Walking the Fire-Based EMS Talk

We want to welcome the newest Geezerguy to our site, FossilMedic (a.k.a. Mike Ward).  Mike is one of the country’s leading authorities on EMS delivery systems and we are fortunate to have him with us.  You can read his bio in the “About Us” page and read his commentary here every Tuesday.

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Walking the Fire-Based EMS Talk

For the last couple of years, FossilMedic has been attending the
meetings and conferences of non-fire ems organizations:  American Ambulance Association, EMS educators and emergency medicine physicians.  Anytime the discussion went to turf, power or politics, fire-based EMS seemed to be the neon red elephant in the room.

This spring the elephant trumpeted, with five major national fire
service organizations supporting the publication of a white paper
“Prehospital 9-1-1 Emergency Medical Response:  The Role of the United States Fire Service in Delivery and Coordination.” Written by the medical
directors of Los Angeles County, Palm Beach County and Dallas fire
departments, the paper emphasizes that EMS is not just an ambulance ride and
makes a compelling argument for changing Medicare reimbursement for
out-of-hospital care to include reimbursement for transportation to
non-hospital facilities and on scene treat-and-release incidents.  You can
download a 17 page Adobe Acrobat version  of the report here:
http://www.nvfc.org/pdf/2007-fb-ems-whitepaper-final-june.pdf

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The paper and DVD “EMS: The Right Response” goes to the fire
service strength in influencing national policy.  The success of IAFF
sweat-equity and FIREPAC contributions to local and national politicians that
best serve professional firefighters places a significant push to this
position paper.  Since the report is also supported by the IAFC, NFPA,
National Volunteer Fire Council and the Congressional Fire Services
Institute this report is the closest to a unified approach to a national
issue.

But the real challenge is in the fire station.  When I was a young
paramedic/firefighter, the bosses were trained in Advanced First Aid.  I
naively thought that by time my generation would be in charge, we would
do better as the bosses.  I was wrong.

A couple of years riding a paramedic ambulance early in a career
provide inadequate preparation to run an ambulance service. Los Angeles County Assistant Chief Mike Metro describes the situation as “good people
who need additional training.”  The California Fire Chiefs
Association started an EMS Leadership Academy that provides information to
prepare command officers to function in one of four disciplines:

1) EMS Manager or Administrator
2)  Quality Improvement Specialist
3)  Educational Specialist
4)  Paramedic Program Coordinator

Many metro fire department ambulance services demonstrate the worst
practices and suffer from benign neglect.  Let’s look at the two biggest
issues:

Excessive ambulance workload is a problem in many cities.  Philadelphia Fire Department has 24-hour ambulances that are running over 9600
responses a year.  That is more than one response an hour.  Using 28
full-time and 12 part-time [12 hour] ambulances, there is a continuing
pattern of high profile, bad outcome events.  Patients are waiting 20 to 30
minutes for the paramedics.  The IAFF says that Philadelphia needs 70
ambulances to meet the workload.

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A similar crisis in Los Angeles city in 1998 resulted in a massive five
year plan to improve the ambulance service.  The three primary
delivery goals were a paramedic asset in every fire station, no more than 11.5
responses a day for paramedic ambulances and nor more than 13.3
responses a day for EMT ambulances.  The upper limit for paramedic ambulances
works out to 4200 responses a year.  LAFD increased its ambulance
fleet by 40%.

Involuntary holdovers and mandatory overtime is problem in even more
cities.  In 1999 LAFD was losing paramedics faster than they could train
new ones.  To get a month off from being ordered back to work (force
hire) a paramedic had to “volunteer” to work 96 hours of overtime
(assigned hire) in the previous month.  The tipping point of mandatory
overtime seems to be when the number of funded paramedic positions exceeds
a 12% vacancy rate.

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When I looked at Philadelphia in March 2006, they had a 22% vacancy in
paramedic positions.  Overworked and understaffed.  Imagine the care
you will get when you are the 22nd patient and the paramedic has been
awake for 30 hours.  That reality does not match the images presented on
the “Right Response” DVD.

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