Why don't some like the fire mix?

[Carlos Danger]

I can't definitively say that fire is better for quality care, or that single role is better for quality care. For every apathetic firemedic, there is an apathetic single role provider that is using the EMS job as a stepping stone, or is stuck there because they don't have the skills to find a different well-paying career. For every stellar fire based EMS department that "does it right," there are stellar single role services that have their act together. For every parasitic fire department absorbing EMS, there is an abomination of a third service agency. Really, the only thing that I can say in favor of single role services is that the provider can focus solely on EMS. This does not mean that the average single role provider will study and train in EMS twice as hard as a firemedic, though. I know/knew plenty of single role providers and fire based providers alike that just do their monthly CEU articles, attend the minimum of CEU training, and not much else.

I don't disagree with a single word of that.

The way I see it, paramedicine is at a crossroads right now (we've actually been stuck at this intersection for a while), and things can go in one of two basic directions:

• We can admit that very little we do in the prehospital arena affects outcomes, and accept that our primary purpose is really just to provide safe, compassionate transport. We can stop making so much noise about increasing educational standards. We can stop pretending that we are like doctors, just with less training. We can de-emphasize or even get rid of all the ALS interventions that don't really help, which is most of them. This doesn't mean we stop trying to get better at what we do, it just means that we accept that adding interventions and skills has more to do with what we want than it does our ability to provide good care to our patients.

• We can strive to become true clinicians, which means first and foremost, LOTS MORE EDUCATION as a basic requirement to entry. That means investing 4 years of our lives and (for most of us) taking on substantial debt in order to become qualified to do the job we want to do. It means taking responsibility for our own protocols and the way our actions affect outcomes. It means doing research - actually learning the methods and statistics, designing projects, identifying funding, getting IRB approval, and doing the hard, tedious work. It means learning real pharmacology, not just memorizing indications, contraindications, and doses. It means realizing that your paycheck will soon rely on your ability to prove that what you do actually helps patients. It means spending a lot of time keeping up with all the new developments and finding ways to incorporate them into your practice, rather than just waiting for the new protocol updates that come out every year or two. It means lobbying bureaucrats and politicians to change statutes and regulations to grant the legal authority to do all of this. It means a lot less talking about "improving paramedicine", and a lot more doing.

Which path should EMS take, and how does that relate to the design of delivery models?

 

[gotbeerz001]

I don't see the trends changing in busy urban settings. The nurses we hand off to generally do not want anything more than a good hx and IV access. Even when we can justify additional meds, the prehospital menu does not often reflect what will be used in-hospital so we, in fact, would generally cause delays to definitive care as they wait for our meds to wear off.

In these settings, higher levels of education and scope would not change the fact that 50% of those transported do not have acute illness, 30% require assessment, access and observation only, 15-18% will actually present with conditions which warrant med administration and (maybe) 2-5% actually require immediate intervention and rapid transport.

I understand that rural settings do not necessarily fit this model, but in a system that mirrors the numbers listed, fire-based EMS will be more than sufficient.

For those systems that require higher levels of care, they should employ PAs.

 

[irishboxer384]

and (maybe) 2-5% actually require immediate intervention and rapid transport.

Fire fighters are not kicking in doors and rescuing blue eyed babies from fires every hour of their shift...nor are cops in fire fights outside banks everyday...less than 10% of soldiers use their weapon in anger in conflict....does this mean we can be content putting the public's trust in personnel with a lesser knowledge of fire science, law or military tactics and strategy? No...we continue to look for improvements....

Surely it is better to be extremely proficient in one career field, than a 'jack of all trades master of none'? If 2 people complete the same level of paramedic education, and one of them has no real interest in emergency medicine... is he/she going to come away with the same level of knowledge? I don't want to be a fire fighter, and I don't blame fire fighters who don't want to be medics: so why put medics in a position where they join the FD just for the money or to guarantee 911 medical response...and why put fire fighters in a position where they are only interested in fire-related response...it could be avoided.

 

[gotbeerz001]

Maybe I haven't made myself clear:
I enjoy fighting fire. I enjoy being a transporting medic. I too get frustrated when I am handed a poorly assessed "flu-like" pt who turns out to be septic.

My views are reflective of the system in which I work. The medical directors do not expand the scope of paramedics since the transport times are so short and definitive care is available in a matter of minutes. While "advanced care" is a great ideal, it is a numbers game. At the private, we have over 450 employees; 300+ of which are medics. When the system is so impacted by subacute illness that can be BLSed in, requiring such higher skills, the training required to maintain such skills and the increased wages that will surely be demanded, the math doesn't add up.

Cutco may make a superior knife, but oftentimes the one in the Leatherman works just as well... And without being so pretentious.

 

[sjukrabilalfur]

I don't disagree with a single word of that.

The way I see it, paramedicine is at a crossroads right now (we've actually been stuck at this intersection for a while), and things can go in one of two basic directions:

• We can admit that very little we do in the prehospital arena affects outcomes, and accept that our primary purpose is really just to provide safe, compassionate transport. We can stop making so much noise about increasing educational standards. We can stop pretending that we are like doctors, just with less training. We can de-emphasize or even get rid of all the ALS interventions that don't really help, which is most of them. This doesn't mean we stop trying to get better at what we do, it just means that we accept that adding interventions and skills has more to do with what we want than it does our ability to provide good care to our patients.

• We can strive to become true clinicians, which means first and foremost, LOTS MORE EDUCATION as a basic requirement to entry. That means investing 4 years of our lives and (for most of us) taking on substantial debt in order to become qualified to do the job we want to do. It means taking responsibility for our own protocols and the way our actions affect outcomes. It means doing research - actually learning the methods and statistics, designing projects, identifying funding, getting IRB approval, and doing the hard, tedious work. It means learning real pharmacology, not just memorizing indications, contraindications, and doses. It means realizing that your paycheck will soon rely on your ability to prove that what you do actually helps patients. It means spending a lot of time keeping up with all the new developments and finding ways to incorporate them into your practice, rather than just waiting for the new protocol updates that come out every year or two. It means lobbying bureaucrats and politicians to change statutes and regulations to grant the legal authority to do all of this. It means a lot less talking about "improving paramedicine", and a lot more doing.

Which path should EMS take, and how does that relate to the design of delivery models?

That second model is the norm in a lot of the world, and I see no reason why investing long term in this sort of education and standard shouldn't happen.

 

[irishboxer384]

Maybe I haven't made myself clear:
I enjoy fighting fire. I enjoy being a transporting medic. I too get frustrated when I am handed a poorly assessed "flu-like" pt who turns out to be septic.

My views are reflective of the system in which I work. The medical directors do not expand the scope of paramedics since the transport times are so short and definitive care is available in a matter of minutes. While "advanced care" is a great ideal, it is a numbers game. At the private, we have over 450 employees; 300+ of which are medics. When the system is so impacted by subacute illness that can be BLSed in, requiring such higher skills, the training required to maintain such skills and the increased wages that will surely be demanded, the math doesn't add up.

Cutco may make a superior knife, but oftentimes the one in the Leatherman works just as well... And without being so pretentious.

I'm not disagreeing with you- it is a numbers game otherwise everyone would have a financially rewarding career and everyone would have degrees and have top of the line training courtesy of the government. The thread was about why some don't like the mix, if you equally enjoy fire and medical aspects I am happy for you as you have found the career for you...but I can see why it bothers people who want a bigger slice of the pie to apply to non-fire EMS, but that is the way the cookie has crumbled.

 

[Christopher]

Yawn.

This is a silly thread. There are dysfunctional, piss poor systems of all shapes and sizes. There are outstanding, role model systems of all shapes and sizes as well. EMS as a public service is obviously newer than fire fighting, and it will take time for wages to catch up as the public funding balance is altered. EMS has flatter organizations and less room for career growth because we don't really have a lot of job/skill differentiation (besides the patch on our shoulder). Maturation of our field (e.g. education, role expansion, etc) will improve both wages and growth opportunities. How this is delivered most effectively will vary by community and system.

Anything else is boring flame bait.

In general, I would stay out of the Carolinas - there's no money there. Medics generally make more than firefighters, but you're still starting at $12/hr or less.

Southeastern NC starts paramedics around $18-20/hr now...but that's neither here nor there.

 

[gotbeerz001]

The trend I see more and more is single-role medics within the municipal system. They are paid less than the first responding fire medics but receive public safety pension/benefits and the (overall) support of the Fire Union.

Seems like a good way for non fire-oriented applicants to have the best of both worlds.

 

[Bullets]

Just a small-sample anecdote.

When I was a student and doing clinicals with [unnamed urban midwestern fire/rescue service], the FF/Medics all vastly preferred being on the pumper to being assigned to the ambulance. They seemed like cool guys, and they weren't derelicts on the ambulance, but they treated it as a chore, or just something they just sort of had to do to get to their next pumper shift and it showed in how they handled their calls. I don't know if that's indicative of how all FF/Medics approach the ambulance side, but if it is, I'd rather the services be separated.

I will also echo this sentiment. Most FFs i know do it because they want to fight fire, and because they want to do the cool stuff. However, i find myself trying to remind them WHY we are cutting this car apart, or going in the water, or this hole....ITS PATIENT CARE. There are a number of EMS agencies in NJ that provide rescue services, and i think it is truly the best model. EMS is a life and health protection service, fire departments are in the property protection business. These are two different mindsets that i do not feel play well together

 

[Tigger]

The trend I see more and more is single-role medics within the municipal system. They are paid less than the first responding fire medics but receive public safety pension/benefits and the (overall) support of the Fire Union.

Seems like a good way for non fire-oriented applicants to have the best of both worlds.

Minus the whole "second class citizen" issue that many of these provides face. I have worked in a fire station as a single role EMS person and there was a definite hierarchy, and I was at the bottom. Obviously n=1, but I am certainly not the first person to have this issue.

 

[DrParasite]

At my current employer, I've had one promotion already, and I'm studying for the next promo. exam that's being held this winter. If I had stayed in single role EMS, there's a 95% chance that I would still be on an ambulance, with no raises other than step increases.

as a related topic, I was applying to work for a FD, and asked about career path. in EMS, you have EMT, Paramedic, (maybe FTO), supervisor, and then management, and you get a 2% raise every year. At the FD I was looking that, they had recruit FF, Firefighter I, Firefighter II, & Master firefighter (which were all non-competitive promotions, but they all carried raises), then you had Lt, Captain, BC, DC, and Chief of Dept. Plus all the ancillary divisions. Which has more of a career path, and which do you think pays more?

The problem with non fire based EMS is that most places put out barely enough ambulances to cover normal call volume, and hire. barely enough people to staff them. This results in busy tours and frequent holdover OT. A lot of places just burn through their people and replace them with new ones. No place is going to put out extra ambulances and hire more people just so that the units can be less busy. Their solution is to enter into automatic aid/mutual aid agreements as a fix, or far worse - System Status Management/PUM.

remember, an ambulance that isn't on a run isn't making money... even in the best systems, they have to justify every ambulance. Think of it this way: if an engine company is 5 miles away from the next due, in a low call volume area, and gets no calls, what happens? nothing, because it's there to cover that area. if the ambulance is in the same station, it's likely to get relocated somewhere else so it will go on more runs, to "justify it's existence." Also, for the FD, if the first due area is too busy, they put another engine in that firehouse 24 hrs a day. in EMS, you might get a power/peak load truck, but after the call volume goes down, the truck goes away.... until you get another call.

Besides the lack of a career ladder and poor pay, what ruined single role EMS for me was the high call volume. I'm not saying that we should just screw off all day and run two calls. What I am saying is that on a 24 hour shift, it should be understood that some on-the-clock sleep should occur. IMO this should amount to a minimum of four hours sometime between 2200 and 0600, preferably more. If it's a busy urban system, then the shifts should be 8's and 12's, with perhaps a day/evening 16 at the most. With these shorter shifts, dedicated off-the-air OOS meal breaks need to be implemented, just like employees in other industries. No more eating breakfast at 2 in the afternoon and dinner at 1 in the morning, and no more grabbing fast food because that's what's available on the road, and having to eat it on the road like damn animals. In my fire based experience, employees have options to get off of the box, and do something else entirely. Just off the top of my head, there's EMS training for the field and the academy, fire training, various suppression apparatus, Hazmat, Tech Rescue, Peer Fitness, and many promotional opportunities in and out of the field.

what he said.

 

[gotbeerz001]

I will also echo this sentiment. Most FFs i know do it because they want to fight fire, and because they want to do the cool stuff. However, i find myself trying to remind them WHY we are cutting this car apart, or going in the water, or this hole....ITS PATIENT CARE. There are a number of EMS agencies in NJ that provide rescue services, and i think it is truly the best model. EMS is a life and health protection service, fire departments are in the property protection business. These are two different mindsets that i do not feel play well together

Victim rescue trumps pt care when rescuers are in a sketchy situation, though. I'm sure you agree with that. While this doesn't necessarily apply to most basic vehicle extrications, if we are in the technical rescue environment (in a hole, in the water), only the most basic interventions will likely be applied... And even then, only if it does not slow down the operation or add additional complexity.

The sooner they are out of their specific emergent situation, excellent pt care has begun.

 

[avdrummerboy]

The title of this thread is why don't some like the fire mix? Naturally, you are going to get mixed opinionated answers and that is what the original question begs. Yes, opinions are like a certain body part, everyone has one and by the end of the day they all stink! I think the point to be taken away here is that there is good and bad in EVERY system/ setup. For every excellent fire dept. I can find you a piss poor single role EMS company. For every excellent single role EMS company I can find you a piss poor fire dept. Mixing a whole lot of stuff into one profession doesn't necessarily make it any better, especially when it is two fairly in depth areas like fire/ rescue and paramedicine, which makes one ask do Fire fighting and EMS need to be combined? Could there be an optimum to strive for, absolutely! I'd love to see EMS in this country move more towards the systems of the rest of the world in terms of training and education requirements.

Ultimately, every system is going to be different and everyone will have a different view of it all. At the end of the day, we both run together so we must make the best of it.

 

[46Young]

Detroit FD is going to start using their firefighters to run medical calls - by training as first responders, the EMT's, and eventually paramedics.

http://www.freep.com/story/news/local/michigan/detroit/2014/10/03/medical-first-responders/16618529/

Apparently their response times are 12 minutes and 40 seconds. This is where I disagree with fire taking on EMS, as a band aid for poor response times. Clearly, Detroit needs a bunch more ambulances, not suppression rigs to keep the patient company until an ambulance eventually gets to them. As I've said before, many employers (of each type) put out the bare minimum amount of ambulances they need to cover normal call volume, and rely on automatic aid/mutual aid and first responder resources to "stop the clock."

At least in my system the engine is either on-scene the same time as an ambulance, or is waiting 2-3 minutes tops for an ambulance in most cases. The manpower is nice to have, and I can get off scene way quicker than I would be able to with just two people. When I worked in NYC, they typical ALS call where I 'm starting lines, pushing meds, etc. would take up to 30 mins. on-scene. Here, if I'm on-scene more than 15 minutes to do ALS, it's too long. Shorter on-scene times result in quicker in-service times. Quicker in-service times makes every unit less busy overall. I consider us fortunate here, because even our busiest units only average 7-9 calls a day, with each call lasting an hour, give or take ten minutes. That's our busiest units on a 24 hour shift. I cringe when I hear of some places running 14 calls in a 24 hour shift with that being a slow day.

Edit: I can see the benefit of a combined service making the calls run quicker, but only if the service chooses not to under-deploy because of this efficiency. Said another way, I feel that it's good to use suppression units, with it's lower net utilization hours, to shorten on-scene times, but not if that results in less ambulances on the road. I can also see a benefit on OT control if members are dual role - it's easier to fill scheduling gaps with employees that are certified to ride in several different positions. Otherwise, mandatory hold and recall occurs to fill sick leave and vacation relief.

 

[46Young]

Fairfax County continuously hires FF/medics, but they're opening up the process for FF/EMT's from Oct. 25th through Oct. 31st only:

http://emtlife.com/threads/fairfax-county-fire-and-rescue-hiring-emt-bs.39653/

 

[Burritomedic1127]

Being that I've worked for both fire and private in the state the OP was from ill add my 2 cents. In MA the general thought process is getting on a fire department is "hitting the lottery" (quotes from co workers when i was hired after the civil service BS) and private EMS is something inferior. If it means anything i left the fire department to go back to the same private company as a medic full time again rather than part time in disgust. The overall thought of EMS in the Fire Depart is that its a punishment in between the RARE fires. The ambulance would be open every shift because people did not work to work EMS even at overtime rates ($1000/day for this dept). So whoever was punished would spread that negativity over to patient care. Dont get me wrong there are some great providers with a strong knowledge but they would not want to even sniff at the ambulance due to "already paying their dues." While on a medical, a fire was toned out and nearly every single person on scene at the medical, cleared up even before the pt was fully assessed, knowing they could call in a mutual aid private EMS crew to take over the call. I wont echo alot of points that have been said in this forum, but i think these FF who look as EMS as a punishment should realize that your job (as a FF) is the only type of job that is trying to put itself out of business (Fire prevention, better building codes, etc). I would recommend starting to embrace the EMS side of things because once a town manager realizes all of this money is being spent on something that rarely happens anymore, Im sure there will be fights to be on the ambulance for the shift because your jobs depend on it.

 

[titmouse]

Here in Miami if you want to make better money FD is the way to go (if you get in)... To say the least when I was in the fire academy and I was asked "Why do you want to be a fire fighter?" I have told the instructor the reason is to be on the rescue (ambulance), they were not impressed and the answer put me in a tough place.

 

[Shishkabob]

Are there plenty of single function medics who are better than I am at that one discipline? Absolutely. You ******* better be... That's your ONE JOB.

So, essentially what you're saying is that someone will be better at medicine because it's their sole job, while you can't be because you have to split yourself in to two different jobs, meaning you're willing to provide less than the best to your citizens when it comes to their health and safety?

 

[TransportJockey]

So, essentially what you're saying is that someone will be better at medicine because it's their sole job, while you can't be because you have to split yourself in to two different jobs, meaning you're willing to provide less than the best to your citizens when it comes to their health and safety?

Holy hell look who's back from the dead

 

[gotbeerz001]

So, essentially what you're saying is that someone will be better at medicine because it's their sole job, while you can't be because you have to split yourself in to two different jobs, meaning you're willing to provide less than the best to your citizens when it comes to their health and safety?

Not exactly. What I am saying is that I believe that the service I provide to be superior overall in regards to health and safety by not being limited to a single function. This is based on the scope of practice identified by the medical director, socioeconomic conditions and corresponding call trends of the system that I work in.

Working here, I am the best bang for the taxpayers buck.

I am realistic enough to say that I may not be the best choice for your system without making some adjustments.

If you would like to operate in a world of fantasy where budgets, training opportunities and experience are infinite, I guess that's what the internet is for.

As I have said before in several different ways, you can buy a $30 pair of pliers, a $45 knife, a $15 screw driver and a $20 file if you choose. However, if you purchase a Leatherman and have ONE TOOL that can do all those jobs just as effectively 90% of the time, you have not only saved money, you have gained flexibility.

My goal is to be the most effective problem solver that I can be in my community. Medicine is one aspect of that goal and I take every aspect of that very seriously.