My Thoughts on Fire Based EMS

I’ve been avoiding this.

Medic999 and HappyMedic have been playing with fire lately. They’ve gone on to speak about one of the hottest issues facing US EMS today. That is, (and please pardon the puns) the issue of Fire-Based EMS.

Now, I’m probably remiss for not jumping in to the fray on this because I hold very strong opinions on the matter. In fact, if you were to catch me in person at the firehouse or the ambulance base I’d be happy to talk your ear off expounding upon the issue. I’m never one to hold back my opinion when I think that I’m right or when I think that my opinion will add value to the discussion. I’m not afraid of my opinions on the matter and I’m happy to speak about them.

But honestly, I’ve been afraid to write about them here. That’s why my posting has been pretty infrequent in the last couple of days. You see, I know what a tinderbox issue this is and I know the flames that can result. I try to speak to my (small, but growing) audience of professional EMS people as equals, because you are. I’m no expert on anything just because I decided to start a blog, but I do care deeply about EMS and the Profession of Paramedicine. I care about the future of EMS. I care how EMS is provided and I want to see it grow and flourish.

And if you’re here reading EMS blogs you’re probably of a like mind. I respect and applaud that and I appreciate that you’ve given me a tidbit of your time to read my ramblings.

But I don’t like Fire-Based EMS. There, I said it. I am a state certified FF II (FF III is pending). I’ve got a bunch of fire credentials. I love the fire service. I love the brotherhood, the tradition, the adrenaline, and the work. I love fighting fire and being an active part of my fire department. My father was a fire chief. The fire service is in my blood.

But as a professional Paramedic looking to advance my profession into the future, I have to put my personal feelings aside and say that I disagree with how the US Fire Service has treated the profession that I love. I disagree with the way they have steered my profession into technician status and fight to hold down true educational standards. I hate that they pigeonhole paramedics into one role that cannot be expanded upon. I hate that the majority of paramedics I see are just “doing this ambulance thing” until they get a “real job” on a fire department. I hate that fire blogs advise young, impressionable kids to “Go get their medic” so they can be marketable to a fire department.

I think that it takes a different (read: “not better”) set of intellectual and ethical reasoning skills to be an awesome paramedic than it does to be an awesome firefighter. The gung-ho pro-fire folks will tell you that because of the rescue component of the fire service and EMS that they’re inseparably intertwined. I disagree inasmuch as the same fact holds true with bus drivers having a “transportation” aspect that they share with EMS. I read paperwork about patients, does that make paramedics one-in-the-same with librarians?

Let me tell you a story about way back when I took my Paramedic class. I went through all of my EMS education at a local community college instead of one of the hospital classes that were offered where I lived because I wanted the college credits. I still think that it’s a great idea to get college credit for EMS classes, because EMS classes should be “Education” and not “training”. In my class there were 23 students. Of the 23, there were 3 of us that actually wanted to be a paramedic. Everyone else was taking the class because in order to get on any full-time fire department in Northern Illinois, you have to be a paramedic AT THE TIME OF APPLICATION. (There are a handful of exceptions, but just a handful) This was a decade (or so) ago, and some of the guys had been told that in order to keep their long-held positions as a firefighter, they had to “get their medic” as well.

How many of those 20 do you think were *really* motivated to be an excellent paramedic and a true healthcare professional? If you guessed a low percentage, you were right. While I’m not necessarily questioning any individual’s motives for becoming a paramedic I do think that it does not say much for any profession when a good percentage of their new members do not actually want to become a professional.

Does it make sense to keep a physician who really desires to be a concert pianist but can’t make it on the ivories so he’s a doc just to pay the bills? Sure, there’s adequate paramedics out there who didn’t really *want* to become medics… but they’re not the ones trying to excel in and advance the profession. They may care about their individual patients to the best that they are able, but are they out there pushing their medical direction to give them the latest tools to better treat their patients? Do they study the latest research so that they can discern the best possible chance of a positive outcome for their complicated patients? Or are they just doing enough to get by, putting their time in “on the bone box” and bitching about being called out for calls that they feel are beneath them while they wait to get back on the engine?

Let me say this. I’ve worked in Hospital Based systems, high-performance private 911 systems, private transport systems, private rural 911 systems, and fire-based systems. I’ve found faults in them all. I’m for EMS based EMS, or “Patient Focused EMS”. If tomorrow, the fire service as a whole decided to change a few things, I would sing their praises and change my tune. If there were such things as “Public Works-based EMS”, or “Parks Department-based EMS” or “Any-other-non-healthcare-based EMS” and I saw the same things with their organization as I do with the fire service, I would disagree with them too.

So here, fire service, do these things and you’ll convert me to your side:

  • Stop making everyone in your agency “get their medic” so that they can get a job – Not everyone can be a great healthcare provider and especially not everyone can be a great paramedic. Stop pretending they can be. Fire Department entry tests like the CPAT test things like physical agility and basic mathematical computation. Yes, they’re important for firefighters and for EMS as well… but what the heck does a hose drag have to do with patient care?
  • Stop making every position on every piece of apparatus an ALS position. I’m diverging with Happy here and saying that a BLS engine response is great, as long as there are enough ambulances out there to guarantee a response and you have well educated and motivated BLS providers. Skill degradation due to too many paramedics attending a patient is a real phenomenon. There’s emerging research (and I can’t find it but it was done out of Kenosha, WI and listed somewhere in JEMS) that states that having over 3 paramedics to any patient actually harms patient outcomes. The “engineer” position and the officer position on a fire apparatus is an earned place of honor. So should be the ONE PARAMEDIC (if any) on a fire apparatus. Right now it’s not and you don’t treat it as such.
  • To use a local FD as an example, they have a population between 125k and 175k. They have around 15 staffed pieces of fire apparatus staffed every day… and 5 ambulances. 80% to 90% of their calls are EMS related… why are 20% of their staff running 80% – 90% of their calls? Where are their priorities? Firmly on the “fun” stuff… and not on the “boring bone box”. Change that.
  • You’ve pigeonholed my profession into a “you fall, you call, we haul, that’s all” system that only values true emergent response. Patients are using our service for all kinds of things and you complain. No other business (and EMS is a business as in we need revenue to survive) relegates customers to second class status because they choose to use us in a way that we don’t want to be u
    sed. Paramedics are capable of all kinds of fantastic things. Allow us to branch out.
  • Fight for more knowledge, more education, and higher standards. Don’t hold us back. To the IAFF and IAFC: Why is the “National Scope of Practice” the way it is? Why aren’t we using something closer to the “Dr. Bledsoe Scope of Practice”? Because fire departments and the IAFF don’t want to do that stuff, that’s why. Yes, you pay well and treat your employees better than I get treated by my employer… but don’t hurt patient care because there are classes you don’t want to sit through and responsibilities you don’t want to have. A Union contract is a terrible way to design a healthcare system.
  • In my area of the country, and in EMS systems that I’ve researched through my travels, I’ve noticed a phenomenon (and it may not be this way in your area): Shared Protocol Systems that include a large (or a large number of) traditional full-time FD ALS providers have less advanced protocols and procedures than do Shared Protocol Systems that do not include the above. The state line between IL and WI is a great example of this. Fix that.

Yes, I’ve ranted… and there, I said it. I’m going to continue this conversation in the comments section of this and many other of the blogs out there. The discussion is alive and it’s burning. The profession is changing and people are starting to wake up to the fact that “EMS-based EMS” is the proper way to go. If your (insert service model here) EMS agency truly strives to provide the best quality patient care and the best possible future for the profession, then I’m in your corner. No matter what it says on the patch on your sleeve.

 

 

 

  • medicblog999

    I dont think that was a rant CK, in fact I think it was quite restrained!

    I feel a little weird pitching in to the discussion becasue I only know a little bit about it at this moment in time.

    All I know is that I would find it difficult working with others who didnt really want to do the job. We have a couple of them over here, and it is hard enough trying to motivate them, never mind if that was the majority.

    As you say though, any service provision would fall down if it wasnt staffed by professionals who are dedicated to their job and are committed to providing the best in health care to their patients.

    An interesting post CK, im looking forward to reading Happy Medics comment.

    (Get that Skype Headset and lets get this discussion onto a podcast!!)

  • The Happy Medic

    CK,
    I am with you 100% on each item you listed. Every one. I re-read you post 3 f'ing times, shaking my head the entire while.

    The difference is, I'm on the inside seeing the problem, you're on the outside seeing the problem.

    We need medics like me who care about patient care and making Paramedic a profession, and medics like you and others on the transport unit who feel the same.

    It works if we are all on the same page.
    If we can get past the "Get your medic" argument so many FDs hide behind, we're golden.

    By the time we get there, you and I will be gray haired and wondering what happened.

    Mark, I love the podcast idea, let's do it.

    Word verification: Revolution

  • EMS Chick

    I agree with you!

    I'm EMS only, I've thought about getting a career job but most places in my area require FF. I don't want to get my FF, it doesn't appeal to me. I was told by one county to just get it and I would "probably never have to use it." That's not a good solution in my eyes. If someone is depending on me and my training I'd rather be giving 100% and confident in my skills not have a cert that they told me I'd "probably never have to use" so I'm not in it 100%.

  • Ckemtp

    I feel for you EMS Chick. I didn't want to do the full-time FD route when I got into the business.

    At first it was because I wanted to be mobile and travel the world (and I did, I'm actually a certified paramedic in Costa Rica which I think is really cool should I have to flee the country) but later because I philosophically disagree with how full-time FD's treat EMS.

    However, I have to say that they've got the benefits, the pay, and the working conditions that I only can dream about. I love rural EMS… but I certainly won't get rich. Maybe Gkemtb will support me in my old age.

    I agree that if you don't want to do fire, you probably shouldn't. It requires a lot of dedication and can and will kill even those who are truly dedicated to it. There's no place for halfway dedicated firefighters… so then why do they think that there's room for halfway dedicated paramedics I'll never know.

    Is there a perfect EMS model out there? I don't think that there is yet. We're going to find it though.

  • TOTWTYTR

    You have identified the major problems with fire based EMS quite nicely.

    I'll add a bit of gasoline to fire by suggesting that every major study showing poor intubation skills by medics was done in areas predominantly served by fire based EMS systems.

    To channel VP Joe Biden, to the IAFF it's all about a three letter word. J-O-B-S. They care not a whit about patient care, they care about retaining fire fighter jobs, pure and simple.

    Until fire departments start to believe and behave as though EMS is their primary function, none of it will change.

  • PGSIlva

    Amen….

  • PGSIlva

    Amen….

  • PGSIlva

    Amen….

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  • Shug

    Interesting post… What part of IL are you from by the way? Im currently working on my medic to become part of the Elgin, IL FF, or the Northern IL FF's (Lake Villa, Fox Lakes, etc).

    I was actually not told I *needed* my medic. I was told that I would have about a 150% better shot if I had my medic. I have family up there in the public services (Brother is a police officer for Elgin, Father worked for Aurora PD for 10+ years).

    I took my medic because I wanted to be a medic. I am applying for fire because I want to be a medic, and run 911 calls (in Arizona, where I currently live, private ambo companies, like PMT and Southwest only do transport, fire does 911 calls)

    I think (speaking from my very very limited experience) that it all comes down to money. Honestly, if a house gets 100 calls a year for fire, if they dont do SOMETHING else, how can they justify a raise? Or better yet, if they run 100 calls a year, and their response time averages 3-3.5 minutes, and another station down the road runs 100 calls a year, and averages 4-4.5 minute response times to the same calls, why not get rid of one of the departments? I mean its only 1 minute right (easy to say, unless your the one in trouble)?

    So, and again I reiterate that my opinion is of limited experience in the field, I would say fire based EMS is really saving fire's *ss, as far as keeping houses open, and keeping firemen employed.

    my e-mail is s@maricopa.edu. If you still check this post for comments, I'd like to hear more about this from you.

  • Shug

    Interesting post… What part of IL are you from by the way? Im currently working on my medic to become part of the Elgin, IL FF, or the Northern IL FF's (Lake Villa, Fox Lakes, etc).

    I was actually not told I *needed* my medic. I was told that I would have about a 150% better shot if I had my medic. I have family up there in the public services (Brother is a police officer for Elgin, Father worked for Aurora PD for 10+ years).

    I took my medic because I wanted to be a medic. I am applying for fire because I want to be a medic, and run 911 calls (in Arizona, where I currently live, private ambo companies, like PMT and Southwest only do transport, fire does 911 calls)

    I think (speaking from my very very limited experience) that it all comes down to money. Honestly, if a house gets 100 calls a year for fire, if they dont do SOMETHING else, how can they justify a raise? Or better yet, if they run 100 calls a year, and their response time averages 3-3.5 minutes, and another station down the road runs 100 calls a year, and averages 4-4.5 minute response times to the same calls, why not get rid of one of the departments? I mean its only 1 minute right (easy to say, unless your the one in trouble)?

    So, and again I reiterate that my opinion is of limited experience in the field, I would say fire based EMS is really saving fire's *ss, as far as keeping houses open, and keeping firemen employed.

    my e-mail is s@maricopa.edu. If you still check this post for comments, I'd like to hear more about this from you.

  • TC_Lifesaver

    Agreed.

  • Anonymous

    Preach it, brother!

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  • http://bit.ly/gwalter gwalter

    Having worked on both sides of the track, I couldn’t agree with you more.  Paramedics working for transporting agencies are very specialized and have a broader knowledge and experience in healthcare.  Paramedics working for non-transporting (generally fire-based) agencies, are more generalized rescue techs.  The jobs are different.

    As a fire-medic, I continued to work for ground and air transport agencies, part-time, because I loved the patient contact – and my job.  I thought all my colleagues wanted to be excellent care providers and had a natural love for helping people.  Yet somehow, I just didn’t fit.

    Now, back in private EMS working for a transport ambulance corporation, I see things more clearly.  First, I’m saddened to see the care provided by my former firefighter paramedics.  I know they don’t have the support of their agencies or their union brothers and sisters, but it is really sad to watch sometimes.  Second, private ambulance services, for the most part, are just a stepping stone to a “real” job – but that has more to do with pay, benefits, and working conditions.  There are some really good medics working for the private agencies.

    Finally, it is sad to see that fire-based agencies are holding back EMS because what we have is good enough; and private agencies are holding it back because of costs.  We are still stuck in the 1980s, and it’s time to move forward.  We need a new model – and Wake County (as are others), may be paving the way for us.

  • http://pulse.yahoo.com/_ABBDHIUISMEUIDWPGCUCCV4GGE David

    How about this one. Since I work for a paid, non-ALS fire department and have a Paramedic license, I’m not allowed to perform patient care because the state EMS office has me (and others in the dept.) listed as “Inactive.” This means legally, while I’m on duty, I can’t even perform CPR, even though I’m an EMT and CPR Instructor. They have in effect taken several higher-trained advanced licenses out of play because the department only provides BLS.

    I love my state. We’re Number 1…alphabetically.

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  • Promedic92

    Wow!!! What a great “tiptoe” through the tulips! EMS is deserving of thier own status in the public service field and I wish we weren’t so late to the ball game. If we had the 200 year history that the fire service enjoys ( or for that matter, the park service ) we would not be having this discussion. But sadly, as the need for a well staffed fire department dwindles and need for pre-hospital medical intervention increases true EMS professionals are getting bastardized for the sake of saving thier jobs. The example of the use of manpower by “a local fire department” is interesting. If they were staffing ambulances as heavy as the engines I bet you would see employees standing in line to work “the bone box” because they sure wouldn’t be taxed! Great article thanks!

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Chris Kaiser aka "Ckemtp"

I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.

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