Mixing EMS and The Fire Service

Two of Hilton Head Island Fire & Rescue's ten advanced life support medic units.

Two of Hilton Head Island Fire & Rescue's ten advanced life support medic units.

When I hear anyone suggest that the merger of fire and EMS is a mistake because “firefighters lack the skills to provide paramedic care”, I am highly insulted.

When I hear the ex-chief of a metropolitan department regretting decisions to bring medical providers and fire services together, I wonder aloud how he can continue to stomach the fact that it isn’t the inmiscible nature of these professions that caused the problem but the culture that the “leaders” of these organizations permitted to continue and encourage.

I admit that I know people with what could be termed the “fire” mentality and those with the “EMS” mentality.  But these individuals seem to be the minority now, rather than the majority.  Fortunately, I work with a lot of people who have the “Fire & EMS” mentality; people who are open to the belief we can do both well, we can exceed at the skills, we can meet our customers’ needs, and we can enjoy the diversity that having two “jobs” rolled into one provides on a daily basis.

I happen to work in an organization that merged fire and EMS together in 1993.  Prior to that, the two fire departments provided first responder service to our community to supplement the response of our local rescue squad.  Ultimately, with the merger, we took all three of these agencies and combined them into an outstanding example of emergency medical service delivery.  EVERY line employee is required to be at the MINIMUM a nationally registered EMT-Basic and of those personnel, over 40 of them are National Registry Paramedics as well.  This doesn’t count each of our chief and administrative officers who were all certified EMTs as well, and also doesn’t count our Training Division officers, who are both NREMT Paramedics as well.  Our organization provides a highly-recognized service to this world-class resort community and has incorporated 12-lead ECG monitoring and interpretation along with telemetry to reinforce our STEMI recognition program, among other programs like Island-wide AED promotion and education, public CPR and First Aid programs, car seat installation, and many, many other efforts.  I honestly work with some of the most outstanding EMS personnel in the nation and I’d be honored to let them work on anyone in my family, which is good, because I live in this community as well.

I have had it with anyone who suggests that EMS should be the exclusive domain of the third-party providers, especially since, with rare exception, a good number of these “non-fire service” providers don’t seem to provide any better of a service than the fire department EMS providers.  In fact, I know that our agency is an excellent EMS provider and is right now striving to be more than just excellent, but to be “state-of-the-art”.  With leaders like Lt. Tom over at the EMS 12-Lead ECG Blog, and Pete at the Star of Life EMS legal blog, we have a very good chance of putting ourselves in the position of being innovators and setters of the gold standard.

I would never suggest that fire-based EMS is the ONLY solution, but there are a few dinosaurs out there who continue to insist that EMS can only be effectively provided by non-fire department providers.  Apparently, stuffing themselves in their too-tight BDUs and hanging out at the local donut shop has occluded some sort of cerebral perfusion.  I hope they are watching carefully as the rest of us, the people who desire to have community-based EMS delivered by competent and caring providers, regardless of agency affiliation, kick them to the curb.

Your agency can only be as good as the personnel you retain; if you continue to recruit people who can’t do the job, the community shouldn’t be surprised if the situation won’t work.  Volunteer or career, you get what you pay for, and if the community doesn’t invest in good training, good equipment, good leadership, and good methods of keeping personnel, they shouldn’t be surprised if all they get is a crappy EMS system.

16 Comments

  • Will Bethea says:

    I couldn’t agree anymore. There is unfortunatley a saying that goes with some of this mentality, “200 years of tradition uninhibited by progress.” For the fire service, EMS is the future. Fires by whole are down. Prevention is working. We, as a service to the public, have to embrace the needs of our customers, and we have to be the best at our jobs. It never ceases to amaze me that people in our profession continue to have narrow visions and not embrace change (the needs of our customers). We joke that change is bad. Not all change is bad. I think our biggest fear is change and the fact the we, as a service, do not share information well (between departments either locally or across state lines). We continually learn lessons but somehow don’t share that information very well. EMS in the fire service is only one example. The department I work for in Maryland (nearly 18 years) has had fire based EMS long before my time, and it has worked very well. Most larger systems in the area have fire based EMS. There are third services but they are used for critical care interhospital transports and the nursing home to doctor’s office transports.
    There is a video series put out by Gordon Graham that I think everyone in any leadership positions should see. One of the vidoes talks about hiring practices. It addresses your last paragraph. It is true that if we continue to hire “losers” we will have a service that matches our employees, whether compensated or not.
    All in all, I think we share in the best profession that anyone could possibly work in. It is a very rewarding while frustrating profession. With a few minor adjustments, we could be even better. If needed, change is good. Change just for the sake of change, not so much.

  • Ben Waller says:

    While the recent events in D.C. are being used as an indictment of Fire/EMS systems by the non-fire EMS advocates, you don’t hear them making the same indictment of 3rd Service EMS due to the recent death in Pittsburgh during the blizzard. In that case, there were multiple calls to 911 during a 30-hour period when EMS made no contact with the patient at all. Should this start a national outcry against 3rd Service EMS systems? A fair comparison says it should.

  • totwtytr says:

    It’s because at every turn where the fire service has been involved, EMS has taken a back seat to suppression. Even in systems where fires are down, EMS takes a back seat. In mixed civilian/fire fighter systems, EMS only providers are treated like second or third class citizens. It’s because almost every major scandal involving EMS delivery takes place in a fire based system. It’s because although every city has more medical calls than fire calls, a fire only officer is in control of medical calls. It’s because in city after city, DC, NYC, LA, the medical director is subservient to the fire chief and has little or no control over the EMS providers, if they are firefighters. It’s because the IAFF has made it a point time after time, to frame the issue as “saving fire fighter jobs” and has never said anything about providing medical care. It’s because in city after city where fire has taken over EMS (this merger BS is BS), care has worsened, costs have risen, and there has been no career path for EMS providers. It’s because even though 90% of their work is EMS related I’ve never met anyone who identifies themselves as a “Paramedic/Fire Fighter, it’s always a Fire Fighter/paramedic. Even if they’ve never once been in a building fire.

    Finally, it’s because in every fire based EMS system I’ve encountered, the managers have mistaken mediocrity for excellence and have been satisfied to provide sub optimal care by demanding that only paramedics can provide care.

    Several years ago someone wrote an article in JEMS suggesting that a MD should be named as a fire chief in a large city FD since that would be the only way that EMS would take the lead role in what are increasingly EMS/fire departments, not Fire/EMS departments.

    Until the fire service as a whole understands that EMS is a branch of medicine and acts accordingly, the fire service will continue to deliver sub standard medical care.

    Oh and it’s crap like this that makes fire based EMS a joke.
    http://www.wdsu.com/health/22894237/detail.html

  • truck6alpha says:

    TOTWTYTR,

    I appreciate the feedback, but unfortunately, I think you think I’m one of these “fire service only” people who believes the ONLY capable delivery system for EMS is through the fire department. I’d ask that you please look over my blog entry again and see what I said. And what I said (and given the angry mail I got from some readers, requires more explanation) is:

    “I would never suggest that fire-based EMS is the ONLY solution, but there are a few dinosaurs out there who continue to insist that EMS can only be effectively provided by non-fire department providers.”

    I believe that the best service is something that needs to be derived from the community. I came from an area (Montgomery County, PA) where there were fire-based systems, third-party systems, and private systems. I have personally worked for both fire-based and third-party (county) systems. I try not to generalize because I know that the moment you do (“It’s because in city after city where fire has taken over EMS (this merger BS is BS), care has worsened, costs have risen, and there has been no career path for EMS providers” and “Finally, it’s because in every fire based EMS system I’ve encountered, the managers have mistaken mediocrity for excellence and have been satisfied to provide sub optimal care by demanding that only paramedics can provide care”) you find there are exceptions to the rule.

    Our organization merged and the original problems weren’t with the fire/EMS side of things but with the differences between the two fire departments. Since both fire departments were already providing EMS and the EMS here was almost 70% off-duty firefighters, things went pretty smoothly. Our costs are just fine, our collections are excellent, and we have some pretty damn good paramedic/firefighters.

    The problem as I see it isn’t with the concept, t’s with the implementation. I agree with your observations 100%; there ARE quite a number of fire-based systems out there who do the job to the exclusion of the EMS professionals. And honestly, if you could find a doc who was willing to be a fire chief (and take the pay cut), I’d be okay with that, so long as they remained as open to fire issues as we should also be to EMS issues.

    Maybe I’m going through my career with rose colored glasses on, but I have been in the business for coming up on 30 years and honestly, the answer isn’t in what agency delivers the service but in WHO delivers the service. If you recruit, train, and foster a joint-delivery culture and assiduously groom new personnel in the right expectations, regardless of whether your agency is fire, county, muni, hospital, or profit-based, your organization CAN be cutting edge, innovative, patient-centric, and support personnel who want to succeed.

    On HHIFR medical scenes, the paramedic is in charge, regardless of rank. Fortunately, we have a lot of paramedics who rose to officer rank (yes, in our organization, you don’t get punished for being a medic, it actually helps). All three of our LINE BATTALION CHIEFS (yes, you read that correctly) are nationally certified paramedics.

    Is doing both difficult? Admittedly so, but we at HHIFR are up to the challenge. Are there other like-minded organizations out there? Yes, there are. Is the mindless “firefighters have to do this job to justify our existence” chant hurting the EMS industry? You betcha.

    Decisions as to the proper origin of service delivery are ultimately left to the customer, if they are willing to vote and to say their piece. In my world, I’m familiar with third-party services who do nothing but continue to shoot themselves in the foot because instead of being patient-centric, they are self-centric. To them, it’s not a matter of quality service delivery; it’s a matter of survival. The focus hasn’t been on what can we do that is best for our customer, it’s what can we do to make our lives easier. So long as ANY agency acts in that regard, the end is coming, it’s not a matter of “if”, but “when”.

    I’m sorry that you misconstrued my rant as another “fire service EMS” war chant, but I was pretty careful in my article to outline that this is absolutely NOT my position. My position is that as leaders, we need to take some responsibility for the culture of our organization and if that culture is dysfunctional, we as leaders have a responsibility to redirect it.

    Thanks for reading-

    Mick

  • joe says:

    3rd service.

  • joe says:

    The Pittsburgh PA issue is solved by NOT having dispatch operations separate from the agency providing the service. Read the whole story.

  • MultiSystemMedic says:

    I think you both identify the issue and fail to account for it in your appraisal of the system. Having worked in all three types of systems as well as internationally I think I have a unique perspective.

    First, I do not think that you can make broad generalizations that adequately account for all systems, however I believe that some assumptions can be made based on call volume and population density. Simply put, multi-role agencies are an excellent solution providing the best compromise in smaller to mid-sized suburban communities. These are the type of agencies that average 1000-4000 EMS med/trauma calls originated through a 911 call center annually. The volume isn’t sufficient to justify a full-time ALS service providing EMS only from a financial standpoint, but a multi-role agency can not only provide ALS emergency response and transport but benefit from the experience, additional skill sets, and activity.

    Unfortunately a system that serves a community either larger in population or more active in demand for emergency response, ie “busier”, needs emergency medical professionals that can dedicate a career to the discipline. Thus far I have yet to see a Fire model that truly allows for a career paramedic with a defined professional promotion track, leadership focused on out of hospital emergency care, and organizational/cultural support in terms of budget. When promotions and advancement require you to test, interview, and “perform” as a firefighter, not as a paramedic, you lose out on the major advantage of a third service: career emergency medical professionals. Paramedics who have spent 15-20-25 years focused on being a paramedic. Having had the opportunity to work in a system where for the first ten years out of paramedic school (plus 2-4 years as an EMT) your partner is likely to have 10+ years of experience more than you and your on duty supervisors/officers at least that – and having worked in a “classic” example of a more transient system where 3-5 years was the norm and those with >10 considered strange and exotic beings I can say that the level of clinical care provided to the community was far superior in the career system.

    When providers and a system commit to career expectations for their clinicians they are more willing to invest in the education, QA/QI process, and financial support that constitute the real future of prehospital care.

  • Ben Waller says:

    TOTWYTR, Your post contains some half-truths, some omissions, and a huge blind spot. There are some fire service EMS systems that have problems, true. There are many other non-fire EMS systems that don’t have fire chiefs, don’t do fire suppression – or anything other than EMS, and that provide terrible service while claiming that they are “the best”.

    Some fire/EMS systems like DCFEMS that have well-documented problems are better now than when EMS was a 3rd service there.

    There are fire/EMS systems that provide excellent service across the board. Using problems with a few big-city fire/EMS systems as condemnation of the entire model is – flatly – bogus.

    If we’re going to condemn DCFEMS for the recent fatality from a medic-induced no-transport, then fairness insists that we condemn Pittsburgh EMS at least as much for running multiple calls for the same patient over a 30-hour period and never even making patient contact until after the patient died!!!

    As for putting a medical director in charge of a fire chief, look at the hospital model – the health care classic. Very few hospitals have a physician administrator. In almost every case, a trained administrator runs the hospital while the physcians run patient care. Why should a fire department be any different? They are managed by administrators, after all.

    Your statement “It’s because at every turn where the fire service has been involved, EMS has taken a back seat to suppression.” is completely bogus. That may be true in some places, but it clearly is not the case in a lot of fire/EMS systems. That means your claim of “every turn” is completely inaccurate.

    As for the Firefighter/Paramedic comment, once a provider is qualified as a firefighter, he/she is a firefighter, regardless of the level of experience.

    The system where Mick and I work isn’t a big city, but the fire/EMS merger clearly improved our system. We have far more ambulances available despite higher call volume than the pre-merger days. We have the ability to be flexible and handle a wide variety of emergencies, not just patient care and transportation. We measurably spend 35% to 40% less on personnel costs than if we funded the same level of services with two seperate systems. Several other locations including Greenville, NC, Clearcreek, OH, and South Kitsap, WA run similar systems to ours and with generally good results.

    Oh, and our medical directors are involved, have a strong influence in patient care, push for agressive protocols, helped us implement a regional STEMI program, and one of them is – wait for it – a former Firefighter/Paramedic.

    If 3rd service EMS had to withstand the same kind of bias which you apply to FD/EMS systems…a lot of them couldn’t, and they don’t have any fire-related reason for it.

    I’ve told you this before, and I’ll say it again. For every Boston, there is a Seattle, and for every Detroit or DC, there is an Atlanta or a Cleveland.

  • Ben Waller says:

    TOTWYTR, one other thing…using your logic, it’s crap like this that makes non-fire EMS a joke:

    http://chown-cairns.com/426323-South-Carolina-s-EMS-data-access-law-strictest-among-8-southeastern-states.html

    …supported by the state EMS association (mostly 3rd service and private providers), and opposed by fire service EMS, including public support by our mayor and…Fire Chief.

  • Dave Springer says:

    To the originator of this thread. I’m sorry that I don’t see your name here. Except for your first sentence it sounds as if you are generally respectful of those who disagree with you, and I do totally.

    It is people like you that take food out of the mouths of people like me who are wonderful medics, but could no more be a fire fighter than the man on the moon.

    Let me leave you with a thought. If you are such a great service are you CAAS accredited? If not, why not? That is NOT to say that there are not some excellent services that have not gone through CAAS certification, but I would ask them the same question. If not, why not?

    There are some fine fire EMS Agencies, and some I would not send a sick cat to. Case in point in my home area that I came from of the Quad Cities. The Iowa side of the river has one of the top EMS services in the country. The Illinois side of the river has a branch of that service, and two fire agencies. The two fire departments, Moline and Rock Island, IL. use the same equipment, training centers, trauma centers, and medical directors. The Moline guys could treat me or my loved ones any day of the week. Years ago I sent a signed not to RICOMM that said my family & I were NOT to be transported by the incompetent boobs in Rock Island.

    The difference – Simply the administrations. One of caring & honesty, the other as crooked as ten miles of bad road.

    Are all fire EMS units great? No. All bad? NO. Are all private or hospital or third service EMS agencies good? No. All bad? No. As someone above said, it is not the agency that runs a call, but the PEOPLE!

  • Ben Waller says:

    Multisystem Medic,

    There aren’t a lot of EMS systems anywhere that have plenty of 10-year paramedics as the norm for a new paramedic’s partner. The norm in a lot of places is likely to be either a basic EMT or another paramedic with 4 to 8 years of experience…or sometimes even another new paramedic.

    A lot of non-fire EMS systems essentially have disposable work forces now. That – not 10+ years on an ambulance, is the norm. In the fire model, at least the paramedics are encouraged to stay for a 25-year (or more) career, even if their primary focus changes from working on an ambulance to an engine, truck, or rescue company, or in increasing numbers, paramedic battalion chiefs. I’ve worked in two high-volume 3rd service systems, and they’ve both have paramedics leave in droves…usually to become firefighters. Some of them stay on as part-timer/side jobbers at the EMS system, but a lot of them don’t.

    The fire service offers a better career ladder than non-fire EMS, and it always will because of riding as a company with a supervisor on each company. The better career ladder, the chance to work units with more diverse work and maybe lower call volumes, and the chance to avoid the one-trick-pony experience will always attract good paramedics to fire/EMS systems.

    There’s nothing wrong with spending 25 years on an ambulance or working for a 3rd service or private provider. If that’s what you want to do, do it and be good at it. Just don’t make the mistake of thinking that firefighter paramedics or Fire/EMS systems are inherently inferior. There are just too many examples that contradict that bias.

  • truck6alpha says:

    To Dave;

    I’m the originator of the thread (and the whole blog, actually) if it is me you are referring to, and if so, I’m Mick Mayers (hello). And yes, I try to be respectful of individuals even with different points of view. I am most certainly not always right, and while I try to be right as much as possible, I am open-minded enough to change my viewpoint on a subject if logic and reasonable consideration of all the facts are presented.

    Our organization IS actually discussing CAAS accreditation. We were already one of the first fire departments in the world to achieve CFAI accreditation back in 2002. But there s, of course, always the discussion as to what CAAS accreditation would do to benefit our community (we had the same discussion with CFAI and we continue to revisit it with ISO evaluation, but I’m not personally convinced that is even worth the paper it is written on). We also strive to comply with NFPA standards, etc.

    But this discussion isn’t about my department, it is about the delivery of EMS as a whole. There is no amount of convincing that anyone can do that will convince me a “one-style-fits-all” approach to service delivery is the answer. Likewise, I have little patience for the individuals who experience one or two bad examples of certain systems and pronounce everything in that category unfit.

    The whole intent of the post was to illustrate my unhappiness with people who say that firefighters are unable to be good at firefighting and simultaneously be good EMS professionals. I’m not in any means apologizing for that belief.

    Excepting the negative e-mails I got from cowards who chose not even to exercise their right to remain anonymous as part of this civil discussion, I am enjoying this thread because it reinforces my belief that there are those who are in strong systems and they’re not all alike. That we have in fact identified the needs and addressed them in certain communities. And that there are plenty of open-minded people out there who just want to discuss their differences reasonably.

    In fact, I also have some problems with the way some EMS people treat their own; like the attitude some EMTs have for the transport medics, or career for volunteer, etc. But that’s no different than the problem I have with people doing it on the fire side of things either. I see the benefits of having career personnel in some communities for whatever reason, but just having a career company doesn’t solve the problem- there are enough all-career departments out there that I think suck.

    Let’s work together to enhance professionalism from EVERY aspect of EMS delivery and in doing so, benefit the patients. And most of all, let’s all be civil about it and discuss our ideas intelligently, and not like a lynch mob. I’ll tolerate spirited discussion here on FHZ, but the crazies, well, you’ll be continue to be moderated unless you act like an adult. Thanks for keeping this discussion going.

    Mick

  • Ben Waller says:

    A few points about CAAS vs. CFAI accreditation…

    CAAS is the Commission on Accreditation for Ambulance Services. That’s fine for services that are only ambulance services. CAAS accreditation simply doesn’t fit most fire service EMS. CFAI, on the other hand, has a lot of overlap with CAAS accreditation, addresses a wide range of services – not just EMS – and omits a very few of the CAAS accreditation objectives.

    Applying CAAS standards to a fire-service EMS system is essentially applying apples standards to oranges. CFAI applies oranges standards to the oranges.

    As Mick says, our system is CFAI accredited, and we’re looking at CAAS accreditation. Our research revealed a grand total of three fire department EMS systems in the entire U.S. that have CAAS accreditation. When contacted, two of those departments indicated that they do not plan to renew their CAAS accreditation when it expires. Their reasons – CAAS accreditation is expensive, time-consuming, and provided no benefit to the community. On the other hand, there are three CFAI-accredited fire departments in my state. All provide some form of EMS, and all are happy with the “oranges” accreditation for our “oranges” departments.

    If CAAS accreditation was more pertinent to fire service EMS, then maybe more fire service EMS providers would be interested in pursuing it.

    Fire-service EMS isn’t designed to keep EMS-only providers out of the job. It’s designed for people who have multiple qualifications, who are flexible, who can handle a variety of emergencies, and who provide lots of bang for the taxpayer’s buck. Some of the reasons that EMS-only paramedics don’t have a lot of career progression in some Fire/EMS systems is that those departments design the supervisor roles for people who are qualified to do more than one thing, who are qualified to supervise more than one kind of emergency service provision, and who supervise people that are qualified to operate more than one vehicle type.

  • Mick Mayers says:

    Earlier I made this statement: “On HHIFR medical scenes, the paramedic is in charge, regardless of rank.” I want to clarify that: In our organization, the company officer is in charge of the scene. In many cases, the company officer is also a paramedic. But along those lines, the patient is only one element of scene management. If the scene is such that it involves other external factors, the paramedic must devote a certain amount of attention to patient management as well as overall scene management.

  • emtguy says:

    I think an interesting point that never seems to be brought up with EMS is billing. If a hopital or private company is doing the transporting then i understand charging the patient for the transport, because they are not being taxpayer subsidized. But it seems to be absolute BS to me when i hear of either a fire or county based system charging for ems. Im not naive, i know this stuff cost money, stuff isnt free. But why are we charging people for transport as well as taxing them. Absolute BS. Of course were always saying that cost shouldnt matter, and that the almighty dollar shouldnt make the final decision, which becomes a common arguement against private ems. But fire departments seem to use that arguement that it will save money money by switching to their system.and that private ems bases care around cost(which by the way isnt always true with private ems). but being public service how the hell do they justify that its okay to charge for ems. the fire and police protection is provided via tax money, why not ems. it just seems really wrong. I guess i just get confused when we dont pour tons of taxpayer money into making an impeccable ems system, nationwide to improve educational training for emts and medics, equipment response times, all that stuff, yet i continue to see fire departments get grants and money to buy a new truck every two years. WTF i dont mean to bash you fire guys out there, it just ruffles my collar.

  • truck6alpha says:

    Emtguy,

    Thanks for the comment. Yes, our organization does bill, as well as is funded via tax dollars. So, however, is the county system we replaced here. I guess in most communities, this might cause some heartburn, but in ours, a large number of the alarms are generated by visitors to our community (we’re on a resort Island)and so relying entirely on tax revenue wouldn’t exactly be fair.

    We have tossed around some different avenues of paying for the service, but what has worked so far (and the taxpayers seem to endorse it) is that the taxes insure the service is there and you just have to pay on a cost plus basis if you use the service. Our billing collectible rate runs between 75 and 80%, which is unheard of in most systems, but we also have a lot of people who either have insurance or are willing to pay their bills because (I like to think so, at least) we provide excellent customer service.

    The residents and tourists on Hilton Head Island get a lot for their money as well; we were last year’s runner up IAFC Heartsafe Community, we run 12-leads that transmit to our hospital via voIP to supplement our efforts as CARES registry participants, and a number of other awards and accolades. AND we are a CFAI-accredited all-hazards response system.

    I think you are right about the costing issues and there certainly are a number of ways to pay for things. I suppose a lot has to do with the local service and how it markets itself, as well as the service it provides, as to how much the people will tolerate. But the flip side is, you get what you pay for.

    Thanks again for your comments and thanks for reading.

    Mick

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