Recently, a lot of my Canadian EMS friends and colleagues have been concerned about proposals for Canadian firefighters to provide emergency medical care. In much of Canada, prehospital care is exclusively the province (pardon the pun) of EMS and the fire service plays a limited role if it’s even involved at all.
I’ve been involved in a variety of EMS systems. I’ve probably observed even more EMS systems. The general rule of thumb is that if you’ve seen one EMS system, you’ve seen one EMS system. EMS systems and the delivery of prehospital medicine is a very local phenomenon, particularly in the United States. What works in New York City probably won’t apply to rural Iowa, the Big Bend of Texas, or even the casinos in Las Vegas. Having said that, I’m going to go ahead and give some general conclusions on the idea of fire-based EMS delivery.
Number one, I don’t have a single problem with firefighter paramedics. I’ve seen some first rate fire medics who are current on the science and share a strong commitment to prehospital care. However, I’ve rarely seen a large urban fire department that actively has a commitment to excellence in emergency medicine. While a large department may have budget issues, this rarely seems to hold them back from buying new fire apparatus and equipment while the EMS side of the station soldiers on with equipment that most likely meets minimum state licensing standards. When you have departments that view “being on the box” as either punishment or a ticket to be punched for promotion, patient care stagnates and suffers. When you have company officers saying things like, “You think too much like a paramedic,” the message is clear — medicine isn’t important to the fire service.
The same firefighters that share hashtags like “Always Training” and “All Hazards” while they train on the Denver Drill or SLICERS are often the same guys who “don’t need to know it” when the latest medical guidelines come out. The same guys who attend FDIC and every IAFF event are the ones least likely to be at an EMS conference like EMS World Expo, EMS Today, or their state EMS conference. Tell me the last time you’ve seen a fire department’s Facebook page showcasing the EMS training that their firefighters go through? Contrast that with the constant barrage of social media posts showing structural firefighting training (and operations) and it becomes clear that most departments don’t consider EMS part of their core mission.
In a certain urban fire department, there was a rivalry between the special operations team and the rest of the suppression side of the department that was summed up with “90/10” — doing ninety percent of the work and getting ten percent of the credit. Sadly, the same ratio probably applies to the EMS side of the fire station.
I don’t have a problem with firefighter/paramedics. I do have a problem with the fire service EMS culture. This pains me, because I truly love the fire station culture of brotherhood and camaraderie, even if it’s not always perfectly expressed. I’ve had some of the best meals and some of the best conversations at a fire station dining table. If the culture refuses to change, then it’s time to keep fire and EMS separate.
No firefighter should be required to be a paramedic. And neither should a paramedic be required to be a firefighter.
If you have to ask whether this blog applies to your fire department, then I hope to see you at the next EMS conference.
The other issue with the Canadian proposal is that they aren’t proposing firefighter-paramedics. They want their firefighters to be able administer medications currently restricted to paramedics, but with less training and oversight.
I think you hit the nail on the head when you wrote “if you’ve seen one EMS system, you have seen one EMS system. In Canada, fire-EMS systems are rare. There’s also a significant difference in education standards in Canada compared to the US. For example, to step foot on an ambulance you have to have graduated as a primary care paramedic. The average length of education is a two-year community college program. Contrast that with the 4 to 6 week entry to practice training as an EMT in the US. This difference makes it easy for a FF to train to work on an ambulance. In Canada, that’s just not as feasible.
More importantly, there isn’t a single Fire-EMS system that has been shown to be expenditure neutral or less expensive in Canada, and I am doubtful there is any such example in the US despite claims to the contrary.
From a cultural an operational perspective, I believe you also hit the nail on the head. When there is a fire EMS merger, it is always about fire and not about EMS . This is a serious problem, given that ~80% of calls are medical.
The reality in Canada, as in the US and around the globe, is that Fire departments are mostly overstaffed, overequipped and overfunded. Politicians are getting wise to their marketing machine and starting to demand greater justification. So Fire turns to EMS and in a merger they appear to be more cost “efficient” because their cost per call goes down, but the overall operational costs increase typically. And, as you say, Fire reaps the rewards even though they do a small fraction of the work.
You say you had some of the best meals and best conversations at a fire station dining table. Therein lies one of the main problems. While working city EMS, a paramedic rarely, if ever, gets to have a sit down meal at an actual table. They run from call to call to call with hardly any breaks. They may grab a grease burger in between calls. And then they are called para-pukes by “the real firemen” who are generally making a fair bit more in wages than the overworked paramedics.
We have to always keep in mind the politics of the situation. A fire department is a budget looking for a cause. A huge number of cities are looking at what they actually get for their massive fire budgets, so they must try very hard to find something more to add to what they already do. EMS is a cause looking for a budget. If any EMS system had even half the funding the fire departments do, what a system that would make! Ambulances likely do at least 4 times as many calls as fire trucks but get minimal amount for funding and a great many Paramedics make minimum wage or slightly better, where as most career fire fighters make a very good living and also manage a small business in their days off. Paramedics usually have to work many extra shifts to make ends meet and are so tired all the time they sleep whenever they can.
I say keep them separate and fund them by call volume, not political stroke.
Seriously, has it been shown that EMS only systems provide better care than Fire based systems? I always ask this question after posts/articles like this but never receive and answer.