Stepchild `O Mine

For a relatively short opinion piece, it generated a lot of mail. Some of the comments were insightful, others informative. Some were threatening, others just vulgar. "I got some e-mails that were basically just a lot of profanity," chuckles David Powers, the South Carolina medic who wrote the column in question. "There was one firefighter who actually threatened to punch a hole in my gas tank. He even went so far as to tell me what kind of car I drove."

Take Powers' word for it: As we enter 2006, the long-running debate over whether EMS should be the province of the fire service remains as combustible as ever. Last June, in a Guest Editorial in these pages (The Redheaded Stepchild: Does EMS Belong in the Fire Service?), Powers offered a view that it doesn't. Both his in-box and ours were subsequently scorched with cyberstacks of passionate responses, testimonials and firsthand views from both sides of the issue.

In some cases, emotion overwhelmed good judgment. But in most, even those disagreeing with Powers seemed pleased to partake in some spirited debate. "Even the firefighters who didn't agree with me seemed happy there was a dialogue," Powers says. "I guess there's been a lot of fighting and not so much dialogue, and they were happy to see that much."

Reluctant Bedfellows

There's no question that the fire service is good at what it does. We all know about the success of fire prevention and the decreasing need for fire suppression. But among many in EMS - not only those working for third services, privates and volunteers, but even among some in fire-based systems - there remains unease with the notion of assimilation. The medical mission and the fire mission are just too different, many say. In a survey conducted by this magazine last summer, just 5% of respondents thought the U.S. Fire Administration a desirable home for any new federal EMS entity.

Why such discomfort? You can probably cite several factors. Powers - who reported agreement with his separatist stance from most of his correspondents - touched on some:

• The M is for medical. EMS is essentially a healthcare undertaking, not public safety.
• EMS can be subsumed in fire-based services. In some cases, it's been given short shrift.
• Cross-trained providers can't be expected to truly master such distinctly different and difficult trades as firefighting and EMS. Each is tough enough to require full-time attention to be good at.

There are other factors as well. There are differences in the types of personalities drawn to firefighting and EMS work. These providers must approach their jobs differently: Firefighters are structured, disciplined and must function as reliable links in a chain. EMSers need to be devil's advocates, outside-the-box thinkers and largely self-directing. It can be hard to reconcile such profound inherent differences, not only in single cross-trained providers, but even within combined departments.

On a macro-level, there's the larger issue of EMS identity. Just who and what is EMS? With the fire service's interest in assuming EMS and established advantages in such areas as funding, manpower and infrastructure, will there ultimately be room left for third services? For privates? For any non-fire models?

"I think the general level of mistrust probably stems from a number of things, and one is job security," says Jack Krakeel, chief of the Fayette County (GA) Department of Fire and Emergency Services and a senior consultant with the emergency services consulting firm Fitch & Associates. "I think people are afraid that the fire service is going to be the sole, single provider of emergency medical services. And by that I mean in the context of what EMS is, not just the transport system. Clearly, emergency medical services in this country is substantially larger than just the patient-transport component. And while a large percentage of transport is provided by fire agencies today, they're also involved in many facets of EMS outside the transport sector. I think it's just a natural fear that ultimately, EMS will evolve into a solely fire-based system.

"Frankly, I disagree with that fear," he adds. "The variables that influence the delivery model in any local community are dependent on that community."

Krakeel's point - that the right answer will vary depending on a host of external circumstances - is probably a good thesis with which to begin. Certainly, there are some fire agencies that provide terrific EMS. By the same token, there are some that have wrestled with the challenge.

'LIMITED APPRECIATION'

The San Francisco Fire Department already provided BLS care, but its EMS involvement grew substantially when it merged with the local Department of Public Health's ALS ambulance service in 1997, bringing DPH medics to the city's stations. Some things certainly got better under SFFD: more units on the street, more field supervisors, faster response times. But the merger brought problems too, issues with things like scheduling, pay and job security. And in the station houses, where the new and the old had to coexist day by day, there were instances of friction. Some old-guard firefighters didn't welcome the newcomers. Some freewheeling EMSers weren't good fits with the FD's regimented style. Some of both had no real interest in cross-training. Many leaders were fire-service traditionalists who didn't fully embrace the EMS mission. Frequently, time heals such divisions, and it did in San Francisco, to an extent. Many fire and EMSers learned to get along, but some didn't. By 2000, some EMS providers were still citing hostility and ostracism from their colleagues, and others were complaining about the slow pace of cross-training and the lack of opportunities to rotate onto ALS vehicles. Enough problems persisted that by 2003, a Civil Grand Jury began to review the merger's outcome. A year later it issued its report. Among its findings were needs for:

• Leadership to ensure that EMS is valued on par with fire suppression;
• Resource allocation to reflect increasing EMS workload;
• Addressing an ongoing shortage of firefighter/paramedics;
• Better management training for officers, and greater accountability for carrying out their duties; and
• Ending "harassment" of fire-medics.

"EMS," the grand jury concluded, "is treated like a poor stepchild in SFFD. Few in number, the firefighter/paramedic providers of EMS are surrounded and led by firefighters and firefighter officers who have a limited appreciation of EMS work." Jurors called for a comprehensive review of SFFD operations by an objective outsider.

"The fire service can struggle with change," observes Art Hsieh, CEO of the San Francisco Paramedic Association, which advocates for medics in the Bay Area. "They pride themselves on tradition, and anything that represents change - whether it's women, whether it's shift differences or whether it's EMS - can sometimes be difficult."

A medic who made the switch from DPH put it more bluntly: "As far as management was concerned, they didn't have a clue about EMS."

The next year saw the release of a report by the city's health department that spotlighted "critical deficiencies" in multiple areas of the department's EMS operation. Auditors who randomly inspected 150 patient files in January 2005 found that:

• Just 10% of medical charts were properly completed;
• For patients transported to EDs, overall clinical performance standards were met just 44% of the time; and
• "Treatment protocol errors or omissions" were found in 70% of cases.

As recently as last August, a local TV station reported that 24 of 26 SFFD ambulances failed their annual inspections due to missing equipment.

"Search the San Francisco Chronicle website, and you can see the level of problems they've had," says Hsieh. "Patients being pronounced dead who aren't dead. Patients basically browbeaten into staying at home who later die. Patients who have mechanisms from a fall for cervical spine immobilization and aren't immobilized, then suffer paralysis. It's not necessarily that those medics are bad. It's that in their stations, the climate is bad for the provision of healthcare. The pressure is on to clear the scene and go - it's a mentality that leads to a lot of shortcuts."

"We were hemorrhaging medics [after the merger], and they wouldn't hire a straight paramedic from the outside - they only wanted firefighter/paramedics," says the DPH medic, who asked his name not be used. "We were getting folks who only became paramedics so they'd get hired by the fire department. And we got a few good-quality folks out of that; there are definitely some folks I'd stand shoulder-to-shoulder with on any call. But a lot of them, while well-meaning, had been in departments that didn't run very many calls, or didn't run them to the standards we did. So there was a stepoff in the quality of care."

RECONFIGURED

While acknowledging that some problems existed, officials within the SFFD and the Fire Commission that oversees it took issue with many of the grand jury's conclusions. In a written response, fire commissioners voiced a "strongly held belief that the snapshot presented by the grand jury report does not accurately reflect the department yesterday or today."

More pertinent, officials felt, was a 2004 report from the city controller's office that advocated personnel-related changes to save money and better handle workload.

"Part of the problem with the grand jury is that you have interested citizens who, unfortunately, aren't really experts in the various areas they delve into," says SFFD EMS Chief Glenn Ortiz-Schuldt. "Some of what they recommended was worthwhile; I think we definitely needed to look at the way we were deploying our resources. But I think the controller really had a better handle on it."

A key recommendation of the controller's report was to create peak-load staffing options and reduce overall staff and units in service during less-busy times. That idea forms the backbone of a reconfiguration plan recently unveiled by the department that's aimed at addressing some of the issues described above.

Key elements of the plan include:

• Scrapping 24-hour shifts in favor of shorter ones for most personnel, and moving the ambulances out of the firehouses, where the high number of medical calls coming in was a source of contention for personnel trying to sleep;
• A more robust quality improvement program, with added resources and performance benchmarks; and
• Positions that don't require cross-training. A new three-tiered system will include firefighters, paramedics and firefighter/paramedics. The medics-only will ride the ambulances, while the firefighter/medics will eventually bring ALS capabilities to all 42 of the city's engine companies.

"It's a model that allows people who want to have careers in EMS to come to San Francisco," says Ortiz-Schuldt. "You have to get people in ambulances who really want to provide care on ambulances. Right now, we have a lot of firefighter/paramedics who really prefer being firefighters. So that's the first step. And the second is ending the 24-hour shifts. Unless you have an enormous amount of resources, 24-hour shifts for ambulance personnel probably aren't the best model for strictly urban environments."

As far as the friction, it's reportedly diminishing over time, as those most unhappy with or resentful of the merger have moved on.

"There were difficulties with the merger back in '97, and there were difficulties with people suddenly being thrown together who hadn't worked together before - they had two different cultures," says Paul Conroy, president of the San Francisco Fire Commission. "From what I hear, that has vastly improved. There may be some people within the department who still kind of hold on to [past problems], but there has been tremendous improvement in the way in which the paramedics and firefighters work together."

"That [friction] was absolutely real and palpable for the first couple of years," says Ortiz-Schuldt. "But now you don't really find it very much. By now, I think everybody realizes we're all in this together. It was definitely a difficult transition; we've had a much higher attrition level in our firefighter/paramedics than in any other ranks. But that was one of the things that alerted us to something being wrong."

HOMEGROWN

When you ask about fire departments that excel at EMS, Miami-Dade Fire Rescue is a name that often comes up. It's a bit of an apples/oranges comparison, but Miami-Dade has avoided many of the problems that plagued San Francisco in the years following its merger, and have been noted at other combined departments.

It was 1973 when the department first assumed medical rescue duties, and it did so in a way markedly different than many others: It didn't absorb an established EMS operation - it simply expanded its own capabilities, using its own personnel.

"We didn't merge; we evolved into a medical fire-based system," says John Gardner, chief of the department's EMS Division. "We grew from within the department out, so it was our people doing it. We didn't bring new people in, and that was important."

Indeed it was, for several reasons: One, there wasn't a feeling of political forces forcing something on providers that they didn't wish to do. Two, there weren't newcomers coming in, competing for jobs and resources and straining established relationships and cultures. Three, it allowed those personnel with an interest in EMS to become involved in EMS. "We created positions as needed," Gardner says. "We didn't reduce anybody's area of control; we added new areas that needed to be controlled. That generated promotions, and it was embraced."

For both department leaders and front-line providers, there was a feeling of ownership. EMS was their baby from the get-go, and hence resentments, culture clashes and friction were minimized. The EMS was being provided by the same familiar colleagues who'd historically been sitting around the table.

With the full imprimatur of leadership, the medical mission received the care and nurturing it needed to grow. Patient care was the priority. Personnel were rewarded for taking on more responsibility.

"You have to pay people for the added responsibility of treating critically ill or injured people," Gardner emphasizes. "You cannot tell them, 'Here's your new job description, and you don't get any money for it. Oh, by the way, you have to go to school for another year or two, and you're not getting any money for that.'

"We're an incentive-based system. Our pay scale allows for basic entry-level salary, and then each specialty you acquire applies another pay incentive onto your base rate. Our people are allowed to choose, on a seniority basis, which unit they want to work on, and we compensate them for working on units that run more calls. We never ask anyone to do work or acquire additional education without compensation. It's no different than corporate America: You promote somebody to vice president, you give him a raise and a bigger office. You promote somebody from a fire truck that didn't run medical calls, tell him to go to school for a year, come back and run medical calls, you have to compensate him."

All this is not to say that every firefighter in Miami in 1973 was enthusiastic about doing EMS; just that it was introduced in such a way as to ease the transition.

"The industry of fire and rescue is resistant to change, and just because the IAFF says EMS is our future doesn't mean the person on the truck is going to buy in to that," Gardner says. "Departments can make the transition much easier if people are receptive to the philosophy within the firehouse. Because we grew from the inside, it was our people who were making the decisions, our people on the trucks and doing the training. It wasn't an outside-the-family, shoved-down-your-throat type of scenario. There are a lot of ways to gradually implement this kind of program and see an easier acceptance on the fire side."

SECRETS OF SUCCESS

What can be taken from the above experiences? They don't make for a perfect comparison, but they do suggest there are certain conditions conducive to successful fire-based delivery of EMS. Let's distill a few.

• Leadership buy-in: "Clearly, there has to be leadership that embraces the concept of an all-hazards organization," says Krakeel, who has also chaired the International Association of Fire Chiefs' EMS Section. "If leadership doesn't emanate from the top, structural changes in any organization are bound to fail."
• Front-line buy-in: The guys in the station house have to be on board, if not with delivering patient care themselves, then at least with their department doing it.
  
  "That's one of the things I look for when I'm asked, 'Is this fire department ready to do EMS?'" says Tim Kiehl, a veteran Maryland-based consultant whose company, TRK LLC, specializes in fire/EMS integrations. "All the chiefs may be saying, 'Let's go, let's go,' but I spend a lot of time hanging out with the rank and file before I ever make a recommendation to move to a fire-based service. It's important that the rank and file are keen to do it, and not everybody is."
• Adequate resourcing: In many departments, fire-suppression budgets grow even as calls decline, while EMS runs on a shoestring despite soaring call volumes. In San Francisco, the 2004 controller's report found that "with 1,150 firefighters and 250 paramedics stationed at fire stations... SFFD staffing is weighted toward suppression activities."
  
  "Every time a budget thing would come up, EMS was taking it in the shorts," the San Francisco medic says. "We were running the majority of the calls, and we were also supporting the department."
  
  "I think the San Francisco Fire Department has to imagine itself as an all-hazards department - that it does, in fact, provide healthcare as part of its public safety job," says Hsieh. "A big part of EMS is healthcare, even at the EMT level. And the priority of providing that, and the money to provide that, have to come from a management-level decision to make that happen."
• Roles and authority: Delivering EMS plugs a department into a healthcare continuum that includes other players: hospitals, health departments, first responders, insurers and more. It makes you a link in a chain, rather than the be-all, end-all. You can't operate with complete independence.
  
  "It ties you into a whole continuum, and it creates and forges partnerships," says Krakeel. "Individuals who have roles, authority and responsibility for a system become part of that. Historically, singular fire suppression-type activities are not dependent on those types of relationships. They're generally internally driven and internally validated. The delivery of EMS requires us to become cognizant of the fact that there are other entities, individuals and organizations that have a voice in that delivery."
  
  Roles and authority also matter within a department. Who calls the shots in any given medical situation, the fire chief or the medical director?

  "That has to be defined at the front end," says Krakeel. "Otherwise, it's going to create conflict."

• Equity in pay/benefits: "One of the problems we saw in Washington, DC, was that the EMS providers were civilian employees of the fire department," says Kiehl, who worked with that troubled department. "In that situation, you can have a disparity between the two types of employees. The firefighter may not go on as many calls, because there aren't as many fire calls as there are EMS calls, and he or she may be making considerably more money than the EMS provider. We call it the stepchild syndrome, where the EMS providers feel like they're second-class citizens, as a result of being on the move all the time and getting compensated less. And inevitably, when you put those two work forces right next to each other, you get a situation where friction starts to occur. And if you don't nip it in the bud, you can find yourself, several years down the line, with a very Balkanized work force."

The All-Hazards Era

As badly as many in EMS want to be a separate and independent "third leg" of the public-safety tripod, circumstances seem to suggest that fire service involvement in the field isn't going away. If anything, many observers say, it's likely to increase.

"There's still a terrorism threat, and whether it's global warming or not, we're in a period of some really funny weather, with a lot of natural disasters," says Kiehl. "I think that's going to drive a movement where people will want to have a strong, healthy fire department. Fire departments can do things like heavy rescue, search and rescue, water rescue, hazmat. And if we're really moving into a time of horrible things happening, people are going to want their fire departments to be bigger, stronger, better trained and ready for every situation. And the way to do that is to give them EMS. It will build up their manpower, it will give them a source of revenue, and it will give a community things like search and rescue and patient care, all under one command."

Having EMS in the fire department "is the most cost-effective way to deliver multiple specialties," agrees Gardner. "We must be fiscally responsible, and politics should not dictate 'I want my fire department,' or 'I want my medical rescue.' Our department has everything from certified airboat operators to dive-rescue kayak paddlers to advanced life support fire trucks to state-of-the-art trauma helicopters to inflatable ALS boats to motorcycle paramedics. We've diversified to meet the needs of our region, and we're only able to to do that through integration and pooling of finances."

Bigger doesn't always mean better, of course, and efficiency in funding and services is another story unto itself. But economies of scale, if taken advantage of, can be a powerful lure for cash-strapped communities.

"That's traditionally why we do consolidation: to take advantage of economies of scale," says Krakeel. "So there aren't duplicate administrative structures in place, so we can utilize existing staff to provide services. Under those scenarios, very often, there is a cost savings."

This is not to say that non-fire EMS agencies can't function smoothly alongside numerous other discrete participants in a multifaceted emergency response. Many such agencies integrate seamlessly into their local emergency-response matrix, serving their communities well and sometimes even sustaining themselves (or coming close). EMS, in many places, has its act together like never before. If that's the case, why change?

"One of the first rules of organizational design is, if it isn't broken, don't fix it," says Kiehl. "That, I think, is one of the pressures that have sort of flatlined the move toward fire-based EMS. Why rock the boat?"

All of which brings us back to the starting thesis: The right answer will vary. Fire departments aren't the only answer for providing EMS, and depending on local circumstances, maybe not even the best one. But if they commit fully and do it right, they can be a good answer.

As EMS veteran Paul Maniscalco puts it: "Value the mission, resource the operation and respect the people doing the job. Do that, and you could stick EMS in the sanitation department, and it will run effectively."

"People pay a ton of money for these services, and they should get the appropriate services," adds Hsieh. "They should get good firefighters, they should get good paramedics, they should get a good prevention program and a good code-enforcement program and so forth.

"A department, in all that it decides to do, should do it well."

If you missed David Powers' Guest Editorial, The Redheaded Stepchild: Does EMS Belong in the Fire Service?, you can now read it online at https://emsresponder.com/publication/article.jsp?pubId=1&id=1803. The website also features many of the responses we received to his editorial.