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.

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