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June 26, 2010 Dear Mr. Smitherman; I was somewhat surprised as I read your recent comments with regards to a “Fire/ems” model of prehospital care. I must say that, in your previous role as Minister of Health, you won my respect. I admired the manner in which you arrived at difficult decisions using evidence and facts from a variety of sources. To read that you have based this service altering decision on an opinion piece developed by a special interest group such as the IAFC, without input from all participants, was disheartening, to say the least. I would respectfully offer the following facts for you to consider: The EMS average response time to high priority calls is 7 minutes and 32 seconds, not 12 minutes as you stated. More than half of all cardiac arrest have the EMS team apply their defibrillator first, before other first responders.. In 50% of high priority calls, EMS arrives before or at the same time as Fire. 5.6% of all cardiac arrests in Toronto survive to discharge not 2.5% as you were quoted. In 26.7% of arrests in Toronto, the paramedics are able to restore a heartbeat before arrival at the hospital. One of the difficulties in determining response times is that various agencies record their times in a variety of ways, making comparisons difficult. Fire starts the clock when the pumper leaves the station; EMS starts the clock when the call is received. If you are truly concerned with improving outcomes, there are other avenues. In some European countries, ALL licensed drivers are legislated to be current in CPR, effectively making their entire population First Responders, not being wholly dependent on allied agencies such as Fire and Police. If the purpose of the exercise is truly to get an Advanced Care Paramedic to the patient in a minimum of time, there are much faster and safer methods than on the back of a pumper with four Fire fighters. Less than 5% of emergency calls require Advanced Life Support. The most effective method of providing this service is to place the ALS medics in rapid, small, first response vehicles. Some jurisdictions use motorcycles, others, small, agile cars. In this manner, an ALS medic can arrive within the shortest time frame and begin care while assessing the scene and determining the type of support needed. You mention cost savings in your speech. Research has shown that brain death occurs in 4-6 minutes. We know that we must get a responder to the scene within this time frame to be effective. We also know that the fire department strives for a 4 minute response time and have their halls conveniently placed appropriate distances to achieve this. The question is why? Insurance actuaries have calculated that a 4 minute response time is as effective as a 7 minute response time and does not result in more property loss. This is reflected in the premiums calculated for both homes and businesses. Accordingly, one can conservatively estimate that 1/3 of fire halls could be decommissioned with no resultant loss of property. Imagine the savings here. Consider further, if you will, the fact that Fire Departments run at a staff to:management ratio of 4:1 whereas EMS averages 9:1. Which system is more cost effective? Consider that Fire deployment is based on a static model simply because businesses and property don’t move. EMS is based on a dynamic model, vehicles and staff moving hourly with the population they serve as commuters flow into and out of the city. Consider that Fire has effectively bargained that each fire truck MUST have four Fire fighters around the clock, regardless of call volume. EMS upstaffs for peak hours and downstaffs during slower times, again presenting a savings to the tax payer. I do find it interesting that the “Fire Act” states that a department MUST have a fire prevention officer but fails to mention that it must have full time Fire fighters likely because fully 75% of Ontario Fire fighters are volunteers. Consider that Fire fighters retire at 25 years of service; have a mandatory retirement of age 60 with an enhanced pension; a “killed on duty” clause which provides their families with free education for their children, a sizable monetary compensation and a partially publically funded funeral; consider that legislative changes lobbied by the Fire Associations has resulted in a “presumptive” legislation that accepts that Fire fighters succumbing to certain cancers are presumed to be job related; that heart attacks occurring within 24 hours of a response are considered to be job related and subject to full work related compensation; consider that Fire fighters are educated and trained at the cost of the employer and that paramedics train at their own cost prior to employment; consider that Fire fighters in certain cities are allowed to work 7 twenty four hour shifts per 28 days, with a built in 8 hour “rest” period and get the rest of the month off. I do not begrudge the Fire fighters any of the preceeding benefits but I find it curious that the paramedics are excluded from these same benefits. If the City of Toronto merges the two services, surely the paramedics will be brought up to par with the Fire fighters? Where then, is the savings that you mentioned? I have attempted to highlight for you some of the more obvious problems with a U.S. styled, Fire/EMS system. An entire tome could be written describing the differences between the two cultures, the differences in training, education, liasing with Base Hospitals, differences in their respective approaches to patient confidentiality, approaches to treatment of patients, medical directives, continuing medical education, etc. I would be pleased to meet with you and discuss some of these at your convenience. Once again, know that I have long admired your approach to medical problems in your previous role as Minister of Health and certainly appreciate the fine work you completed in that role. I find these latest comments poorly researched and certainly out of character for you. I must express my disappointment in your presentation. Respectfully, Dr. Martin McNamara. CCFP/EM As an aside... I had the extreme fortune over the G20 week-end here of working with many RCMP EMRT medics. Great people, who at times wouldn't even let me carry my own bags, ha. Seriously though, some of the nicest people you will ever meet and great hosts for the assignment I had.

Good post for the newbies, but I would like to add to all the old folk here remember you were new once and your response to a newbie can make or break them. After 15 years of being on this job I can honestly say that I learn something new each and everyday and its normally from the old ones, and yes even with all the years on the job I still consider myself a newbie.

Sure, there's goofballs all over, but why do so many of them work in EMS? Not funny . . . Didn't he stop to think about the note thing? The store owner could have pulled a gun and killed an innocent Explorer.

Are you sure your continuous neb includes the iprotropium bromide and is not just albuterol? If so, then wouldn't it be like anything else? Your protocols are there to allow you to do what you need, but you still need to monitor your patient and withhold or change treatments as necessary. It's a fine art...