The IOM Report on EMS: What Will Its Impact Be on the Fire Service?

Last summer, the Institute of Medicine (IOM) released three separate and widely touted reports on the state of emergency care in the United States. One of those reports was an EMS component called Emergency Medical Services at the Crossroads.

Collectively and in summation, all three reports indicate that the United States emergency care system is fragmented and stretched to the breaking point, and unable to respond to disasters. The reports call for an end to gridlock in emergency departments and support the notion that any future emergency care system should be more patient focused.

Instead of writing on this last summer, I decided to wait and see what would come of this report, hyped as the second coming of the National Academy of Sciences/National Research Council's groundbreaking 1966 report, Accidental Death and Disability: The Neglected Disease of Modern Society. According to many, that report led to the formation of pre-hospital emergency medical service systems around the country.

Now, as we sit with another report, I wonder what the implications will be for the fire service. First, out of the entire group of individuals responsible for generating the report, there was only one fire service representative - and that person sat on a subcommittee, not the main committee. Even with only one representative from the fire service, the report recognizes the vital role the fire service plays in delivering EMS. On page one of the report, it says, "There is enormous variability in the design of EMS systems across states and local areas. Nearly half of these systems are fire-based, meaning that EMS care is organized and delivered through the local fire department."

In reality, the numbers are higher. Approximately 90% of career fire departments and many combination and volunteer fire departments provide some form of EMS delivery in their communities - even if it is only a first-responder company. The report mainly makes reference to fire departments that provide EMS transport.

Aside from the lack of fire service representation, the committee hits on many points that are accurate. Additionally, some recommendations in the report are favorable to the fire service while others are not. One that is not, however, is where the report recommends that "Congress establish a lead agency for emergency and trauma care within two years of the publication of this report. This lead agency should be housed in the Department of Health and Human Services, and should have programmatic responsibility for the full continuum of EMS, emergency and trauma care for adults and children, including 911 and emergency medical dispatch, pre-hospital EMS, (both ground and air), hospital-based emergency and trauma care, and medical-related disaster preparedness."

This recommendation is not surprising, considering the number of physicians who sat on the main committee as well as subcommittees. The placement of a federal lead agency in the Department of Health and Human Services (DHHS) would mainly view EMS from the medical side of the equation and discount that EMS is largely delivered by public safety agencies. Many of those public safety agencies deliver EMS from non-transporting vehicles such as engines, truck companies and squads. The age-old question remains: Is an ambulance that shows up at your door a medical agency providing public safety service or a public safety agency delivering medical care? In many cases, delivering EMS at an emergency scene is not just medical. Specialized and technical rescue has to occur simultaneously in order to free a victim from a car, roof, a collapsed trench or many other possible scenarios.

Under a DHHS scenario, expect other EMS delivery systems such as third-service agencies, hospital-based systems and private ambulance companies to share in the dollars that the Feds will dole out for the delivery of EMS care that might have gone to the fire service. We saw some of this movement when Congress passed legislation several years ago mandating that 2% of any FIRE Act grant money go to EMS services that are not fire-based EMS agencies. Under a DHHS scenario, money that goes for training at the National Fire Academy in Emmitsburg, MD, for education programs in fire service EMS would surely be transferred to DHHS and training programs would divvied up among not only fire service agencies, but others.

One topic the reports get right concerns evidence-based results. We have been delivering EMS for 40 years, and there is hard evidence to validate whether the care that is provided is suitable. The term "evidence-based" appears 25 times in the 230-page document. Evidence-based approaches to delivering EMS are the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. Using evidence-based EMS means integrating individual clinical expertise with the best available external clinical evidence from systematic research.

The question when you start looking at evidenced-based EMS delivery is whether all the current approaches will be wiped out. What about the current standard of care that is taught in our textbooks? What about response time standards found in National Fire Protection Association (NFPA) Standard 1710 and other standards such as those from the American Heart Association as to when CPR should be started in a cardiac arrest event before biological brain death occurs?

Only time will tell whether any of the recommendations in this report come to fruition. There is no doubt that emergency medical services should be adequately funded at local levels in order that we respond to daily operations, plus disasters. But no matter what, the fire service needs to be diligent as future money flows from Congress.