I was exchanging emails with a fire officer who happens to work in the same city I do. This all started with a comment about the number of new ambulances we recently put into service. His comment was that it was nice that we got new ambulances and will be getting more, but the fire department needs new apparatus as well. Only they don’t seem to be getting replacements with the frequency that they used to. He also commented that we get a lot of “stuff” due to having better grant writers than the FD does. During the course of the discussion he mentioned that a lot of the wear and tear on the apparatus was due to the increased number of EMS runs they respond to. I think the implication was that EMS should shift some funds to the FD to pay for apparatus. Or something, I’m really not sure.
I commented back that maybe they shouldn’t respond to so many medical calls since most of the time first responders don’t really do anything positive for the patient. Which ended that particular exchange of emails because that sort of thing just beyond contemplation. The FD HAS TO RESPOND TO MEDICAL CALLS. Lives hang in the balance, don’t you know?
Back in September I posted An Idea as a tongue-in-cheek jibe at fire first response. Mr. Fixit understood the spirit of the post, as did a few others. This time, I’m more serious about the topic. I expect that some in the fire service won’t agree with me, but that’s OK too.
The email exchange with the fire officer got me to thinking. I don’t recall any sort of peer reviewed study regarding whether first response by anyone, fire, police, boy scouts, has any impact on patient survival. There isn’t even a well researched standard for what types of calls first responders should go to. Some few cities don’t use first responders, some send the FD to every EMS call, some have one set of criteria, others have a completely different set. In my system the FD does not go to shootings or stabbings, even though they want to. In other cities they do.
The first question we should answer is; Why do fire departments respond to medical calls? There are a couple of reasons for this, and they deserve some explanation.
Since the late 1980s, most fire departments have done a terrific job in reducing the incidence of fire as well as the number of deaths and injuries to civilians. Smoke detectors, better building codes, and lots of new construction all helped to do that. Also, some fire departments, such as the one in the city where I work, are terrific at structural fire fighting. Aggressive interior attacks, along with advances in technology, have decreased the time it takes to put out a fire. That of course limits the amount of time that fire fighters spend at fire scenes. All of which is really, really, good. Terrific in fact, but solutions seem to spawn problems sometimes.
As the number of fires decreased, the amount of down time for fire fighters increased. You can only train, drill, and clean the station and apparatus so much. Fearing layoffs (which would be a stupid idea) both fire unions and fire chief’s associations cast about for new duties to fill the gap. At the same time a couple of other things happened. Hazardous materials awareness was raised in industry, government, and the general public’s minds. It seemed natural to train the fire service to respond and do at least initial containment of HazMat incidents. Actually, probably a good idea, although a lot of fire fighters I know absolutely hate HazMat responses. I don’t blame them because despite being trained to respond to them as well, they scare the crap out of me. I prefer to take the Monty Python approach to HazMat. “Run away! Run away!” whenever possible is my mantra.
At the same time some things were going on in EMS that lead many to think that the fire service should be involved in EMS, even if they didn’t run the ambulance service in their community. The first was a concept called the Public Utility Model of EMS system design. Under a PUM system the city or county government creates an EMS Trust that contracts with a provider to run the system. The government provides the vehicles and equipment (usually), and the contractor hires the staff and operates the system. Ideally, the government pays nothing for the service and the contractor gets to keep any surplus funds generated. This sounds great on paper, but there are a few problems. First, in order to maximize profit the contractor will try to cut the number of ambulances on the road and increase the amount of time that the crews are actually on responses. This increase in efficiency often comes in the form of “System Status Management” where in ambulances are moved around based on computer predictions of where the next calls are likely to be. If three ambulances in a row line up, then change falls out of the dispatch computer. Sort of like a slot machine, only not as precise. OK, I’m just kidding there.
PUM systems usually have to meet some sort of response time criteria to meet their contract requirements. Which is where the fire service comes in.
Another piece of this puzzle is how response times are measured. There really isn’t any standard of how response times are measured in EMS. Which allows some systems to sort of manipulate response times. Some measure response times from when the phone first rings at the 9-1-1 center until the ambulance arrives. Some measure response time from when the call is entered into the system until the ambulance arrives. Some from when the call is entered into the system until someone arrives. Someone can be an ambulance or a first responder. In most, but not all cases, the first responder is in the form of a shiny red truck. The theory being that the fire fighters can provide treatment for the patient and that when the ambulance arrives is less important because the ambulance is mostly a transport service. In some cases, the fire department provides advanced life support and either hands off the patient to the ambulance or fire fighters ride in the ambulance to the hospital.
First response like this is almost tailor made for a fire department that has fewer and fewer fires to face. Honestly, there aren’t that many HazMat incidents out there, especially as compared to medical calls. Seems like a win – win, doesn’t it?
Only there are few problems with this model or any first responder model. First, as I stated earlier, we don’t know what calls first responders are of benefit for. I’ll talk about that more in Part II.
The other problem is wear and tear. Not only on the equipment, but on the fire fighters. A lot of fire departments work twenty-four hour shifts, but those were predicated on fire only response. Responding to EMS calls all night long wears on the fire fighters, especially if they are ALS level providers. For the record, I think twenty-four hour shifts for busy EMS systems are unsafe too.
If the ambulance provider shifts part of the burden for responding back to the government entity they are contracting for, are the savings real? While the city or county is using more staff and equipment to respond to calls, the ambulance provider can commit fewer resources, still bill, and get the benefit of short responses. The problem is that often fire fighter unions will want more money for the added responsibilities, the maintenance costs for vehicles and equipment goes up, and replacement cycles become shorter for the fire apparatus. Which I’d have to call a false economy at best.
The second thing going on in EMS was that we became more popular. For a variety of reasons I won’t go in to here, more people started to go to Emergency Departments instead of primary care physicians for problems that EMS and EDs were never designed or intended to treat. That increased the demand for EMS, but few systems added more units to their deployment and so response times started to creep up. Once again, the fire service was called on to provide some level of response until the ambulance arrived. The public came to expect, with our encouragement, rapid response no matter how acute, or not, the problem. Once again fire apparatus showed up to have “someone” there to meet the public’s expectations.
Then there is the issue of whether or not first response positively impacts mortality and morbidity. I’ll tackle that in Part II.