EMS and the Fire Service Need Wholesale Change

My Situation

On my fire department, and many other departments around the county, the fire service is the "tail wagging the dog".  The fire service has become the big brother to emergency medical services or at times the not-so-nice step father...  Where I'm from, our city had two different entities, fire and EMS, that were merged in the early 2000's.  While this was seemingly a good thing, it was not and is not without it's challenges.  

Fast forward almost 20 years later, we continue to be a slow changing, inefficient, stuck-in-our ways department that is teetering on the edge of trouble.  We continue to have paramedic shortages, disgruntled paramedics and EMT's, and management that is hesitant to address the issue.       

The Big Picture

We did ourselves a disservice by advertising the 911 system so well.  We receive calls through the 911 system for anything from a rug burn caused by a piece of yarn, a toe nail that caught in a blanket and possibly ripped off, a quicker ride to the hospital because the waiting room was too busy, and someone who inserted something into something he shouldn't have.  And YES, those are all calls I personally have been a part of!  People are calling 911 and seeking help from the emergency departments for ailments and injuries that deserve a family practitioner, a nurse, or sometimes, just a little ice and to go to bed.   Instead, ambulance calls are on the rise and emergency rooms are too full.     

As emergency departments and ambulance services are getting busier and busier, the acuity level of calls are decreasing.  This adds to paramedic  burnout and it feeds some of the fire service's thoughts and the public's thoughts that paramedics are just ambulance drivers.  It's tough to be a paramedic, in charge of calls and running patient care.  You'll go from one call that doesn't even deserve a Band-Aid, to another call that is so beyond a paramedic's scope of practice, but we have to make due until we can get them to the hospital.  And to find out that decisions about the EMS service are being made while we are out making these tough calls... it's defeating at times.

​What can we do though, where can it change?    

EMS vs. Fire Service

A common pubic misconception is the breakdown of our calls, medical vs. fire related.  At our department, we say that it's 80% medical vs. 20% fire.  But that 20% "fire related" is just that, related...  That could be an alarm, a rescue situation, lift assists, etc.  And some of that 20% requires an ambulance and paramedic on scene as well.  In a recent article for JEMS by Dr. Bryan Bledsoe, he mentions less than 10% of calls actual involve fires.  I would agree with this statistic, especially in our area.  

Another thing that is changing the climate of the fire service, is that the latest and greatest fire attack strategies all seem to involve "hitting it hard from the yard".  That means spraying water on the fire through a window or open door, prior to going into the building.  Old Salty Firefighter would tell you the opposite though, that the water in our hoses can push fire, so it would be best to go inside a burning structure, expose themselves to the fire creeping over their heads, so they won't push fire to the unburnt part of the house.  This, over time, and many years, has been debunked, leading us to spray water in open windows and putting out the majority of the fire prior to exposing ourselves to the lion's share of the danger.  The fire service is, in a round about way, "safetying" ourselves out of justifiable jobs.  

Because of this, the fire service has started to focus more on being first responders and getting into the EMS business.  This is what happened at my department.  Without the "fire side" going to medical calls and assisting the ambulance, our run volume would have dropped to almost nothing...  This would have certainly lead to reducing our minimum manpower for the day.  This also led to the bigger dog in the yard, eating the smaller dog, and now the fire side is making decisions for the EMS side.  This has caused contractual changes and personnel changes that have taken some of the benefits away from the EMS side.

The fire side is use to responding to calls in big, million dollar trucks, where the EMS side was used to responding to calls in smaller, more mobile, and cheaper vehicles.  The fire side is used to sending more than enough guys to fire scenes, but the EMS side traditionally sent two guys, and they made due.  The fire side is slow to change, but the world of EMS is frequently and ever changing.  

​What can be done?    

Solutions

This is where the wholesale change comes in.  Like Dr. Bledsoe said in the title of his article, "EMS Must Be Fixed with Bulldozers, Not Tweezers".  

We must move away from a system where there is over $1 million worth of fire trucks and ambulances responding, lights and sirens, to some calls that don't even require a Band-Aid.  This could mean driving in smaller vehicles, SUV's, pick up trucks, much smaller fire trucks, etc.  There is a lot of money, a lot of time, and a lot of man power that is utilized for 10% of the calls, when the other 90% is struggling to keep up.  

I listened to a podcast a couple years ago, that touches on some of this as well.  Listen below:

NPR Planet Money Podcast

Dr. Bledsoe thinks that our industry has too many paramedics, but I don't believe that is the case in our area.  But this could be due to the way our area's fire service use our paramedics.  Our paramedics get ridden hard and put away wet.  Our department, at times, makes poor hiring decisions because they are in desperate need for paramedics.  Instead of making long term decisions and policies that would garner long paramedic careers, they make the short term decision to avoid short term costs.  This has lead to the hiring of some sub-par paramedics, that personality-wise would struggle to fit into the fire service.    

Dr. Bledsoe also discusses the "Everyone Goes to the Hospital" Rule.  This is a rule we follow in our area.  When we ask someone about their transport decision, it's not "Would you like to go to the hospital?", it's "Which hospital would you like to go to?"  There are times, of course, that a patient decides not to go to the hospital, but you have to have a legal conversation with them about their assumption of personal liability due to not seeking further medical attention...  It's intense.  This is an area where we can gain A LOT of ground.  If a quality trained paramedic could make a decision that is best for the patient and best for the emergency medical system, enable and empower them to do that!  The threat of legal action and malpractice lawsuits are so scary that most, me included, will transport the yarn burn patient to the ER...  

The Conclusion

I don't know what the fix is, but I do know it's going to take a lot of time and a lot of effort.  It won't just be one change, it'll be a lot of big changes.  More and more, there are times that there aren't ambulances to respond to serious calls.  Sometimes they are tied up at other serious calls, but other times they are tied up at calls that aren't as serious.  The 911 system is struggling to keep up all over the country, big changes need to happen, or else this system could fail...