Several cities in no general direction of me sits a municipality that is, in much respects very similar to where I primarily work. Call volume and some minor things are different, but the two areas are pretty comparable. Let’s call them Metropolis.
Metropolis has a fire department. And a good sized-one too, I guess. I don’t really know what constitutes a “good sized” fire department to be completely honest, but I think they have at least three battalions.
Metropolis is served by a private EMS service, and have been for many years. As far as I know, it has been a good relationship.
Enter new fire chief with a new way of thinking. Now, in all fairness, I don’t know when this new chief showed up, and it doesn’t really matter. You see, the new fire chief was riding around one day and saw a big shiny ambulance with orange stripes and said “hey, I bet we could buy a new pumper and hire some more firefighters if we ran the ambulances.”
Of course, I don’t know if that’s exactly what the chief thought, or even remotely close to the thought process. It doesn’t matter. Metropolis FD has intimated in city council meetings that they want to take over the EMS contract.
“Quit paying the ambulance a subsidy, and we stop losing money. Start billing for ambulances, and we start making money.”
Sounds good on paper, or in a 30 second sound bite on the 6 o’clock news.
Now we have to make all the firefighters (that aren’t already) EMTs, and we have to hire paramedics. Not to speak for anyone else, but I wouldn’t be too hurried to work for the city that shut down my ambulance service and put my friends out of a job.
So let’s fast-forward a little bit. Someone gets the bright idea that they can complete EMT training in eight weeks. They will cycle firefighters through the class, twenty at a time, and make every firefighter an EMT, and create new ALS ambulance units with the paramedics they plan on hiring out of thin air.
Eight weeks for an EMT class. 8 hours per day. 5 days per week. 320 hours.
My EMT training was 4 hour days, three days per week, over 13 months. Over 600 hours. My Paramedic training was 16 hours per week for 18 months. Almost 1200 hours. We all know how woefully inadequate our initial training is already.
And now we are going to have an entire city fire department running EMS with a bunch of 320-hour EMTs?
Imagine the shock and consternation when the city’s first EMT class finished, and 3 of them passed their National Registry exam.
Three. 15 percent.
This is obviously not how fire-based EMS is supposed to run, and I would venture to say that it’s not done this way anywhere else in this country.
But this is a good argument to keep EMS separate.
I believe in EMS-based EMS, and I will continue to advocate for such. We shouldn’t force firefighters to go to EMT school when they only want to fight fire. We shouldn’t force EMSers to don turnout gear if they only want to take care of people.
“This is obviously not how fire-based EMS is supposed to run, and I would venture to say that it’s not done this way anywhere else in this country.”
HA HA HA HA – wait! You’re serious? It’s pretty much how fire based EMS is run in much of the country. EMS is very easy to do, as long as you don’t have to do it. Once a FD has to run EMS, they find out it’s much harder to do than it looks. Well, if you care about patient care and not just response times and revenue.
Some of the kids in my EMT class were Fire Science majors that swapped to the new Paramedicine major we have at school.
None of them are in it for the right reason. All they want is a Fire job. Which is going to reflect poorly on themselves, the municipality that they work for, and most importantly the patients.
What we all need to understand is that EMS is NOT a Public Safety agency like Police and Fire. We deliver health care.
I disagree with that very much. I have worked for a hospital based service for years now and we have a huge role on Public Safety. It is the mindset that we are not part of it that is holding EMS back in wages and respect. If you look at NIMS we have a part of the unified command structure and that alone makes us part of Public Safety.
Part of the problem I see today is that EMS has gotten away from the public education rhelm and other public service duties that we once played a part in. Those dutied have been given to fire departments and others in the name of keeping trucks in service or the game of running as few trucks as possible because of budgets. We should be in the community as much as the fire departments doing education and prevention programs being proactive. We should have a hand in all disaster planning instead of being reactive to emergencies. We should be working with and educating our PDs as to what we do and are capable of in order to be utilized in the correct ways instead of running on the drunk without medical problems at 3am who does not need an ambulance. We should have regular training with the fire departments in auto extrication and basic fire suppression since we arrive first at a lot of accidents. Properly utilizing the fire extiguisher on the truck can save lives prior to excrication or knowledge of the proper use of the required tools on your truck can have a door opened and pt extricated prior to FD arrival.
We have a large part of Public Safety and should exploit it for our advancement. The mentality of we only deliver health care is not using our abilities to the fullest.
Let me suggest a different take on your approach. I agree we need to be involved in Public Safety, but that needs to come internally. Just as police are encourage to be proactive, citing dangerous drivers, etc, and Fire performs inspections, etc, EMS should find it’s proactive niche in Public Health.
By involving ourselves in everything from disease transmission prevention in the community, scheduled well-being checks on frail or at risk members of the population or assisting in health screenings.
These actions not only get our staff out into the community, interacting with citizens on good terms, and building community support (as well as familiarity to the people and places for our staff), but also moves us from only reactionary medicine, keeping EMS involved in the overall health and safety of our communities, and acting as the mobile arm of the public health department and hospitals.
Duke is actually spot-on. If I had a blog or column, I’d probably write more about this. In the civilian world, we are, for lack of a better term, “The Coast Guard”.
The Coast Guard has managed to achieve a more or less equal status with the Army, Navy and Air Force…but they are not true equals…except in wartime when they are absorbed by the US Navy.
For many years prior to 9/11, they didn’t even report to a cool-sounding higher authority like the Department of Homeland Security. They’re big bosses weren’t at the Pentagon. They were part of the DOT.
They operated in many of the same dangerous conditions as their DOD counterparts; even protecting USN assets in foreign ports. But they are NOT part of the DOD folks…except when it comes to pay/benefits; where they get the same as their traditional military counterparts. They have a different mission.
We in EMS do have a role in public safety (just as the Coast Guard has a role in Defense). However, our mission is different than that of police or fire (both of whom swear to protect life *and* property). Our scope is truly limited to protecting life and aiding the sick and injured.
Delivering health care does not mean we cannot take a role in public education. Yes, budgets are tight for many EMS agencies (in many cases because unlike police and fire, EMS receives no direct funding from the local taxpayer…they make ends meet on their own revenue…). Budgets are also increasingly tight for police and fire as taxpayers grow weary of hyperbole being used to reach in their wallets. All that said, there is no reason EMS cannot deliver public education; either on their own or by partnering with their local hospitals.
Sorry CombatDoc, but you missed the mark on this one.
I abhor the logic of fire based EMS, firefighter first, everything else when we get around to it. But then again these are the same people who would bar Kelly Grayson (and myself with 17 hrs experience) from providing paramedic services because it’s unlikely we would pass the CPAT.
What I hate is the fact that firemen probies are on the ambulance for their initial employment period as some sort of hazing/initiation ritual. If you want to be on an engine or ladder, you first must do your time ‘in the box’. What awesome patient care they must provide! They don’t want to be there and I’m sure their patients know it. Pitiful.
@CC I absolutely agree, and am as “shocked” as you, but one point of correction.
A 320 hour EMT class is quite long compared to many others in the country. There are some states that require as few as 110/120 hours in class, and programs still have 95% NR pass rates with these classes. There’s either something wrong with the instructors, or the students? Let’s ask ourselves who has the motivation to do well…?
Or there could be something wrong with National Reg…..
I agree with you 100% but, would like to add from my experience. I have worked for the hospital based and municiple based services. EMS should have it’s own command structure equal to fire departments. Planning and preperation for disaster response, daily operational control, seperate dedicated employees, etc. If we are to be a part of the fire department a great model that is working well is Indianapolis, IN. Fire department based Paramedics and EMTs that are members of the union but, not part of fire suppression. That marries the interests of the community with the intrest and desire of the employees. You are a Paramedic because you want to be not because you wanted a fire job. EMTs have a oppertunity to go to school and advance because they want to be on the ambulance. The Firefighter/Paramedic or EMT model creats a couple of things. Paramedics are not happy at 3am picking up grandma because they are missing what they love with that structure fire a few blocks over and EMTs that are good and capable never become Paramedics for fear of being stuck on the ambulance.
I also am not a fan of hospital or health system based EMS. Too often the best interests of the system or hospital is placed first leaving gaps in coverage for 911 response. I have time and time again not had a second truck when needed or had to listen to someone make a 15-20 mile response to my primary coverage area because of a BLS transport that originated from another area because it is our health system. The communities we serve deserve better and we deserve better than being ran to death for the good of the health system’s EMS budget.
Back to the topic of a 320 hour basic EMT class. I could care less how long the class is as long as they are prepared for the tests and it is up to preceptors and co-workers to do the real training on the job. A basic EMT with a new certification is an EMT the same as a EMT that could have had 1000 hours of training. Class room and real world are different enviroments. I care how trainable they are when they come out of class. If they hire the appropiate Paramedics the EMTs will become proficient and well trained under the guidance of their partners. I have to agree with the previous comment that the instructors need to be looked at, or the student, if the pass rate was that low. Indiana only requires 126 hours classroom and clinical hours for a EMT-B class so 320 should have been more than adequate. My best guess is that the difference is the students here were required to take the class and do not have the desire to do EMS.
@CombatDoc…I’ll take a wait-and-see position with Indy.
Actually, I prefer a third-service model of EMS delivery…but lacking that, I think being hospital-based is the most appropriate choice for a variety of reasons (including such budgetary reasons as improved supply and logistics, as well as having medical direction built-in).
The response issues you bring up sound less like a hospital-based problem and more like an EMS system problem. A problem that is won’t go away with any sort of pure structure in EMS; but rather needs to be addressed at the regional or state level.
The response issues I brought up are directly because of the health system. When my truck is sent 30 miles away out of the county to take a patient from the flagship hospital to another of their hospitals in the same city for inpatient rehab it creats a void in our 911 response. We would not be doing that if the local EMS system where the flagship hospital is based would do it for the same cost. The non emergency transfers that we do have are a big part of what we do and I have no problem with it when they originate from our hospital or return to our county. Just yesterday we had one of our trucks out of our coverage area for 9 hours of their 12 hour shift while I did their emergency runs from 13 miles away and then ran all night in my coverage area, I worked for 23 of my 24 hours straight. The state has no regulations controlling this and there are no regulations nationally. We are held to a standard of national average response times for a rural service but no requirements. These problems come from a private, not community, hospital providing the facility in the area making the EMS system a private, hospital based service. In essence we are not much different than AMR or Rural Metro because we are a private service that has a contract to provide service but, worse because we are used at the will of the health system spread out over hundreds of miles.
As far as budgets, these private hospital based services tend to be that last part of the budget that gets addressed. The reason is we do not make money for the health system on the front end making it appear that we cost them money just based on billing vs. revenue. Top that off with the need to spend $150,000-$200,000 a year on a vehicle and we appear to be a large money drain and that does not even include the cost of running the service and keeping all equipment in operating condition.
When I referred to municiple based EMS I was referring to the County owned hospital that runs the EMS system. I have worked in those and it goes very different. Our budget was set by the county as part of the hospital’s budget and we were taken care of because the county council knew 911 response was vital to their relection. The aspect of another hospital miles away that did not have an EMS system to do their transfers did not exist. Does that make sense?
CombatDoc,
The issue with transfers taking precedence over 911 is not a hospital-based issue. It is an issue for any service that is not tax-payer financed.
The simple fact is that IFTs are as a rule more profitable than 911 responses. For that reason, any service that does not have an alternate financial source (e.g. taxes) will take all the IFT they possibly can; and rely on mutual-aid or overworking/rushing the remaining 911 response units. Hell, out here in California, there are FIRE DEPARTMENTS that are taking all the IFTs they can grab; and relying on mutual aid from other FDs or private ambulance back-up to cover their areas.
CombatDoc,
When I speak of system, I’m speaking of EMS System (ie. county, municipal, etc.) rules/laws, not corporate policies. Yes, if you’re working in an area where the community has not yet decided how important EMS is (enough to establish some sort of expectations), then it does allow private (hospital or otherwise) agencies (or even 3rd service or FD agencies) to run roughshod. If the community doesn’t take EMS seriously, then EMS won’t be taken seriously.
I am curious about the budgetary issues. Of course, a lot of that comes down to volume as well. We are a high revenue generator (both alone and when combined with admits to our hospital) in the hospital. As such, they do take us more seriously.
@mpatk: While transfers are a growing issue, not all EMS agencies not receiving direct taxpayer subsidy are at the point of doing transfers yet. We don’t (public hospital-based EMS) do traditional interfacility transfers. We do get 911 calls from the children’s hospital for adults who present with an emergency. We also get 911 calls from area EDs who have a walk-in trauma. But those result in a fraction of a percentage of our call volume.