Fire Based EMS

[IAems]

Admittedly, this is just a personal opinion, but as long as the majority of the country continues to operate on fire-based systems while the rest of the civilized world moves to increase the scope and training of EMS providers acting in a more healthcare-oriented vs. public safety role, the US will continue to fall behind with regard to EMS. Furthermore, I was always confused as to why, when I call 9-1-1 for a medical problem, I get a firefighter. I have an immense amount of respect for firefighters; I believe that anyone serving on one of those trucks is a hero, but at what point does it become excessive and even a little ridiculous to ask them to serve in two separate and totally unrelated jobs, one which the only true similarity is the method of response (e.g. Code-3). I think we need to work to expand the training, scope, and system of emergency medicine and separate EMS from Fire completely.

 

[chaz90]

Public Safety is the responsibility of fire, EMS, and police. Where I'm from fire and EMS mesh together like peaches and cream. They share way more mission objectives than either one with law enforcement. The multi-ton fire vehicles have nearly all the same EMS equipment as the responding ambulances. They are staffed with paramedics that rotate from engine, truck, rescue, and transport unit. Their skills are not dulled because of it. They are enhanced. We always have a minimum of one paramedic on the suppression apparatus, but based on who happens to be working that day we may have 2,3, or even 4 paramedics on an engine. Just last week A shift ran an asthmatic arrest in a 7 year old. The Rescue Engine was first on the scene with three very experienced paramedics. The driver of the engine also rotates to the transport unit as a paramedic officer when needed. Not far behind was the transport unit staffed with two paramedics. The officer of the transport unit also fills in as the driver of the Rescue when needed. It's truly a highly functioning cross trained group of professionals. 5 out of 6 of the responders on scene were experienced paramedics who all worked together as a cohesive team. They were on the scene for less than 5 min and at the nearest pediatric specialty hospital in less than 12 min total with a successful resuscitation and any intervention you can imagine for a case like that performed. The crew from the engine went with the transport unit to the hospital. While the ambulance crew was writing their report and restocking their equipment the Engine was responding with a different ambulance to another EMS call and doing it all over again. That's not a waste of money or a dumb thing. It's poetry in motion and top notch service to the public. I'm not sure that kid would have survived in other parts of the country.

Firstly, a sincere congratulations on a call that sounds like it was run well with a great outcome. That's great that your service functions well with this kind of system in place.

Personally though, I've seen similar models backfire completely and become a breeding ground for discontent and lackadaisical medicine. Any backlash you get here isn't directed at your system in particular, but more towards the overall concept of ALS oversaturation. Fact is, having more paramedics has not been proven to improve outcomes in the slightest. There are only so many ALS skills that ever need to be done at once. With just a couple hands to assist, even the most complicated patient can be appropriately managed without 6 paramedics running around the scene.

Skill dilution happens with this many medics on a scene, even if you don't see it that way. At any given time, only one person can run a scene, only one person can pass a tube, and only one person is truly making the patient care decisions. I won't say too much on this, but I'm completely with Bullet regarding his thoughts about running fire apparatus on medical calls. These are highly specialized vehicles, and even with a few bags of medical supplies tossed in remain wholly unnecessary on the vast majority of EMS calls. I really am glad this model works out where you are, but it's a complete disaster in most of the country.

 

[Arovetli]

EMS and police closely overlap in the "community caretaker" role, perhaps moreso than the traditional fire service role.

 

[abckidsmom]

Skill dilution happens with this many medics on a scene, even if you don't see it that way. At any given time, only one person can run a scene, only one person can pass a tube, and only one person is truly making the patient care decisions. I won't say too much on this, but I'm completely with Bullet regarding his thoughts about running fire apparatus on medical calls. These are highly specialized vehicles, and even with a few bags of medical supplies tossed in remain wholly unnecessary on the vast majority of EMS calls. I really am glad this model works out where you are, but it's a complete disaster in most of the country.

First I will say that I don't work in Craig's system, although I do have a lot of experience working with several providers from his department. Then I will say that I do work in a rural fire based EMS system.

Now, about the skill dilution:

I believe that in a system like Craig's, the intense oversight and pressure to perform highly keeps everyone performing with the precision that is needed. From my outside look at the system, the laissez faire freedom of the medic in the ambulance doesn't exist. There is no cowboy time- everyone is always in the presence of 1-2 experienced medics on scenes, which leads to more compliance with what can be seen as the standard of excellence.

Compared with my rural fire-based EMS system in which the only time I see another medic is in a meeting or at the hospital, I'm totally on my own with limited feedback and no help.

You tell me whether you want skill dilution or wild Wild West.

I think somewhere in the middle is a budget-possible medium. Our system literally can't afford another medic, whereas theirs is swimming in them.

Locality funded EMS is always going to have some drawbacks in that arena.

I do know for sure, that in a similar situation as that asthmatic arrest Craig tells about, the patient would have died. Even though I consider myself to be a decent medic, there's no way I could get the work of 5 experienced medics done in time to catch that little girl before death ran off with her.

This is a function of system design, funding and leadership structure, but it also illustrates that in a system with extremely limited resources, having a medic on the engine only costs 10-15% more and can result in dramatically improved outcomes in critical cases.

 

[Dwindlin]

I worked in both Fire based and EMS only systems. I worked with just as many :censored::censored::censored::censored:ty providers in EMS only as I did in the Fire services. The only real difference was that the fire based guys were more fun to be around.

 

[Cleric]

I really, really hate Fire/EMS mixing. Very few other modernized nations do things that way. It's really just designed to cut corners and hire the least amount of people possible, to the detriment of the people. Paramedic training in America is a joke compared to most other first-world countries, specifically to allow more Firefighters to become "Paramedics." What ends up happening, is that you have people who are truly passionate about Fire Science, that only take Medic classes as fluff to get hired and give terrible medical care. Conversely, you get people like me, who are truly passionate about EMS, but have to take fire science classes and become "FF/EMTs" or "FF/Paramedics," and may not take fire fighting as seriously as someone who is actually interested.

In my opinion, Fire should stay Fire, and EMS should stay EMS. Not to say they can't be close. I'm all for Medic Rigs and EMT Cars being stationed at Fire Stations, with the EMS staff living beside Fire staff, but I'd rather have 2 really fantastic Medics who love their jobs than 6 who see EMS as "the stuff we do between fires." In fact, I'd wouldn't even mind smaller cities with firefighters who are also EMTs in the engines to assist on critical ALS calls, and for BLS calls, with private ambulances doing transport. As it is now, the EMT-B qualification seems to be designed for firefighters and private ambulance drivers. I often feel like the only person who wants solely to be an EMT to work towards being a paramedic.

 

[Craig Alan Evans]

I've always been concerned about the "dilution of skills" with six paramedics on scene. How many intubations in the field does each paramedic get per year? How many RSIs? How many other invasive procedures does each paramedic do each year? How do you maintain competency?

If your fire service absolutely, positively has to get its fingers in EMS, A tiered system, similar to Seattle fire, is probably best. If you really have to run suppression apparatus to ambulance calls, then put EMTs on fire engines that are able to triage appropriately to BLS transport or request an ALS unit if needed.

I don't see how any paramedic can maintain competency when they "rotate from the engine to the squad to the ambulance." To me, that just sounds like a mishmash of skills. Mediocrity at its best. You might be able to do a lot of things, but none of them really well.

Of course, this is just my opinion. :/

I can tell you that we do struggle with this, but we are a small department and are able to overcome this pretty well I think. We send every medic to the OR annually to perform intubations, the EMS lieutenants monitor the issue on a daily basis and do their best to assure skill rotation. Any noted deficits are made up through EMS drills. We have a physician led CME program that is continually improving the clinical judgement skills and overall education of all the EMS providers. In short, we take EMS very seriously and it shows. With that being said I can tell you there are providers that are naturally good at one aspect of the job than others. Some are better firefighters, some are better EMS providers, some are better at technical rescue. We all have are specialties. We all have our comfort zones, and our niches where we shine, but we are small enough that we know each other very well so during a critical incident we all know who to look to for any given need. We continually learn from each other and we do our best to excel in every area. It's not a perfect system by any means, but over the years I can think of several situations where having the cross trained personnel has been a direct benefit to a situation and very few situations where it has been a problem.

 

[Sandog]

In my area, the fire staff is sent as adjunct to the EMS rig. Our EMS is handled by Rural Metro and AMR. The fire personnel usually ascertain if the scene is safe before the EMS enter the scene, and provide assistance to the EMS as needed. Overkill? Maybe, but I see very few reports of EMS injuries while on duty. It is a symbiotic relationship and should not be viewed as turf invasion.

 

[Wheel]

I can tell you that we do struggle with this, but we are a small department and are able to overcome this pretty well I think. We send every medic to the OR annually to perform intubations, the EMS lieutenants monitor the issue on a daily basis and do their best to assure skill rotation. Any noted deficits are made up through EMS drills. We have a physician led CME program that is continually improving the clinical judgement skills and overall education of all the EMS providers. In short, we take EMS very seriously and it shows. With that being said I can tell you there are providers that are naturally good at one aspect of the job than others. Some are better firefighters, some are better EMS providers, some are better at technical rescue. We all have are specialties. We all have our comfort zones, and our niches where we shine, but we are small enough that we know each other very well so during a critical incident we all know who to look to for any given need. We continually learn from each other and we do our best to excel in every area. It's not a perfect system by any means, but over the years I can think of several situations where having the cross trained personnel has been a direct benefit to a situation and very few situations where it has been a problem.

The sad thing is that you're in the minority in this. Your service is one of only a handful that I've ever heard of rotating through the OR for tubes, including ems only organizations. I think ats great, and you should keep it up, but don't mistake your motivation for quality ems as something that's true of all agencies, fire based or otherwise really.

 

[Wes]

My experience with fire-based EMS is that it's usually the smaller suburban departments that have embraced EMS excellence. The large city fire departments are too heavily unionized and set in their ways to truly embrace excellent patient care.

 

[Craig Alan Evans]

The sad thing is that you're in the minority in this. Your service is one of only a handful that I've ever heard of rotating through the OR for tubes, including ems only organizations. I think ats great, and you should keep it up, but don't mistake your motivation for quality ems as something that's true of all agencies, fire based or otherwise really.

So I am learning.

 

[Craig Alan Evans]

My experience with fire-based EMS is that it's usually the smaller suburban departments that have embraced EMS excellence. The large city fire departments are too heavily unionized and set in their ways to truly embrace excellent patient care.

I am seeing this as well. We are a small department with two stations and about 70 employees, of which about 40 are paramedics. We are located in the suburbs of Washington DC in Northern Virginia. I feel we are one of the most progressive and innovative EMS systems in the state of Virginia. We make a point of always being on the cutting edge of EMS. It's one of the reasons I started working there. I can't say enough good things about the administration and the people I work with. If you find a job you love you don't have to work a day in your life. My point is that fire based EMS can work to the betterment of both the service to the public and the budget of the municipality, but there has to be a commitment from the top down to make it happen. I think we have and continue to be the example in this area. I didn't realize when I asked this simple question that I would receive so much negative feedback on fire based EMS, or that where I worked was such an exception. It's all I've ever known so I am clearly biased, but I see and understand everyone's points against it. I'm just not seeing those points play out in my area which is a good thing.

 

[abckidsmom]

So I am learning.

As EMS-based fire depts go, yours is exceptional.

 

[ExpatMedic0]

I have absolutely no idea why anyone would consider a fire/EMS system a good thing for EMS or for health care. I think the topic has been beat to death on this forum but I will entertain the idea a little. The fire service is great, in fact to great... They are so good at there job they have put themselves out of business. Fire prevention and technology has made them almost useless in the majority of areas concerning fire suppression. As a result they exploit EMS to justify there existence, gain revenue, and protect there jobs. Many paid suburban fire departments would be screwed if they where eliminated %100 from EMS response (as they should be). Do you think most paid american fire departments could maintain current staffing if EMS was eliminated from there job duties? Fire suppression and Rescue is a fraction of what they are called out to in many areas.

- Many fire department exploit EMS to increase revenue.
-Many fire departments exploit EMS to help justify there existences (sending an entire useless engine crew on every single medical call in tier response systems)
- Many fire departments advocate for vocational and paramilitary style training of personal NOT higher education and advancing EMS as a profession
- Many fire departments fail to advocate for EMS as its own profession and as a healthcare entity. When was the last time the IAFF advocated for increased education and training of EMS personal, such as degree's?
- Many firemen don't care or want to do EMS but have no choice. Many get Paramedic certificates not because they want to be Paramedics, but to help them get a job on the department or get a promotion. Is that who you want working your on your wife or your mother?
-Honestly the list could go on and on

I say all this based on my 10 years of experience in multiple systems working along side dual role fire based providers.

 

[Craig Alan Evans]

I have absolutely no idea why anyone would consider a fire/EMS system a good thing for EMS or for health care. I think the topic has been beat to death on this forum but I will entertain the idea a little. The fire service is great, in fact to great... They are so good at there job they have put themselves out of business. Fire prevention and technology has made them almost useless in the majority of areas concerning fire suppression. As a result they exploit EMS to justify there existence, gain revenue, and protect there jobs. Many paid suburban fire departments would be screwed if they where eliminated %100 from EMS response (as they should be). Do you think most paid american fire departments could maintain current staffing if EMS was eliminated from there job duties? Fire suppression and Rescue is a fraction of what they are called out to in many areas.

- Many fire department exploit EMS to increase revenue. single medical call in tier response systems)
- Many fire departments advocate for vocational and paramilitary style training of personal NOT higher education and advancing EMS as a profession
- Many fire departments fail to advocate for EMS as its own profession and as a healthcare entity. When was the last time the IAFF advocated for increased education and training of EMS personal, such as degree's?
- Many firemen don't care or want to do EMS but have no choice. Many get Paramedic certificates not because they want to be Paramedics, but to help them get a job on the department or get a promotion. Is that who you want working your on your wife or your mother?
-Honestly the list could go on and on

I say all this based on my 10 years of experience in multiple systems working along side dual role fire based providers.

For every negative comment about fire departments I can point to a department that is the exact opposite. I highly trained ALS engine is anything but useless and I can tell story after story of lives saved by just such a crew. Go every negative comment about firemen becoming medics for all the wrong reasons I can point to 10 guys and girls that are an example of who you would want to come take care of your family. There are two sides to every coin. I understand your point of view and I have seen the same. I would just be careful about blanket statements. The IAFF is not your local fire department. They never claim to be. The IAFF does sponsor and EMS conference. The Dominick F. Barbera EMS Conference explores all aspects of fire based emergency medical services. From the tenets of emergency response system design and operations, to medical direction and privatization, and from quality assessment and data collection to billing for transport, this Conference covers the most relevant topics affecting fire service-based EMS systems. Not all fire departments are created equal, and not all fire departments view EMS the same. Every time you use the word exploit I would exchange it with the word embrace. Where I am from the best paramedics work for the fire department. There is no third service EMS except for non-emergency for profit companies that usually hire the medics that the fire department lets go because they don't pass our ALS internship. It's been great seeing how things operate in different parts of the country and world. I love this forum. We argue and bicker but in reality if you are on this site then you are an exceptional provider because you pass the first and most important test...you care.

 

[46Young]

If suppression units are largely idle, it only makes sense to do EMS, and not have to put out extra ambulances. The suppression units need to already be in place to achieve staffing and deployment objectives. It's not as simple as determining deployment based in call volume alone. Geographical distances need to be addressed as well. Cross-training personnel also saves on OT costs.

It's unreasonable to argue against ALS first response by saying that the fire department should put out more ambulances instead. Most non-fire systems put out the bare minimum of units needed to cover the usual call volume, let alone any call surges or significant incidents. This is why we have mutual aid. This is why we have systems that use SSM. This is why high call volume in EMS causes burnout - not enough ambulances in single role services.

Also, dual role systems offer many different job functions than just EMS transport. Most single role EMS employees are stuck doing EMS transport for their whole career. We have the opportunity to do TROT, Hazmat, Fire Inspections, Peer Fitness Training, EMS training, Fire Academy Instructor, Safety Officer, and many more positions. There's many promotional opportunities to be had, unlike in EMS. Fire based EMS is better for one's career, and better for one's longevity in EMS. The average time to burnout for a single role EMS worker is 7-10 years. Within that time period, there's typically a lot of movement from employer to employer. Most people in the fire service stay put until retirement.

 

[ExpatMedic0]

Would either of you firemen care to elaborate on how the fire service is currently helping EMS progress? Or the last time the fire service advocated for increased higher education standards for providers? How do you suppose the fire service will deal with the future of EMS in regards to mandatory college degrees in EMS with states like Oregon, or Critical Care Transport, HEMS, and concepts like Community Paramedicine?

 

[46Young]

Would either of you firemen care to elaborate on how the fire service is currently helping EMS progress? Or the time the fire service advocated for increased higher education standards for providers? How do you suppose the fire service will deal with the future of EMS in regards to mandatory college degrees in EMS with states like Oregon, or Critical Care Transport, HEMS, and concepts like Community Paramedicine?

I don't know, why don't you ask the plethora of EMS third service, hospital based, and private EMS systems that have a GED as a minimum stanard for hiring, and value field experience over education. These employers far outnumber the number of fire deparments, and single role Ems positions far outnumber those in the fire service. What have they done for EMS lately? If anything, these single role EMS providers stand to benefit from ample supply due to low barrier of entry, and low pay.

Most places I've seen, to apply, just ask for a GED, no felonies, 21y/o, valid cert, good driving hx, and perhaps experence.

If anything, the average firemedic in a mid-size to larfe dept is more likely to have a degree than a medic in a single role system. Fire departments value degrees for promotion, so more of us have degrees for that purpose. Single role EMS - "promotion?" What's that?

 

[Arovetli]

Would either of you firemen care to elaborate on how the fire service is currently helping EMS progress? Or the last time the fire service advocated for increased higher education standards for providers? How do you suppose the fire service will deal with the future of EMS in regards to mandatory college degrees in EMS with states like Oregon, or Critical Care Transport, HEMS, and concepts like Community Paramedicine?

I have a feeling this was a goal of AEMT, to keep a certificate level "Advanced" provider so fire can still paint that A word on the side. of their engine.

By and large I don't think fire is holding EMS back as much as insurance companies or politicians who use the emergency systems for dumping grounds have held it back. Fire probably helps a good bit with PR, maybe not actual patient outcomes, but definitely with manpower.

The reality of the whole issue isn't fire vs. ambulance, its the reality that in a community there are a zillion people who just don't give a damn about being responsible citizens, another zillion who just need to go to the damn doctor, and five people who will have heart attacks, strokes, and get into terrible accidents. Making it all work is a necessary disaster.

 

[abckidsmom]

I have a feeling this was a goal of AEMT, to keep a certificate level "Advanced" provider so fire can still paint that A word on the side. of their engine.
.

I disagree. I think it's there to appease the people who want to do the flashy part of doing EMS, but don't want to commit to being a paramedic.