I grew up riding fire-based ambulances: as a volunteer, a seasonal employee and within my municipal career.  Done part-time work with a commercial ambulance. Teaching high school EMT in rural Virginia sensitized me to the needs of all-volunteer community life-saving squads.

My first column, Walking the Fire-Based Talk, discussed the 2007 release of  “Prehospital 9-1-1 Emergency Medical Response:  The Role of the United States Fire Service in Delivery and Coordination.” This was the white paper promoting the vital role of the fire service in delivery of emergency medical services. (17 page 162 KB  HERE).

HOW THE NON FIRE SIDE THINKS

I spent the past eight years attending conferences, business meetings and hallway discussions held by non-fire ems organizations. American Ambulance Association, EMS educators, high performance systems status advocates and EMS physicians. Fire service was the neon red elephant in the room at every discussion of turf, power or politics.

Hanging out in Las Vegas with an ems expert who is grounded within commercial and third-service systems. Comparing ems conferences, he noted that the IAFF was one of the better organized venues. Provided a more diverse group of speakers: politicians, economists and highest level of regulators/ administrators. He reflected that firefighter labor was a well-resourced and politically-astute sleeping giant that could dominate ems.

Two years after that conversation the giant awakened, as one of five national fire service organizations sponsoring the fire-based ems white paper

WHY TALK ABOUT THIS NOW?

IAFF and IAFC reaffirmed their support for fire-based ems (JEMS item). On JEMSconnect a discussion question was posted that exceeded 147 posts at the time this item was published (HERE).

The first Public Utility Model of EMS delivery, Kansas City MAST, is scheduled to be taken over by the fire department in May 2010, ending three decades of service. (HERE)

This is particularly heartbreaking to the high performance advocates, since the fire department does not intend to maintain an ambulance response time of 8:59 minutes to priority one calls 90% of the time.  Fire Chief Dyer points out that their implementation of fire company delivered compression-only resuscitation has almost doubled the number of patients showing a return of spontaneous circulation.

David Williams, a senior  Fitch and Associates consultant, tells Best Practices in Emergency Services “MAST is a reaccredited ACE center that does Medical Priority Dispatch and advanced systems status management, none of which the fire department has any experience with.” (HERE) Stephen Dean, PhD, provides a great PUM description (HERE).

ITS NOT ABOUT CLINICAL EXCELLENCE OR CAREGIVER DEDICATION

Delivering municipal services is a political and economic activity. The voters are not focused on the details of delivery of the service, until it becomes perceived as a problem. Two examples:

Voters failed to approve the renewal of funding for the King County/Seattle Medic One program in 1997 (HERE).

Philadelphia tolerates grossly overworked ambulances, 20 to 40 minute waits and occasional fatal outcomes. (HERE)

SOME SYSTEM DELIVERY PRACTICES MAY NOT BE IMPORTANT

Patient outcome studies are challenging ems system design assumptions, with the amazing results from uninterrupted compression-only CPR (HERE).

Last year the U.S. Metropolitan Municipalities EMS Medical Directors Consortium issued recommendations impacting six areas of clinical treatment.

• ST-Elevation Myocardial Infarction (STEMI)
• pulmonary edema
• asthma
• seizure
• trauma
• cardiac arrest.

Their recommendations for cardiac arrest are surprising:

Response interval of less than 5 minutes for basic CPR and automatic external defibrillators (AEDs). No response interval was specified for ALS arrival.

In justifying its cardiac arrest recommendation, the group noted that much of the clinical research used to establish acceptable ALS response time intervals was conducted prior to the widespread dissemination of AEDs and at a time in which the compression component of CPR was not emphasized as it is now.

As a result, the consensus group proposed that EMS systems not focus response time measurement on ALS ambulances, but rather pay greater attention to first response/BLS response time to measure what it called the “most important predictive elements for optimal outcome: time elapsed until initiation of basic chest compressions and time elapsed until defibrillation attempts.” (PEC article HERE)

IT IS ALL ABOUT FIREFIGHTER JOBS

General President Harold A. Schaitberger, speaking at the June 2009 EMS Conference, noted that hundreds of IAFF members lost their jobs. By June 2010 it may be thousands.

If aggressive takeover of private and third service 9-1-1 ambulance service preserves jobs, then expect to see fire departments reaching out.

Fire Service-Based EMS Advocates

Mike “FossilMedic” Ward

Edited 22:15, November 22: fixed links, changed some formatting and added Fire Service-Based EMS Advocates.