Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Will Atlanta be the next city to switch to Fire Department EMS?

There is a story about cuts to funding of EMS in Atlanta at The Atlanta Journal-Constitution. The article Fewer ambulances, longer waits for Fulton residents? suggests that there will be continuing funding problems for EMS in the area and that the fire department is chomping at the bit to take over.

In a recent letter, Pamela Stephenson, CEO of Grady, which furnishes ambulances to the central part of the county, asked the commission to reconsider its vote and appoint a panel of residents and medical experts to look at the EMS issue.

Without public funds, she wrote, Grady would have to cut the number of ambulances and attendants on duty, which would mean response times “greater than thirty (30) minutes for all life threatening emergencies.”


According to the quote, it would take longer than half an hour to arrive on scene for emergencies. Not just some of them, but all of them. That is just plain ridiculous. How is it going to take that long if there are available units, for example during off-peak hours or on slow days.

Is she threatening a policy of deliberately slow responses?

Or is it just another example of someone who is incapable of communicating in English?

Or is there a mistake in the quote from her recent letter?

In their vote, Fulton commissioners relied on a document prepared by Alfred “Rocky” Moore, director of the county’s Emergency Services Department. It recommended that the commission eliminate public funding and settle for a countywide standard response of up to 12 minutes in 90 percent of emergency calls.

But with fewer vehicles to handle what is expected to be the same, if not an increasing, demand, calls would back up and response times would grow “far beyond just 12 minutes,” said Dr. Patrick O’Neal, director of the Office of Preparedness in Georgia’s Department of Human Resources.


A response time of 12 minutes, or less, on 90 % of calls does not sound like over 30 minutes for all emergencies, but they appear to be talking about the same thing.

The EMS cuts are hitting Atlanta when the city faces its own projected shortfalls of about $65 million for the budget cycle ending June 30, and $120 million for 2009. Officials cite the increased costs of pensions, health care and fuel, decreasing revenues, and budgeting errors.


Budgeting errors?

That does sound interesting.

Here is where it becomes even more entertaining.

One possibility for Atlanta would be to have the city’s fire department take over ambulance service. Already firefighters are first responders to 911 calls, usually beating the ambulance there by at least a couple of minutes.

“If you’ve got a guy who’s a fireman and an EMS, he can do both jobs,” said Chief Mike Beckman of the Atlanta Fire Department’s EMS service.

There’s one big problem. The fire department has no ambulances.

Grady has about 26 in the field at peak times, stationed throughout the city. Grady officials estimate start-up cost for an ambulance system based in the fire department would be about $20 million.

The fire department has to be prepared to step in, Beckman said, even if that means using Grady ambulances.

“It’s a logistical nightmare, that’s what it is,” said Beckman. But, he added, “If they threw the keys in the parking lot July 1, we’d pick them up and make it work. … We would do what we have to do.”


There is only one big problem?

Maybe I am a bit of a cynic, but if the fire fighters are on the ambulances treating patients and there is a fire, do they treat patients or fight fire?

If the problem is a lack of ambulances, having the ambulances less available, because the personnel are fighting fires, is not a sensible answer.

How many paramedics does the fire department have?

The chief of EMS describes “a guy who’s a fireman and an EMS.”

What is an EMS?

I believe that Georgia uses the classifications of EMT (Emergency Medical Technician), EMT Intermediate, and EMT Paramedic. EMS is Emergency Medical Service. Does he think that one guy is going to be all of EMS?

How much will the skills of paramedics be improved by having to be cross-trained as fire fighters?

“Sorry, I didn’t provide good care, but you should see me fight fire!”

Not exactly the condolence that you might want to hear after a medical error.

Will they send a bunch of fire fighters to medic school and have a whole cluster of inexperienced paramedics?

Will they hire experienced paramedics, but send them to fire fighter school, so that they can dilute their skills?

After all, paramedics have a problem of being too good at their jobs. They are so good that they need to find other things to train in to keep them from going in to the hospitals and taking jobs away from those foolish doctors.

When the funding problems hit the hospitals, why not have the fire department take over and cross-train the nurses and doctors as fire fighters to improve the system?

I wouldn’t even be surprised if JCAHO, sorry, make that TJC (The Joint Commission) approved of this. After all, they are named for what they appear to be smoking.

There are some people who do well at both jobs, when cross-trained. They are not common. Cross-training may be effective if the jobs do not require much skill.

If the EMS chief of the Atlanta Fire Department does not recognize that the bigger problem with EMS is competence – not a lack of a fire department uniform – then things will only get worse with him in charge. Then, maybe a 30 minute response time would save lives by encouraging patient to seek their own transportation to the hospital.

They mention a $20,000,000 start up cost. Yes, we can save you almost $10 million, but the down payment is going to be $20 million.

Suckers!

There is no estimate of how high the costs could go with the fire department in charge.

There are plenty of medics who have to work hard to maintain their level of education and skills. If you cross-train them, they now have to divide their time between maintaining fire fighting education and skills and maintaining paramedic education and skills. It is only in a fairy tale world that you get competence at both for less money.

Therefore, I am expecting that within a year there will be plans to have Atlanta Fire Department take over paramedic service for the city.

If costs do decline, it will only be at the expense of patient care, but that’s OK. I do not live in Atlanta.

Chief Mike Beckman of the Atlanta Fire Department’s EMS service will be a much more powerful man, but it is cynical for me to suggest that has anything to do with his comments. He probably means well, just as Dr. Deborah Peel means well.

But Mom, all the other cool cities are doing it. It must be better than crack!

Suckers!

Comments

  1. Judging by your post, I would guess that you’ve never worked in a system in which the fire department runs EMS. However, in MD (where I’m from), 911 EMS is provided exclusively by the fire department, with the private sector handing only the inter-facility junk. Before starting in med school, I worked in both Baltimore City and Baltimore County, so although they were both fire department based, I saw two different philosophies of training.In Baltimore City, if you want to be hired as a firefighter, you must also obtain your EMT-I certification (which in MD, is practically equivalent to EMT-P). If you do not pass NREMT-I within 3 years, you’re done. Unfortunately, this leads Baltimore City to run a very easy EMT-I class (just barely enough to pass NREMT-I exam) and push people through who have no business being medics. It also forces people, who have absolutely zero interest in EMS, to become ALS providers. As you can imagine, this makes for some atrocious EMS providers and I have seen some things done on those medic units that should NEVER be done in EMS. There are many providers who really don’t know what to do, so they just throw them quickly in the back of the medic unit and haul ass to the hospital, hoping they stay alive at least that long. And, since the medic units are so busy (I’ve run 26 calls in one 14 hour shift), there is very little quality control. As long as you’re friendly, you’ll probably never get in trouble.On the other side, the Baltimore County fire department does things much differently. Everyone must become an EMT-B, which makes sense since the fire department so often responds to assist the medic, and it’s nice if they know what a backboard looks like, or can help out with basic care. I’m not saying that they’re good EMT’s (some are, some are not), but at least they have some idea what’s going on. However, no one ever makes you become a medic…that’s something you have to want to do. And, if you want to be on the medic unit, you will NEVER be on the fire suppression equipment, because I can guarantee that no fireman is fighting to get on the medic. And, while fire fighters that have no interest in EMS do sometimes get stuck driving the medic unit, they never have to get ALS certification or actually really be responsible for anything. Although I have not worked in a private based 911 EMS system, I would not ever want to either. I like that between calls, we have a firehouse to go hang out at and a comfortable place to sleep at night. There are also tons of promotional opportunities within the fire department (even sticking strictly to EMS), that would not be available on the private side. Finally, I enjoy firefighting as well, so every once in a while, I’ll rotate with the other paramedics and ride the suppression equipment. And, it is not at all difficult to be a competent firefighter and medic. Lets just be honest here…fire fighting is not terribly difficult. Also, keep in mind that many fire department (particularly the rural ones) can be very slow and only run maybe a couple calls a week. At my firehouse, even though I only run fire calls once in a while, when I’m not on the medic, I still have probably spent more time on the engine than many people who are strictly devoted to fire side. But, i still ride primarily EMS, dedicate a lot more time to EMS training (I was actually an EMS Lieutenant the year before I began medical school), and definitely maintain my competence in EMS!As far as worrying about fire fighters having to decide between fighting fire or going on the EMS call…it’s a non-issue. Fire stations (career, not always volunteer) are always staffed so that there is a full suppression crew and medic crew. The EMS crew is almost always people who just want to be on the medic (especially the ALS provider), and the fire people want to be riding the fire trucks. They are very good at what they do, but they also happen to have some training in the other half, and can help out there as well.

  2. Hey Scott, dont be so quick to turn your nose up at a private 911 system. RM and I worked for the same company many moons ago and it was quite the sweet little gig. Details best left for discussion over a cold beer or two. 😛

  3. Not that we were treated with any kind of respect by management, but we returned the favor.

  4. Oh, oh, oh, I have a reply to this. But it’s to long for here. Will post in the near future to my blogggggg.

  5. I don’t have any real problems with private 911-EMS (as I’ve never worked in it). Just pointing out that fire department based is not necessarily bad either. I’m sure there are advantages and disadvantages to both.

  6. dummy… you have no clue what you’re talking about. stop venting from behind the french fry maker….

  7. Anonymous,Please, be a bit more specific. Getting these french fry orders out is very time consuming and I am easily distracted. As you know, working with a fryer, but without venting is not a safe thing to do. One problem is that this might produce conditions that lead to a fire. Based on all of the details you provide, I must conclude that what you are trying to tell me is that things are much worse than what I describe and I am only scratching the surface.

  8. This week Atlanta City Council just adopted the 2009 City of Atlanta Fire Department Budget. Budget cuts reduces fire department administrative staff from 38 to 10 civilians, firefighters from 1,108 to 717, technical services staff from 66 to 36, and a Total Authorized Personnel – strength from 1,122 to 763. The proposed budget of $ 86,889,097 was reduced to $ 78,511,398. The budget also looks at closing fire stations 27, 26, 3, 7, 28, 8, 34, 1and 5. The budget abolishes 94 sworn firefighter positions (Over 10%), no cost of living increase or performance-based pay step increases, increase health insurance premiums by over 20%, eliminates firefighter Health and Wellness program, eliminates Advanced Life Support supervisors, eliminates Special Operations Section, eliminates Homeland Security liaison, eliminates Office of Community Affairs, reduces Training Center staff, reduces Assessment & Planning Section staff and eliminates cable channel public safety programming.The Grady Hospital Health System EMS is a highly respected and cost-effective 911 provider that serves all areas within the Atlanta City Limits. It is under the medical control of the Emory University School of Medicine-Department of Emergency Medicine. Grady operates 32-35 paramedic ambulances and has a field medical director physician. Cities, like Atlanta, are finding it very hard to justify the response of a fire department pumper with 4-5 firefighters that gets 5 miles to the gallon at best on every EMS. On some calls, they may dispatch a BLS engine along with a paramedic level engine. This greatly reduced the immediate response to a fire that may occur in the same area because the closest first (or second) engine companies are committed to the EMS call. A cities I.S.O. fire insurance rating is based on that cities availability of fire fighting capabilities including fire apparatus and water supply system. A business and homeowner’s annual property insurance premium is based on this rating. A recent National firefighter union website even advocates that fire departments take over all non-emergency patient transport and special events in order to increase their revenue. The number of working fires has been reduced significantly thanks to NFPA standards, sprinklers and greatly improved building codes. Yet fire departments are determined to maintain excessive staffing despite these reductions. EMS is viewed as their only salvation through upgrading their own union “brothers” and “sister” union members from EMT to paramedics who will replace those medics who currently work for a non-fire service 911 provider. Grady should invest in establishing nine-(9) paramedic level Triage/Assessment & Control (TAC) units that will have telemedicine capability and expanded scope of practice to replace the highly expensive fire department pumpers under the medical control of a Pre-Hospital Primary Care Coordination Center (PHPCC) which is staffed by emergency physicians, critical care paramedics with full telemedicine capabilities to properly assess and direct patients to the most effective medical care facility via the most cost effective transport means. The Grady EMS “TAC” squads can also be dispatched on working fires, where their two-person crews can provide the incident commander with an additional resource to set up a rehab/EMS station and save the need to dispatch yet another expensive pumper and excessive personnel for that same function. The EMS ambulance abuse within urban areas has now reached epidemic proportions. In Dallas when a fire department paramedic unit finds no medical justification for transporting a patient by ambulance, paramedics have the option of refusing transport. Crews carry brochures that describe alternative transport options

  9. Anonymous,Thank you for the update. This is not a good situation for anyone there, not for AFD, not for Grady, not for the people who need an ambulance.It is another example for people who think that private EMS, or private anything, is just concerned about the money, while the government would never make decisions based purely on losing money. The government is losing money and cutting services, just as if it were a private company. Big surprise? Hardly.

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