Floridia Medical Director wants Fire out of EMS

[Dustdevil]

I LOVE THIS GUY!!! =D>

By I.M. Stackel

Naples News

Copyright 2007 Naples News

COLLIER COUNTY, Fla. — It was somewhat of philosophical debate in the 1990s.

With unrestrained growth in the eastern and northern portions of Collier County in the past decade, some county leaders say fire district consolidation— and absorption of ambulance service — is now a necessity.

From July 1, 2006, to July 1, 2007, Florida’s population grew by 194,000 to 18.3 million, according to U.S. Census spokesman Robert Bernstein.

While fresher numbers will be released in March, Collier County saw a 25.2 percent population hike between July 1, 2000, and July 1, 2006, from 251,377 to 314,649 residents.

Consolidation of services is hardly a new concept.

Nationwide, more often than not, fire and emergency medical service coexist in one department, although there are some counties that choose to keep fire rescue and EMS services separate.

According to a joint position paper prepared in 2007 by the Florida EMS Advisory Council, it was only about 35 years ago that advanced life support paramedics began performing life-saving services in a pre-hospital setting.

Miami was a forerunner, providing documented accounts that show as far back as 1941 rescue trucks were so utilized, according to the state report.

“The shortage of paramedics is a nationwide problem that transcends traditional borders of paid vs. volunteer, fire-based v.s. third service, private vs. public, or basic life support (BLS) vs. advanced life support (ALS,”) states the position paper, which was endorsed by the Florida Ambulance Service, Florida Association of County Emergency Medical Services, Florida Fire Chiefs Association, Florida Association of EMS Educators, Florida Professional Firefighters, Florida Association of EMS Medical Directors, EMS Providers of Florida and Florida Association of Rural EMS Providers.

While Collier County’s independent and city-run fire districts are working hard to address these issues — at the request in 2006 by county commissioners — meeting regularly for consolidation committee and subcommittees, EMS officials are flailing against the possible takeover of ambulance and EMS services.

In the past few weeks, EMS Medical Director Bob Tober has raged against fire departments proposed absorption of EMS and ambulance service, claiming lack of clinical skills, even bashing some of the paramedics that he trained who are now with fire departments.

“Fire wants EMS. EMS and the ambulance service are one and the same. Ask the question: Why can’t the (fire departments) simply consolidate and leave us alone?” Tober asked in a Christmas Day e-mail to a Daily News reporter. “They bring nothing to the table. What they take from the table is revenue from transport.”

“Somehow, providing BLS and the initial ALS (which is all they are really trained to do) is not enough for them because of 1) control, 2) power, 3) influence, 4) some revenue from transport, 5) justification of their existence,” Tober wrote. “Do not forget that 90 percent of what fire (rescue) does is medical. Since EMS is the medical specialist job description in our county, why is it never discussed that EMS take over fire?”

When asked if he raised these issues with county commissioners 18 months ago when they asked fire districts to consolidate, Tober said, “No.”

“I have not yet addressed this with the Board of County Commissioners. I had no idea that their first move would be to demand equality with EMS paramedics,” although Tober acknowledged that ambulance and EMS is one service, that one can’t be managed without the other.

“I struggle ... to keep up the skills of 111 medics and another 22 in training and they are running all of the calls. What the hell am I supposed to do with another 100 medics that want the same protocol? First, and foremost, (it) was their desire to get the fire departments to consolidate among themselves. The idea was that perhaps if they were offered EMS, this might be the push they need to consolidate.

“My question is why should they get EMS in the first place. Why in the hell do we still have nine independent fire districts in 2008? Is this Mars? That is nine fire commissions and nine bureaucracies with nine fire chiefs; nine assistant fire chiefs etc. No wonder they want EMS. They don’t have anything else to do!”

Fire commissioners, chiefs and firefighters have remained relatively quiet during this dispute, paying more attention to analysis of each district’s resources, the means to consolidate and equitably distribute fire and EMS services to all county residents. Currently, here are the agencies that provide fire rescue and/or basic life support or advanced life support services. The latter is a certification bestowed by the state, although not necessarily recognized by Tober.

City of Naples, City of Marco, Big Corkscrew, East Naples, Golden Gate, Immokalee, North Naples, Isles of Capri, Ochopee, and EMS.

According to the preface of the draft consolidation plan, issued two weeks ago, some fire districts have implemented their own advance life support emergency medical response capabilities to support EMS, including East Naples, Marco and North Naples.

“This enhancement in local service is intended to improve the quality of pre-hospital care provided to local residents (although) these enhanced services do no exist countywide,” the report states.

Currently, fire operation chiefs are studying placement and staffing of apparatus, using existing vehicles, stations and personnel. Minimum safe staffing levels would be established at three workers for engines/pumpers, three for aerials/trucks, and two for transport units.

The numbers reflect the current minimum safe staffing levels in a number of organizations, and will not represent a reduction in service in any part of the county.

The operations committee began by examining the locations of each fire and/or EMS station within the county, and identified the apparatus assigned to each station. The committee also determined the number of workers employed by each agency, and the total number of workers per unit.

“Across the county, the total number of personnel currently utilized to staff all the units making emergency responses is 151 daily,” the report states. “This number represents only those people assigned to shift responsibilities, meaning that they work a 24-hour schedule. It includes shift supervisory personnel, through the rank of battalion chief.”

“There is a significant disparity in the current daily staffing of 151 (workers) and the proposed minimum safe staffing of 164. The committee (members) believe that these numbers can readily be resolved through a relocation of fire and medic unit assets,” the report states. “For example, a number of stations house two engines which are currently staffed fulltime. There are also five locations where two medic units share quarters....In a countywide system, available daily shift staffing (in excess of) 155 could be assigned to provide three people on rescue units, place an additional engine or transport vehicle in service in rural or areas of need, place brush trucks in service without affecting engine staffing, etc.”

Overall, there are a total of nine fire-only stations, 16 combination fire/EMS stations, and four EMS-only stations. The latter are close to fire stations.

Apparatus countywide is 25 engines, seven aerial ladders, five water tenders, two crash fire rescue (CFR) trucks, and 26 medic-staffed ambulances. These numbers represent units that are staffed at all times.

“There is an undetermined number of reserve apparatus used for back-up, which are not staffed unless they are placed in service,” states the preliminary consolidation report.

One consolidated countywide district would enable rescue leaders to explore alternative revenue sources.

Currently, here is a fast snapshot of the cost of fire services to various areas of the county, of available money, and how they could be combined and equalized.

-- Collier FD 1 charges $1.94 per $1,000 worth of property, bringing in $547,389.

-- Isle of Capri charges $1.49 per $1,000 worth of property, bringing in $1.28 million.

-- Ochopee charges $3.69 per $1,000 worth of property, bringing in $1.78 million.

-- Immokalee charges $2.73 per $1,000 worth of property, bringing in $1.86 million.

-- Big Corkscrew charges $1.83 per $1,000 worth of property, bringing in $4.8 million.

-- Golden Gate charges 92 cents per $1,000 worth of property, bringing in $8.4 million.

-- East Naples charges $1.34 per $1,000 worth of property, bringing in $14.4 million.

-- North Naples charges $1 per $1,000 worth of property, bringing in $28.8 million.

Marco, Naples and EMS are not included in the above because as divisions of larger governments, all pass-throughs, subsidies and loans from other department funds could not accurately be accounted for. As Ave Maria University in eastern Collier, the Immokalee Fire Department will be responsible, in part, for providing fire-rescue service to the new town.

Also, as residential and commercial development continues along U.S. 41 East — beyond the turnoff to Goodland — East Naples, Golden Gate and Ochopee will have to provide fire and rescue service. Golden Gate and Ochopee firefighters do not have ALS divisions.

[frontcrawl]

Here is another story by the same reporter

Clash mars fire/EMS merger talks

(By I.M. Stackel

Naples News

Copyright 2007 Naples News)

Gail Dolan tried to mediate on Wednesday when fire chiefs and Emergency Medical Services Director Bob Tober verbally clashed.

“How about we focus less on training and focus on patient outcome?” asked Dolan, who is the Chief Operating Officer of NCH's North Naples hospital campus, and an EMS Advisory Council board member. “Then, you’ll see (the answer, which is) ‘how did patients fare?’ ”

Her suggestion came shortly after Tober yelled at Marco Island Fire Chief Mike Murphy for alleging bias against emergency workers with advanced life support training, but who weren’t shepherded by Tober.

The ALS workers are licensed by the state.

“I didn’t bring this up as an ‘us against them’ issue, but I do believe we have opportunities (and should) seize opportunities to improve the system. We have rural areas of the county (and there’s) fragmentation on patient care,” Murphy said.

The inconsistency is due simply to the vehicle on which paramedics arrive and by which agency they are employed, Murphy said. Firefighter-paramedics in other jurisdictions are treated equally, but in Collier, they are not considered capable of the same duties, Murphy said.

Tober lashed back.

“This is the same exact nonsense about improving training. How much plainer do I have to be about this?” Tober asked, hollering.

“I have a right to question it,” Murphy said quietly.

“And I don’t have to listen to it,” Tober yelled.

The interaction was more public than usual, occurring at an EMS Advisory Council meeting, but it is the same fundamental debate that has mucked up efforts by Collier County fire chiefs and EMS to work out a platform for consolidation, as was requested in spring 2006 by Collier County commissioners.

Tober reiterated his rage in an e-mail on Thursday.

“You heard me yell because I had very, very good reasons to be outraged, and remain outraged. This is medical public policy that safeguards you and I, pitted against a very organized, national movement of fire departments (attempting) to take over county EMS organizations, regardless of the consequences,” Tober wrote to a Daily News reporter, who witnessed Wednesday’s outburst.

Wednesday’s exchange began at the Oct. 30 EMS Advisory Council meeting, when Murphy requested a Tober presentation on county emergency medical protocol, a program Tober designed in the late 1970s.

When Tober arrived in Naples in June 1978, Collier farmed out its transport service to American Ambulance.

On Feb. 2, 1979, Tober launched the first set of six ambulances, staffed by the 18 paramedics he trained.

“Over the years, these six ambulances have grown to 26 ALS units, and, in addition, the emergence of some ALS engines staffed by both EMS and fire departments,” Tober said. Differentiating between basic life support (BLS) and ALS, Tober noted that the system is inconsistent from one area to another.

Fire departments in Immokalee, Corkscrew, Golden Gate and Ochopee still only have firefighters skilled in basic life support, Tober said.

“I have increasingly heard the statement that a paramedic is a paramedic is a paramedic,” Tober said. “That is, all such medics from both the fire departments and EMS are state-certified and licensed, so why is there any difference in their protocols or clinical liberties? Why are they medically credentialed at different levels within our one protocol, and why do fire departments continue to hire and develop additional paramedics in their own systems? Collier County has but one single protocol.”

It is the one Tober created, he said.

“If I diluted this system down (to) another 80 to 100 paramedics, I would face serious skills and decision-making degradation,” Tober told the EMS Advisory Council board.

“I, personally, am insulted for all medics in Collier County, (that they should be forced back to) helper status,” said Murphy, an EMS Advisory Council board member.

But Tober had his defenders.

EMS Advisory Council Vice Chairman Nancy Lascheid, whose husband founded and operates the Neighborhood Health Clinic on Goodlette-Frank Road, said there’s no need to interrupt service protocol and she doesn’t think skill levels are equal.

Fellow EMS Advisory Council board member Jeffrey Panozzo both came to Tober’s defense but also questioned why ALS couldn’t be considered comparable to EMS.

Referring to Tober as his “mentor,” Panozzo — who is the director of Emergency Medicine for Physicians Regional Medical Center on Pine Ridge Road — said he worked as a firefighter during medical school.

“Medics can be firemen and firemen can be medics. We’re talking about enhancement of service,” Panozzo said. “I have zero personal bias, except that I'm interested in EMS (so) why don’t we allow the merging of these teams? You mentioned that 80 percent of calls are attended to by fire engines.”

Firefighters start the call, Tober stressed, noting his 26 ambulances are “the primary immersion method.”

“I don't need 60 ambulances,” Tober said.

“I think you underestimate firefighters,” Naples Fire Chief Jim McEvoy told Tober.

That was Diana Watson’s take, as well.

Once an EMS-employed paramedic, Watson is now an East Naples Fire Rescue chief.

An EMS paramedic may be fresh out of training, trying to guide a former EMS worker with 20 years of experience, Watson has said in the past.

“Your most experienced medic may not be from EMS,” Watson said Wednesday.

“Now, my certification is lower than it was at EMS?” she asked.

She called for parity and recourse.

“We want to provide ALS engines for our people, but Collier County holds the ‘certificate of necessity.’ I still consider myself a paramedic,” Watson said.

EMS Advisory Council board member Dolan said she began her career as a nurse, and there needs to be a committee to talk out these issues.

“Bob Tober could go to Tahiti tomorrow. Then what? Things change. In my mind, the patient is No. 1. We need to try to change the system to work together,” Dolan said.

But, that’s already happening.

Thursday, the Collier County Fire Chiefs Association rolled out the first, very rough, draft of a consolidated, countywide district, which would erase political and geographic boundaries.

Representing 10 public fire-rescue districts, including the county-run EMS, assistant chiefs of operations for several districts hammered out a flow chart and plan that will be reviewed in January by the Fire Chiefs Steering Committee.

The consolidated fire districts would become one single entity responsible for all fire-rescue and emergency medical responses throughout the county, and would be independent of the Collier County commissioners who suggested it.

The position of medical director would be established as a contract employee, reporting to the top fire chief.

Former EMS Chief Jorge Aguilera, who moved over to North Naples Fire last year, said the operations team looked at strengths, weaknesses, opportunities and threats.

First off, elimination of political and district boundaries will result in better response time to people who need help, he said, although those response time calculations won’t be completed until all the research is finished.

Also, there will be one manual, with one single standard of operating guidelines, he said.

“There will be a single ALS protocol, countywide,” Aguilera said.

While taxpayers will not see immediate savings in the first few years of consolidation, that will eventually follow.

Likewise, the disparity in benefits from one fire district to another will dissolve, as there will be one labor union.

Thursday, fire chiefs said their unions continue to talk about merging, and those discussions are moving along nicely, although no details were immediately available.

North Naples Fire Chief Mike Brown observed that districts, alone, can’t push ahead with consolidation, that public support is essential.

“This has to gain a constituency unto itself. It is going to require public relations, newspapers, and a lawyer or two. This is just step one,” Brown said. Also, Brown said he doesn't want to send out a message leading county residents to believe the system is broken.

It is not broken, he said.

“This will just improve our system for decades to come,” Brown said.

[JPINFV]

“If I diluted this system down (to) another 80 to 100 paramedics, I would face serious skills and decision-making degradation,” Tober told the EMS Advisory Council board.

Where did that one study go that stated that skill retention and decision making ability went down as the number of medics went up?

“We want to provide ALS engines for our people, but Collier County holds the ‘certificate of necessity.’ I still consider myself a paramedic,” Watson said.

Why do you need ALS engines if you don't hold the certificate of necessity to begin with? Can we say, "money grab?"

[aussiephil]

Surley it makes sense to keep the services seperate. Fire is one profession, EMS is a profession, policing is a profession. They should be seperate.

When the reporter claims statistics like 90% of fire responses are medical it shows that all fire are trying to do is justify their existance. Keep all services as seperate stand alone units, not private companies, that compliment each other, not one trying to envelop the others

[HellsBells]

The position of medical director would be established as a contract employee, reporting to the top fire chief

WTF?

Why the hell should a medical director have to answer to a fire chief?

[akflightmedic]

WTF?

Why the hell should a medical director have to answer to a fire chief?

Because that is how it is in every system I have worked...SC, LA, OR, AK, FL, Philippines, Afghanistan,etc.

We hired our medical directors, they were employees of the service, city or county. Since they were our contract employees, we could hire or fire at our discretion if we had issues with them. Fortunately, it never really came down to that but it allowed us leeway as well when it came to certain procedures or treatments. If we could provide valid documentation and support for a new procedure, drug, or treatment, we could apply a little pressure to make it happen. Once again, it never really came down to that as we tried to select progressive docs that had or currently have emergency experience. Most of the docs were on board with the proposals, however a few were shot down as well and that was ok too.

[p3medic]

Our medical director doesn't answer to fire chiefs, they answer to him. A physician in charge of an EMS system wouldn't dictate how a fire chief fights fire, why would he dictate anything that has to do with the delivery of medicine? I realize not all medical directors are physicians although they should be.

[JakeEMTP]

Our medical director is an employee of the hospital. He oversees all EMS for the County and you must pass his oral boards to function. He answers to no one when it comes to the delivery of Medical services to the citizens.

[firedoc5]

I'm not up to speed on other state's, especially in the last few years. But it was my experience fire/rescue/ambulance can work together IF Chiefs, Directors, etc. would put aside the ego's and power trips. From what I have notice, and I might be wrong, but it seems like those personalities are prerequisites to be in those positions. But I know many that are not like that.

Enough of that.

To more of my personal experience, I started working at a private ambulance service just before I turned 19. We were the only service in the county. But for city calls the FD responded with their Paramedics and they rode in with us, just like the old Emergency show. There was always some sort of stress between the two entities. Not between personnel, but the ambulance owner, the Fire Chief, and whoever had their nose in things. The medics between the two got along great for the most part.

After five years of being with that private service with low pay $5.50/hr (highest paid with two others) and NO benefits, I finally got on the Fire Dept. And actually one of the one's who worked with me got on the FD three weeks before I did. So the serv. lost two of their prime employees. Needless to say that created more strain.

To make a long story somewhat shorter, it was proposed to have a separate EMS division within the FD, leaving out the private serv. from making emergency calls and transport in the city limits. You thought Robert E. Lee and U.S. Grant rose from the grave and started shooting at each other. The Fire Chief at the time was actually against having EMS in the FD in the first place. He was constantly reminding those of us who were already Paramedics prior to coming to the FD that our main duty was no longer EMS but firefighting. Which he was right. But it came to almost harassment about it. He even went as low as lowering our yearly pay as Paramedics to $250/yr. That's it for an entire year.

He is no longer Chief, and there has been three other Chiefs since then. But now, the current Chief was a fireman the same time I was. He only had three years ahead of me. But he was a Paramedic. In fact, we were in the same class and I tutored him and two others. He was my best friend on the Dept. I go by from time to time. And he did mention again having an EMS based program through the FD. He explained that the Chief of EMS would not answer to him, but they would be equal and work together. To me that would be the ideal set up. And definitely not bragging, but he said that if I was still there I would be the top candidate for EMS Chief. But that won't happen.

Sorry, so long. Coffee and nicotine hasn't reached my brain fully.

[Lucky~13]

Our medical director is an employee of the hospital. He oversees all EMS for the County and you must pass his oral boards to function. He answers to no one when it comes to the delivery of Medical services to the citizens.

Same as ours. But god help you if you cross him, no matter what service your in!