q taxpayer is still reaming over the events on 9/11. I think its more PR than anything.


Um, but like what’s on TV every September 11th since 2001 and stuff?


CALEMT said:


> So why are there crappy providers at every FD in the nation? Same reason theres crappy providers at private EMS companies and crappy cops, nurses, accountants, etc.


...because all they wanted to do was put out a goddamn fire?

Sorry, I couldn’t resist, CAL.


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## Tigger (Oct 21, 2017)

VentMonkey said:


> Are their EMS divisions truly focused on doing the best with what they have, and are their cadres, and medical director(s) clinically, and EBM-driven?
> 
> Are they spearheading trials, and do they remain sought after by single-roles throughout the country for their reputations as systems on the whole, versus, the benefits? IIRC, there’s a pretty well-respected EMS third service in the state capital of Texas which is slowly rebuilding its reputation as a solid EMS-only system after some tumultuous times.
> 
> Will they provide an actual career-ladder for EMS-only driven folks who truly want to only do EMS their entire career from their 20’s well into their 50’s?


Colorado Springs Fire has all the things you talk about. The med division is larger than the fire training division. The medical director is top notch. They have EMS educators who want to be on the cutting edge. There are tons of in service training opportunities. They run "studies." Yet the average level of care provided is well, average. There is a disconnect between the line and the office. There are plenty of guys who want to be good at EMS, but few that want to focus. That just isn't why most of them joined fire, and it shows.


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## jayrutjr (Oct 21, 2017)

I work for a Fire service that requires you to get your paramedic to keep your job. You have three years to do so, if you don't bye bye! So that means you do have some patch medics but I can honestly say we do have people that are great fire medics. our dept has a combat side and a rescue side .  I knew going in that I wanted to spend some time on the box. So I took the promotion, after all we run mostly medical calls. Fire calls are few and when we respond to fires it's such a heavy response you barely get to fight the dragon! Just like someone stated earlier your going to have half *** in any situation.


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## RocketMedic (Oct 21, 2017)

So when I think of good Fire departments, I think of systems like Harris County's ESD-48....but for every ESD, there's a Houston Fire that sets the bar really low.


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## VentMonkey (Oct 21, 2017)

@Tigger that sounds unlike most FD’s I know of in terms of the efforts put towards their EMS division. To have all of that at your disposal (even my own service isn’t that lucky), and still fall short of what I would imagine is put into the medical aspects is unfortunate.

I’m not knocking individuals as firefighter/ paramedics, I’m simply saying on average the culture within most of the departments certainly seems to overshadow the paramedics that do fancy themselves “medics first”. I really don’t know what the big deal is about realizing that the overall sum does not reflect the ability of individual parts to be able to provide good ALS care.

It seems more of a blow to their pysche perhaps, but even given all of the proper training, funding, and tools- to still have an “I’d still rather fight fires” sort of attitude, clearly the big picture is being missed.

I think if they focused on being the best MFR/ EMT they could be enthusiastically so much so that they realize what exactly ALS care _doesn’t_ do we would all be better off, and I don’t mean that as a knock. There aren’t many EMS-only agencies that fight fires, or train their paramedics to fight fires “just in case”, but why is it ok to have 5 or more (arguably inactive) paramedics on a call...”just in case”?


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## PotatoMedic (Oct 22, 2017)

I saw something on the "send paramedics" Facebook page linking to a report that firefighters have a faster dispatch to enroute time to dumpster fires faster than cardiac arrests.  I'm trying to find it again but I know I saw it.


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## EpiEMS (Oct 22, 2017)

FireWA1 said:


> I saw something on the "send paramedics" Facebook page linking to a report that firefighters have a faster dispatch to enroute time to dumpster fires faster than cardiac arrests.


It seems likely for FDNY...


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## FiremanMike (Oct 24, 2017)

I think we're glossing over the fact that there are terrible providers in third service and private systems just as there are in fire based systems.  Conversely, there are also rock stars in each of these environments.

Under-performing EMS "professionals" exist, and not just on the fire department.


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## VentMonkey (Oct 24, 2017)

FiremanMike said:


> I think we're glossing over the fact that there are terrible providers in third service and private systems just as there are in fire based systems.  Conversely, there are also rock stars in each of these environments.
> 
> Under-performing EMS "professionals" exist, and not just on the fire department.


Hardly glossing. I openly admitted this fact in one of my other posts. Also, who’s to say (statistically) how many of those providers are, or aren’t jaded would (never) be firefighters?

On the whole, regardless of their professionalism, how many boots they raise, blood pressures they check, CPR’s they train, or public services they provide—fire-based EMS does not operate, nor function nearly the same as a single paramedic unit trained to provide ALS care sans fire prevention education, and training.

That is a fact that I feel is glossed over by many-a-fire departments to the general public in their respective districts.


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## EpiEMS (Oct 24, 2017)

VentMonkey said:


> fire-based EMS does not operate, nor function nearly the same as a single paramedic unit trained to provide ALS care sans fire prevention education, and training.



And costs a *lot* more, I'd wager, especially if you're running million dollar ladder trucks to BLS calls.


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## FiremanMike (Oct 24, 2017)

VentMonkey said:


> Hardly glossing. I openly admitted this fact in one of my other posts. Also, who’s to say (statistically) how many of those providers are, or aren’t jaded would (never) be firefighters?
> 
> On the whole, regardless of their professionalism, how many boots they raise, blood pressures they check, CPR’s they train, or public services they provide—fire-based EMS does not operate, nor function nearly the same as a single paramedic unit trained to provide ALS care sans fire prevention education, and training.
> 
> That is a fact that I feel is glossed over by many-a-fire departments to the general public in their respective districts.



I did miss your concession of under-performers in all agencies, my apologies.

As for the rest of your post, with due respect, I think your statement of fact is more of an opinion, difficult if not impossible to actually quantify, and probably regional.  In this area, the relatively few number of single role EMS agencies are subjectively at an equal level of competence when compared to fire based systems.  Additionally, I would say that the fire based systems are slightly better equipped than the single-role EMS agencies.


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## FiremanMike (Oct 24, 2017)

EpiEMS said:


> And costs a *lot* more, I'd wager, especially if you're running million dollar ladder trucks to BLS calls.



**my answer is regional and based on my area

That million dollar ladder truck is probably going to be sitting there whether they're taking first responder runs or not, and those ladder guys are getting paid their hourly rate whether they're on the EMS run or not.  I'd wager a guess that the cost of fuel to drive that truck within it's little 5 square mile bubble to take the first responder run for the medic probably isn't that much after all.


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## EpiEMS (Oct 24, 2017)

@FiremanMike

You're right - the marginal cost of driving and staffing that ladder truck is probably pretty low*.

*But when you dispatch 4 FF/EMTs and an officer to a medical call, they can't respond to a fire call...so you have to have *more* fire apparatus around to cover the slack. And, let's go back to why we even bothered acquiring a ladder truck in the first place. What was the cost of the truck (over its life) per life-year saved? $100,000? $50,000? $25,000? Why do we have so many fire companies when we have so few fires? What if we could cut back fire staffing by a couple FTEs and upstaff EMS?


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## VentMonkey (Oct 24, 2017)

FiremanMike said:


> As for the rest of your post, with due respect, I think your statement of fact is more of an opinion, difficult if not impossible to actually quantify, and probably regional.


Fair enough, and points well taken, but myself and others in this thread are from regions all across the country, yet we seem to cite similar experiences with regard to the thread topic. So, why such a commonality?


FiremanMike said:


> Additionally, I would say that the fire based systems are slightly better equipped than the single-role EMS agencies.


Define “better equipped”, and please explain exactly how this translates into higher-than-average results versus the non-fire-based EMS agencies?


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## FiremanMike (Oct 24, 2017)

EpiEMS said:


> @FiremanMike
> 
> You're right - the marginal cost of driving and staffing that ladder truck is probably pretty low*.
> 
> *But when you dispatch 4 FF/EMTs and an officer to a medical call, they can't respond to a fire call...so you have to have *more* fire apparatus around to cover the slack. And, let's go back to why we even bothered acquiring a ladder truck in the first place. What was the cost of the truck (over its life) per life-year saved? $100,000? $50,000? $25,000? Why do we have so many fire companies when we have so few fires? What if we could cut back fire staffing by a couple FTEs and upstaff EMS?



So, this is where my own regional experiences come in to play.  Every firehouse here has an ALS Ambulance usually with two paramedics.  Several firehouses actually have 2 ALS ambulances.  For the most part, they put fire companies in positions so that they can get to locations within their individual run districts in a timely fashion so as to prevent significant fire spread.  I can't think of a fire company in the last 20 years that was put in around here who's primary purpose is to provide ALS first responder capabilities.

*ETA, I did think of one local scenario where an ALS ambulance was removed from a firehouse to move it to a different part of the district, leaving a fire truck alone in that station to take fire runs as well as EMS first responder runs.  Ironically, it's a ladder truck, lol


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## FiremanMike (Oct 24, 2017)

VentMonkey said:


> Fair enough, and points well taken, but myself and others in this thread are from regions all across the country, yet we seem to cite similar experiences with regard to the thread topic. So, why such a commonality?



<shrug> maybe I really am blessed to work in an area where fire based medics, on the whole, are doing a good job.  I truly say that with no sarcasm intended.



> Define “better equipped”, and please explain exactly how this translates into higher-than-average results versus the non-fire-based EMS agencies?



It wasn't my assertion at all that better equipped equals higher than average results, and my statement about equipment was more of a response to some earlier statements that EMS received less funding than fire in fire based systems.  I'm also not trying to imply that our local single-role brothers are poorly equipped, by the way.

The two most recent examples that come to mind that would qualify the statement "better equipped" would be power-load cots and powered stair chairs, which found their home in some of the fire-based trucks around here before making their way to the single role trucks (although I'm still not sure they have them?)


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## gonefishing (Oct 24, 2017)

Different strokes for different folks.  I've seen some horrendous care by fire medics and crews over the years and majority of those just do it for the pay or because gaining a P card was an entry to getting hired to ride big red in the first place and could honestly care less for running medical aids.  I have also seen a minor majority that take pride in the craft of emergency medicine and are some outstanding providers but that's few and far in my experiences.   Nothing like a fire captain chewing out your nurse wife for calling 911 on somebody having a possible drug fueld psychotic episode.  I guess per that captain psychiatric emergencys are for cops not medical.  I've seen some outstanding private services and providers though and would place my life or my familys lives in place of them over any fire provider.  Just my oppinion and experiences though.


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## FiremanMike (Oct 24, 2017)

C'mon now, if we really wanted to start swapping stories, I think everyone's service model would be embarrassed by the tales.


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## gonefishing (Oct 24, 2017)

FiremanMike said:


> C'mon now, if we really wanted to start swapping stories, I think everyone's service model would be embarrassed by the tales.


True, reason why I said different strokes for different folks.  Everyones got bad apples in the bunch.


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## VentMonkey (Oct 24, 2017)

Bullsh*t aside, medicine, I’m talking medicine. Because there really is a big difference in how the fire-based delivery model does things vs. what I personally would mostly not do/ practice.

Think _Jems_ vs. pretty much any well-respected EBM journal...


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## GMCmedic (Oct 24, 2017)

EpiEMS said:


> @FiremanMike
> 
> You're right - the marginal cost of driving and staffing that ladder truck is probably pretty low*.
> 
> *But when you dispatch 4 FF/EMTs and an officer to a medical call, they can't respond to a fire call...so you have to have *more* fire apparatus around to cover the slack. And, let's go back to why we even bothered acquiring a ladder truck in the first place. What was the cost of the truck (over its life) per life-year saved? $100,000? $50,000? $25,000? Why do we have so many fire companies when we have so few fires? What if we could cut back fire staffing by a couple FTEs and upstaff EMS?


ISO ratings. It all comes down to the cost of homeowner insurance in the response district.


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## FiremanMike (Oct 24, 2017)

I guess I’m curious what you mean by “how Fire based delivery model does things”?


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## VentMonkey (Oct 24, 2017)

FiremanMike said:


> I guess I’m curious what you mean by “how Fire based delivery model does things”?


Well to be frank- it’s watered down. Everyone blindly getting high-flow O2, IV’s when not warranted, no IV’s when they most likely would be. I could go on and on, but it’s fruitless.

I’ve sat in on con-ed with plenty of fire departments, and the way things are explained to many of them aren’t what I’ve come to find as exactly forward-thinking; let’s just say it leaves a lot to be desired. 

Is it my mind, and opinion? Sure, but I highly doubt I am alone. But! To be fair, I roll pretty solo even at my service with what I consider prudent, forward-thinking practices. 

I think that most fire departments willing know (at the “brass” level) that when you’re teaching a group of individuals who are taught to fight a “dragon” you don’t exactly to need to go as in-depth on many of the topics that the paramedic-only-paramedics see daily. 

So, again why do you need 5, or more, paramedics on a single medical aid?


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## TXmed (Oct 24, 2017)

@FireWA1 

"In 2001, using stopwatches, city officials found that Washington firefighters don’t respond as quickly to medical calls as they should. Their finding prompted the city to buy global positioning equipment so officials could track the movement of rescue vehicles.

USA TODAY reviewed more than 85,000 emergency calls to examine those delays more closely. The analysis of turnout time — the time it takes for firefighters to run to their rig and roll out the door toward an emergency — shows that Washington firefighters’ median response time was faster to a dumpster fire than to a report of a cardiac arrest.

The fire crew responding to a report of a structure fire got rolling in 82 seconds, despite having to don protective boots, pants, coats and breathing apparatus. In response to a report of a cardiac arrest, which requires no special preparation, the crew took 124 seconds to reach the rig."

http://elevaed.com/archives/4585


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## NPO (Oct 24, 2017)

TXmed said:


> @FireWA1
> 
> "In 2001, using stopwatches, city officials found that Washington firefighters don’t respond as quickly to medical calls as they should. Their finding prompted the city to buy global positioning equipment so officials could track the movement of rescue vehicles.
> 
> ...


There was a similar study at FDNY; same results


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## VentMonkey (Oct 24, 2017)

I really think 1 paramedic/ firefighter per shift per day is all that is needed. And I mean literally not cross-training, let alone paying for umpteen more half-arsed “paramedics” on the training schedule.

Perhaps make it part of a formal pre-hire interview and see where their priorities lie? Nothing wrong with squeezing the paramedic-strong-juice for all of its worth. But, clearly as the article posted by @TXmed shows, we’re really doing an overall disservice to the masses with drowning people with patches.

Let’s get real, folks. A single-paramedic on an assessment engine who along with his co-working equally clinically-driven assessment medics gets the invested training needed, and takes heed would yield sooo much more than all of his “brothers” having the same medic patch with, at best, half of the paramedic value. What kind of public service is that?


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## FiremanMike (Oct 25, 2017)

Alright, well it sounds like you have had some pretty bad experiences with FD medics.  I maintain that this is an indictment of their training bureau and quality assurance than the big red truck in the app bay.

For my own curiosity, as I ponder why this is playing out differently outside of my little corner of the world... What is the pay like for FD medics compared to single role medics in your area(s)?


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## FiremanMike (Oct 25, 2017)

TXmed said:


> @FireWA1
> 
> "In 2001, using stopwatches, city officials found that Washington firefighters don’t respond as quickly to medical calls as they should. Their finding prompted the city to buy global positioning equipment so officials could track the movement of rescue vehicles.
> 
> ...



So we're comparing a single incident to a single incident?  n=2?  No documentation of potentially mitigating circumstances (time of day, tenure of crew, etc)?  Not really a fair comparison there..


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## FiremanMike (Oct 25, 2017)

This coming June marks 20 years from my initial certification.  During that time I've worked in a variety of different environments, including FD, two different third service EMS agencies, in the ER, in home health, and in critical care/HEMS.  I have seen horrible and great training/protocols in every single one of those environments.  I've seen absolute morons and absolute geniuses in all of those places.  I've seen treatment/knowledge deficiencies that would make your skin crawl and absolutely remarkable things happen in all of those places.  I've seen folks take forever to respond and folks sprint to the truck in all of those places.

In my experience here, there is no appreciable difference in the proportions of morons to normal medics to brilliant providers between these environment.  The only difference is the patch on the shirt and the name on the paycheck.


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## EpiEMS (Oct 25, 2017)

GMCmedic said:


> ISO ratings. It all comes down to the cost of homeowner insurance in the response district.



Certainly, this is a factor in FD staffing. But at the end of the day, color me skeptical that a better ISO rating really means material savings (it may very well just be something for fire brass to brag about)...the ratings' impact on premiums vary hugely by insurer, for one. 



NPO said:


> There was a similar study at FDNY; same results


FDNY publishes data weekly, and the story is always the same - fires get FFs moving faster than medical calls.


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## FiremanMike (Oct 25, 2017)

EpiEMS said:


> Certainly, this is a factor in FD staffing. But at the end of the day, color me skeptical that a better ISO rating really means material savings (it may very well just be something for fire brass to brag about)...the ratings' impact on premiums vary hugely by insurer, for one.
> 
> 
> FDNY publishes data weekly, and the story is always the same - fires get FFs moving faster than medical calls.



So, FDNY is kind of a convoluted third service where the fire truck guys aren't assigned to the ambulance and the ambulance guys aren't assigned to the fire truck.  Do you think this plays into a lack of ownership for EMS and could affect run times?


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## VentMonkey (Oct 25, 2017)

FiremanMike said:


> Do you think this plays into a lack of ownership for EMS and could affect run times?


From the left coast, so I can only speculate. But, last time I checked their EMS division was under the fire departments umbrella, so who would it really fall under?


FiremanMike said:


> What is the pay like for FD medics compared to single role medics in your area(s)?


Generously lopsided, but does that—or should that—have any bearing on the level of provider? I don’t think that’s why you asked this, but I ask so that this thread is kept going.

Has my experience been less than stellar? Yes, but c’mon, at some point the fire guys (and gals) have to at least admit to the fact that while yes they got into their line of work to fight fires, and took the “medic assignment” and endured it, it doesn’t mean that they’re A) any good at it, or B) even want to do it, thus rubber banding back to “A”.

Again, are there good and bad providers everywhere? Yes, but that isn’t the question at the top of this screen. The question begs to ask why the fire-based systems are lacking. I’m attempting to provide answers, or at least reasonable possibilities from what I’ve seen and dealt with.

A good friend of mine, a firefighter/ paramedic, who I actually trained at one point finally got onto a career department. Guess what his station has? A plethora of inactive patch-medics. He did hazmat, and liked it. He also has very little desire to go on and be a paramedic anymore. 

So again, can you at least answer why fire departments need so many paramedics for the 3 a.m. elderly hip fx?


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## gonefishing (Oct 25, 2017)

What ive noticed with most departments in my reach that do have ems spend way more time focusing training on fighting fires vs ems.  I think I saw once of a rather large department spending only 3 hours a month on ems education the rest on fire.  Add this to a watered down set of protocols but at the same time screaming for more paramedics because per the IAFF posters 5 medics vs 2 is a greater service so their for a justification for a tax increase is needed.  Sadly those taxes go towards fire equipment like the latest greatest apparatuses vs ems tools, education or equipment.  I know many would have to agree as what was taught in my fire science classes is that with the improvements of structures, code enforcements and regulations, fire will eventually be near non existent.  Majority of calls are ems for these departments so why not focus on improvements? LAFD spends large amounts of dollars on a NP, 2 Paramedics on a rig for "community medicine" meanwhile in a county an hour away AMR (who I don't care mjch for) does it for way less with 1 paramedic and a pick up truck some times an emt.  Why does fire have to blow money when a private corporation is doing it for half the cost with lesser man power? Maybe the IAFF and Nurses union have something to do with it who knows.


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## Summit (Oct 25, 2017)

gonefishing said:


> What ive noticed with most departments in my reach that do have ems spend way more time focusing training on fighting fires vs ems.  I think I saw once of a rather large department spending only 3 hours a month on ems education the rest on fire.  Add this to a watered down set of protocols but at the same time screaming for more paramedics because per the IAFF posters 5 medics vs 2 is a greater service so their for a justification for a tax increase is needed.  Sadly those taxes go towards fire equipment like the latest greatest apparatuses vs ems tools, education or equipment.  I know many would have to agree as what was taught in my fire science classes is that with the improvements of structures, code enforcements and regulations, fire will eventually be near non existent.  Majority of calls are ems for these departments so why not focus on improvements? LAFD spends large amounts of dollars on a NP, 2 Paramedics on a rig for "community medicine" meanwhile in a county an hour away AMR (who I don't care mjch for) does it for way less with 1 paramedic and a pick up truck some times an emt.  Why does fire have to blow money when a private corporation is doing it for half the cost with lesser man power? Maybe the IAFF and Nurses union have something to do with it who knows.



This is a quality rant for the most part...  it is the classical "EMS is the cash cow and justification for more taxes too" in order to fund the primary mission that isn't the actual primary mission. So why would they provide more CE than is needed to keep the cash collectors certified? EMS isn't sexy compared to most fire fighting. Even the sexiest part of EMS, the code, isn't that sexy because dead people stay dead more often than not, also no hoses or SCBA. Saving a cat from a tree is sexier than that! 

The last half you got a bit off message... a master prepared NP fills a fundamentally different role and capability than a medic. NPs don't belong to unions typically. Kinda different topic though...

Can we talk about Wildland doesn't get paid like Municipal? :-D


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## gonefishing (Oct 25, 2017)

Summit said:


> This is a quality rant for the most part...  it is the classical "EMS is the cash cow and justification for more taxes too" in order to fund the primary mission that isn't the actual primary mission. So why would they provide more CE than is needed to keep the cash collectors certified? EMS isn't sexy compared to most fire fighting. Even the sexiest part of EMS, the code, isn't that sexy because dead people stay dead more often than not, also no hoses or SCBA. Saving a cat from a tree is sexier than that!
> 
> The last half you got a bit off message... a master prepared NP fills a fundamentally different role and capability than a medic. NPs don't belong to unions typically. Kinda different topic though...


Yes but! It keeps paramedics at a lower level of education and no real advancements.  Increase the education and or protocols.  In ems have long faced an uphill battle with the nursing unions.  I get an NP can write scripts ect but do we honestly need two paramedics with an NP to do a welfare check when paramedics are doing this single handed? Educate the public, ensure the well being and they will stop treating the ed as a personal physician.


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## Summit (Oct 25, 2017)

gonefishing said:


> Yes but! It keeps paramedics at a lower level of education and no real advancements.  Increase the education and or protocols.  In ems have long faced an uphill battle with the nursing unions.  I get an NP can write scripts ect but do we honestly need two paramedics with an NP to do a welfare check when paramedics are doing this single handed? Educate the public, ensure the well being and they will stop treating the ed as a personal physician.


Let's not turn this into a nursing vs paramedic thread! We can go start another thread about what a no-degree medic with a 96hr addon class offers vs a BSN prepared CHRN or a MSN/DNP NP.

If you want to look at what is holding back paramedic education, it is not nurses. It is the FD's need to cheaply and easily certify and maintain all their Paramedic FFs to keep the $ flowing.

If Paramedic was a dedicated 4 year degree or even a 3 year degree, it would put a dent in the myth that one can be a FF first and a medic second (but do both fine), not to mention the economics of having 5 of them on a 1 million dollar fire truck for non-emergent flu like symptoms.

With education comes more autonomous protocols.

Even an associates degree medic minimum would make the paramedic component twice as lengthy, not to mention the depth, of FF2s.

That will happen over IAFF's dead body.


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## gonefishing (Oct 25, 2017)

Summit said:


> Let's not turn this into a nursing vs paramedic thread! We can go start another thread about what a no-degree medic with a 96hr addon class offers vs a BSN prepared CHRN or a MSN/DNP NP.
> 
> If you want to look at what is holding back paramedic education, it is not nurses. It is the FD's need to cheaply and easily certify and maintain all their Paramedic FFs to keep the $ flowing.
> 
> ...


LOL I agree.


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## VentMonkey (Oct 25, 2017)

gonefishing said:


> Educate the public, ensure the well being and they will stop treating the ed as a personal physician.





Summit said:


> If you want to look at what is holding back paramedic education, it is not nurses. It is the FD's need to cheaply and easily certify and maintain all their Paramedic FFs to keep the $ flowing.


Both quoted for truth. And yes, we are our own worse enemy when it comes to educationally increased standards. 

I just want to know when the fire service will openly admit—even on a somewhat anonymous public forum—that what they’re mostly doing has nothing to do with patient care, but everything to do with propaganda?

Also, to his credit, and I believe he is/ was a firefighter, @DrParasite was honest in his overall size up of the situation.


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## EpiEMS (Oct 25, 2017)

FiremanMike said:


> So, FDNY is kind of a convoluted third service where the fire truck guys aren't assigned to the ambulance and the ambulance guys aren't assigned to the fire truck.  Do you think this plays into a lack of ownership for EMS and could affect run times?



Certainly, it's related. That said, the FDNY (fire side) may have EMTs, they only run as CFRs, as far as I know. And there is a huuuuge gap between the pay in EMS vs. fire side (on the order of $6k starting and going up to a five-figure difference!). The real problem is the FDNY spends an insufficient amount on the EMS side...and doesn't like EMS. EMS needs to be third-service in NYC, like in Boston.



VentMonkey said:


> From the left coast, so I can only speculate. But, last time I checked their EMS division was under the fire departments umbrella, so who would it really fall under?



EMS is the red headed stepchild of the FDNY...
(Interesting note to demonstrate how much the FDNY actually cares about EMS, see item 6)



Summit said:


> If Paramedic was a dedicated 4 year degree or even a 3 year degree



See: The rest of the Anglosphere, where EMS is third service & government provided


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## gonefishing (Oct 25, 2017)

VentMonkey said:


> Both quoted for truth. And yes, we are our own worse enemy when it comes to educationally increased standards.
> 
> I just want to know when the fire service will openly admit—even on a somewhat anonymous public forum—that what they’re mostly doing has nothing to do with patient care, but everything to do with propaganda?
> 
> Also, to his credit, and I believe he is/ was a firefighter, @DrParasite was honest in his overall size up of the situation.


You mean the IAFF propaganda posters where they state 6 paramedics is better than 1 on a scene? So increase taxes no to tax cuts song and dance routine?


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## Summit (Oct 25, 2017)

gonefishing said:


> You mean the IAFF propaganda posters where they state 6 paramedics is better than 1 on a scene? So increase taxes no to tax cuts song and dance routine?


This one? (I thinke EpiEMS or DEmedic found it)


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## gonefishing (Oct 25, 2017)

Summit said:


> This one? (I thinke EpiEMS or DEmedic found it)


That be the one! The town that was getting these mailed in are neighborhoods with million dollar homes, old money and foreign money.  They wanted to go to a private ems system for cost saving due to it being a town of 1 fire station with mutual aid from the city next door for fire protection.  2 current ambulances.  The program they had for fire ems is only 12 years old.  They were sold a song and dance that fit the budget.  They kicked out a private service went in house with dual paramedic fire fighters, city saw the cost vs demand wanted to go back private.  These than appeared courtesy of the iaff.  Scare tactics.


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## EpiEMS (Oct 25, 2017)

@Summit, that's exactly the one! Thanks for finding it!



gonefishing said:


> Scare tactics.



Indeed. I'm scared because 6 paramedics is 4 (maybe even 5) too many!  But seriously:

Paramedic #1: That's an EMT job (and also a cop job)

Paramedic #2: Definitely a medic job...and this guy could be the one pushing drugs...

Paramedic #3: doing documentation - OK, you can just get a voice recorder, or record events on the monitor, or have a EMR/EMT do that...

Paramedic #4: Bagging is an EMT job. The inbtubation can be delayed...and the same person who intubated can be getting access via IO in all of 30 seconds.

Paramedic #5: A medic isn't necessary for CPR. Get a LUCAS, or have a EMR/EMT do that.

Paramedic #6: Meh, a dedicated provider for drugs seems excessive...I guess it is nice?


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## gonefishing (Oct 25, 2017)

EpiEMS said:


> @Summit, that's exactly the one! Thanks for finding it!
> 
> 
> 
> Indeed. I'm scared because 6 paramedics is 4 too many!


Nah, they hose down the driveway so when the real medic arrives he can walk on water.


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## VentMonkey (Oct 25, 2017)

Back on track! Focus, y’all. The rants do no good, and only serve to discredit our validity in these ongoing debates.

Why is their delivery-model subpar? Funding aside. Their *MEDICINE*!!!


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## gonefishing (Oct 25, 2017)

VentMonkey said:


> Back on track! Focus, y’all. The rants do no good, and only serve to discredit our validity in these ongoing debates.
> 
> Why is their delivery-model subpar? Funding aside. Their *MEDICINE*!!!


Diluted protocols.


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## EpiEMS (Oct 25, 2017)

VentMonkey said:


> Why is their delivery-model subpar? Funding aside. Their *MEDICINE*!



Absolutely - and the lack of focus on EMS vis a vis fire/rescue, which creates a feedback loop.


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## VentMonkey (Oct 25, 2017)

gonefishing said:


> Diluted protocols.


Right, but take a look at the example @Tigger laid out. I hardly doubt CSFD has diluted protocols when compared to say, SoCal. He even went on to say how their EMS brass seems to invest more into that aspect of their ops, but by and large most of the dual-roles don’t reciprocate such investments.

So, even given all of the funding, and tools, why make that investment, fire guys? Why take the time to train a sea of patch collectors when the patches they really want have nothing to do with what EMS has to offer?

@FiremanMike live outside your world, and step foot into everyone else’s and perhaps answer this question. I know patch medics where I work, who again, are just waiting to get picked up, or move on. So, statistically do they fall under the single-role or dual-role category?

ETA~ EMS-only people, this only sets the bar, and standards that much higher for us. Hopefully we all realize that as well. A non-fire-based EMS in the U.S. leaves little room, or margin for error. 

There would undoubtedly be a need for a prehospital provider level of expertise, universally, that echoes that of the fire services capabilities to fight fires without critique from outside agencies.


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## EpiEMS (Oct 25, 2017)

VentMonkey said:


> EMS-only people, this only sets the bar, and standards that much higher for us. Hopefully we all realize that as well. A non-fire-based EMS in the U.S. leaves little room, or margin for error.



Shouldn't be a problem for major to mid-sized cities. Might be an issue for small municipalities, though, especially ones that are aging.



VentMonkey said:


> There would undoubtedly be a need for a prehospital provider level of expertise, universally, that echoes that of the fire services capabilities to fight fires



For a level of prehospital care provider for professional FFs? I'd say EMR is appropriate.


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## FiremanMike (Oct 25, 2017)

Holy cow.. what an explosion since I last checked.. The IAFF is to blame for keeping paramedic education back.. Firefighters are lying to the taxpayers.. Firefighters have bad protocols and bad training..

Look.. We've had fire based EMS in this area for 30+ years, where firefighter/medics rotate between the trucks.  EMS is invested in, trained upon, and accepted.  I'm unaware of any local bait and switch schemes with the taxpayers in which we beg for EMS dollars and then spend it on fire stuff.  As stated, every firehouse in the entire county and most of the adjoining counties have at least one ALS ambulance in it staffed by cross-trained firefighter/paramedics.  As a matter of fact the newest station in the region is an ALS ambulance only.

ALS runs in this area will have anywhere between 2-9 paramedics on the scene.  We're used to it, we train on it, we don't regularly step all over each-other, but what we can do is lead the run, ask someone to intubate or push a drug, and know that they can legally do it..

From a protocol and training standpoint; I would put my current protocol up against any in the nation (critical care protocols notwithstanding) as well as the training opportunities in this region.  Sim labs, cadaver labs, pig labs, degree programs, all of which staffed with high functioning educators who love to teach.

As for the IAFF holding back education, I mean how do you even qualify that.  The only way you could even start down this pathway is if there was evidence that hiring education standards were higher for the firefighter portion of their training than they are for EMS.  At this point, the entry requirements are lopsided towards prior EMS education and experience, given that obtaining your paramedic certification is markedly more expensive and time consuming.  Fire school is 6-8 weeks, paramedic school (once you include EMT school, and A&P) is 18-24 months.  Here, with 1 exception, all departments require a Firefighter II and Paramedic card just to apply.

So here it is.  There have been a lot of rants, a lot of arguments made mostly emotion.  The original assertion is that fire based EMS produces low results.  It's time to put your money where your mouth is.  Objectively quantify the statement that FD EMS produces low results.  Show me hard numbers that morbidity and mortality are higher in areas with fire based EMS.  Show me hard data.


I'll leave my reply with this.. 

Recently, the department administration put out a memo that moved our "extended truck check" day to Tuesday mornings instead of Wednesday mornings.  The union was convinced this was to screw with them, as union meetings were the first Tuesday of every month.  Because the relationship between management and line personnel was contentious, this explanation made sense, fueled further discontent, and spread like wildfire.

The truth?  I (a union member myself) asked the chiefs to move truck check day to Tuesday mornings because it was much easier for me to do department-wide EMS trainings on Wed, Thurs, and Fri as opposed to Thurs, Fri, and the following Tuesday.  I forgot about the union meeting being on Tuesday when I proposed that idea.  So there I sit at the next union meeting and listened to folks start to grumble about the chiefs screwing with the union meeting times.  I raised my hand, explained the situation, and the fire was immediately extinguished.

My point for bringing that up?  Knowledge is power.  Sometimes changing your perspective or gaining insight beyond your current worldview can go miles in furthering your understanding.  Sure it's easy to feel like the FD medics suck and then pick out all of the reasons why but perhaps taking some time to consider all of the factors might change your mindset.  Just a thought..


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## VentMonkey (Oct 25, 2017)

EpiEMS said:


> For a level of prehospital care provider for professional FFs? I'd say EMR is appropriate.


I think perhaps you misunderstood me, Ep. as far a for the FD’s, yes MFR and/ or EMT seems entirely appropriate. I don’t know why they insist on convincing the public that their respective FD’s absolutely need paramedics on their apparatuses. Again, politics aside.

If they trained their people in the basics to a tee, meaning stellar BLS CPR, bleeding control, etc. well those alone would prolong lives. I don’t see so much heroism in EMS alone, and I am ok with that. Same thing with an EMS “brotherhood”.

None of these things should be our primary focus, or anything to desire within EMS alone. It’s an extension of a doctor, and in turn, an extension of the hospital—specifically ED’s. I just don’t think EMS and fire should be blended so much so. 

At best 1 paramedic/ firefighter, but at least honestly tell the public most of what a paramedic does is not worth where they’re presumably putting their tax dollars. At least, an AEMT to start what the medic may need started prior to arriving.

...or, as you stated, @EpiEMS, well trained MFR’s/ EMT’s who are given quarterly specialized in-house training with their local paramedic agencies.


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## FiremanMike (Oct 25, 2017)

VentMonkey said:


> @FiremanMike live outside your world, and step foot into everyone else’s and perhaps answer this question. I know patch medics where I work, who again, are just waiting to get picked up, or move on. So, statistically do they fall under the single-role or dual-role category?



I'm not really sure what you're asking?  If they're working for a fire department and could be assigned to a fire truck or an ambulance on any given day, they're dual role.  If they could only be assigned to the medic, then I'd say they're single role?



> ETA~ EMS-only people, this only sets the bar, and standards that much higher for us. Hopefully we all realize that as well. A non-fire-based EMS in the U.S. leaves little room, or margin for error



You think I get more leeway for protocol knowledge and practicing EMS because my shirt has an FD patch on it?  No way Jose, not in a million years.  We have the same margin of error as anyone else.. Standard of care means doing what any other reasonable paramedic would do in a given situation, it doesn't make allowances for what color your truck is or who signs your paycheck.



> There would undoubtedly be a need for a prehospital provider level of expertise, universally, that echoes that of the fire services capabilities to fight fires without critique from outside agencies.



Not sure what you mean here.


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## VentMonkey (Oct 25, 2017)

FiremanMike said:


> I'm not really sure what you're asking?  If they're working for a fire department and could be assigned to a fire truck or an ambulance on any given day, they're dual role.  If they could only be assigned to the medic, then I'd say they're single role?
> *If they are working for said service, be it private, or 3rd service but all they dream about day and night is fighting fires, or chasing down bad guys what kind of provider does this make them and where do their priorities lie? With paramedicine or the other?
> 
> I have known entirely way too many of these types. Are they in a whole different category with regard to lackluster performances? Do they fall through the cracks of private and fire-based EMS combined?*
> ...


Again though, could you please justify why we need so many paramedics on a fire departments payroll? And do you see, or feel any skill degradation would really result?

Think about the captains and engineers who have kept their medic, but no longer practice. Do they need to keep up with it if it’s on the departments, and in turn (I would imagine), the public’s dime?


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## FiremanMike (Oct 25, 2017)

I don't really care to invest any energy into the debate of how many paramedics on scene are justified.  That ship has sailed here, all the ambulances and most of the fire trucks are fully ALS capable and we're just never going back to tiered response.  I personally believe that it's not impossible to maintain and improve knowledge and skills simply because you work in a saturated system, it just takes more effort.  It's not that I don't care about this issue, i just know that it's not worth my time to get worked up over something that's not going to change where I am.. 

I do wonder, however, how far we go down this rabbit hole?  So too many paramedics causes a diffusion in the exposure to skills and acuity, sounds good, and honestly it's probably even able to be statistically quantified.  What about trauma docs.  If there was just one trauma center in the entire region and they saw ALL the trauma, would they be 50% better than they would be if there was 2 trauma hospitals?  4? If 2 is ok but not 10, what's the cutoff, how does one even study where that cutoff should be?  This could be applied to law enforcement, legal aide, primary care, car making, you get the picture.

As for your example of the distracted paramedics who'd rather be doing anything else.  That paramedic doesn't just work at the fire department, they might be your partner on your next shift.  That paramedic works at absolutely every department on the planet.  To put it back into the context of this thread, it's kind of unfair to use that as an example that FD paramedics are more distracted than those who don't work for the FD and aren't dreaming of their next ship to the engine.


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## DrParasite (Oct 25, 2017)

I do think a clarification needs to be made when discussing fire based EMS. 

There is the system such as FDNY, Washington DC, Philly, Detroit, Chicago (I think) etc where the EMS (ambulances) are run by the FD, but staffed with  EMS only people, where firefighters may be on the ambulance for OT but that's about it,  a system where you have firefighters that has rotating from suppression units to transport units (either by the week/month, in a single pull station, by the call, so every active person has experience working on an ambulance, or the two most junior firefighters are assigned to the ambulance, and they stay there until they can get moved to a suppression unit and a new junior firefighter takes their place), and departments where the FD does Fire-based EMS, particularly at the ALS level, but never actually rides in an ambulance, and all of what they have done is act as a first responder (even at the ALS level) until the ambulance arrives and takes over patient care.  

All three might be considered fire-based EMS systems, but they all are functioning differently, and can result in a different level of EMS performance based on experience level.


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## VentMonkey (Oct 25, 2017)

DrParasite said:


> I do think a clarification needs to be made when discussing fire based EMS.
> 
> There is the system such as FDNY, Washington DC, Philly, Detroit, Chicago (I think) etc where the EMS (ambulances) are run by the FD, but staffed with  EMS only people, where firefighters may be on the ambulance for OT but that's about it,  a system where you have firefighters that has rotating from suppression units to transport units (either by the week/month, in a single pull station, by the call, so every active person has experience working on an ambulance, or the two most junior firefighters are assigned to the ambulance, and they stay there until they can get moved to a suppression unit and a new junior firefighter takes their place), and departments where the FD does Fire-based EMS, particularly at the ALS level, but never actually rides in an ambulance, and all of what they have done is act as a first responder (even at the ALS level) until the ambulance arrives and takes over patient care.
> 
> All three might be considered fire-based EMS systems, but they all are functioning differently, and can result in a different level of EMS performance based on experience level.


Thanks, DrP. I’m somewhat familiar with the differences as many are prevalent in the LA Basin. I’m not discounting individuals, I’m say the whole fire-based “ALS” model is convoluted at best, and a waste of time and money at least.

The smaller ALS departments that transport in the areas that I grew up in and around seem to take it a bit more serious than the larger departments. Perhaps with good reason? I don’t know completely. I do know my mom pays into their budgets, so she deserves the best care that they can provide in the whopping 3-15 minutes it takes to get to a case-specific hospital.

@FiremanMike you seem to be misunderstanding my viewpoints, and that’s fine if you don’t want to answer some pretty simple questions. The praise that fire departments get is completely justified from all of the years of public service to their communities. Law enforcements is (often) overdue as well.

Where does EMS fit into that, IMO? Nowhere really. What is shown to improve neurologically intact SCA survival rates? Early CPR and defibrillation, which can be properly taught at any local fire department, or even (eeegad!) police department. I would even go so far to say it would be a “win/ win” for both the agency, and the public...practice makes perfect after all.

I’m saying ALS-only care should remain a sub-specialty to the sub-specialty that is EM. Less paramedics on ambulances (be it fire, private, or 3rd service) would surely reverse the watered down debacle we currently know as “prehospital care” now.


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## TXmed (Oct 25, 2017)

@gonefishing I dont believe diluted protocols have anything to do with it. Its how you apply the protocols that makes the difference.

sorry this thread is going faster than i can keep up lol.


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## FiremanMike (Oct 25, 2017)

VentMonkey said:


> Thanks, DrP. I’m somewhat familiar with the differences as many are prevalent in the LA Basin. I’m not discounting individuals, I’m say the whole fire-based “ALS” model is convoluted at best, and a waste of time and money at least.
> 
> The smaller ALS departments that transport in the areas that I grew up in and around seem to take it a bit more serious than the larger departments. Perhaps with good reason? I don’t know completely. I do know my mom pays into their budgets, so she deserves the best care that they can provide in the whopping 3-15 minutes it takes to get to a case-specific hospital.
> 
> ...



If I missed some of your questions, I apologize, it wasn't intentional.


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## FiremanMike (Oct 25, 2017)

@VentMonkey - what about keeping the same number of paramedics we have, but actually holding them accountable for their knowledge/skills?  I get why it's cool to be the lone paramedic on a scene.  I've been on intercept runs and when I was lucky enough to be on a helicopter, I worked in an area with primarily BLS providers, admittedly it's quite fun!  That said, isn't there even a part of you that can admit it's nice (or would be nice, if you've never experienced it) to not have to worry about taking a break from being the team lead in order to drop the tube, start the IV, and/or push the drug, because everyone else with you is trained and legally able to do those tasks for you?


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## DrParasite (Oct 25, 2017)

VentMonkey said:


> Think about the captains and engineers who have kept their medic, but no longer practice. Do they need to keep up with it if it’s on the departments, and in turn (I would imagine), the public’s dime?


Absolutely.  How can you evaluate a paramedic if you aren't a currently credentialed paramedic?  Meaning, how can he evaluate the EMS abilities of the firefighters on his crew?

The same argument would be that a chief officer needs to maintain his paramedic... if nothing else, it shows that the man at the top goes through the same con ed and everyone else, he leads from the front, and he can speak as an authority on prehospital medicine (as the paramedic certification is supposed to represent).  They might not have touched a live patient in 5+ years, but they keep up with the updates just like every other person on their department.

Personally (and this is only my narrow biased uneducated opinion), I don't think FDs have any business being in EMS, and the only reason many are involved in EMS at any level is because of (historically) underfunded and understaffed EMS systems.  The typical medical emergency requires 2 providers, 3 if they are really sick, preferably with 2 of them being paramedics.  And yes, sending the FD on MVAs, cardiac arrests, and bariatric calls is great, but in those cases, they are functioning more as a rescue resource, not as a "stop the clock" resource because EMS has an extended ETA.  

But if you have a career department where the FD isn't doing anything during their downtime, than sure, make them EMT and first respond; but EMS should still be on scene within 8 minutes; 4 would even be ideal, and if you can't meet those response times, than guess what?  you need to get more staffed ambulances, not cut corners as many places try to do (SSM, etc).  

Putting several paramedics on an engine is a waste of money, plain and simple.  I've seen no evidence or studies that have shown that it saves lives.  There is evidence that too many medics result in a dilution of skills. 

I've also seen horrible EMTs, who are career firefighters.  Downright scary, to the point of me asking "did you really pass your EMT exam?  did you bribe someone?"  Maybe they got their EMT cert in the 90s, and have simply renewed their certification by sitting through a BS continuing education class year after year.   And I'm confident if they had to retake the state exam they would have a hard time passing it.  But I also know some pretty good Firefighter/EMTs; most of them worked EMS before getting hired by the FD.

I've said it before, and I will say it again: if you have never been on an ambulance, never worked regularly on a 911 truck, than my confidence in your assessment abilities will not be very high, and I will be skeptical about anything you tell me that isn't blatantly obvious.  Sorry, but I've been burned too many times by inaccurate information.


FiremanMike said:


> You think I get more leeway for protocol knowledge and practicing EMS because my shirt has an FD patch on it?  No way Jose, not in a million years.  We have the same margin of error as anyone else.. Standard of care means doing what any other reasonable paramedic would do in a given situation, it doesn't make allowances for what color your truck is or who signs your paycheck.


I'm throwing the BS flag on this one.  That might be how it is at your agency, especially since you said your people also rotate to the ambulance (I think), but that is far from the norm.  

Everywhere I have worked EMS has "covered" for first responders who missed stuff, didn't do stuff, or left stuff for the ambulance people to deal with.  I've not saying they covered up major issues, but if something bad happened, more often than not it would fall on the ambulance crew's head for not catching it, and the answer "well the firefighter told me..." wouldn't be acceptable.  

An ambulance crew (EMT or paramedic) does EMS day in and day out.  how much EMS training do you do?  I think earlier you said it was once a week?  in the morning, covering all three shifts.  now how much fire training do you do?   now compare that to your ratio of fire calls to EMS calls.... see the issue?  So the ambulance crew does it more frequently, for their entire shift.  Their patient assessment skills better be good; after all, they reinforce that skill multiple times during their shifts.

My ideal system is a tiered EMS system, where you have several staffed BLS 911 ambulances in every town, and scattered all over a response area (and busier areas have several trucks located in that area, so if one went on a call and transported out of town, there were others ready for the next call).  ALS ambulances are regionally located, covering several towns (maybe a ratio of 5 staffed BLS ambulances to every 1 ALS ambulance), and the FD only goes on MVAs, cardiac arrests, and bariatric calls, when additional muscle is needed.  They aren't used to stop the clock, and because they aren't going on every EMS run (the BLS ambulance would get there first anyway, since we now have more of them to handle the call volume and surges), they are more available for non-EMS fire calls.   ALS would be reserved for sick patients, and would be good at what they do since they frequently see sick patients; the vast majority of calls can be handled at the BLS level.

Let the ambulance people be ambulance people (which is the job they signed up for), and let the firefighters do what they want to do, which for many of them is not deal with EMS unless they are specifically called.


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## VentMonkey (Oct 25, 2017)

FiremanMike said:


> @VentMonkey - what about keeping the same number of paramedics we have, but actually holding them accountable for their knowledge/skills?  I get why it's cool to be the lone paramedic on a scene.  I've been on intercept runs and when I was lucky enough to be on a helicopter, I worked in an area with primarily BLS providers, admittedly it's quite fun!  That said, isn't there even a part of you that can admit it's nice (or would be nice, if you've never experienced it) to not have to worry about taking a break from being the team lead in order to drop the tube, start the IV, and/or push the drug, because everyone else with you is trained and legally able to do those tasks for you?


I can’t but help grin, and shake my head at this. I don’t recall ever saying I wanted to be some lone-wolf paramedic coming to save the day from the clutches of improper BLS care.

Again, do your own research into this thread and wait for what I am saying to click. Furthermore, if you think my entire position on this debate is about cool skills, and being the only one to perform them, then again you have no idea who you’re talking to.

I think it’s safe to say we’re just not going to see eye to eye here, and that’s ok. Thanks for adding your two fire cents, and thanks for vaguely dancing around all of the questions directed at why an over saturated fire-based EMS system is anything but effective. Have a good one, Mike.


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## MonkeyArrow (Oct 25, 2017)

gonefishing said:


> Educate the public, ensure the well being and they will stop treating the ed as a personal physician.


But this isn't true. The NEJM published a study about an increase in ED utilization in one state (oh, I want to say either Colorado or Washington) that saw increased ED usage after generous medicaid expansion. It is going to take a whole lot more than educating the public.


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## FiremanMike (Oct 25, 2017)

DrParasite said:


> I'm throwing the BS flag on this one.  That might be how it is at your agency, especially since you said your people also rotate to the ambulance (I think), but that is far from the norm.
> 
> Everywhere I have worked EMS has "covered" for first responders who missed stuff, didn't do stuff, or left stuff for the ambulance people to deal with.  I've not saying they covered up major issues, but if something bad happened, more often than not it would fall on the ambulance crew's head for not catching it, and the answer "well the firefighter told me..." wouldn't be acceptable.



I can only speak for my own department and our QI process (as I'm the guy in charge of it) and say that yes, we hold everyone accountable.



> An ambulance crew (EMT or paramedic) does EMS day in and day out.  how much EMS training do you do?  I think earlier you said it was once a week?  in the morning, covering all three shifts.  now how much fire training do you do?   now compare that to your ratio of fire calls to EMS calls.... see the issue?  So the ambulance crew does it more frequently, for their entire shift.  Their patient assessment skills better be good; after all, they reinforce that skill multiple times during their shifts.



*I* only do training once per week, the crews do training on their own on top of that, and on top of that we are running ~7500 call out of our station (2 ambulances and an engine).  There's only so much time for EMS training, but before I have to put my foot in my mouth, let me get you an accurate count of how many hours of fire/ems training we do each year.  I'm inclined to say it's equal if not skewed towards EMS, but I will happily admit if I am wrong on that one.  I'll let you know tomorrow



> Let the ambulance people be ambulance people (which is the job they signed up for), and let the firefighters do what they want to do, which for many of them is not deal with EMS unless they are specifically called.



Everyone here signed up to be both.  Everyone here either had to be paramedics before they apply or knew they would be forced to become paramedics within 4  years.  No punches were pulled, no wool was removed from eyes, everyone knew what they were getting into.  We signed up to be ambulance people and fire truck people.


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## E tank (Oct 25, 2017)

The only way this issue (FD v. dedicated medic) would ever be settled is with adequately powered outcome studies looking at specific elements of care. Good luck ever getting those studies done  (sorry if someone else already pointed that out...didn't read the whole topic).

This is nothing new, but I thought the source was interesting:

http://www.governing.com/columns/sm...hink-delivery-emergency-medical-services.html


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## FiremanMike (Oct 25, 2017)

VentMonkey said:


> I can’t but help grin, and shake my head at this. I don’t recall ever saying I wanted to be some lone-wolf paramedic coming to save the day from the clutches of improper BLS care.
> 
> Again, do your own research into this thread and wait for what I am saying to click. Furthermore, if you think my entire position on this debate is about cool skills, and being the only one to perform them, then again you have no idea who you’re talking to.



There are nuances of communication that are missed over the internet.  I did re-read my statement and understand why it came across that way, and it was unintentional.  I was merely trying to humanize and personalize your position on "fewer medics are better", I did not intend to come across that way.



> I think it’s safe to say we’re just not going to see eye to eye here, and that’s ok. Thanks for adding your two fire cents, and thanks for vaguely dancing around all of the questions directed at why an over saturated fire-based EMS system is anything but effective. Have a good one, Mike.



My entire entry into this thread was to challenge the notion that fire based medics that are bad are bad simply because they're fire based medics.  From there, we have gone back and forth and jumped from one tangent to the other and I have done my very best to offer reasonable and objective debate into the ever changing focus of this thread, which was originally that FD medics that suck only suck because they're FD medics which moved into FD EMS is under funded, then poorly trained, then poor protocols, then that they lie to the public, suppress EMS education, and finally we landed on the fact that there were too many paramedics in the system as a whole and then whittled it down to the notion that there were too many paramedics in the fire service. 

I very clearly answered your question about the effectiveness of fire-based EMS, over the course of several posts within this thread and tried to show you that there was another side to fire-based EMS than your corner of the world.  I have danced around nothing, I have answered your questions to the best of my ability.

You want to talk about "vaguely dancing around all the questions", I directly asked within the in this thread to objectively quantify how FD based medics provide a lower level of service (because at it's true core, that is the sum total of the thread).  Stop posting anecdotes, stop posting war stories, show me outcome based studies that show FD EMS has a higher rate of morbidity and mortality than non FD based EMS.  

If we want to just back off and say "you know what, this was really just a thread to ***** about the FD", I'm ok with that.. Truly I am.. But we continue to go back and forth with "no, it really is bad because of (insert anecdote)".


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## EpiEMS (Oct 25, 2017)

FiremanMike said:


> Show me hard numbers that morbidity and mortality are higher in areas with fire based EMS.





FiremanMike said:


> show me outcome based studies that show FD EMS has a higher rate of morbidity and mortality than non FD based EMS.



I don't think - and correct me if I am wrong - that such studies exist. In the absence of this, all we have is anecdote & studies that are tangentially related. Experience, we know, matters (e.g. more codes/provider). So does the number of providers on scene (too many paramedics is bad, and EMT/Medic configurations are best for cardiac arrest). Cost (seen & unseen) matters, too (and fire trucks are expensive). I'll freely admit all this. Since we cannot run true controlled trials - and I have yet to see good data comparing fire-based systems to third service to private, we don't have a great way to "conclude" that fire-based EMS is better, worse, or equal to those other models.


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## Ensihoitaja (Oct 25, 2017)

FiremanMike said:


> I do wonder, however, how far we go down this rabbit hole?  So too many paramedics causes a diffusion in the exposure to skills and acuity, sounds good, and honestly it's probably even able to be statistically quantified.  What about trauma docs.  If there was just one trauma center in the entire region and they saw ALL the trauma, would they be 50% better than they would be if there was 2 trauma hospitals?  4? If 2 is ok but not 10, what's the cutoff, how does one even study where that cutoff should be?  This could be applied to law enforcement, legal aide, primary care, car making, you



There's actually a recent study on this for trauma centers:
https://www.sciencedaily.com/releases/2016/07/160721151447.htm



> "So, the study suggests the negative impact of declining patient volume is significantly greater than that of the positive impact of increasing patient volume," said senior author Jason Sperry, M.D., M.P.H., associate professor in the Pitt School of Medicine Departments of Surgery and Critical Care Medicine. "Granting unnecessary designation to a trauma center in a region that doesn't have the patient volume to support it not only hurts patient outcomes at that new center, but it will likely lead to a decline in patient outcomes at other nearby centers."


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## DrParasite (Oct 25, 2017)

FiremanMike said:


> *I* only do training once per week, the crews do training on their own on top of that, and on top of that we are running ~7500 call out of our station (2 ambulances and an engine).  There's only so much time for EMS training, but before I have to put my foot in my mouth, let me get you an accurate count of how many hours of fire/ems training we do each year.  I'm inclined to say it's equal if not skewed towards EMS, but I will happily admit if I am wrong on that one.  I'll let you know tomorrow


I look forward to seeing the results of your training numbers.  Assuming you run 2 on each ambulance and 4 on the engine, and everyone rotates on a regular basis, and you hold people to appropriate standards, than I think your department is doing it right.... and is in the minority among fire based EMS systems across the nation. 



FiremanMike said:


> My entire entry into this thread was to challenge the notion that fire based medics that are bad are bad simply because they're fire based medics.  From there, we have gone back and forth and jumped from one tangent to the other and I have done my very best to offer reasonable and objective debate into the ever changing focus of this thread, which was originally that FD medics that suck only suck because they're FD medics which moved into FD EMS is under funded, then poorly trained, then poor protocols, then that they lie to the public, suppress EMS education, and finally we landed on the fact that there were too many paramedics in the system as a whole and then whittled it down to the notion that there were too many paramedics in the fire service....
> 
> If we want to just back off and say "you know what, this was really just a thread to ***** about the FD", I'm ok with that.. Truly I am.. But we continue to go back and forth with "no, it really is bad because of (insert anecdote)".


You know what?  you're right.  Seriously.   We (everyone who posted here, myself included) generalized that Fire based EMS produces low results.  We painted everyone with a broad brush.  And yes, we grouped all fire department based EMS under the same poor provider stereotype.

I happen to think that your department is the n=1, the exception to the rule, instead of the norm.  Think of all the departments that were already listed....  Detroit fire ems, FDNY, phillidelphia, & DC FEMS..... need I go on?  

So your right, not every fire dept based EMS system sucks.... but a lot of them do..... your department just happens to be one that is doing it right.


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## gonefishing (Oct 25, 2017)

MonkeyArrow said:


> But this isn't true. The NEJM published a study about an increase in ED utilization in one state (oh, I want to say either Colorado or Washington) that saw increased ED usage after generous medicaid expansion. It is going to take a whole lot more than educating the public.


No kidding!? Do you have a link? I would love to read it.  You can pm me so this thread stays on topic.


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## akflightmedic (Oct 26, 2017)

FiremanMike said:


> As for the IAFF holding back education, I mean how do you even qualify that.



If you care to invest the time and energy, research which group of people were the most resistant and lobbied against National Registry becoming a standard across the nation. While the process has its flaws, it IS something, it IS a start and many states adopt it. But get on a state level and find out why some have refused to accept it as the one and only or adopt any of it in part. Find out which states adopted it, dropped it then adopted different parts of it.

Then find out which Collective group of individuals was against making a two year degree for Paramedic mandatory and why,

 Florida is a very interesting case study for that.



FiremanMike said:


> I do wonder, however, how far we go down this rabbit hole?  So too many paramedics causes a diffusion in the exposure to skills and acuity, sounds good, and honestly it's probably even able to be statistically quantified.  What about trauma docs.  If there was just one trauma center in the entire region and they saw ALL the trauma, would they be 50% better than they would be if there was 2 trauma hospitals?  4? If 2 is ok but not 10, what's the cutoff, how does one even study where that cutoff should be?  This could be applied to law enforcement, legal aide, primary care, car making, you get the picture.



It is interesting you mention the Trauma Centers and how many are enough. I can only speak for three states personally and my assumption was a similar process took place across the others. But in the states I know, including FL you cannot just open a trauma center. You must apply for and justify the need for a Certificate of Need. If you do not have the data to support your position, then there is no CoN issued thus no saturation of hospitals or trauma centers. 

This same process is applied to ambulance services as well.

Law Enforcement is regulated by the numbers.

Legal Aides...well the market regulates those. Many of them sit at home staring at their degrees.

Seems like they are on to something and should streamline the paramedic pool....

I don't think you had solid logic in this example.


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## FiremanMike (Oct 26, 2017)

akflightmedic said:


> If you care to invest the time and energy, research which group of people were the most resistant and lobbied against National Registry becoming a standard across the nation. While the process has its flaws, it IS something, it IS a start and many states adopt it. But get on a state level and find out why some have refused to accept it as the one and only or adopt any of it in part. Find out which states adopted it, dropped it then adopted different parts of it.
> 
> Then find out which Collective group of individuals was against making a two year degree for Paramedic mandatory and why,
> 
> Florida is a very interesting case study for that.



That does seem interesting to me and I will be looking into it, thanks for pointing me in the right direction!  I would say, though, that this would only be a fair piece of evidence that FDs hate/devalue EMS if they were opposed to standardized EMS training and increased EMS education requirements, while at the same time promoting standardized fire training and increased fire education requirements.0




> It is interesting you mention the Trauma Centers and how many are enough. I can only speak for three states personally and my assumption was a similar process took place across the others. But in the states I know, including FL you cannot just open a trauma center. You must apply for and justify the need for a Certificate of Need. If you do not have the data to support your position, then there is no CoN issued thus no saturation of hospitals or trauma centers.
> 
> This same process is applied to ambulance services as well.
> 
> ...



Actually, you're right.. Trauma centers are a bad analogy.  I think cath labs and stroke labs would be a more appropriate comparison?

I don't think law enforcement is regulated by numbers, what are you referring to?


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## akflightmedic (Oct 26, 2017)

I cannot just add a police department nilly willy....nor can I just add 20 police officers to the budget just because. They are regulated again by showing an increase in crime, growth of population or stats which show having X number of cops reduces Y.

I think your examples support the other side of the debate. Less is More and Yes, regulation should be in play and there are existing systems....except within the FD.


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## FiremanMike (Oct 26, 2017)

So I looked at my training file, here's what I found.  Now this data is incomplete because I didn't comb through to factor in folks going to conferences and I also didn't check my secondary online CE site because datamining it is a pain in the butt, but here's what I have.. 

Department developed and led training - 54.75hrs EMS, 79.5hrs Fire
Online (self initiated) training - 511.5 hrs EMS, 227.0hrs Fire - This is credits given

So internally we do more fire training than EMS training, but not necessarily by an alarming amount IMHO.


Overall, I think this conversation still contains some good information and I'm sorry for any escalation that may have been caused by me.  Sounds like I'm getting the chance to go to Eagles this year, so if anyone else will be there, I'd love to discuss further ways to solve all the world's problems over an adult beverage!


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## akflightmedic (Oct 26, 2017)

So take the number of training hours in one area versus another and then compare the following:

Call volume Fire Versus EMS --Would you agree that the greater need is getting the lessor training/education?

And if you want to make it a life safety issue....analyze the fire runs. What type of fire versus life at risk. Do the same for the EMS runs.
Which ones had greater impact on the population at risk (the tax payers), which one yielded the best return?

And once you get done crunching all that data, you will see dollar for dollar that EMS, even within your own stellar FD (not sarcasm) is still treated/viewed as the 2nd class citizen. 

I am a guy who has done both sides of the argument and then some...I am not a crunchy paramedic with an ax to grind.


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## EpiEMS (Oct 26, 2017)

akflightmedic said:


> Which ones had greater impact on the population at risk (the tax payers), which one yielded the best return?



The only problem with this is that in some places (densely populated areas, mainly), there is a very strong case to be made for lots and lots of fire training. To generalize, one ambulance crew can only really make a difference for one patient...but one fire truck responding to a small kitchen fire in an apartment building can make a difference for a lot of people


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## Summit (Oct 26, 2017)

FiremanMike said:


> Actually, you're right.. Trauma centers are a bad analogy.  I think cath labs and stroke labs would be a more appropriate comparison?



Cath lab facilities have some very quantifiable and reportable quality metrics. Spend some time in a cath lab that has low volume. Unless you have extraordinarily experienced and dedicated staff working a well supported system, you can see some bad results. Hospitals carefully consider their potential volumes and the availability of qualified employees before they consider investing millions in a cath lab+personnel+training.

What is your point? Do you just not believe in skill dilution in EMS? Do you think it is a non-issue? How do you believe the issue should be determined? In Fire/EMS systems, it is seemingly determined by IAFF political goals and how much money taxpayers can be convinced to cough up. In private systems, it is determined by the market vs government contract requirements. 3rd services run the gamut from KCM1 to double-medic-every-bus (which is still less dilution than 6 FF/medics on every BLS call).


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## FiremanMike (Oct 26, 2017)

akflightmedic said:


> So take the number of training hours in one area versus another and then compare the following:
> 
> Call volume Fire Versus EMS --Would you agree that the greater need is getting the lessor training/education?
> 
> ...



I'm not sure it's quite as simple as proportionally comparing the amount of hours spent on EMS runs vs Fire runs to EMS training and Fire Training.  I think one could actually make a small argument that because there are less fires, we are less experienced at fighting fires, and we should spend more time training on that.  This obviously only works if you have someone paying attention to EMS deficiencies and addressing those deficiencies as they arise through education.

I will definitely admit the disparity between fire/ems training in my own wasn't what I was expecting to see, but I certainly don't think it's as horrible as it is at other places.



Summit said:


> Cath lab facilities have some very quantifiable and reportable quality metrics. Spend some time in a cath lab that has low volume. Unless you have extraordinarily experienced and dedicated staff working a well supported system, you can see some bad results. Hospitals carefully consider their potential volumes and the availability of qualified employees before they consider investing millions in a cath lab+personnel+training.
> 
> What is your point? Do you just not believe in skill dilution in EMS? Do you think it is a non-issue? How do you believe the issue should be determined? In Fire/EMS systems, it is seemingly determined by IAFF political goals and how much money taxpayers can be convinced to cough up. In private systems, it is determined by the market vs government contract requirements. 3rd services run the gamut from KCM1 to double-medic-every-bus (which is still less dilution than 6 FF/medics on every BLS call).



I do believe in skill dilution, but I believe the issue is far more complicated than "FiremanMike takes 10 ALS runs per shift and Summit takes 30 ALS runs per shift, so obviously Summit is better.."

Clearly, there is a breaking point, past which there is no appreciable difference.  25ish years ago in this area, there were only 6 ALS Ambulances in the entire county and 20 or so BLS squads.  Those ALS trucks got their absolute balls smashed with a hammer every single shift they came to work, taking 20+ runs per 24 hour shift.  I hope we can all agree that likely isn't safe for the patients or the mental health of the providers, so clearly more paramedics are needed, which circles us back to the original point; at what point do we decide "that's the right amount of skill/acuity exposure" which I would take even further to say "at what point are we blaming lack of accountability on skill dilution".

Which I suppose brings me to what has motivated me to stay so fervently engaged in this thread.  There is a lot of "I've experienced this setup not work, so that means it is unlikely to ever work".  6 paramedics on a cardiac arrest isn't a bad thing just because there are 6 paramedics, but it can be a bad thing if 3 of those paramedics never take EMS runs and the team leader lacks crew resource management skills to direct the cardiac arrest.  FD based EMS isn't bad because the guys wear fire department tee-shirts and have a red ambulance, but it can be a bad thing if the department doesn't show value to EMS and EMS leadership.  

I have very much moved my mindset into one that truly wants to move beyond just identifying problems, I want to know the mitigating factors and start working through the potential solutions.


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## EpiEMS (Oct 26, 2017)

FiremanMike said:


> 6 paramedics on a cardiac arrest isn't a bad thing just because there are 6 paramedics,



I don't agree with that - in simulation settings, more medics has not been shown to be better (in fact, it's worse). Furthermore, when those medics are doing BLS skills during the resuscitation - as three of them should be (BVM, chest compressions, getting a history/preparing to move/recording events) - they aren't doing the ALS skills that they ought to be practicing (ECG, medication administration, advanced airway placement).



FiremanMike said:


> Those ALS trucks got their absolute balls smashed with a hammer every single shift they came to work, taking 20+ runs per 24 hour shift.



Definitely not a good thing - but this is unlikely to be a "too few paramedics" problem, this is a "not good enough EMTs" or "overuse of paramedics" problem, I'd wager.


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## FiremanMike (Oct 26, 2017)

EpiEMS said:


> I don't agree with that - in simulation settings, more medics has not been shown to be better (in fact, it's worse). Furthermore, when those medics are doing BLS skills during the resuscitation - as three of them should be (BVM, chest compressions, getting a history/preparing to move/recording events) - they aren't doing the ALS skills that they ought to be practicing (ECG, medication administration, advanced airway placement).



So I'd say 4 paramedics would be ideal for the way we roll.  1 to be the team lead, 1 for the intubation/airway management, 1 to mind the monitor, and one to get the IV/IO and push the drugs.  This way every one of those roles is filled by someone who is trained and legally able to carry out what needs to be done in their assignment.   So the other two guys will be the chest compressors, at least until its time to move to the autopulse/lucas.  Sure, it's overkill that the chest pushers are paramedics?  Sure, I suppose, but is it enough to get up in arms about over saturation?  Nah.






> Definitely not a good thing - but this is unlikely to be a "too few paramedics" problem, this is a "not good enough EMTs" or "overuse of paramedics" problem, I'd wager.



Well I wasn't there, but the guys insist they were running from ALS call to ALS call..


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## DrParasite (Oct 26, 2017)

FiremanMike said:


> Department developed and led training - 54.75hrs EMS, 79.5hrs Fire
> Online (self initiated) training - 511.5 hrs EMS, 227.0hrs Fire - This is credits given
> 
> So internally we do more fire training than EMS training, but not necessarily by an alarming amount IMHO.


Respectfully disagree.  your department does more fire training that EMS training (which is what I said earlier).   But it's actually a lot closer than I expected to see

Online (self initiated) training is more for EMS, but that is a HUGE amount of training (almost a 10:1 ratio of online training to departmental training), and, depending on the caliber of the training, can also determine how beneficial it is.  I will also reiterate, it seems like your department is doing it well, and not the norm



akflightmedic said:


> I cannot just add a police department nilly willy....nor can I just add 20 police officers to the budget just because. They are regulated again by showing an increase in crime, growth of population or stats which show having X number of cops reduces Y.


why not?  

If you are located at Penn Station in NYC, within a 2 block radius, you have NYPD, Amtrak PD, USPS PD, Port Authority PD, NJTransit PD, and all but USPS PD have their own ESU units.  And citywide, you ave all of these: https://en.wikipedia.org/wiki/Law_enforcement_in_New_York_City

Where I am currently located, within a 4 block radius of my current seat, I have City PD, the state Highway patrol, General Assembly PD, State capital pd, and the county Sheriff's deputies, and they all have have been here in an official capacity.

If you have the money to do it, you can do it.  



akflightmedic said:


> And if you want to make it a life safety issue....analyze the fire runs. What type of fire versus life at risk. Do the same for the EMS runs.
> Which ones had greater impact on the population at risk (the tax payers), which one yielded the best return?
> 
> And once you get done crunching all that data, you will see dollar for dollar that EMS, even within your own stellar FD (not sarcasm) is still treated/viewed as the 2nd class citizen.


 agreed.


FiremanMike said:


> I think one could actually make a small argument that because there are less fires, we are less experienced at fighting fires, and we should spend more time training on that.  This obviously only works if you have someone paying attention to EMS deficiencies and addressing those deficiencies as they arise through education.


I think that's a fair argument to make, especially in your department.  I don't think that applies elsewhere, but it's a valid point.


FiremanMike said:


> Clearly, there is a breaking point, past which there is no appreciable difference.  25ish years ago in this area, there were only 6 ALS Ambulances in the entire county and 20 or so BLS squads.  Those ALS trucks got their absolute balls smashed with a hammer every single shift they came to work, taking 20+ runs per 24 hour shift.  I hope we can all agree that likely isn't safe for the patients or the mental health of the providers, so clearly more paramedics are needed, which circles us back to the original point; at what point do we decide "that's the right amount of skill/acuity exposure" which I would take even further to say "at what point are we blaming lack of accountability on skill dilution".


maybe they should have switched to 12 hour shifts?  maybe a better question is were those 6 ALS ambulances going on ALS calls, or BLS calls?  were they transporting every patient?  and more accurately, were they transporting patients that could have gone with the BLS crew without any negative patient outcomes?  Are BLS squads transport capable ambulances, or non- transport first responder vehicles?  

You brought it up.  Assuming your entire county is fire based EMS (and without getting into specifics, it's hard to know), and made a claim about the past.   All of NJ is a few paramedic trucks and a lot of BLS ambulances.  All of DE is a few paramedics and a lot of BLS ambulances.  NYC is a bunch of paramedics and a whole lot of BLS ambulances.  Maryland has a mix of BLS and ALS Ambulances.  Currently.  With few exceptions, I don't see people getting run into the ground (and those that do switched to 12 hour shifts), nor do I see or read about dead bodies lining the streets because they aren't enough paramedics to save them.


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## FiremanMike (Oct 26, 2017)

DrParasite said:


> Respectfully disagree.  your department does more fire training that EMS training (which is what I said earlier).   But it's actually a lot closer than I expected to see
> 
> Online (self initiated) training is more for EMS, but that is a HUGE amount of training (almost a 10:1 ratio of online training to departmental training), and, depending on the caliber of the training, can also determine how beneficial it is.  I will also reiterate, it seems like your department is doing it well, and not the norm



So the comparison between online and in person training isn't really accurate and I'm too lazy to really break it down.  It would have been more accurate for me to actually multiply the number of hours per in-class training offered by the attendees for each class to then compare it to the online training total, does that make sense?



> I think that's a fair argument to make, especially in your department.  I don't think that applies elsewhere, but it's a valid point.
> maybe they should have switched to 12 hour shifts?  maybe a better question is were those 6 ALS ambulances going on ALS calls, or BLS calls?  were they transporting every patient?  and more accurately, were they transporting patients that could have gone with the BLS crew without any negative patient outcomes?  Are BLS squads transport capable ambulances, or non- transport first responder vehicles?
> 
> You brought it up.  Assuming your entire county is fire based EMS (and without getting into specifics, it's hard to know), and made a claim about the past.   All of NJ is a few paramedic trucks and a lot of BLS ambulances.  All of DE is a few paramedics and a lot of BLS ambulances.  NYC is a bunch of paramedics and a whole lot of BLS ambulances.  Maryland has a mix of BLS and ALS Ambulances.  Currently.  With few exceptions, I don't see people getting run into the ground (and those that do switched to 12 hour shifts), nor do I see or read about dead bodies lining the streets because they aren't enough paramedics to save them.



Again, I wasn't there, so I can only go off the lamentations of our dinosaurs who talk about the good old days.  Should they have gone to 12s?  Increased the number of medics by 50%? Gone to fly cars? Increased BLS education?  Who knows, all of those solutions were likely considered and it was ultimately decided that they would just make all of the ambulances ALS trucks and staff them with 2-3 paramedics and all of the engines (and some of the ladders) ALS capable and staff it with at least 1 paramedic.  

I'm not necessarily implying that our current system is the best, and if we are doing the true penny pinching money crunching, it clearly isn't the most financially efficient means, but that's the system we're in and it seems to be working for us.


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## EpiEMS (Oct 26, 2017)

FiremanMike said:


> So I'd say 4 paramedics would be ideal for the way we roll. 1 to be the team lead, 1 for the intubation/airway management, 1 to mind the monitor, and one to get the IV/IO and push the drugs.



I don't see the benefit in having an ALS team lead, myself, and why do you need a medic for airway & for access + drugs? Can't the medic get access (via IO, probably), then throw a rescue airway in? BVM should be more than adequate initially. Heck, you could probably just throw on an NRB in most adult arrests of cardiac origin for the first couple minutes.


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## Summit (Oct 26, 2017)

EpiEMS said:


> I don't see the benefit in having an ALS team lead, myself, and why do you need a medic for airway & for access + drugs? Can't the medic get access (via IO, probably), then throw a rescue airway in? BVM should be more than adequate initially. Heck, you could probably just throw on an NRB in most adult arrests of cardiac origin for the first couple minutes.


I'll go ahead and play devils advocate and present a model (of many) that you ideally get for an in-hospital code.
1-2 docs
1-2 nurses
0-1 RT
Maybe 1 pharmacist to mix up TPA (usual etiology and response times are different in a hospital vs field)
Several bodies to do compression, hold mask, record, lab courier

You have a RN running the monitor/IO/drugs.
You have a MD running the code often with a RN copilot. Their job is to stand back, manage, and think.
You have the RT or another doc (anesthesia) on airway or establishing central access, a-lines.
You have ancillary personnel for compressions, bagging, recording, run labs

Prehospital is different.

In the field you aren't dropping femoral lines, alines, running labs... you are more likely to have lucas devices (although I work at one hospital that has these for in hospital use), EMR/EMT can compress, hold mask seal, drill an IO (if your locale lets them...and they should... a mentally challenged lemur could start an IO and an IO takes much of the stress out of a code).

I think 3 ALS providers and a couple EMTs are a good thing for a prehospital code... but that does NOT mean you need 3 ALS providers on every engine. Fly cars! Command cars!

It is really easy to jump on to whether much of ACLS is useful... or whether ALS does more good than bad... when you start looking at the data you stop asking about how many paramedics you need on each engine and start asking if you want any at all vs whether to heavily reform what and how ALS does ALS care.


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## FiremanMike (Oct 26, 2017)

EpiEMS said:


> I don't see the benefit in having an ALS team lead, myself, and why do you need a medic for airway & for access + drugs? Can't the medic get access (via IO, probably), then throw a rescue airway in? BVM should be more than adequate initially. Heck, you could probably just throw on an NRB in most adult arrests of cardiac origin for the first couple minutes.



If we want to get really serious about trimming the fat, you don’t need any paramedics on the scene of a cardiac arrest.. high quality chest compressions, a BVM, and an AED are all that’s needed, if wer is being honest..


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## Summit (Oct 26, 2017)

FiremanMike said:


> If we want to get really serious about trimming the fat, you don’t need any paramedics on the scene of a cardiac arrest.. high quality chest compressions, a BVM, and an AED are all that’s needed, if wer is being honest..


So... why not do that?


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## FiremanMike (Oct 26, 2017)

Summit said:


> So... why not do that?



<shrug> dunno..

If I'm forced to give a real answer, I'd say it's because Paramedics are out and about and will be on scene.  If paramedics are on scene and not doing paramedic crap, then does that put them into any scenario of medicolegal liability, given todays standard of care?


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## DrParasite (Oct 26, 2017)

FiremanMike said:


> .  If paramedics are on scene and not doing paramedic crap, then does that put them into any scenario of medicolegal liability, given todays standard of care?


does that mean every fire department that doesn't have paramedics on their engine are at risk for medicolegal liability, given todays standard of care?

And if a paramedic (or RN, MD, trauma surgeon, who just likes being on the ambulances etc) is working as an EMT (based on job, not actual credentials), should he or she be functioning based on his knowledge or job description?  Even moreso, if you have an EMT who has been there for 5 years, and recently completed his paramedic school but isn't a released paramedic medicolegal liability is he or she at risk for when he doesn't even attempt an IV or tube or give drugs that are outside of his positions scope of practice for his job, but not for his personal certification?  Do you see how far down the rabbit hole we can take this?


Summit said:


> I'll go ahead and play devils advocate and present a model (of many) that you ideally get for an in-hospital code.
> 1-2 docs
> 1-2 nurses
> 0-1 RT
> ...


Hospital's have a scribe somewhere too.  

I like the idea of a paramedic "code commander."  He is in charge, he watches the monitor for any rhythm changes, he directed people when to push drugs. and what drugs to push, he presses the shock button.  Maybe a second paramedic to actually give the drugs, establish IO, and intubate (and two of these things are one and done move on).  one you have the tube, ventilate it and hand off to BLS.  otherwise, king airway and move on.    And do you really call a doc during a code?  aren't most things standing order?  maybe to pronounce, maybe if there is something weird, maybe if your out of ideas and want a second opinion..... and even if you do, it's a once and done thing.

despite what the IAFF propaganda says (and I don't blame them for it, because it serves their interests only, which is their job), don't need a medic to get history, ventilate, do compressions, attach defib pads or speak to the family.


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## FiremanMike (Oct 26, 2017)

DrParasite said:


> does that mean every fire department that doesn't have paramedics on their engine are at risk for medicolegal liability, given todays standard of care?
> 
> And if a paramedic (or RN, MD, trauma surgeon, who just likes being on the ambulances etc) is working as an EMT (based on job, not actual credentials), should he or she be functioning based on his knowledge or job description?  Even moreso, if you have an EMT who has been there for 5 years, and recently completed his paramedic school but isn't a released paramedic medicolegal liability is he or she at risk for when he doesn't even attempt an IV or tube or give drugs that are outside of his positions scope of practice for his job, but not for his personal certification?  Do you see how far down the rabbit hole we can take this?
> Hospital's have a scribe somewhere too.



Given our current legal system, I think the obvious answer to all of those questions is "maybe".  With that said, and in my non-lawyer trained opinion, none of those rise to the same level of liability of a properly credentialed paramedic on scene of a cardiac arrest who has immediate access to ALS interventions that are the current standard of care but elects not to use them.  Now, if we're talking about the medical director taking a stand and changing their protocols, then they may be operating outside of the standard of care, but within their scope of practice.  The medico-legal liability in that case would fall back to the medical director.



> I like the idea of a paramedic "code commander."  He is in charge, he watches the monitor for any rhythm changes, he directed people when to push drugs. and what drugs to push, he presses the shock button.  Maybe a second paramedic to actually give the drugs, establish IO, and intubate (and two of these things are one and done move on).  one you have the tube, ventilate it and hand off to BLS.  otherwise, king airway and move on.    And do you really call a doc during a code?  aren't most things standing order?  maybe to pronounce, maybe if there is something weird, maybe if your out of ideas and want a second opinion..... and even if you do, it's a once and done thing.
> 
> despite what the IAFF propaganda says (and I don't blame them for it, because it serves their interests only, which is their job), don't need a medic to get history, ventilate, do compressions, attach defib pads or speak to the family.



I don't disagree with you on any of these points.  We didn't choose to go "all paramedic" because we pushed that it was a requirement that every position on every run MUST be a paramedic, we did so because we wanted to add paramedics to give our paramedics at the time a break every now and again, then at some point it just became logistically more sensible to make everyone a paramedic, to where we are now that you can't even apply without your paramedic card in hand.


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## EpiEMS (Oct 26, 2017)

FiremanMike said:


> it just became logistically more sensible to make everyone a paramedic



I don't know about that...it's a pretty straightforward optimization problem. You can figure out how many medics you need in total to have, say, N medics on every shift.


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## FiremanMike (Oct 26, 2017)

EpiEMS said:


> I don't know about that...it's a pretty straightforward optimization problem. You can figure out how many medics you need in total to have, say, N medics on every shift.



Firefighter A is a FF/EMT who retires.  Do we only interview FF/EMTs to replace him?  What if one of the Firefighter/medics wants to "drop their card" an ride out the rest of their days on the fire truck.  Who sets the process for "dropping your card" and what does it look like?  What if one of the interview candidates is really a stand-out candidate, best we've ever seen, but he's a firefighter/medic.  Do we hire him and tell him he'll be making FF/EMT pay and not riding the ambulance?

We have 2 ambulances and a fire truck.  We decide that we want to have 5 paramedics per shift, 2 on each ambulance and 1 on the fire truck.  One of them goes home sick or is off on injury.  Do we now saddle the 10 paramedics off the other crews with the overtime coverage?

We decide we want 5 paramedics but we want to get really fancy and actually staff 6 paramedics on each crew, but we'll tell the 6th guy that he's only getting the FF/EMT rate because he's not actually working as a paramedic that day, he's just the back-up for sick call.  So then the backup ff/medic steps up and intubates on the next arrest because he was sitting near the head, does he get to put in for FF/medic pay for that shift now?  What about his skill degredation for being "just the back-up medic"?

Sure, it sounds simple to just say "you need x medics, so have x medics" but nothing is ever as simple as we want it to be.  We have 11 guys per shift with a minimum of 9, at some point they just said "you know, it's just easier to make everyone a medic, train everyone to the same standard, and rotate everyone equally between the trucks".


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## EpiEMS (Oct 26, 2017)

@FiremanMike Fair point, it is seems like a simple enough solution. It's probably not the most efficient way to do things, but simplicity has a value.


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## Bullets (Oct 26, 2017)

Summit said:


> So... why not do that?



I need a paramedic to pronounce. 

As it stands now, when my BLS agency responds to arrest, we dont break out the BVM until 10 minutes into the arrest. Its just compression, AED and NRB(actually a HFNC).


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## Tigger (Oct 27, 2017)

FiremanMike said:


> So I'd say 4 paramedics would be ideal for the way we roll.  1 to be the team lead, 1 for the intubation/airway management, 1 to mind the monitor, and one to get the IV/IO and push the drugs.  This way every one of those roles is filled by someone who is trained and legally able to carry out what needs to be done in their assignment.   So the other two guys will be the chest compressors, at least until its time to move to the autopulse/lucas.  Sure, it's overkill that the chest pushers are paramedics?  Sure, I suppose, but is it enough to get up in arms about over saturation?  Nah.



This is going to be a long post. @FiremanMike I am not trying to start a fight. I respect you, your knowledge, and what you do for your agency. After the first paragraph this is really just going to turn into a repressed rant that's been building for months, please know that it isn't directed at you so much as an example of what some of us deal with. 

I'm going to use the above to maybe illustrate a point. Here (and legally I might add), I can have an EMT drill the IO/start an IV and push the drugs I request. I can have an EMT manage the airway until I am at a point (if there is one) that I want to intubate. I can have an EMT show me the monitor and then charge and deliver a shock. These are all money skills. They were things I was very comfortable with before I set foot in paramedic school. The reason? That's how our system operates. That is my experience, it is no doubt different than yours. Your place sounds like it has its crap together when it comes to EMS. I have no doubt there are many fire departments that do as well. But you cannot keep citing your own agency as proof that not all fire agencies provide bad EMS. We get it, it's not 100%. But do you really suppose it's a coincidence that so many here have had watched a lower level of EMS be provided than by that of their own, co-responding service?

As alluded to, prehospital care in my area of Colorado is not like SoCal or the other much maligned areas of fire based EMS. The system is pretty well done and the guidelines actually change when practice does. Significant money, time, and resources are put into EMS by all parties in the system and it shows. But still, the care provided by the fire departments throughout the system is often below that of the single role providers.

Since you have shared your experiences, I will share mine. CSFD sends most of their paramedic students to a less than awesome program in Denver only because it is accelerated (I was fortunate to go to my program the year they sent their guys to the local program, truly have some lifelong friends (and good medics) from it). They then have a joke of an FTO period before they are released as a medic. Fortunately they're usually the only medic on their piece. Compare this to AMR, who will only pay for medic school if you went to the local (and better credentialed) program and pass an extensive FTO process that had well defined standards and FTOs who received additional training for their role to include EMS Instructor certifications. AMR now runs their own paramedic program, I hope the same initial educational standards are met but I have no reason to think they would not be.

In addition to the usual CE, there are several mandatory training events (usually regarding guideline updates) that all system paramedics must participate in. CSFD pulls companies out of service to do theirs, AMR employees must come in on their days off. Yet still, who is responsible for the vast majority of public M&M write ups that are published each month? You guessed it. Nevermind the fact that the per provider their medical division is three times as large. Or that they routinely get placed out of service to get education time from a well trained and equipped division. Lessons just aren't taken to heart, likely because their is no internal pressure to practice good medicine. Their is no self policing. At AMR, if I make a mistake, my peers will make sure I have the education to ensure it does not occur again. It'll still get to clinical education, but at that point it's likely water under the bridge. If you keep making mistakes, you'll get demoted to a transfer ambulance, and then you'll be terminated. CSFD? They'll promote you to lieutenant and remind you that officers needs not maintain their medic. Recently I ran a call in which a BLS truck company had administered several ALS medications prior to my arrival. They then proceeded to argue with me (the only medic on scene) about how their treatment path (dex) was more appropriate than mine (IM epi) for the about to arrest status asthma patient. There was no formal discipline aside from their medical supervisor lieutenant sitting them down and telling them not to do that again. If a BLS crew at AMR did that, they would be immediately terminated. Why is this difference acceptable? Why are they unwilling to maintain high standards? I mean you know it's bad when a medical division captain comes to your new hire AMR orientation and tells you that you are going to have to be on your game because his guys are not.

There are more than a handful of good fire medics. But watching them get belittled on scene by their (mostly EMT/FF) peers for being "too smart" is awful to watch. How do you think those guys feel about delivering in-station medical training to the rest of their crew? I interned at their busiest station for a change of pace. My preceptor made an effort to run scenarios with me everyday using their training equipment. Everyday someone had a less than encouraging comment for us. I could give two about the actual comments, it's the attitude that is worrisome. I think I spent as much time doing EMS training as I did learning to force doors there. There is not just no institutional want to be really good at EMS, like there is the want to be really good at forcible entry or smoothly deploying a department lay. While the majority of the line staff are "only" EMTs, the majority of their calls are "only" medicals.

And AMR is just a part time job. 36 hours a month maybe. But after four years, I haven't seen a lot of change. Meanwhile, at my full time job we were the only paramedics in the service area until a few years ago. The one paid fire district we cover decided they wanted a medic on each shift of four. Mind you they average being on scene without us for less than four minutes, but still, those four minutes multiplied by their yearly 6-700 medical runs equalled a lot of total minutes and boom, an ALS program was funded. One of their medics had worked part time on ambulance running 1500 total calls a year prior to this. The other two have no prior experience. None of them are willing to go get it. None of them will ever get the experience they need with that call volume and they certainly don't have the education to make up for it. Again, there just isn't an institutional want. Meanwhile, my employer all but mandated that I maintain employment as a part time medic for AMR (we only run 25-700 a year) and had me attend every single call out of the busy station for year. While awful, I sure learned. Vastly different agencies, but somehow the EMS only agency maintains and enforces the high standards while fire does not.

I am sure I sound a bit salty and certainly biased. But here's a twist, I also work part time as an FF/Medic. It's a little district with one cross staffed ambulance, but I kinda dig it honestly. The FFs treat the medic well and participate in our daily trainings. They take pride in their part of running the ambulance. I know first hand that it's possible to run a solid FD EMS service because I work with one. I think they are an anomaly, and I am happy to be here. But at the end of the day, given the choice between a fire and and a medical, you know what they'd rather be doing, whether it's real or training.

And I don't sit at home and type these sorts of things and leave it at that. All of my jobs involve running relatively often with small FDs that provide some EMS. Most of them don't do much better than an average job. I figure you can't complain about that unless you try to change it. So I started teaching for one of medical direction hospitals. I do monthly CE training and get the opportunity to dispel myths and encourage these places to embrace and take pride in EMS. I don't think I'm personally having much of an effect, but I am trying to be a part of the solution. I don't want to watch a good system be brought down by low standards pressed forth by fire departments.

TLDR; Locally, throughout the whole large system, the fire departments simply lack any pride in doing EMS well.


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## jbiedebach (Oct 27, 2017)

RocketMedic said:


> *Disclaimer: This isn't a slight against firefighters, and it's not necessarily targeting the high-functioning fire departments out there that do the right things, or even the fire-medics that actually do their jobs the right way.
> *Disclaimer 2: I'm not a firefighter, not particularly interested in being a firefighter.
> 
> So we hear a constant stream of anecdotes from across the nation, mostly from larger cities with big fire-based EMS systems, and there's a pretty common thread- systems operating at the limits of their operational capacity constantly, long shifts, provider and patient abuse, and terrible medical practice. So, why is this happening?



I am a firefighter and a medic and an ER tech/nursing student so I have seen all sides of it.  I would say the primary challenge is money.  Large fire departments spend less per capita than midsize departments. Example: Dallas spends about $190 per resident on FD/EMS.  Plano spends about $226.  That may not sound like a big difference but the extra $36 per resident is about 19% of DFD's budget.  Imagine what they could do with a 20% budget increase.  Stack on top of that the fact that big cities have older buildings (more prone to fire) and a larger indigent population (much harder on EMS) and the result is a much busier FD/EMS system (less time for training and recovery between calls) with less money, typically older equipment and fewer personnel than a smaller suburban department.

Another example: Dallas runs about 3700 calls per station in a year.  Plano runs just over 2100.  Divide that by 121 (number of shifts in a 24/48 year) and you get 30 calls/station per shift (this number is not what it seems because Dallas runs a number of double company houses) vs Plano = 17 calls per station/shift.

Bottom line Plano has more money, people and time to do less work.  Which system do you think is going to produce a better outcome?


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## DrParasite (Oct 27, 2017)

Bullets said:


> As it stands now, when my BLS agency responds to arrest, we dont break out the BVM until 10 minutes into the arrest. Its just compression, AED and NRB(actually a HFNC).


Not saying your wrong (in fact, this was a discussion at the bar several years ago when I went to DC for EMS Today between me an a paramedic education down in Georgia), but who directed you could do this? I haven't seen any studies that says this is more effective, the AHA doesn't say to do this, and as of 3 years ago, it wasn't standard practice in NJ.  

Like I said, not saying your wrong, but want to know who supported this decision (as has some documentation behind this) so I can bring it up with my medical director.


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## EpiEMS (Oct 27, 2017)

jbiedebach said:


> Bottom line Plano has more money, people and time to do less work. Which system do you think is going to produce a better outcome?



Being over-resources can produce pernicious effects, too. Too many medics, too few skills performed per medic, lower quality outcomes.



DrParasite said:


> I haven't seen any studies that says this is more effective, the AHA doesn't say to do this, and as of 3 years ago, it wasn't standard practice in NJ.



That CCR isn't more effective? I have seen some evidence that it may be, especially for cardiac origin OOHCA (e.g. this Yang et al. 2012 and Mosier, et al. 2009). Even if it is *only* equivalent to CPR, it's definitely easier - logistically, anyway.


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## DrParasite (Oct 27, 2017)

EpiEMS said:


> That CCR isn't more effective? I have seen some evidence that it may be, especially for cardiac origin OOHCA (e.g. this Yang et al. 2012 and Mosier, et al. 2009). Even if it is *only* equivalent to CPR, it's definitely easier - logistically, anyway.


I've read the studies that continuous compression are better (although I didn't know it was called CCR, had to look that up).

But I didn't know if any agency had stopped doing CPR for cardiac arrests and switched to CCR as a standard procedure for cardiac arrests.  Nor did I know of anyone in NJ that no longer initially uses a BVM for cardiac arrests, and instead using a NRB or HFNC for the first 10 minutes.


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## EpiEMS (Oct 27, 2017)

@DrParasite CCR is actually protocol for a number of places - we have it in our CT protocols for adult cardiac arrest of suspected cardiac etiology (Protocol 3.2A) & it's also in the National Model Clinical Guidelines (page 102).


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## Bullets (Oct 27, 2017)

DrParasite said:


> Not saying your wrong (in fact, this was a discussion at the bar several years ago when I went to DC for EMS Today between me an a paramedic education down in Georgia), but who directed you could do this? I haven't seen any studies that says this is more effective, the AHA doesn't say to do this, and as of 3 years ago, it wasn't standard practice in NJ.
> 
> Like I said, not saying your wrong, but want to know who supported this decision (as has some documentation behind this) so I can bring it up with my medical director.


Our medical director. All of his agencies use this protocol. It has caused some friction with our ALS providers and our and their medical directors were fighting for some time about it. He has cited Yang and Mosier as well as some others. I will get them from him. There are a couple other agencies that do this, IIRC Philly FD was the biggest agency doing this. It is very helpful for us to not have to worry about BVM until additional units arrive, as most of the cops arent CPR trained and less than enthusiastic about doing anything on EMS calls. 

Ill post the links when i get them


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## VentMonkey (Oct 27, 2017)

I still standy by less paramedics is a win/ win. I don’t really care if it’s in an all fire-based EMS system or not. Having a handful of skillfully qualified paramedics regardless of the system it is ran by can surely be worth more than what we all know hasn’t been shown to do much—flooding the field with paramedics.

Fire guys, I don’t understand what is so hard to comprehend about this idea; it’s by no means new and works quite well in many of the systems that practice this way. This means third service, private, or fire-based—less paramedics alongside of better qualified, and God willing, better educated EMT/ AEMT’s.

So what if I have 5 guys around me who can do skills that I will get to at some point in a code that, again, in reality hardly matter right then and there. Am I saying paramedics should be obsolete? No, I’m saying flooding the market with them should be an obsolete practice. 

Am I saying if the the BLS ambulances are 5 minutes from the ED should they load and go with good CPR, and an SGA? Absolutely. Maybe that would free up an ALS car for the next highly acute call. I prefer efficiency, and not just sufficiency.


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## EpiEMS (Oct 27, 2017)

Bullets said:


> as most of the cops arent CPR trained and less than enthusiastic about doing anything on EMS calls.



Cops without CPR? Crazy stuff...



VentMonkey said:


> Am I saying if the the BLS ambulances are 5 minutes from the ED should they load and go with good CPR, and an SGA? Absolutely.



I don't love doing compressions while moving...once we get a LUCAS, sure, I'm ok with that. But generally, shouldn't we (BLS folks) be working on scene for a couple of cycles (3)?

Btw, I'm of the opinion that cardiac arrests are really the ultimate BLS call...everything that actually works to improve neurologically intact survival to discharge is a BLS skill (defibrillation, compressions, and...eventually...ventilations)


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## VentMonkey (Oct 27, 2017)

EpiEMS said:


> I don't love doing compressions while moving...once we get a LUCAS, sure, I'm ok with that. But generally, shouldn't we (BLS folks) be working on scene for a couple of cycles (3)?


Nor do I, and yes A) Lucas/ AutoPulses would be ideal, and B) giving BLS criteria to call or ask a doc for termination orders would also be extremely helpful.

I wasn’t implying hauling every DB off to the ED blindly. I sort of rushed through the post because I just got off, and I am admittedly tired.

Tiered right, a capable AEMT/ EMT configuration with 12-lead capabilities, ASA, and the ability to either intercept with an ALS chase car, or bypass that idea and head directly to the PCI facility is wrong why?...


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## EpiEMS (Oct 27, 2017)

VentMonkey said:


> giving BLS criteria to call or ask a doc for termination orders would also be extremely helpful.



Agreed! Something like 5 cycles, no shockable rhythm, no bystander CPR, not witnessed...etc.


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## Bullets (Oct 27, 2017)

EpiEMS said:


> Cops without CPR? Crazy stuff...


But they all have 36 doses of narcan and love using their personal tourniquets on any extremity wound.....

Imagine you're driving a tesla and you have to work with someone who insists on using a Model T, and thinks that the Model T is perfectly fine for todays travel and thinks the Tesla is actually witchcraft. Thats the current EMS/PD relationship.

When i went into management i thought the hardest part would be dealing with my staff. Its actually dragging people kicking and screaming into the 21st century. Which wouldn't be so bad if they were in the 20th century, but they are actually in the 19th century....


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## Summit (Oct 27, 2017)

EpiEMS said:


> I don't love doing compressions while moving...once we get a LUCAS, sure, I'm ok with that. But generally, shouldn't we (BLS folks) be working on scene for a couple of cycles (3)?



I'm with you... I hate the idea of interupting compression in the loading process and the sometimes subpar compression while moving... then unloading.

If I was medical director, I'd say if no LUCAS/Autopulse, then BLS work it on scene until ALS shows up... unless it meets termination protocols...

Can someone tell me why we don't have telemetry with all of our modern high bandwidth communications, SSM, GPS tracking, CAD, toughbooks, and electronic PCRs? Why is Telemetry so Johnny and Roy? Telemetry = remote termination order for BLS made easy. Many ambulance EMTs have taken a 3-lead EKG course in my state. Hell, most of our EMTs could facetime med control and point the phone at the monitor. See? Asystole in two leads!


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## VentMonkey (Oct 27, 2017)

Circling back to the thread topic and tying in to my viewpoints, since it was mentioned that there were several rants, and tangents:

Fire-based EMS on the whole is typically on the lower end of the performance threshold because in my opinion, too many of them creates skill dilution. The fact that many, not all, many don’t really care for EMS to begin with only catapults the results in general.

Can it be effective? Absolutely, just like single-function systems can be ineffective. But again, when all single-functions focus on is, well, a single function, they’re naturally honed with duties set forth by their employer, and not tasked with it as some sort of “hiring commitment”, which to me sure sounds like a great reason to become good at something you never intended to become, let alone excel at.


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## Tigger (Oct 27, 2017)

EpiEMS said:


> Agreed! Something like 5 cycles, no shockable rhythm, no bystander CPR, not witnessed...etc.


We have and use that here. 5 cycles with three consecutive no shock advised notifications.


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## FiremanMike (Oct 27, 2017)

Man I'm sorry I've not had a chance to respond today.

Let me add this, after the day I've had today, it's pertinent to mention that we're definitely not perfect.  We do have stupid crap here just like everywhere else.


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## VentMonkey (Oct 27, 2017)

FiremanMike said:


> Man I'm sorry I've not had a chance to respond today.
> 
> Let me add this, after the day I've had today, it's pertinent to mention that we're definitely not perfect.  We do have stupid crap here just like everywhere else.


Understandable, humans are certainly nothing short of infallible. That said, I just think that the paramedic per capita has gone way up, and it really needs to go way down.

It would not only better serve the community—which I think we can agree we all want—but it would also raise the bar for the provider, and increase entry-level standards and requirements. I certainly think that the fire department will always serve as an integral role as first-line, first responders, and rightfully so.

Giving them, and (hopefully) one day law enforcement, the ability to order either an ALS or BLS unit depending on the severity of complaint would be so much more ideal than how almost every system in the U.S. functions. But again, less ALS units would more than likely dictate proper EMD protocols—a good thing.

If we cannot educate the public, we may have little left in terms of realistic options when it comes to “forcing their hand” at proper prehospital care, and/ or treatments.


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## RocketMedic (Oct 28, 2017)

I think Fire based ems can actually potentially be very much better than single-role. Funding, PR, alternative career models, deployments, and even the health and physical-exercise traditions of the fire service can potentially be a lot better for employees and communities than contracted private providers. I even sort-of like the team approach to EMS many fire services bring- and to disagree somewhat with VentMonkey, although I don't think that it is necessary to have paramedics literally everywhere, I don't think that it really contributes too much to skill degradation either. It is pretty inefficient though. Fire-based services can be exceptional too- good people, good care, etc. The probelm is that so many of them are NOT of high quality, and proceed to set a minimalisrtic standard of care that is woefully inadequate even by their own protocols. Houston Fire, for example, can provide fairly generic levels of care- think CA-standard, which isn't that bad- and yet, they often don't, because it is easier for them to do the minimum possible. Other departments, like Dallas and Los Angeles County and a lot of other places, are just as bad, to the point where we can sharpshoot them online with a high degree of confidence.


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## Colt45 (Oct 28, 2017)

I'm sure this has been stated, and I've tried to read through majority of this thread, but the topics have been so sporadic I didn't know how I wanted to point my reply. But besides some very basic hose monkeys, every fire based paramedic that works in my state that I have worked with have exceeded my expectations. It's kind of opposite here honestly. Our county IFT  is looked down upon in many ways- but not for good reasons. Where I'm from Fire based EMS is the golden standard and they provide medical care for the surrounding areas in their jurisdiction. And most of the people are outstanding paramedics. There are also amazing paramedics on our private ambulance systems who work with the fire medics on calls, but ultimately it's the fire medics who are running the calls because they are legally bound to providing that care in that area, and if anything were to go wrong it's on them not the private agency. So i guess it just depends where you're from. To say all fire based EMS systems are less efficient in delivering care overall is kind of a biased statement. Especially when you're practicing in one area. Same goes for me. I shouldn't and don't think every fire based EMS department is a golden star, but just from what I'm used to working around that seems to be the facts I see when witnessing the patient care rendered.


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## RocketMedic (Oct 29, 2017)

I mean, all I really have to measure Fire EMS by is Houston Fire, which is stunningly mediocre.


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## RocketMedic (Oct 29, 2017)

I don't think its the providers that are bad, I think it is the system that they are working in that is bad. Systems like HFD, LACoFD, etc...for some reason, they allow their people to become poor providers. Why?


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## VentMonkey (Oct 29, 2017)

I call bullsh*t on the “it’s a system’s fault overall” mindset. No one forces these providers to become mediocre once they’re licensed. Everyone has a choice, system or not.

I have seen good LACoFD paramedics make a watered down system work for them, why? Because their ability to, or not to, give certain medications hardly defined their patient care abilities. Most were medics in a previous life, some were not. Either way, these folks chose to make miracles happen in a notoriously troubled system.

Saying it’s a system as a whole I feel only further serves as a testament to the generation we’ve become. The individuals may not make the system, but that doesn’t mean they’re always overlooked. Accountability, man.


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## Summit (Oct 29, 2017)

Sure its a system problem! A system set up to prioritize Fire and attract those who prioritize Fire is a kind way to describe the average FF/EMS system.


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## VentMonkey (Oct 29, 2017)

Summit said:


> Sure its a system problem! A system set up to prioritize Fire and attract those who prioritize Fire is a kind way to describe the average FF/EMS system.


Lol, I took the @RocketMedic post more along the lines as referring to the system, i.e., county that they function in. He can clarify for us, and I’m typically hit or miss with reading into some posts.

I think you’re referring to the fire-based culture, which yes, overall leaves lots to be desired. It really does suck for the guys and gals that grind it out trying to do right by their patients; I’ve witnessed it firsthand—I think most of us have.


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## RocketMedic (Oct 29, 2017)

I don't necessarily think it's Fire culture. In fact, Fire culture has a lot to be praised: a focus on employee rights and quality-of-life (in excess of the average private service, at least), a sense of comraderie that is generally non-toxic and positive, solid community engagement, ownership and funding, a sense of professional purpose and a deployment model that can facilitate real, positive mentorship and professional development beyond the two-man team. In fact, there's a lot of fire departments that I reckon I'd really enjoy being a part of, and part of me wants to get the minimal Fire training to get hired as a medic (or single-role medic lol). 

With that being said, some of these departments build incredibly disrespectful, minimalistic cultures that do not emphasize quality care, patient advocacy or even basic medical fundamentals. I don't think it's because they're busy...plenty of small departments have similar workloads on a per-unit basis. I don't think it's a quality-of-person issue; most of the firefighters I've met are very intelligent, capable people and EMS isn't exactly rocket surgery. I don't even think it's a regional issue; as VentMonkey pointed out, there's good medics who provide good care everywhere, regardless of protocols (and most of the most egregious faults against fire-based EMS aren't necessarily failures to push the upper limits of what can be done, but failures to even begin to start what can and should be done...ie non-medicated open isolated extremity fractures, brushing off chest pain, etc). Why is this? Is it that urban fire departments are less capable of providing good service than their rural counterparts? Is it just bad luck?


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## VentMonkey (Oct 29, 2017)

Rocket, you make good points about the culture that the fire service does bring, but as I eluded to in another post- do they really need to be so involved with ALS care in such settings?

Now, again smaller departments aside may really have no choice other than to provide ALS services to their communities; I am referring mainly to major metropolitan FD’s. I don’t know how many times that the departments in my county want to “go ALS” because there’s no ALS ambulances available, not ambulances, ALS ambulances. 

To me this says (at least here) they’re severely lacking the knowledge possessed to comprehend what not only paramedics can bring, but what paramedics _can’t bring_, what a good BLS ambulance can, or even what their own proper BLS care can do. They’re selling their selves short, and way overselling the value of a trade that may, or may not be entered in a 5-10 minute ride to the hospital.

I don’t necessarily feel that having that comradeship as paramedics—in EMS—if there were less of us, used appropriately, and able to fit in to part of their BLS team is all that important. A specialzed skillset called upon properly and accordingly in an urban/ suburban setting makes much more sense to me. Isn’t that what is was intended to be, and not what we’ve seen it become?

I think we can both agree that some of the larger fire-based system’s ineffectiveness does nothing for the populations that they serve. Sure they may take it seriously, but they will never take it more seriously than a fire, and that’s ok. What is not ok is these over saturated systems pretending that it is.

And yes, having seen how they often pass many of their fellow “brothers” while the intern who actually puts time, and effort into their internship is heckled and ridiculed leaves no doubt in my mind why their care is often subpar. If that isn’t cultural, then I don’t know what is. 

In essence, *as a whole*, the larger FD’s I have seen are very incapable when compared to their counterparts.


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## RocketMedic (Oct 29, 2017)

I don't think it's actually an ALS vs BLS split, VentMonkey. The crappy Fire care I've witnessed has been crappy care in general, and the fact that it wasn't really good care in the first place was the only thing that made it BLS, not necessarily the certification level of the call. If anything, I think a lot of HFD and LACoFD's problems (to cherry-pick two) are because they do have the belief in a tiered BLS-centric system, where the vast majority of calls are BLS.


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## Tigger (Oct 29, 2017)

RocketMedic said:


> I don't think it's actually an ALS vs BLS split, VentMonkey. The crappy Fire care I've witnessed has been crappy care in general, and the fact that it wasn't really good care in the first place was the only thing that made it BLS, not necessarily the certification level of the call. If anything, I think a lot of HFD and LACoFD's problems (to cherry-pick two) are because they do have the belief in a tiered BLS-centric system, where the vast majority of calls are BLS.


I agree. A failure to embrace EMS as a core mission happens to all levels of providers. It is amazing to watch three FF/EMTs crap all over their own medic for trying to do right for the patient just because they look at EMS as something beneath them.


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## gonefishing (Oct 29, 2017)

If such large departments that im use to like LAFD/LACO went to single role and had a division..... oh wait! They did! LOL they phased out their single role providers and most are on forced retirement now.  It worked and from what I heard too well.  They needed to justify shifts for fireman vs single role emts and medics.


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## Uclabruin103 (Nov 1, 2017)

I'm one of the much despised fire medics, and it feels like a lot of the non-fire medics on here are the ones who create this divide between us when there's no need for it.  If you guys think we sit at the station and talk trash on the ambulance, you're wrong. 

First off, I've worked for both fire and privates. Training for both is usually just the minimum mandated by the licensing agency. So I'm asking, how many hours a month do the single role medics spend on training?  What's the training consist of; video, live instruction, online?

As was mentioned earlier, there's good and bad providers in all aspects of healthcare. Hell, I'm trying to pick a pediatrician for my kid and there's horrible providers and excellent providers, and those are MDs. Why would medics be different?  Navy seal medics are cross trained and spend a majority of their time on combat. Do you think they're poor medics because of it?  I'm sure you'd trust one with you family's life. 

The whole slow response issue. Again, that's seen everywhere. I've seen just as many ambulances slow roll as engines. 

Can't we just agree that there's good and bad people in all fields? 

Stop with this silly arguing. It's counter-productive to the advancement of EMS.


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## DesertMedic66 (Nov 1, 2017)

Uclabruin103 said:


> I'm one of the much despised fire medics, and it feels like a lot of the non-fire medics on here are the ones who create this divide between us when there's no need for it.  If you guys think we sit at the station and talk trash on the ambulance, you're wrong.
> 
> First off, I've worked for both fire and privates. Training for both is usually just the minimum mandated by the licensing agency. So I'm asking, how many hours a month do the single role medics spend on training?  What's the training consist of; video, live instruction, online?
> 
> ...


If you take an ambulance based paramedic who has no desires to become a firefighter and compare them to a firefighter paramedic you will usually find many differences. How many firefighter paramedics on “assessment” engines who actively seek out medical educational opportunities? Are they only getting the minimum CE hours needed to recertify or are they getting much more? Are they only maintaining the bare minimum classes that are needed to stay employed (ACLS, BLS, etc)? Do they enjoy running medical aids? If they are on scene of a medical aid and a fire breaks out will they bail out as soon as the ambulance arrives? Will they even open their drug box and give a patient pain medication or “just wait until the ambulance gets here”. Do they try to take over the scene of a call regardless of who was already on scene? Do they follow directions or do what they want on medical calls?

All of the questions that I just asked are issues that my area has to deal with on a daily basis. Yes there are good firefighter paramedics however the vast majority of them are not. Heck, as long as the firefighter medic who responds is friendly that’s all I can ask for. 

I was a firefighter explorer for 5-6 years (I know, just an explorer). During that time I thought we were hot **** because that is what we were trained to believe. I thought we came before God on every call and that the normal citizens should bow at our feet. 

When I started working on the ambulance I was exposed to the truth (at least for my area) that the vast majority of firefighters hate medical aids and a vast number of them became paramedics just to get the fire job. In my area all firefighters have to be at least EMTs so there are a lot who became an EMT just to get hired on. 

We have firefighter medics who will force patients to go to the hospital against their will. They will threaten patients. They will flat out lie and get pissed when I call them out on their lies. We have fire crews who will cancel themselves before getting on scene of a medical call because the ambulance is already there. We have fire crews who will only send in one person to the house while the rest of the crew stays in the engine. We have fire crews who will decide to enter an unsafe scene we were staging at because PD was taking too long. 

Yes there are good and bad people at my company however out of all the ones who do not want to go fire, they are passionate about being a medic and are actually great providers. In my area the same can not be said about the vast majority of firefighters.


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## DrParasite (Nov 1, 2017)

Uclabruin103 said:


> I'm one of the much despised fire medics, and it feels like a lot of the non-fire medics on here are the ones who create this divide between us when there's no need for it.  If you guys think we sit at the station and talk trash on the ambulance, you're wrong.


no one ever said you trash talk the ambulance, but let me ask you this: your a single company house, and in your first due you get two calls at the same time, one for a cardiac arrest, and one for a structure fire in a vacant dwelling....... its your decision, which are you going to?





Uclabruin103 said:


> Navy seal medics are cross trained and spend a majority of their time on combat. Do you think they're poor medics because of it?  I'm sure you'd trust one with you family's life.


honest answer?  I would trust them to handle any traumatic injury..... would I have the same level of confidence in treating a Tricyclic Antidepressant overdose?  ehhh......





DesertMedic66 said:


> We have firefighter medics who will force patients to go to the hospital against their will. They will threaten patients. They will flat out lie and get pissed when I call them out on their lies.


so you advocated for your patients, and filed a complaint with the department of health right?  forcing patients to go to the hospital against their will is kidnapping (a criminal offense), and if you have medics who are threatening their patients, than they don't deserve to be medics, and should have their certs yanked.


DesertMedic66 said:


> We have fire crews who will cancel themselves before getting on scene of a medical call because the ambulance is already there. We have fire crews who will only send in one person to the house while the rest of the crew stays in the engine.


So you or your supervisor had a chat with their battalion chief right?  In all honesty, if the ambulance is already there, there is no need for first responders (unless there is a need for additional hands).  But if they are cancelling themselves inappropriately, why have their not been formal complaints raised up the chain of command?


DesertMedic66 said:


> We have fire crews who will decide to enter an unsafe scene we were staging at because PD was taking too long.


define an unsafe scene..... an overdose?  an assault?  a drunk?  a medical call as a location with a history of violence?  ehhh, I've been first in on all of those, rarely with an issue.  Plus if I'm on an engine with 4 people, I'm pretty sure we can handle it.  even a shooting or stabbing on the outside, do a drive by and see what is going on.  Now if you are talking about active assault in progress, active gun fire, penetrating trauma inside a structure, or whatever, that's their issue and that sounds more like an organizational culture issue.


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## akflightmedic (Nov 1, 2017)

Uclabruin103 said:


> Navy seal medics are cross trained and spend a majority of their time on combat. Do you think they're poor medics because of it?  I'm sure you'd trust one with you family's life.



First, it is SEAL. Never, ever lower case it.

Second, hands down I would absolutely trust them for trauma. Medical....well, when the general population they see are the healthiest and fittest of the healthiest and fittest. I am not quite sure Grandma's chest pain and other comorbidities is within their immediate wheelhouse.

Poor comparison.

I have worked both sides of the equation as relevant to this discussion (Single Role Medic versus FireMedic) in several different departments both paid and volunteer. There is a very real disparity in how EMS calls are viewed versus Fire calls...even from the Fire Medics. I still standby an old post I have made several times actually...this goes to biology and human psychology.

There is something primal about fire and leading the fray. Then there are natural care giver type personalities. Some people have a little of both, a lot of both or just one or the other. The fire service and EMS are two completely different mind sets and personalities. "We" conform them/ourselves to make it fit cause we have been told to do so, however it is an outdated practice, one that was done with the mindset of saving dollars with no real thought or analysis given to the actual career and the types of people who enter these careers.

It is almost like holding onto a declining stock and refusing to sell. We have pumped the model so much and invested time, energy and funding into it...no one wants to be the one to say "You know, this really is not the best utilization of our public services...let's try something different...". Humans are resistant to change for the most part.


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## DesertMedic66 (Nov 1, 2017)

DrParasite said:


> so you advocated for your patients, and filed a complaint with the department of health right?  forcing patients to go to the hospital against their will is kidnapping (a criminal offense), and if you have medics who are threatening their patients, than they don't deserve to be medics, and should have their certs yanked.
> So you or your supervisor had a chat with their battalion chief right?  In all honesty, if the ambulance is already there, there is no need for first responders (unless there is a need for additional hands).  But if they are cancelling themselves inappropriately, why have their not been formal complaints raised up the chain of command?
> define an unsafe scene..... an overdose?  an assault?  a drunk?  a medical call as a location with a history of violence?  ehhh, I've been first in on all of those, rarely with an issue.  Plus if I'm on an engine with 4 people, I'm pretty sure we can handle it.  even a shooting or stabbing on the outside, do a drive by and see what is going on.  Now if you are talking about active assault in progress, active gun fire, penetrating trauma inside a structure, or whatever, that's their issue and that sounds more like an organizational culture issue.


Making complaints against the fire departments goes no where at all, believe me I have tried. 

Fire views us as “less than they are” so our supervisors have zero power to do anything. 

Unsafe scenes where we have zero information about the call and are told to stage by Dispatch or for confirmed assaults/domestic violence and are once again advised to stage. Domestic violence calls are some of the most dangerous calls that law enforcement responds to.


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## FiremanMike (Nov 2, 2017)

Ok, which one of you f-er's are sitting behind your keyboard and praying that things start going poorly at my department???? 

This week has been an absolute ****storm.. 

On the plus side, everything is being taken seriously and issues are being addressed


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## VentMonkey (Nov 2, 2017)

I hardly wish bad on any department, let alone one with a seemingly involved EMS coordinator. I seriously don’t care if it’s fire-based or not. Is it good to, and for the community it serves? Shouldn’t this be all that truly matters?


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## Melbourne MICA (Nov 27, 2017)

RocketMedic said:


> *Disclaimer: This isn't a slight against firefighters, and it's not necessarily targeting the high-functioning fire departments out there that do the right things, or even the fire-medics that actually do their jobs the right way.
> *Disclaimer 2: I'm not a firefighter, not particularly interested in being a firefighter.
> 
> So we hear a constant stream of anecdotes from across the nation, mostly from larger cities with big fire-based EMS systems, and there's a pretty common thread- systems operating at the limits of their operational capacity constantly, long shifts, provider and patient abuse, and terrible medical practice. So, why is this happening?



Hi all,

Have a lot of interest in this topic from the point of view of the mixed models of EMS operation used in the US especially private EMS companies and subcontracting to other service industries like, firefighting. Is there an argument to suggest EMS is best served by a dedicated industry sector not tied to profit driven operations or as an appendage to other organisations where EMS is a secondary activity next to their primary service and mainly used to generate another income stream/public relations bonus? Are the mentioned failings resulting from a insufficient enthusiasm and oversight because of these contrasting agendas? Fire services In Australia have been keen to expand into EMS but there is very little enthusiasm from the troops on the ground, just from the bosses who see personal political and prestige gains from taking on EMS rather than a genuine interest or understanding of pre-hospital emergency care. When people apply to ambulance anywhere in Australia they know it is a service oriented industry run by the state for the public good, no other reason. Funding models through our universal health care system/ government funding and small subscriptions to ambulance (around $80 AUD/year) keep ambulance going profit or not, such is the public attachment to this industry. Suggested attempts to privatize ambulance in the past have met with enormous public backlash. I'm not suggesting fire services in the US or similar agencies can't do pre-hospital health care well. Rather,is the non centralised nature of EMS in the US an encumbrance to smooth operations and oversight to maintain standards short of designing practices around reducing risk of litigation? Less than 50% of US states have a standard set of protocols and even where these exist they are not uniformly or universally used by services in the those states. And you have a dozen or more EMS models employed. Short of setting up practices that might get you sued why wouldn't a private company want their operation aligned only to their agendas? Hope I'm not coming across as disparaging. Not my intention. I've done a lot of work on burn injury 1st aid/Rx, published some material and discovered CPG's and practices in this area in the US can only be described as a basket case from a clinical point of view. You can cross a county line and have different service provider operation, different payment system and a burn may not even get the same first aid delivered by the different EMS company. Interested in opinions.


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## RocketMedic (Nov 28, 2017)

Dude, you can literally cross a _street _here in the USA and get wildly different care. If I get hurt in Houston, HFD will probably send a BLS truck and they might let me bite down on Kerlex or something for pain management. If I'm in Cy-Fair's area, I'll probably get a few micrograms of fentanyl...but if I am able to drag myself across the road into Cypress Creek/ESD48/Northwest (Tomball) or MCHD, I'm getting the world's best care.


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## Melbourne MICA (Nov 28, 2017)

RocketMedic said:


> Dude, you can literally cross a _street _here in the USA and get wildly different care. If I get hurt in Houston, HFD will probably send a BLS truck and they might let me bite down on Kerlex or something for pain management. If I'm in Cy-Fair's area, I'll probably get a few micrograms of fentanyl...but if I am able to drag myself across the road into Cypress Creek/ESD48/Northwest (Tomball) or MCHD, I'm getting the world's best care.


Thanks Rocketmedic.

I know there have been major attempts at standardising protocols more than once. Which begs the question - why haven't things changed because I was reading about these same issues back in the early 1990's. My perspective is the issue has a broader dimension - its because US citizens can't accept a universal health care system which of course entirely changes the funding for health care and hence the resourcing landscape. Its madness. Universal health care doesn't mean commies and state control of everything. Ours started in 1973 - smack bang in the middle of the Cold War. This idea has been a figment of the American imagination as long as I've been alive.Just about every other Western country has one although not all of course run public only ambulance models. I appreciate their are local nuances, but while everyone is fixated on making money and being "individual" concerns like those noted here  will go on and on. Total BS.


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## FK911 (Nov 29, 2017)

DesertMedic66 said:


> I can only speak for my area but 100% of the daily training they do is based on fire and rescue training. The only time they cover EMS is when they are forced to take a BLS CPR, ACLS, and yearly mandatory meetings by the EMS system.
> 
> We were a training center for the fire department however when we found out they were allowing their medics to recertify in BLS CPR, ACLS, and PALS in one 8 hour day, we quickly stopped being the training center for them.


And a good attorney will hang them at a jury trial. 
This question will be asked on cross examination 
How many hours a month do you spend on training? 
How many hours of that is in fire suppression and rescue? 
Can you produce training logs to vailidate your answer? 
How many hours are spend on EMS training? 
Can you produce logs to validate your answer?
What percentage of calls are fire and rescue? 
What percentage of calls are EMS? 
“We all know most calls are EMS and they drilll on fire rescue” we just need th jury to know this...

Then the attorney will say.. 
based on your answers your Training time is possibly inadequate in relation to the type of calls your running.
Please answer the question... you are under oath! 
Defense will object 
Jury has a picture in there mind. 
That’s all that’s needed 
City will settle?


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## needsleep (Dec 7, 2017)

I know I'm late to the party, but as a new "brother" (gag me) to a Fire-based EMS system, patient care is often times an atrocity. I'm in one of the biggest career departments in my (large) state. If you enjoy EMS you are looked at as a p**s* who must be scared of fire or mentally deranged. Were told to "quit talking about ambulance crap, we're firefighters." We do have a very, very, very, very, small number of passionate providers but they are only here until the next nursing classes start. Extremely discouraging and disappointing


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## RocketMedic (Dec 7, 2017)

needsleep said:


> I know I'm late to the party, but as a new "brother" (gag me) to a Fire-based EMS system, patient care is often times an atrocity. I'm in one of the biggest career departments in my (large) state. If you enjoy EMS you are looked at as a p**s* who must be scared of fire or mentally deranged. Were told to "quit talking about ambulance crap, we're firefighters." We do have a very, very, very, very, small number of passionate providers but they are only here until the next nursing classes start. Extremely discouraging and disappointing



Sad, isn't it?


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## needsleep (Dec 7, 2017)

I asked one of the guys who has been in the fire service for a while why it is that way. He stated to me there was " no masculinity in EMS." I guess its not "manly" to have a desire to actually help others vs. sitting in a recliner all day watching porn on your phone except for the once a day you leave on the engine to go get groceries.


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## DrParasite (Dec 7, 2017)

needsleep said:


> but as a new "brother" (gag me) to a Fire-based EMS system


You know, your might not like the brotherhood mentality, but it works in the fire service, it works in law enforcement, and it helps build cohesion, something that is frequently lacking in EMS, and leads to retention, limited loyalty to your employer, and a general feeling that this is a job, not a career.





needsleep said:


> patient care is often times an atrocity. I'm in one of the biggest career departments in my (large) state. If you enjoy EMS you are looked at as a p**s* who must be scared of fire or mentally deranged.


Truth be told, I know of many EMS people that are a little out there..... But I do agree, that patient care tends to suck, especially among people on the engine who don't want to be on the engine.  If they don't want to do it, if they don't care about it, and if their supervisors don't enforce that they need to be good at it or they should find another job, well, this is what happens.


needsleep said:


> Were told to "quit talking about ambulance crap, we're firefighters."


Again, the culture of the fire service is that they are the fire department; it won't change until they change from a fire department that runs EMS calls to an EMS First responding department that runs fire calls





needsleep said:


> We do have a very, very, very, very, small number of passionate providers but they are only here until the next nursing classes start. Extremely discouraging and disappointing


Which is even worse, because they are only using their current status as a stepping stone to a nursing career.  EMS has a rough time retaining our best, brightest, and our most passionate providers.


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## DrParasite (Dec 7, 2017)

DesertMedic66 said:


> Making complaints against the fire departments goes no where at all, believe me I have tried.


So you filed a complaint with the department of health and it went nowhere? wow, now that's impressive.  Most departments I am aware of don't have the pull to quash a regulatory agency investigation


DesertMedic66 said:


> Unsafe scenes where we have zero information about the call and are told to stage by Dispatch or for confirmed assaults/domestic violence and are once again advised to stage. Domestic violence calls are some of the most dangerous calls that law enforcement responds to.


I'll repeat my earlier advice: dispatch is often overly cautious. If they tell me to stage, and I, using my own judgement, experience, and situational awareness, decide to ignore their advice, that's my decision. 

If the FD (or anyone really) wants to enter a potentially unsafe scene, that's their issue, not your concern.  Just look at the Aurora Colorado movie theater shooting.... all the EMS crews staged in a safe location, and many fire crews went directly to the scene before the cops even knew what was going on.  In all reality, until they get burned by doing it, and a firefighter gets injured or killed, and during the investigation the statement of "dispatch told you to stage, and you didn't; as a direct result of your personal negligence, we are terminating your employment and you are personally liable for any civil liabilities that arise," nothing will change. 

But it's still not your issue, so you shouldn't concern yourself with their actions.


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## EpiEMS (Dec 7, 2017)

DrParasite said:


> that's my decision.


Your employer may not like it...and it should probably be part of their SOP to stage for calls on scenes of violence, no?



DrParasite said:


> You know, your might not like the brotherhood mentality, but it works in the fire service



Yes, that's true. But EMS doesn't work like the fire service (mostly) - 2 people in an ambulance, often of equal provider levels, working as a pair is so very different than the dynamic of 4-6 people on an apparatus with clearly defined different roles (engineer, officer, etc. etc.). Hence, the "team style" brotherhood concept is more of an equal partnership - a "marriage", if you will.


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## DrParasite (Dec 7, 2017)

EpiEMS said:


> Your employer may not like it...and it should probably be part of their SOP to stage for calls on scenes of violence, no?


So back when I was on the ambulance, pysch calls, assaults, overdoses, man down/unconscious person calls generated an EMS response, and units were sent when they were available.  The only time EMS was not sent was to psych calls where the patient was KNOWN or REPORTED to be violent or armed, assaults that were currently in progress, or any time when the call taker was told that there was an active threat on the scene; in those cases, a request was made to PD, and they were told to contact us when they were on scene (which often took a while).  The only calls we staged units for were stabbing and shooting calls.  That was their written policy.  Everything else we told PD to call us back when they got on scene, regardless of if it took 5 minutes or 3 hours

And as I stated earlier, my employer doesn't care as long as I didn't get hurt in the process, and I suspect that is the same line of thinking that the FD is applying.





EpiEMS said:


> Yes, that's true. But EMS doesn't work like the fire service (mostly) - 2 people in an ambulance, often of equal provider levels, working as a pair is so very different than the dynamic of 4-6 people on an apparatus with clearly defined different roles (engineer, officer, etc. etc.). Hence, the "team style" brotherhood concept is more of an equal partnership - a "marriage", if you will.


You're right.... they work more like the police:  two person teams, equally trained, working together for an entire shift?  And they have their LEO "brotherhood"

The brotherhood isn't between you and your partner; it's between you and the industry as a whole.  Very big difference.


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## VentMonkey (Dec 7, 2017)

DrParasite said:


> The brotherhood isn't between you and your partner; it's between you and the industry as a whole.  Very big difference.


You know? I get teamwork, collaboration, and all of the important things that go along with it, particularly with critical or difficult calls, but why does EMS need a “brotherhood”?

I mean think about, it’s ultimate purpose is primary prehospital care in the out of hospital setting. There’s a stronger need for a universally adopted level of clinical-based providers at a standardized, and increased level. This seems much more prudent than a sense of “belonging” within prehospital services, respectively.

I’m not saying that mentality is bad, I’m saying I don’t think it’s as pertinent to this particular public service. The sooner we realize this, and focus on the paragraph above, the better off our respective services will be.


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## EpiEMS (Dec 7, 2017)

DrParasite said:


> You're right.... they work more like the police: two person teams, equally trained, working together for an entire shift? And they have their LEO "brotherhood"



Fair enough. That said, I don't know many cops that work in pairs (at least in suburbs or rural areas).



VentMonkey said:


> You know? I get teamwork, collaboration, and all of the important things that go along with it, particularly with critical or difficult calls, but why does EMS need a “brotherhood”?



The whole "brotherhood" thing is nice, but I'd settle for higher education requirements


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## VentMonkey (Dec 7, 2017)

EpiEMS said:


> The whole "brotherhood" thing is nice, but I'd settle for higher education requirements


Yup, and EMS wasn’t founded on things such as this. Again, it doesn’t make these qualities wrong, or less than. It just doesn’t fit into EMS as a public service. But more specifically, it prohibits the full extent of the services that we _could_ potentially provide by trying to fit our square into the other’s (proverbial) cultural hole.

God forbid I ever have to call for an ambulance, but if I did I sure wouldn’t be thinking: “Man, their medicine was marginal, but I’m sure glad they displayed a sense of ‘brotherhood’ throughout that call.”...


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## EpiEMS (Dec 7, 2017)

VentMonkey said:


> It just doesn’t fit into EMS as a public service.



ACEP says "EMS holds a special position at the intersection of public health, health care, and public safety."
I think this is right. We've got elements of all three. From an organizational perspective, the last is...an unfortunate, if necessary one - you're going to a place emergently, and people associate lights and sirens with public safety.


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## VentMonkey (Dec 7, 2017)

EpiEMS said:


> ACEP says "EMS holds a special position at the intersection of public health, health care, and public safety."
> I think this is right. We've got elements of all three. From an organizational perspective, the last is...an unfortunate, if necessary one - you're going to a place emergently, and people associate lights and sirens with public safety.


Yes, exactly what the ACEP is saying. Unfortunately @EpiEMS, you and I both know outside of this forum many of us are outnumbered at our respective services with this train of thought.

So keeping the thread on topic, we are but a pivotal hodgepodge of the trifecta listed above. We don’t train for calls the same way a fire department would train for a house vs. veg fire, or are taught to “watch our partners six” (gags) the way perhaps law enforcement does with absolutely founded intentions. 

Do we, and should we look out for one another? Absolutely. Clearly without ourselves and our partners we’re an ineffective trifecta. 

It’s just unfortunate that many of our co-workers and colleagues fail to see, read, acknowledge, or listen to what it is you’ve shared above that the ACEP—a seemingly credible source of EMS-info—has gracefully bestowed upon our...profession.


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## BobBarker (Dec 8, 2017)

DrParasite said:


> So you filed a complaint with the department of health and it went nowhere? wow, now that's impressive.  Most departments I am aware of don't have the pull to quash a regulatory agency investigation


It's California LOL. I've filed a complaint on a hospital one time when they almost killed my father by overdosing him on Dilaudid in the ER and the nurses not knowing what to do after. I had to bag my own father for about 2 minutes until more competent staff showed up. Not to mention this same hospital was fined for overdosing and killing a patient about 3 years before our incident. Did the Department of Health care? Nope. I called and emailed the investigator assigned multiple times and never heard back in 2 years. The only good that came out of this was the hospital waived our copay/coinsurance for life (and we are forced to use them due to insurance)


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## E tank (Dec 8, 2017)

Billy D said:


> It's California LOL. I've filed a complaint on a hospital one time when they almost killed my father by overdosing him on Dilaudid in the ER and the nurses not knowing what to do after. I had to bag my own father for about 2 minutes until more competent staff showed up. Not to mention this same hospital was fined for overdosing and killing a patient about 3 years before our incident. Did the Department of Health care? Nope. I called and emailed the investigator assigned multiple times and never heard back in 2 years. The only good that came out of this was the hospital waived our copay/coinsurance for life (and we are forced to use them due to insurance)



Stuff like that goes through the state board of nursing and/or medicine.


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## BobBarker (Dec 10, 2017)

E tank said:


> Stuff like that goes through the state board of nursing and/or medicine.


Well, maybe. But considering it was literally almost the exact circumstances as the fine they had received previously and the Department of Public Health was the one who handed that down, I went down that path. I forgot to mention the other things I complained about was the first 2 EKG machines didn't work and the understaffing of the hospital as well. CA actually has a minimum nurse to patient ration mandated by law. I think they also investigate it because it took place in a hospital and they investigate hospitals. I will be calling the Board of Nursing tomorrow morning, but I doubt they will even listen to an incident that occurred 2 years ago and didn't have a terrible outcome. Thanks for replying


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## Djohnson (Jan 15, 2018)

I've been on both sides of the fence on this one. I started my career in a fairly big city that had an EMS system that was separate from fire. The firefighters were great at fighting fire and the paramedics were, for the most part, great EMS providers (ALS only 911 trucks). The issue was that the engine company (99% we're BLS) almost never had to perform patient care past vital signs because the ambulances were usually right behind them. Many of the firefighters became complacent and did not do much, if any, EMS training. This meant that on the calls where they did have to perform patient care, usually on critical patients, their skills just we're not there. I ended up leaving to work for a combination fire and EMS system just outside the city. The environment and culture in this department is completely different than the city. Because it is a combination system, we do fire and EMS training almost equally. There are a few narrow minded firefighters that feel like EMS was forced on them, but they are the minority.


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## StCEMT (Jan 15, 2018)

Djohnson said:


> I've been on both sides of the fence on this one. I started my career in a fairly big city that had an EMS system that was separate from fire. The firefighters were great at fighting fire and the paramedics were, for the most part, great EMS providers (ALS only 911 trucks). The issue was that the engine company (99% we're BLS) almost never had to perform patient care past vital signs because the ambulances were usually right behind them. Many of the firefighters became complacent and did not do much, if any, EMS training. This meant that on the calls where they did have to perform patient care, usually on critical patients, their skills just we're not there. I ended up leaving to work for a combination fire and EMS system just outside the city. The environment and culture in this department is completely different than the city. Because it is a combination system, we do fire and EMS training almost equally. There are a few narrow minded firefighters that feel like EMS was forced on them, but they are the minority.


There are a few hidden gem stations/crews like 6, but I know exactly what you mean hahaha.


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## ParamagicFF (Mar 30, 2018)

I believe this all boils down to the leadership and culture of the Fire and or EMS agency. I don't think it's appropriate to make too broad of strokes here. There may be regional tendencies, but I do not think it's appropriate to say that Fire based EMS employees are inherently worse than single role employees.

I began my ems career as a hospital based ALS provider. My "preceptor" was unable to read EKGs, hadn't reviewed ACLS for at least 10 years, and in general couldn't do much more than push a cot. First week in she was unable to catch an obvious STEMI, and when I pointed it out she did not know how to treat it. I brought these concerns to management and they admitted it was a known problem, but that it hadn't caused any major problems. We were all just warm bodies in seats. The leadership was more concerned with other things than ensuring appropriate care was given. There was no CQI at all beyond ensuring billing requirements were met. Missing a run, or failing to fill out billing paperwork were the only real punishable events.

I then moved to a medium city fire/EMS agency where medics split time between transport and suppression. We drilled on fire and EMS almost equally. The culture was one of excellence and accountability in all things. The medicine was progressive, and we were all expected to keep up. It wasn't a department filled with geniuses, or all even paramedics. However, we were all expected to perform to a standard, and that standard was reviewed. We had CQI for certain events, and then random chart reviews. This was an EXCELLENT EMS system.

I now work for a big city Fire/EMS dept where there is virtually zero accountability. We split time between suppression and transport. Because of the lack of accountability, performance is based almost exclusively on each provider's personal drive. We have some truly excellent EMTs and Paramedics, and we have some that TRULY can't even push a cot effectively. We have a formal CQI process, but I don't know exactly how it works. Despite participating on MANY critical calls, I've never been contacted. I've anecdotally heard of people being contacted for trivial matters. It is not used as a training tool, and they are seperate from operations.

Sorry for the long winded post, but I believe it was all worth saying.


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## VinceVega91 (Apr 8, 2018)

Our city runs a third service EMS system separate from the Fire Department in an urban setting. We do all the transports, Fire shows up as a first responder, mostly BLS but some ALS pumpers, and they provide initial care before we show up to transport. The firemen are great at fighting fires and for the most part very good at medical calls. Most of them clearly want nothing to do with us or want nothing to do with a merge and neither does our department, but most of our trucks are housed at the fire stations. Some of our trucks are housed at police stations, one is eventually housing with a dog kennel lol, and the rest just roam the city and sit on a street corner. Some of the trucks that cannot fit in a fire or police station are left outside and in the winter they are left running until they get a call, and that's terrible sometimes for the trucks in terms of wear and tear. We get a lot of trucks out of service as a result too. The fire stations however, have a separate room for us EMS guys, but no sleeping quarters, because we don't get the down time they do, we run 12 hour shifts and they do 24's, and there is barely any comradery or brotherhood in the fire stations between EMS and Fire since we are separate departments. There's no animosity either, but we at least get along together and work well together on our emergency scenes and get the job done.

As far as how patients are treated is concerned, the firemen are very helpful on our more serious and critical calls such as full arrests, traumas, critical medical calls, etc. The guys are able to do IVs, give meds, interpret ECGs adequately and it really helps us out a great deal when they do that. Of course, there are older, old fashioned firemen who don't want to do much and don't help at all, but then again we have guys who won't even get out of the truck or prepare the cot for when we are at Structure Fire Standby's, so yeah there's going to be morons on both ends who don't want help each other and do the right thing and that's not cool. We strictly do EMS so we should and we do a very good job at what we do, the Firemen strictly do firefighting and do great at what they do too. So I think third-service really isn't a bad way to go especially for major cities, it's just a matter of the cities having the funding to take care of each public safety division appropriately, which our city could do a little better at. What I mean is if they want us to stay separate, then at least make separate base stations that are specifically made for us and our trucks, but that's asking for too much.


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## EMT Rookie (Dec 8, 2018)

RocketMedic said:


> *Disclaimer: This isn't a slight against firefighters, and it's not necessarily targeting the high-functioning fire departments out there that do the right things, or even the fire-medics that actually do their jobs the right way.
> *Disclaimer 2: I'm not a firefighter, not particularly interested in being a firefighter.
> 
> So we hear a constant stream of anecdotes from across the nation, mostly from larger cities with big fire-based EMS systems, and there's a pretty common thread- systems operating at the limits of their operational capacity constantly, long shifts, provider and patient abuse, and terrible medical practice. So, why is this happening?


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## EMT Rookie (Dec 8, 2018)

Such an interesting thread....I never really thought about the interplay between the Fire based and the EMS based systems but can see now just how different they are in terms of overall patient care and outcomes.


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## KingCountyMedic (Dec 10, 2018)

You're all doing it wrong.


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