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?