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

[gonefishing]

@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.

 

[VentMonkey]

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!!!

 

[gonefishing]

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.

 

[EpiEMS]

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.

 

[VentMonkey]

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.

 

[EpiEMS]

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.

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.

 

[FiremanMike]

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..

 

[VentMonkey]

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.

 

[FiremanMike]

@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.

 

[VentMonkey]

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?
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.
Never said you got more leeway. In fact, as an EMS coordinator I’d venture to guess you chase your tail quite bit, and play somewhat of a middle-management style role between line guys and upper management.

If that is the case, my hat goes off to you, as after 6 years of playing that game I realized management of any form was definitely not for me.
Not sure what you mean here.
What I meant was all of the EMS-only people on this thread need to realize that fewer paramedics means a profession. It means taking our craft as serious as fire takes mitigating fires, or law enforcement does fighting crimes.

Think of all of the EMT and paramedic students in a classroom, and now think of how many raise their hands when asked if their goals are something beyond becoming a paramedic.

That isn’t fire problem, or an IAFF problem, that is a fundamentally dysfunctional problem with EMS as a whole.

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?

 

[FiremanMike]

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.

 

[DrParasite]

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.

 

[VentMonkey]

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.

 

[TXmed]

@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.

 

[FiremanMike]

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.

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

 

[FiremanMike]

@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?

 

[DrParasite]

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.

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.

 

[VentMonkey]

@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.

 

[MonkeyArrow]

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.

 

[FiremanMike]

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.