Wear and Tear Part II

14
685

In Part I, I gave some background on why some fire departments (maybe even most) respond to medical calls. I’m not going to go into the more than fifty different models of EMS system design here, since it really has nothing to do with the topic at hand. Suffice it to say that first response ranges from CPR and first aid trained fire fighter to paramedic/Fire Fighters on fire engines. It doesn’t really matter for the purposes of this post.

As I mentioned in Part I, we don’t have any evidence to direct us as to when the fire department should respond to medical calls and when they shouldn’t. Most FD first response plans are based on politics or contractual agreements with ambulance providers. Which often leads to confusion as to who is the “real” EMS provider with the FD first responders claiming that they do the real medicine and the ambulance service is just a ride to the hospital. Which again, is not on point here.

Here is a fairly short list of various classes of medical response and my best guess as to whether there is benefit to having any first responders go to the call first.

Cardiac Arrest There is a considerable amount of science that shows that there are only two therapies that positively impact cardiac arrest survival. One is time to first defibrillation, the other is good, timely, CPR. Which is why it makes sense to send someone to cardiac arrest calls if the ambulance can’t be there in a less than six minutes. Which for the most part, they can not. Nor can fire departments in many instances, but the odds are better because generally there are more of them and they are less likely to be on a response. In some areas that somebody is the fire department, but in others it’s the police. In many areas it’s neither as health facilities, casinos, airports, shopping malls, amusement parks, and high rise office buildings have their own defibrillators and people who can use them and do CPR. Even if the FD brings oxygen to the scene, there isn’t any evidence that oxygen, or any other drug or procedure for that matter, make any difference in survival to discharge for cardiac arrest patients. In fact, there is some small body of evidence that suggests that room air resuscitation might in fact be better. If the studies done in neonatal patients and animal tests hold, then this will have further ramifications down the road. Still, I’ll say that the FD should respond to cardiac arrests.

Chest Pain Of suspected cardiac etiology. The question here is if the two or three minutes that the FD will be on scene to give Oxygen to chest pain patients is of any benefit. Or if the same amount of time with ALS trained fire fighters will give any benefit. No evidence really and since the measure for treatment of Myocardial Infarction patients is generally time until the patient gets in a cath lab, getting an ambulance on scene with staff that can do a 12 Lead ECG is more important. Even if the fire fighters can do a 12 Lead and transmit it to the ED, I don’t think that it’s a significant benefit to the patient. “But what about the patients that go into arrest after they have chest pain”? That’s a valid thought, but in almost 30 years I’ve seen that three times. Two were defibrillated immediately by the EMS personnel on scene, the FD was no where around. The third occurred way back in the days before BLS personnel were trusted with something so sophisticated as an AED. No ALS available, so we did CPR and transported. He survived too. Maybe your experience is different, but that’s my experience.

Seizure Patients As the lawyers are wont to say “It depends”. If the seizure is the terminal event in a cardiac arrest, we’re back cardiac arrest response. The question is if there are enough of those to make it worth the added risk and wear and tear to have the FD respond to every active seizure. If it’s a postictal event, then there is no reason to send the fire department. The problem is that we probably can’t know for sure so if the seizure is active and the patient has no known seizure history, it’s probably reasonable.

Diabetic Emergencies Absent the ability to check Blood Glucose and administer Dextrose or Glucagon, there isn’t any reason to send the fire department. Oxygen is often given to these patients using the Chicken Soup theory. Again, no evidence exists that Oxygen helps hypoglycemic patients.

Unconscious Person We’re once again back to possible cardiac arrest. If the circumstances suggest that the person is unconscious and not just unable to walk, then on the likelihood that it might be a cardiac arrest, a fire response is prudent. If nothing else, the first responders can open the airway and if needed, defibrillate. Still, the fire fighters are going to share the joy EMS workers have in getting to know the homeless folks in their area on a first name basis. It’s always nice to meet new friends and renew acquaintances.

Stroke Patients
In my system, absent respiratory distress or airway compromise, this is a BLS call. Much as with MI, transport and early notification of the ED is the most important therapy we can give. There is considerable evidence that Oxygen is not helpful and might even be harmful to stroke patients. Stroke patients with respiratory distress or the inability to open maintain their airway are few and far between. They also have poor outcomes as a rule.

Difficulty Breathing
The only question is if the few minutes of Oxygen that the patient will be given is going to provide any relief or long term benefit to the patient. I guess this one is a toss up. Again, I’d like to see some science either way.

Trauma Patients I’ll lump this into one category. As a rule there is no benefit to having the fire department respond to these calls. Unless there is some entrapment issue, there is little the first responders can do. Really, think about it. It’s nice to have the extra hands at a MVC with a number of patients with acute insurancitis, but most of the time there is no need. Someone trapped in or under a vehicle? By all means, although in Pittsburgh the EMS guys do that sort of rescue. Fell off a building? As long a they landed on the ground and don’t need extrication the FD is of little value. Struck by a car? Back to stuck under the vehicle. If the patient is up and around or even lying in the street, but not under the vehicle, then what’s the basis for a FD response? So, trapped and need extrication? Fire Department. Not. No Fire Department.

In general the reader should think in these terms. Is there a benefit to the patient? Is the fire department being used to prop up an EMS system that hasn’t committed enough resources to servicing demand? Is having the first responders on scene for the benefit of the patient or is it just for image purposes?

Then think about how much it costs in dollars, risk, and wear and tear on people and equipment to achieve whatever goal you’ve chosen. Then think if the goal is reasonable and necessary. Is the value of having first responders on scene for two or three minutes before the ambulance arrives worth the added cost?

When you think of cost, don’t just think of dollars and cents. Think of the real costs.

Any counterpoints out there?

14 COMMENTS

  1. I am assuming this does not apply to Rural EMS, where I run. Generally, each Fire Comp has a squad vehicle that they is dispatched specifically for EMS calls. When ambulance response times to calls can be 15 minutes or more (especially if volunteers have to respond to the station first) a more closely located fire company can get first responder resources on scene a bit faster.

  2. Here in the UK, the FD are not used for EMS at all (excluding a few trials).Reading some American blogs, and having seen some Youtube videos, it seems to me that the US system leads to a ridiculous number of people dealing with the casualty.All this does is to stress out the casualty, which is not good for them.Also, considering how many more calls EMS go to than FD, we have more, and more strategically located, ambulance stations than fire stations.Perhaps something else to consider is the balance – are there too many fire fighters? I would suggest that if fire stations are generally closer to an incident than ambulance stations, then either there are too many fire stations, too few ambulance stations, or both

  3. ulsh72, if you can prove that a problem is time critical AND that first responders serve as more than positive PR, then response would be appropriate. Chris, you’re a radical suggesting cutting fire units and shifting resources to EMS. Are you seriously suggesting matching resources to need? 😉

  4. This doesn’t apply to rural EMS? Whether the patient is 5 minutes away from a hospital or 45 minutes away, and whether paid or vollie medics show up to help, human anatomy and physiology simply does not change.

  5. I had a MI at work in August. After a 911 call, the fire department were the first responders. giving me oxygen and aspirin. Then the ambulance showed up, putting in an IV, etc. and taking me to emergency. In September I once again had to call 911 for chest pains, I had 2 ambulances and 1 fire truck show up. I don’t know why the fire truck showed up as they did nothing. A few years ago I was involved in a rear-ender accident on the freeway (I was the rear-ender) and the fire truck showed up. Again – they did nothing. I just don’t think it is necessary most of the time.

  6. I think you know we agree on most of this. As a bit a preface for my comments, keep in mind that in my deaprtment, and indeed the DFW metro area, the EMS is provided by the FD. Paramedic firefighters on the MICU, and on the Engine. Our guys ride the MICU one shift, and then the engine the next. Basically the fire truck is a way to transport more paramedics to the scene.My thoughts;Is the engine crew needed at the scene? From a patient care point of view, likely not(strictly speaking). However, what that does accomplish is manpower for lifting, moving gear, scene safety and the like. Is it absolutely needed? We both know it isn’t. But, it does make it a bit easier for the guys. Also, for the times that an MICU is across town, or out of district, patient care starts quicker, paperwork starts quicker, and instead of spending that time AFTER the MICU arrives, transport starts faster. It’s kind of like having a 6 man MICU crew, only 4 of them ride another vehicle, and don’t transport.As to the other side of the situation, where the FD and the EMS provider are indeed separate entities responding within the same area; Yes, short of some very specific situations where there is a specific FD function that need to be done, there really is no need.My wish is that folks in the EMS and the Fire sides in other areas would realize that in some areas, where EMS/Fire are the same people, don’t have these territorial problems and shouldn’t be lumped in with either the straight EMS or the Fire only departments.

  7. It’s far less a question of inter service rivalry than it is one of medical necessity. Even in systems such as yours, it might make more sense to have more ambulances and fewer fire trucks. EMS seems to work better in smaller fire departments than in larger ones. I’m not quite sure why that is, but it’s my strong impression that it is that way. Although having more hands on scene might make for less work per person, I’m not sure if it’s defensible from a medical standpoint. It almost certainly is in terms of wear and tear on the personnel, which might be of value itself. Then again, as I get older, I tend to leave the lugging to the newer and younger members of the service. 🙂 I can tell you that a number of patients have complained to me over the years about the presence of fire fighters at calls. The most frequent complaint being that they stood around doing nothing until we got there. That’s probably more a function of a FD that never wanted to do EMS, but wanted to keep the run count up. It’s also changing as the fire fighters get younger, including a good dose of former EMTs and paramedics from my service.

  8. I think FD medical responses are good, being a Volly EMT/ FF in NJ, it seems to make sense for the FD to show up to medical calls. Firstly, if they can get there faster, than they are on scene getting medical Hx, SAMPLE, OPQRST etc, which means less work for the ambulance to do, providing more time for them to do medical things (ie O2, ALS stuff etc). Because they can get there first, they can pick up on things that are very important (for example a “lift assist” turning into full on CPR 15 minutes from the ER or a female “unable to hold bladder” turning into a possible TIA/CVA), and they can also take an RMA, and cancel the rig before they even get on scene, freeing up the ambulance to go do more important things. As for MVCs, what is a better traffic buffer between you and an interstate than a huge fire truck? Also think about how many people you carry on your rig. I’m fortunate to have between 3-4 EMTs on any given call, but for paid trucks they run with only 2 EMT-Bs/ EMT-Ps, where as a fire truck runs with a minimum of 3 large, strong firefighters. Do the math, 2+3= 5, 5 people to obtain medical history from family, asses Vitals, do SAMPLE, OPQRST etc, lift and move the Pt, do CPR, hold C-Spine, operate a BVM, run the D-fib, talk on the radio, fetch equipment etc. Basically, the more people who can help you do your typical 1001 tasks on scene = a patient getting to the ER much faster, and as they always say for strokes heart attacks etc “Time is brain/muscle”

  9. John, not one thing you say is particularly persuasive. I’ve done a lot of ambulance calls, most of them as an EMT. Once in a great while, we would need someone for a lift assist. We preferred to have another EMS crew, since we didn’t trust the FD not to drop the patient. There’s actually some science behind how to lift a person in a chair, and I never felt comfortable having someone who didn’t know what they were doing the carry. Mostly, firefighters get in the way. I certainly wouldn’t trust them to get any information that I would need to rely on to make a clinical decision. Their bad information causes me to screw up? Guess who is going to own that one.Fire trucks at MVAs usually block the ambulances from getting near the vehicles. That of course just makes more work for me. I won’t even go into how much it pisses the cops off when they screw up traffic while standing around watching EMS do the work. Finally, if you need 3-4 EMTs on each call you do, UR DOIN’ IT RONG!

  10. First let me say that I will admit, quite willingly may I add, that you have probably seen more in the last week where you run EMS than I have in the last half year or so, and that medically you can run circles around me. I see what you are saying, especially about lifting the pt. As long as the Firefighters showing up are at least First Responder certified (thus having been trained in lifting and moving) then it makes sense, if they are just firefighters, than as you said they just get in the way. As for MVC’s, if you have a good IC and proper communication and Apparatus staging, than the fire truck serves some purpose, if that does not exist than they are useless, save maybe finding the MVC in the first place. As long as we all work together, know what we are doing and have some advanced form of medical training (like above the training level of 1st aid or a life guard) than FD response is good. And to the point about ff’s gaining medical Hx, even a monkey can go to someones medical cabinet and write down the names of all the medications for a specific person. Finally, may I add, it doesn’t take my squad 3-4 EMTs to do something, we are just blessed with that kind of man power on the average call.

  11. It seems that this is becoming more of a question of ‘Do you have competent Firefighters’, not ‘Should the Fire Company be responding to EMS calls.’ TOTWTYTR, while you started off in the original blog post citing some concrete reasons, in these responses, it seems it is the incompetence of the FF’s in your area causing your disdain of having their ‘help’ on Med calls. Which I would totally agree with in your situation, however, not all of your readers are in the same boat.

  12. ulsh72, were it just my area, I’d say it was just my area. Alas, I hear the same stories from providers all over the country. “Stare of Life”, applying Non rebreathers on cardiac arrest patients, poor CPR, parking the apparatus right in front of the response address, the list just goes on and on. That aside, there are still situations where the fire should respond, as I’ve outlined them. The idea that having the FD on EVERY call is a plus is just plain silly. It is intended as make work for a trade that is facing a decline for their primary service. That’s a good thing overall, as fewer fires mean fewer fire deaths for civilians and fire fighters as well. It does create a problem for the fire service, but not one that should be solved at the expense of patients and EMS professionals.

  13. Totally agree TOTWTYTR. And there is a middle ground that needs to be met. The 2 problems you are outlining are excessive FF response to EMS calls, and ineffective (or negligent) treatment. Many EMS calls don’t need a FF response. But the ones that they do respond to, require that they have the proper training (and use it effectively). Both areas desperately need addressed.

  14. So with the exception of being two years late, actually I didn’t even understand what the difference was between a emt-b and p then.

    Anyway… you said in the post on Jan 8, 2008 that one of the physiological effects of 02 was production of glucagon. In this post you state that there is no evidence to suggest 02 is good for the hypoglycemic pt. I know that glucagon would only be beneficial in certain situations and not immediately but still…

    Obviously props on the blog, that I’m reading back through several years of posts.

Comments are closed.