CCC over at Captain Chair Confessions had a nice post on fire department first response to medical calls. He pointed out the inherent silliness of using fire fighters as EMS first responders most of the time. It’s a theme I’ve explored here and in other places more than once. CCC does a nice job explaining why this happens and you should go and read his post before you continue.
I’ll wait right here until you get back.
Welcome back. The post that follows started out as a comment on his post. When it got to the point that the comment was longer than the original post upon which I was commenting, I decided to make it into a blog post. Which allowed me to blather on longer than I might have otherwise.
Please read with CCC’s post in mind.
Increased FD response to EMS is the result of two separate decisions, both financial and neither remotely related to medical care.
First, as you note, fire responses started to drop dramatically in the late 1980s. As older buildings were either renovated or torn down and replaced and new buildings were constructed, modern fire code requirements reduces the incidence and severity of fires. The exception is wild fire fighting, but that’s not part of our discussion.
As a result, the fire service unions (IAFF) and advocacy groups (NFPA, IAFC) started to look for activities to keep fire fighters busy and justify keeping large budgets. The two emerging areas were EMS and HazMat. EMS is more frequent, has shorter response and on scene times, and is cheaper than HazMat. While the fire service took over response to HazMat, there was more money to be had in EMS. Hence they moved in to that area. Despite what fire chiefs and union presidents say in public, it’s well known that behind closed doors at union halls and FD headquarters, it’s about jobs, jobs, jobs, and money, money, and money.
A second, lesser factor was the move by private companies and “Public Utility Model” systems to supplant municipal services and even volunteers in 9-1-1 response. In addition to being able to provide less expensive service, the PUMs and private, for profit services, touted that they could provide faster response using fewer units.
They did this by a rather ingenious (in the short term) strategy called “cost shifting”. They didn’t use that term, but that is in fact what they did. To meet response time goals that were promulgated by many of the same people who were bidding on the service, they convinced municipalities to use their public safety systems to use their employees and equipment as first responders. Under this scheme, the response time clock stops when a vehicle, any vehicle, with blinky lights and a siren arrives at the scene of the emergency. The first responders make the citizenry happy because someone, anyone, is there to reassure the patient and bystanders that help has arrived.
Even if they don’t do a thing. Even if it’s not really an emergency. Even if there is no need, not the least need, for a rapid response.
In addition to stopping the response clock, this gives fire fighters something to do. Not only something to do, but something to claim in vital to patient survival. Which is patently silly since there are only very few instances where time is of the essence in response. It’s even more silly to put paramedics on fire engines since they generally won’t have time to do anything ALS before the ambulance arrives.
So, the cost of rapid (if unnecessary) response is shifted to the fire service while the transport provider can come along in a bit more leisurely fashion. The cost is not only having to have more personnel than a service would need if they weren’t going to medical calls. In addition many fire departments have increased equipment and personnel costs. That doesn’t even take in to account the increased costs of running fire trucks to medical calls. Which is not what they were designed for and is a very expensive way deliver people to an emergency scene where like as not, they aren’t even needed.
Oh, and of course the transport provider get to bill for their part of the service and keep all of the money. It’s complex, but depending on the exact circumstances, providing reimbursement to the city or fire department can be considered a “kick back” under federal Medicare rules.
An additional bonus for the PUM providers is that often the city or county owns the ambulances and any buildings being used. Which means that the transport service provider doesn’t have to pay for vehicles or buildings. They have to hire the actual providers and manage the service, but since those providers are usually young and turn over is high, salaries are much, much, lower than they would be if the city hired the the EMS employees themselves.
Finally, all of the “triage card” based systems are intended to do two things. One is to produce a repeatable and consistent nature or type code for dispatch purposes. Not one that is accurate, but one that is consistent. Which supports the second purpose. Liability protection. They are also heavily weighed towards over triage. Thus we get the scenarios in CCC’s post. Response overkill, if you will.
Oh, and since many, if not most, 9-1-1 call taking centers hire people who aren’t medical experts, the system is meant to “guide” the call takers to the right call type and priority. Well, to a consistent call type and priority.
The last thing, and maybe the most important in this discussion is public perception. Generally, the public neither knows nor cares who it is that is responding. Most people don’t know the difference between an EMT and a Paramedic. Just this past week I was teaching an ACLS class and one of the students (an experienced nurse) asked me what the difference between the two was.
Nope, all the public cares is that when they dial those three magic numbers and give an address, someone comes along to take care of their problem.
Based on my experience in over three decades of EMS service and what I read in the news, the number one complaint is “The ambulance took too long to get here”. It doesn’t matter if the emergency is real, imagined, or non existent. They want the ambulance on scene even before the call hangs up. The service I worked for still requires RLS response for every priority of call. I’m reasonably sure that the managers of the service know that it’s needless, and more than little bit dangerous, but they are powerless to stop it. City Hall receives the response time complaints and they want happy voters, so we get to put our lives (and those of the voters) in danger by responding in emergency mode for calls that are clearly not emergencies.
I don’t expect that to change. Ever. Unless we get Star Trek like transporters and can beam patients to the hospital. I’m not holding my breath.
Part of my new career path involves visiting several small fire departments that also provide EMS, including transport. EMS response is 80% or so of their call volume. If not for that it, many of them could have four full time firefighters on duty at any one time and supplement that with mutual aid and even volunteers.
A former co worker of mine left about three years ago to become a fire fighter in a small town. Three years ago. Last week he went to his first building fire. It wasn’t even in his own town, it was mutual aid for a house fire in a neighboring community.
So, it’s all about money, jobs, and public perception. None of it is about patient care. In reality the fire service could be sent to calls for unconscious people (including cardiac arrest), choking calls, and seizures, and patient care and outcomes would be largely unchanged. Why seizures? Because often that’s the terminal act of someone who is in ventricular fibrillation. A fire truck with people to do CPR and use a defibrillator would be all that is needed for those calls. Forget sending fire trucks to shootings or stabbings, they don’t do any good. Train the cops to put on tourniquets until the ambulance gets there and you’ll do more good. Not to mention keep the crime scene more clear and allow for faster access to the patient.
If the fire service ever finds out my real identity I might have to go in to the witness protection program. I’ll opt for somewhere that doesn’t have FD first response, thanks.