Interesting Perspective on Fire-based First Response EMS

[usmc_chris]

Edit: I posted this in the wrong forum somehow, I apologize, I have no idea how to put it in the correct forum.

I'm an occasional lurker on the forums, but haven't really contributed much. A little bit about me first - I began in volunteer EMS since 2003, been an EMT since 2004, began working professionally in 2007, and finished my Paramedic degree this Spring. In addition to my A.A.S. in Paramedicine I also have a B.S. in software engineering (don't ask) and an M.P.A. My goal is ultimately to become an EMS manager.

I generally agree with the "consensus" among the most active posters - that the Fire Service may not be the best way to run EMS. That being said, I had an interesting discussion with an individual at my part-time job the other day. His full time job is in the Fire Service, with an agency that does BLS first response only. Now, I don't want this to turn into a fire service bashing thread, regardless of how any of us might feel about that method of delivery.

The way the system works is that this fire department "first responds" to all medical "emergencies" within their district - regardless of severity or origin - they respond to the doctor's offices, to low-priority psychiatric complaints, etc - everything except for scheduled interfacility transports. A private service (my full-time job) responds for the ALS and transport components. I personally believe that they don't need to respond to everything in their district, I would advocate for no more than NAEMD-coded "Delta" and "Echo" level responses, as well as special assists (known severely morbidly obese patients, MVA's, etc.). However, their position is that as they are tax-supported, they have a responsibility to respond for every fire, medical, or rescue request within their district.

Let us assume, for the purposes of this discussion, that this is the way the system is set up. Let us also assume that for the foreseeable future this arrangement cannot be changed - we will have a minimum of 2 firefighters trained to the EMT-B level or higher (but only capable of practicing with this agency at the EMT-B level) responding on an engine, truck, or light rescue, with an ALS or BLS transporting ambulance, depending on the EMD coding of the response.

Recently, the "posting scheme" (the private service uses system status management) was changed within the service area at the request of the fire department. The ultimate purpose of this, it seems, was actually to DELAY responses within the district. The assumption among many employees of the private service was that the department wanted to "look good" by "showing up first." I must confess, from our perspective, this is exactly what it looks like.

Now, response times for the ambulances are still well within contracted targets, and well within NFPA standards (contracted targets are 7:59 for NAEMD Echo, Delta, Charlie, and Bravo responses; 11;59 for Alpha and Omega responses). The reason for the change, it was explained to me, was not to "look good." Rather, this department was experiencing a problem. Their EMT's were becoming too reliant on the ambulance crews and the Paramedics. Due to the ambulance being less than thirty seconds behind the fire apparatus in many cases, and often even being first on scene, the BLS assessment and treatment skills of the firefighters were being degraded. The concern of the department that should the ambulance service be experiencing higher-than-normal call volumes, or a delayed response for whatever reason, the EMT's on board the fire apparatus would simply not know what to do if they had, say, 10 minutes with a patient rather than between 30 seconds and a minute as is often the case.

The solution, of course, was to shift the starting locations of the ambulances so that the firefighters would have on average 2-3 minutes with the patient, allowing them to complete their initial assessments including vital signs and begin "routine" BLS interventions - ASA, O2, etc. - prior to the ambulance crew's arrival and beginning of ALS assessments and interventions.

I personally don't agree with the solution that was presented and in effect. However, I came to fully understand the fire department's point of view - assuming the firefighters will in fact respond, how do we ensure that they have adequate "patient contact" time to maintain their skill levels? Should it be required that they complete mandatory monthly ride-alongs with the ambulance crews? Should it be required that they maintain part-time employment with an ambulance service?

Your comments and suggestions would be appreciated. I'm not really in a position to change anything, but as someday I hope to be in a position where I would have an impact and a decision-making role in an EMS system, it is, I think, a useful discussion. Again, I would appreciate if this doesn't devolve into yet another fire-service EMS bashing thread - rather a genuine thoughtful discussion of our identified problem. Thank you all for your input.

Edited February 2, 2011 by usmc_chris

[Kiwiology]

Any Fire Service involvement should be limited to confirmed cardiac arrests (nine echo).

Omega cat calls get a response? Not here they don't!

[usmc_chris]

Any Fire Service involvement should be limited to confirmed cardiac arrests (nine echo).

Omega cat calls get a response? Not here they don't!

I personally tend to agree with you, but this is the way the system is. As for the Omega category, I personally have only seen one or two calls ever actually coded that way, I believe they upgrade all of them to Alpha responses - but yes, we do frequently get a dual response for a call that gets entered as a "lift assist request." But to the question at hand... considering that all of these firefighters are in fact "medically" certified (let's debate the merits of the EMT-B certification another day), how do we ensure that they get adequate "patient contact" time so they don't choke in the event that the ambulance/ALS response gets delayed for some reason (without purposefully delaying the ambulance response on a routine basis)?

[akflightmedic]

One 12 hour ride along per month is more than adequate for an EMT B to be able to practice/maintain his skills.

Research Dr. Tober in Florida..he had a similar requirement for his Fire Paramedics, yet even that small of a request proved to be too much effort for them.

If the town FD is truly supportive and this is their legitimate reasoning, help them develop a plan where the guys are rotated on an ambo for 6-12 hours a month.

However intentionally delaying the arrival of a vehicle with higher level of care and thus affecting the transport times of a patient to definitive care is ethically wrong and should not be tolerated. This is a gross injustice to the patient in the here and now simply for the benefit of the EMTs knowledge on a future potential patient.

[spenac]

It is a ploy to make fire look good and EMS contract look bad. Then they can throw the numbers out and take over EMS. Don't fall for it. Get involved and get your people to fight this delay plan that hurts patients and makes fire look good.

[Bieber]

If they want to delay EMS in order to "hone" their skills, why don't they just leave the ambulances where they were initially and have them always respond without lights and sirens to the scene? The science suggests very few calls are actually time sensitive, being restricted primarily to cardiac arrests, strokes and MI's, and at least this way in addition to fire getting to practice you get the added (and much more important) benefit of EMS crews being at reduced risk of getting into a car accident.

[Chief1C]

I guess until the information that every 9-1-1 caller gives is 100% on the money, spot on, truthful and correct... I'm okay with folks showing up, pre-EMS, to give aid.

[DwayneEMTP]

Yeah, morally and ethically this is completely unacceptable from the point of view of your service. And I just simply to refuse to believe that you're service agreed to delay response times to give a bunch of fire basics the opportunity to practice. It's bullshit brother, truly.

My guess would be that whoever makes that decision for your service, assuming that there is no chance that you are incorrect in the things that you state above, is so far gone that your best bet is simply to run away from this service before the whole fucking thing comes tumbling down. Cause I'll tell you this....If my wife and son die on the side of the road waiting for EMS so a bunch of hosemonkey basics can "practice" their 140hrs or training? I'm coming visiting and there will certainly be changes then....

And come on, if they truly care about the patients, if they truly want to participate in EMS in a meaningful way, the answer is not terribly tough, right? Go to medic school. You will then have all the skills you need to care for a patient from first contact to transfer of care whether that should be 5 minutes or 2hrs. It truly is the answer. But they don't really want to participate, they just want to get paid. That's not meant to bag on them, only to keep these comments in what I believe to be a real world context.

I'm grateful for you posting this scenario, but if you should knowingly allow treatment to be withheld from the people that you are tasked to care for? Then you are participating in the travesty, and you should find that unacceptable. You don't have the power to make change? Untrue, you don't have the power to make change without taking a beating for it...those are two different things, right? What do you suppose would happen if your local newspaper decided to compare current ambulance response times to those logged before your new posting algorithm? I"m guessing things would change....

Tough spot, but your Fire buddy is yanking your chain most likely. Occam's Razor says that the simplest of two competing theories is most often correct, and the simplest, most likely theory here is that the hosemonkeys want to make you look like an incompetent asshole while their new ambulances are being painted.

Good luck man...

Dwayne

Edited to fix a few spelling errors. No contextual changes made.

Edited February 2, 2011 by DwayneEMTP

[JTpaintball70]

Sounds similar to the setup in Denver, CO. DFD has medics but they operate as BLS only, with DG being a semi-private service that handles transport duties for 911 in City and County of Denver. IT seems to work well, but then again the hosemonkey don't want to be on scene with the patient by themselves so there'd never be the FD having the ambulance get there slower.

It does sound like a ridiculous idea to have the bus standoff farther just so the FFs play EMT and get their handson time that way. I agree with making them do at least 1 12 hour third ride with the transport service a month.

[Richard B the EMT]

Any 9-1-1 system that uses any variant of the "send someone to verify need for an ambulance" method, to me, sounds like they need to update and upgrade their system, and join the 21st Century. I have always been a believer in what I was always told, that it is always easier to stop a response, than to get it going in the first place.