White Paper fails to make justification for FD-EMS

A review of the White paper - Prehospital 9-1-1 Emergency Medical Response
The Role of the United States Fire Service in Delivery and Coordination shows shortsightedness on the part of some leaders.

This document points to the direction of emergency medical service in a fire service-based delivery model and highlights several benefits of that system. Although the document correctly notes the history and structure of the American Fire Service, it fails to achieve its self described mission; that “decision makers should recognize that the U.S. fire service is the most ideal prehospital 9-1-1 emergency response agency.” While this report makes several points many will find interesting, it lacks a comprehensive view of emergency medical service. Rather than accounting for the various aspects of EMS such as the provision of non-emergency and specialty care transport, the authors focus on only emergency response.

Emergency medical service is often considered as an ambulance only service. The public needs to understand the vital role of that first-response, non-transporting fire departments play in the total delivery of out-of-hospital care. Many fire departments provide both transport and first-response EMS with many of those being larger metropolitan areas staffed by career fire departments. However, with nearly 70% of fire departments being staffed by volunteer firefighters, the question is weather or not the fire service-based EMS transport model is sustainable. Numerous reports have indicated the need for more volunteers in any community.EMS has been cited as a drain on volunteer fire department resources and some departments only provide an emergency medical response to the most critical events.

The document also states that the fire service is the agency that first delivers on-scene health care services under the most true emergency situations and that “...it [EMS] has become almost universally, a principal duty of the fire service as well” and “fire service-based EMS systems are strategically positioned to deliver time critical response.” Its true that most if not all communities have a fire station strategically placed, usually near the center, of the population or a high-hazard area. While the traditional fire station may meet the needs of fire protection, I’m not sure the same structure is efficient for ambulance service. As population shifts occur at various times of day, the needs of a geographic area will also change. Ambulance services have practiced strategic staging of ambulances to meet changing needs of an area. Reliance on a fixed facility as a singe base of operation may not meet the daily changing needs of a community.

The report suggests that it is the fire service that provides the majority of medical services during emergencies that occur out of the hospital. What about the rest of the patient care cycle? Is the care and treatment provided during transport to be considered in a minority? These statements imply that once care is delivered on-scene (by fire department personnel), the patient needs only a ride. We know that this couldn’t be further from the truth. Patient conditions can change at any time...that’s why we continually reassess and examine.

The use of NIMS, the National Incident Management System, is also indicated as another reason for the fire service to have the lead role in the provision of EMS. However, NIMS compliance among fire departments is not universal. Although most, if not all, fire departments have adopted NIMS or utilize some form of incident command many are not fully NIMS compliant. NIMS is far more than an incident management system and encompasses an agency philosophy of management. Unfortunately, too few EMS ambulance services have taken the initiative to become NIMS compliant and embrace the concept in service delivery.

Ambulance sub-specialties are mentioned in the report and the reader is cautioned that these services “must not be confused with 9-1-1 emergency response.” I think this is one of the most disturbing comments I’ve ever heard. I we’re going to look at the global needs of EMS delivery, we have to included specialty care units like critical care transport. To exclude the specialty services is to fail to address the needs of not only the patient but the health care system as well. The emergency-only approach to pre hospital care is self-limiting and will not fulfill the mission of the fire service, the public, or the health care system.

Perhaps the most disturbing question asked in this report is “...what does a non-fire based EMS crew do on the scene of a motor vehicle accident when the care is engulfed in flames and occupants are trapped inside, and fire crews were not dispatched?” When did dispatch error become a justification for the fire service to provide ambulance service? Crashes with cars on fire a occupants trapped and similar situations are dangerous threats to civilian life and responder safety. The threat exists regardless of the availability of personal protective equipment. So, to answer the question of what non-fire based crew should do in these situations...let’s answer play your position and get the proper resources to the scene.

And what if we were to ask the question in another way? “What does a fire service based crew do with all the structural firefighting personal protective equipment and apparatus at the scene of a heart attack?” The fact is, that if we were to apply this line of thinking towards an overwhelming majority EMS response the fire department “emergency only” service would seem like a large expenditure with limited return.

My conclusion is that the report Prehospital 9-1-1 Emergency Medical Response: the Role of the United States Fire Service in Delivery and Coordination fails to make a valid claim that the fire service is universally the best provider of EMS. As I’ve attempted to point out in this summary, the delivery model that best serves a community is the best delivery system and that is certainly not a one-size fits all situation. The fact is that there are several delivery forms that will meet the needs and expectations of a community. The job is to evaluate, study and choose the best option for our individual area.

(a link to the original document can be found at www.mitigationjournal.com on the updates page)