Cleveland to merge fire and EMS

[46Young]

http://www.firehouse.com/news/top-headlines/cleveland-integrate-fire-department-ems

There are people on my department that have either worked in Cleveland EMS or know people that do (we get a lot of Ohio refugees in NOVA). From what I've been told, EMS is pretty poor there, so I don't think the merger will make it much worse.

It's not clear if they're going dual role, and if so, what is going to happen to the existing EMS personnel.

Anyone have any additional info on this?

 

[46Young]

http://blog.cleveland.com/metro/2011/11/cleveland_moves_to_merge_fire.html

Sounds like the same rhetoric - faster response times, saves money, etc. Perhaps it's true, I don't know.

Edit: I hear that they want to force EMS to take the CPAT so that they can be forced into fire school, that EMS admin will be placed under a suppression BC, and will be phased out with attrition. ALS first response on the fire side.

 

[usalsfyre]

So, they took the typical way of doing it....

 

[atropine]

While agree with the cpat thing, Iam too sure about the forcing people into the suppression side of things, but then again these are the sign of the times and if you don't like it go somewhere else I guess. The only reason I do agree with the cpat is because I believe everyone should have to be in a healthly state to prevent any injury to ourselves.

 

[46Young]

So, they took the typical way of doing it....

Unless we go to a four year degree for medics, which would choke off the supply to the FD's, it looks like this is the ongoing trend. The only FD's that give EMS it's due attention and funding are those that have always been combined. What I mean is that not all FD's that have always been combined do EMS well, but the only ones that do are ones that have always been combined (from what I've seen). It appears that FD takeovers generally don't end well for the EMS side.

 

[46Young]

While agree with the cpat thing, Iam too sure about the forcing people into the suppression side of things, but then again these are the sign of the times and if you don't like it go somewhere else I guess. The only reason I do agree with the cpat is because I believe everyone should have to be in a healthly state to prevent any injury to ourselves.

I agree 110% on some sort of PAT, that must be completed every year, along with passing a physical exam including a pulmonary function test, blood work, mobility testing, vision and hearing, etc.

The problem with the CPAT is that EMS is not pulling lines, raising ladders, pulling ceilings, crawling through tunnels, or forcing entry. These are the things that the CPAT tests.

 

[JPINFV]

Edit: I hear that they want to force EMS to take the CPAT so that they can be forced into fire school,

So, fire fighters, would you feel comfortable making an interior attack knowing that your backup is only there because they were forced to do so in order to keep their job, and would drop fire suppression faster than a Kardashian marriage if they could?

 

[medicsb]

ALS first response = waste of money and time. Not a single shred of evidence anywhere that even remotely associates it with any improvement of patient outcome. And, all in all, it probably makes for really crappy medics.

 

[46Young]

So, fire fighters, would you feel comfortable making an interior attack knowing that your backup is only there because they were forced to do so in order to keep their job, and would drop fire suppression faster than a Kardashian marriage if they could?

We have people on the job right now that don't want to go interior. Either the're EMS minded, or they're just there for the pay, schedule and benefits, and want to do the least amount possible to keep their job. These individuals tend to work their way onto ambulances all of the time, or just go to slow houses. The thing is, way more people will join a dual role FD mainly for suppression, and accept EMS as part of the job, than the amount of people that want to do EMS only but will accept that they have to run into burning, collapsing buildings. The threat of losing life or limb will turn off most that would join a FD to do EMS while having no suppression interest.

There are also people in single role EMS that don't want to be there, either. They're easy to spot - they're minutemen at shift change, they try to walk whoever they can even if they shouldn't, they'll find reasons or use creative documentation on a regular basis to withhold meds or other interventions, they never pick up a call in their first due if it goes to someone else (and they're reaonably close), and they take as long as possible with their reports (They'll just give us another call if we go available).

I'm also told that existing dual role FD's will not consider hiring single role EMS to help with staffing since that opens the door for the privates to take over the EMS txp. It's too bad. I know a good number of medics where I work that enjoy EMS, but not 100% of the time. When they're kept off the engine for an extended period of time, they begin to resent EMS. That flip-flop makes for a long, enjoyable career. There's a reason why the average single role EMS tenure is only 7-10 years. I'm at 9+ years right now. Had I stayed in NY, I'd be in a different medical field by now, or working feverishly to that end. I wouldn't do single role EMS for 25-30 years. There's no career ladder, it becomes both stressful and mundane, has lots of needless drama from dispatchers and admin, and sitting in the box every day and then lifting heavy objects and people will break down your body sooner or later.

I'd have liked dual role EMS/police if it were available. Plenty of career advancement and different areas to move into courtesy of the police side.

 

[46Young]

ALS first response = waste of money and time. Not a single shred of evidence anywhere that even remotely associates it with any improvement of patient outcome. And, all in all, it probably makes for really crappy medics.

I feel that it's a matter of degree. I've worked in an urban environment (NYC) where there were plenty of EMS resources without needing suppression personnel. due to population density, we had units stacked on each other, sometimes only blocks away, and the tax base to support it all.

In the suburbs, it's a toss up. My current environment is more or less suburban. We could handle most of our calls without manpower or another medic, but there are times that we do need another medic and/or another basic or two.

In rural areas, the backup is necessary, and sometimes vital. I used to work in Charleston county, SC. You can go from urban (Charleston/N. Charleston) to suburban (James Island, Mt. Pleasant, IOP) to rural (Edisto/Kiawah/John's Island/Awendaw/Mclellanville), where EMS txp has 20-45 min response times. First response can initiate care, and also call for HEMS early if appropriate. They've come in real handy on many occasions due to sparse deployment.

 

[Fish]

So, fire fighters, would you feel comfortable making an interior attack knowing that your backup is only there because they were forced to do so in order to keep their job, and would drop fire suppression faster than a Kardashian marriage if they could?

I think people missed the real Gem in your post. "faster than a Kardashian marriage" buwahahaha! Funny stuff

 

[Fish]

ALS first response = waste of money and time. Not a single shred of evidence anywhere that even remotely associates it with any improvement of patient outcome. And, all in all, it probably makes for really crappy medics.

Agreed, show me the evidence it works. You can't, because it doesn' exist. Now show me how much waisteful spending it causes, and this you can because it is fact!





Also, it was already a city run ALS service. I guess they are thinking grouping admin and such will save money orrrrrr? Who wants to take bets that somehow the budget towards the EMS department actually decreases after this merger.

 

[46Young]

Agreed, show me the evidence it works. You can't, because it doesn' exist. Now show me how much waisteful spending it causes, and this you can because it is fact!





Also, it was already a city run ALS service. I guess they are thinking grouping admin and such will save money orrrrrr? Who wants to take bets that somehow the budget towards the EMS department actually decreases after this merger.

I would have never of thought it possible before I sold out to the fire side, but I like the extra hands to carry my equipment, move my patients, drop a line, get vitals, admin. the meds I choose while I gather a Hx. It makes my job a lot easier, it spares my musculoskeletal system, and makes for a long career due to that and being able to work in other areas than just EMS txp. I used to pride myself on handling the logisitcs of most calls with just me and my partner, but I like it better this way. If I'm going to run a bunch of calls, at least I don't have to hump much equipment or break my back lifting heavy hitters as much. It's also nice to have an extra person available to turn your rig around if needed.

Sure, it may be cost neutral or cost more, but I'd never go back to single role unless I was desperate. I have all the tools and equipment I need to do my job effectively, such as CPAP, in line nebs, jet insufflation, EZ-IO w/ bariatric needle, King LTS w/ sump tube, the Rad 57 CO monitor, vacuum splints, ETCO2 capnography and nasal capnoline, IN Versed, Narcan and Fent, and fairly liberal protocols/guidelines w/ st. order pain management. With my previous single role jobs we worked too hard, the pay and retirement was undesireable, and the career ladder was not there. Total dead end job.

Having said that, I don't agree with takeovers, just that already existing dual role systems that have been around for decades deserve to be there, just like these Cleveland EMS employees also deserve to be there and not be forced out by having to pass a CPAT and possibly be forced to successfully complete the fire academy as a condition of future employment. I'll never agree with any agenda that puts people needlessly out of work, no matter what type of service we're tallkng about.

Honestly, I could care less how much a sytem costs to run, so long as it's sustainable, performs it's function as designed, and provides me with adequate working conditions, benefits, salary, retirement, and a career ladder.

 

[Fish]

I would have never of thought it possible before I sold out to the fire side, but I like the extra hands to carry my equipment, move my patients, drop a line, get vitals, admin. the meds I choose while I gather a Hx. It makes my job a lot easier, it spares my musculoskeletal system, and makes for a long career due to that and being able to work in other areas than just EMS txp. I used to pride myself on handling the logisitcs of most calls with just me and my partner, but I like it better this way. If I'm going to run a bunch of calls, at least I don't have to hump much equipment or break my back lifting heavy hitters as much. It's also nice to have an extra person available to turn your rig around if needed.

Sure, it may be cost neutral or cost more, but I'd never go back to single role unless I was desperate. I have all the tools and equipment I need to do my job effectively, such as CPAP, in line nebs, jet insufflation, EZ-IO w/ bariatric needle, King LTS w/ sump tube, the Rad 57 CO monitor, vacuum splints, ETCO2 capnography and nasal capnoline, IN Versed, Narcan and Fent, and fairly liberal protocols/guidelines w/ st. order pain management. With my previous single role jobs we worked too hard, the pay and retirement was undesireable, and the career ladder was not there. Total dead end job.

Having said that, I don't agree with takeovers, just that already existing dual role systems that have been around for decades deserve to be there, just like these Cleveland EMS employees also deserve to be there and not be forced out by having to pass a CPAT and possibly be forced to successfully complete the fire academy as a condition of future employment. I'll never agree with any agenda that puts people needlessly out of work, no matter what type of service we're tallkng about.

I am not saying having extra hands is not needed, because I think it is. I was saying ALS first response is not cost effective because it has no scientific value or backing. BLS first response does however, and those same BLS first responders can lift equipment and help you treat and assess just as well as the ALS first response. After all, only one Medic can talk to the patient at a time.

Multiple research studies by universities have shown when BLS FR is compared to ALS FR, ALS has no sigificant improved survive rate and that it is not an efficient EMS model.

I am an advocated of FD BLS first response, I think if you give them the tools to handle any true emergency until ALS arrives than the system works. Let do the following:

o2 Admin
CPR
AED
Epi 1:1,000 IM
Albuterol
Oral Glucose
Check BGL
ASA
Nitro
First Aid

These have been shown through research to be the drugs and procedures that can save a life when given early on, within 8mins of onset of 911 call.

Infact, most studies show that the most efficient model is to have BLS within 5-8mins and ALS between 8-12mins.

Denver Health, Wake County, and one other busy Metro service all did studies on this.

Also, and I cannot remember the name of it for the life of me. But an FD did a study like this and the end result was the Medical Director recommending that they delete ALS first response due to it having no value and being inefficient.

I do believe that Medical Director was later fired after much pressure for the FD union *rolls eyes*

 

[Fish]

A google search found this

http://onlinelibrary.wiley.com/doi/10.1197/j.aem.2005.02.013/abstract

Paramedic response in less than 8mins shows no improved survival rate, but give the tools I mentioned above to a BLS first responder and have them respond in 4mins or less and we see a survival rate increase compared to having no one respond for 8mins.

And I mistated above, it was not wake County, it was Mecklenburg.

 

[Tigger]

I am not saying having extra hands is not needed, because I think it is. I was saying ALS first response is not cost effective because it has no scientific value or backing. BLS first response does however, and those same BLS first responders can lift equipment and help you treat and assess just as well as the ALS first response. After all, only one Medic can talk to the patient at a time.

Multiple research studies by universities have shown when BLS FR is compared to ALS FR, ALS has no sigificant improved survive rate and that it is not an efficient EMS model.

I am an advocated of FD BLS first response, I think if you give them the tools to handle any true emergency until ALS arrives than the system works. Let do the following:

o2 Admin
CPR
AED
Epi 1:1,000 IM
Albuterol
Oral Glucose
Check BGL
ASA
Nitro
First Aid

These have been shown through research to be the drugs and procedures that can save a life when given early on, within 8mins of onset of 911 call.

Infact, most studies show that the most efficient model is to have BLS within 5-8mins and ALS between 8-12mins.

Denver Health, Wake County, and one other busy Metro service all did studies on this.

Also, and I cannot remember the name of it for the life of me. But an FD did a study like this and the end result was the Medical Director recommending that they delete ALS first response due to it having no value and being inefficient.

I do believe that Medical Director was later fired after much pressure for the FD union *rolls eyes*

As you note, BLS first response when done right is what is most effective in a true emergency. The only thing I would add to the above list of interventions is perhaps a King-type airway considering the difficulties that many have using only a BVM. That an including albuterol nebulizers along with rescue inhalers (maybe you meant that...).

The city of Boston only generally staffs six paramedic ambulances at peak times, yet in the last study I saw Boston was the "second best" city to have a heart attack in. There are a lot of Boston EMS BLS trucks on the streets with competent crews that good at managing real emergencies, and the medics are great since they see the "sickest of the sick." It doesn't seem like to many other cities still place so much emphasis on BLS anymore, which is why I find the heart attack study interesting.

 

[Tigger]

Agreed, show me the evidence it works. You can't, because it doesn' exist. Now show me how much waisteful spending it causes, and this you can because it is fact!

While I don't disagree that there is a lack of evidence showing the effectiveness of ALS first response, I also question how we measure effectiveness in EMS. Cardiac arrest survival rates may not be changed by ALS first response, but that doesn't mean it isn't making a difference for the patients. All else equal, I'd rather a fire medic giving me an antiemtic for extreme nausea then wait for the ambulance alone. I've taken many people on my BLS truck that could have benefited from ALS level care, but I couldn't get ALS because they were in danger of dying anytime soon, a situation that doesn't happen with ALS first response.

Obviously EMS isn't all about saving lives, it's about doing good for your patient. It just seems very difficult to measure how do good for the patients when they have a serious, but not life threatening complaint.

 

[akflightmedic]

The city of Boston only generally staffs six paramedic ambulances at peak times, yet in the last study I saw Boston was the "second best" city to have a heart attack in. There are a lot of Boston EMS BLS trucks on the streets with competent crews that good at managing real emergencies, and the medics are great since they see the "sickest of the sick." It doesn't seem like to many other cities still place so much emphasis on BLS anymore, which is why I find the heart attack study interesting.

One could also argue that in the city of Boston, the position of Paramedic is a promotion. There are dozens of EMTs working who actually are paramedics just waiting for the advancement when a slot opens.

To expand on that further, if they are on a BLS truck I will make the assumption they have no ALS equipment because by job title alone this is prohibited...HOWEVER what they DO have is Paramedic knowledge.

Did the KNOWLEDGE of a paramedic working in an EMT role increase the proper use of ALS units in a timely fashion thereby skewing above results? Did the KNOWLEDGE of the paramedic working as an EMT keep ALS units free from those iffy calls where just an EMT may have called ALS for confirmation so that the ALS unit which remained free was able to respond quicker to true ALS emergencies, thereby again skewing times?

I think one could argue and prove that BLS supplies coupled with ALS knowledge/education could save more lives overall.

 

[Fish]

As you note, BLS first response when done right is what is most effective in a true emergency. The only thing I would add to the above list of interventions is perhaps a King-type airway considering the difficulties that many have using only a BVM. That an including albuterol nebulizers along with rescue inhalers (maybe you meant that...).

The city of Boston only generally staffs six paramedic ambulances at peak times, yet in the last study I saw Boston was the "second best" city to have a heart attack in. There are a lot of Boston EMS BLS trucks on the streets with competent crews that good at managing real emergencies, and the medics are great since they see the "sickest of the sick." It doesn't seem like to many other cities still place so much emphasis on BLS anymore, which is why I find the heart attack study interesting.

Yes, Nebulizers is what I was referring to with the Albuterol

 

[Fish]

While I don't disagree that there is a lack of evidence showing the effectiveness of ALS first response, I also question how we measure effectiveness in EMS. Cardiac arrest survival rates may not be changed by ALS first response, but that doesn't mean it isn't making a difference for the patients. All else equal, I'd rather a fire medic giving me an antiemtic for extreme nausea then wait for the ambulance alone. I've taken many people on my BLS truck that could have benefited from ALS level care, but I couldn't get ALS because they were in danger of dying anytime soon, a situation that doesn't happen with ALS first response.

Obviously EMS isn't all about saving lives, it's about doing good for your patient. It just seems very difficult to measure how do good for the patients when they have a serious, but not life threatening complaint.

That is not what the evidence suggest, it still is suggesting that Fire BLS First response arrives within 4mins. And an Ambulnace arrives within 8-12. No one is advocating not sending first responders to a call at all.

The cities that the studies were done all have a Medic on the Ambulance, so it is stating that a Medic arrives at every call. The medic just does not need to be there in under 4mins if an EMT is going to be there in under 4mins.