Philly FD (and EMS) slammed in report

[paramedicmike]

Yes. I know this is the EMS News Discussion Forum. I understand that the title of the article mentions the Philly Fire Department. But there is significant discussion of EMS within the article and report itself.

The report is available through this link and story.

Reporters are seldom a credible bunch. And there is always more to the story than what is reported. (Kudos to Mr. Dunn for actually linking the report to his story.) I just found it interesting given the recurrently hot topic of fire based EMS.

Thoughts, comments, criticisms, concerns and more if you wish. Or ignore it. That's ok, too.

[island emt]

This surprises you How. Philly has long been an abomination in prehospital care.

[paramedicmike]

It doesn't surprise me at all. It's just nice to see it in print.

[DwayneEMTP]

"Moreover, the study finds that morale issues are exacerbated by a culture within the department that is resistant to change, and an organizational structure that “tends to reinforce the status quo.”

http://philadelphia.cbslocal.com/2012/01/18/study-rips-management-operations-of-philadelphia-fire-department/#.Txb-dl-RCVY.facebook

Say it isn't so!!

[ERDoc]

A few thoughts from reading the news report only. National standards for on-scene time always bothers me. Having an ambulance on-scene in 9 minutes is not necessary in most cases and expecting to achieve that puts providers/public at risk. I think it would be more appropriate to make that requirement on calls that are truly medical emergencies. Someone's stubbed toe should not require an ambulance in 9 minutes.

They recommend cross training medics as firefighters. WTF? We've discussed this ad nauseum but seriously, to have a major report make this recommendation just cheapens EMS. I hope my the guy that does my taxes this year is cross trained as a veterinarian.

They also recommend that medics keep the same schedule as the FFs. I know nothing about the schedule in Philly so maybe someone can fill the rest of us in as to what the schedule looks like. If the FFs are doing something like 24 on, 48 off, this will lead to EMS burnout in no time. You cannot have 24 hours on in a major urban setting. You will kill you medics, either through psychiatric breakdown or literally killing them through fatigue and all that comes with it.

[systemet]

A few thoughts from reading the news report only. National standards for on-scene time always bothers me. Having an ambulance on-scene in 9 minutes is not necessary in most cases and expecting to achieve that puts providers/public at risk. I think it would be more appropriate to make that requirement on calls that are truly medical emergencies. Someone's stubbed toe should not require an ambulance in 9 minutes.

I agree completely.

I think the 90% in 9 minutes guideline stems from an old ICU study on VF and shock-conversion rates, something like 10% decrease every minute in delay. I think the idea was pre-PAD/pre-first responder defibrillation, to place an ambulance on scene before the point of futility in a cardiac arrest. There's probably also an element of the rapid transport / golden hour for penetrating trauma pseuoscience in there, too.

I don't think MPDS really allows us to study this well. All the dispatch determinants are sensitive but nonspecific, and the life-threatening conditions are not very prevalent, and only a subset of those are really time-dependent. So there's so much noise that it's difficult to know what a reasonable benchmark would be.

It's intuitively reasonable (a la the EBM parachute article), that there's some really sick patients that will benefit from field ALS, but it's hard to separate these from the noise when there's a rigid adherence to the idea that dispatch should be provide from a ring-binder by a lay person who's taken a 24 hour EMD course.

There's also that huge litigation medicine aspect, as well. MPDS provides EMS systems with a means of largely escaping liability for making decisions regarding rapid response / slow response. If a system gets sued then a product being sold by an expert group of physicians is under attack, and this system will defend itself vociferously. I think it makes it very hard from anyone to move to a more rationally designed dispatch system. A fall without injury in a patient with a cardiac history is going to continue to get a hot response in many systems, because that's what the cards say.

As discussed in another thread, I think this and the 10 minutes on scene benchmarks need to largely disappear. They're not strongly supported by EBM. I think an emphasis on short scene times for all calls / all ALS calls / all MPDS B and higher calls / any call on a day ending in "y", cripples the ability of providers to perform a thorough on scene assessment, and focuses EMS on an uneducated, rapid transport mentality.

They recommend cross training medics as firefighters. WTF? We've discussed this ad nauseum but seriously, to have a major report make this recommendation just cheapens EMS. I hope my the guy that does my taxes this year is cross trained as a veterinarian.

I think there's a small role for EMS on specialty teams like technical rescue, where a medic with some fentanyl and ketamine might be very useful. But for any large urban center, this just seems like a waste of time. Can you really make someone a good medic and a good firefighter in this setting?

It's maybe a little different for the suburban departments where they're not as busy on the EMS side, and the fire side is dead. There's maybe an efficiency-saving there. But a lot of dual-role departments do a great job of being fire department and a poor job of doing prehospital care.

They also recommend that medics keep the same schedule as the FFs. I know nothing about the schedule in Philly so maybe someone can fill the rest of us in as to what the schedule looks like. If the FFs are doing something like 24 on, 48 off, this will lead to EMS burnout in no time. You cannot have 24 hours on in a major urban setting. You will kill you medics, either through psychiatric breakdown or literally killing them through fatigue and all that comes with it.

Completely agree.

[croaker260]

Actually the 8:59 rule is from a seattle /king county study that was well done, but dates BEFORE the advent of AED's, but in a time /era when people (laypersons through doctors) took CPR much more seriously than we do today. Thankfully we are slowly returning to that mindset. TOday AED's have moved defib out of the relm of paramedics into the relm of laypeople.

With the advent of AED's and CPR, I think that a repeat study would find that AEDs and QUALITY CPR matter in the first 4 minutes, but that the arrival of ALS becomes much more variable.

[HERBIE1]

You could probably take this same report, substitute Phillie for nearly any major US city and the results and recommendations would be nearly the same.

Around 15 years ago we had a similar study done here(different consulting company), as well as in several other cities around the US. I cannot speak for other places, but it essentially became a $250K paperweight here. Not only were most of the recommendations ignored, many of the identified problems were actually made worse by doubling down on the same behavior.

In other words, there needs to be buy-in from all stakeholders-the members, the union, the department, the city, and even the citizens. That means you need proactive and progressive leadership, which in many places are not the hallmarks of the fire service- especially those with an EMS component. Simply mandating a change is not the answer- you need new leadership that agrees with the new plan. Without knowing anything about Phillie Fire, I can still almost guarantee that most of these changes will not be met with open arms by either most of the members or the management.

I think there could be a better outcome from this study than in prior years, since the economy is in such lousy shape, and politicians look for ANYTHING that could make a department more efficient, and more cost effective. Granted, public safety is not about turning a profit- although at least EMS DOES generate revenue(albeit certainly not enough to make them revenue neutral), so streamlining and cutting waste is priority one.

I get the hour change thing. There is an originizational culture issue, and with every difference between EMS and fire, it's simply another wedge between the 2 groups. Not saying 24's are bad or good, but I understand the rationale behind this.

Personally, I am all for cross training- it simply makes sense from a management standpoint. It's more cost effective to have an employee who can wear 2 different hats, but obviously there cannot be a drop off in quality of care. Around here, many departments- especially the busier ones- mandate dual roles for various periods of time, but generally allow someone to opt out- if they wish- of working on the ambulance after- say 10 or 15 years of service.

Unless the recommendations of this study were somehow binding- ie a certain percentage of these ideas needed to be implemented- I'm afriad this will be a long and ugly fight.

[JakeEMTP]

Personally, I am all for cross training- it simply makes sense from a management standpoint. It's more cost effective to have an employee who can wear 2 different hats, but obviously there cannot be a drop off in quality of care. Around here, many departments- especially the busier ones- mandate dual roles for various periods of time, but generally allow someone to opt out- if they wish- of working on the ambulance after- say 10 or 15 years of service.

I agree with this statement, to a point. Is cross training really cost effective? Every fire scene I have ever been on there is at least 1 ambulance dedicated to providing rehab and emergency care if needed. This crucial service cannot be provided if the crew is fighting the fire. So, in essence, somebody has to staff the ambulance and is unavailable to put the wet stuff on the red stuff.

The shift thingy is a sticky subject. If one is working in a busy urban system, 24 hours is ludicrous. There is absolutely zero chance of the provider providing the same quality of care at the end of the shift as they did at the beginning. Again, firefighting and EMS are two completely different professions and to try and melt them together is a recipe for disaster in a extremely busy system.

[HERBIE1]

I agree with this statement, to a point. Is cross training really cost effective? Every fire scene I have ever been on there is at least 1 ambulance dedicated to providing rehab and emergency care if needed. This crucial service cannot be provided if the crew is fighting the fire. So, in essence, somebody has to staff the ambulance and is unavailable to put the wet stuff on the red stuff.

The shift thingy is a sticky subject. If one is working in a busy urban system, 24 hours is ludicrous. There is absolutely zero chance of the provider providing the same quality of care at the end of the shift as they did at the beginning. Again, firefighting and EMS are two completely different professions and to try and melt them together is a recipe for disaster in a extremely busy system.

Agree about the shift issue, but if you have a bunch of folks who rotate through that ambo duty, then it won't be the same people getting the crap beat out of them every single day. One day on an engine, one day on a truck, one day on an ambo, etc. That way you split up the workload. It also depends on the number of days off between shifts- 24, 48, or 72. Traditionally, the fire service works 24 on, 48 off for a period of time, and then they have a Kelly day or something where they get 5 days in a row off to reduce the number of hours worked. Part of the problem with EMS working a similar shift is the issue of FSLA and OT. The laws vary, but police and fire are generally exempt from mandatory OT after a 40 hour work week- meaning they do not get OT after 40 hours in a normal work schedule. EMS is not considered to be exempt, so in many places, shift schedules needed to be adjusted to take that into account.

Believe me, I know 24 hour shifts are brutal- I've done them for nearly 30 years- and the last 25 in a very busy urban system. Problem is, call volume is always increasing, so something needs to be done, but the limiting factor is warm bodies and money. To increase the number of rigs means money, and to staff those rigs means a lot of money, and when you are talking about fire based EMS- especially ones with single role medics- we all know how eager the fire bosses are to address the needs of their EMS people.

When fire "adopted" EMS into their world, they simply made them conform to their work schedule, their rules, and their culture. There was no effort made to explore the differences in the jobs, and since the EMS folks are always the minority, their issues have essentially been ignored. We've been through this before- unless and until the culture of the fire service is changed, the same issues will arise.

Again- we'll see if this Philly report generates any of those changes, or it's simply another report that will gather dust on a shelf. Let's just say I'm not too optomistic.