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

- Rogue Medic

More Medics Means More Medical Misadventure – commentary

30 year FF/Medic in the Southwest US wrote a comment that I could not easily answer with just a comment. Here is the original comment broken up by my responses.

Sorry, kind of late to this party.
No wonder AmbulanceDriver links you. He seems to dislike fire medics also.

I do not think that Ambulance Driver dislikes fire fighters, but he can speak for himself.

I do not dislike fire fighters. I would like to see administrations find sensible ways to meet staffing needs. This FF/EMT-P idea is bad fire fighting and bad medicine. Having fire fighters make medical decisions is as bad as having medics make fire fighting decisions. Having EMS run by FD and having FD run by EMS. Both are bad ideas.

I think fire fighters should fight fires and paramedics should provide medical care. It seems that most of the fire fighters I know do not want to have anything to do with EMS. They want to fight fires. In the midatlantic states fire departments have to require minimum amounts of time working as a fire fighter, before they can be released form that obligation and be just fire fighters.

Do you want someone taking care of patients who does not want to be taking care of patients? Yes, It does happen with burn out and everyone has bad days, but this is intentionally recruiting from those who have to be forced to sign a contract just to have the chance to fight fires later on.

Are either of these jobs so simple that we want to force people, with no interest in the job, to be the ones who are responsible for life and death decisions?

“The silliness of sending a fire engine to a medical emergency deserves a post on cluelessness all to itself.”

OK, how about 515 sq miles to cover and no one to do it?
When you have the 10th largest city in the country land wise, and someone codes or yet another 2 yr old drowns, I don’t have a problem getting on my fire engine and having an *average* response time of 5 min.
Why would you??
They’re in the neighborhood. Why not utilize them?

Having a person become a medic, because the person is already in the neighborhood performing another job, is a bad staffing decision. Hire the right number of medics for the EMS workload. Hire the right number of fire fighters for the fire fighting workload. Don’t complain if some of them are not busy.

The comment you quoted was about the waste of sending an engine just to transport personnel. Why do you need to send the big truck out on a shoe run? Why not get a utility vehicle and leave a driver at the station to rendez vous with the rest of the crew at the scene of a fire – if a fire call comes in?

Why put all of that wear and tear on such an expensive piece of apparatus?

Engines sure don’t maneuver better than much smaller trucks. They do not decelerate as well, when required to. They do not accelerate back up to speed well, either. In some places they avoid this problem by just blowing through the lights without slowing.

There was an accident in Baltimore, in December 2007, that demonstrated this problem.

“Fire department policy requires a truck operator to stop before proceeding through a red light. But in this case, the truck was going 47 mph at the time of the crash.

“The fire truck was third in a line of four emergency vehicles and reached the intersection eight seconds after an ambulance had safely gone through it, officials said.”

That all of the fire apparatus sped through the red light tells you that this is not an unusual occurrence. This appears to be the common practice. This is one of the problems of driving a truck that is so difficult to slow down and to speed up. They were responding to a report of smoke, so this is not an EMS call, but would they have responded any differently if it were an EMS call. We are supposed to be protecting the public, not endangering them.

And this article does not describe an isolated incident.

I just don’t understand the fire bashing. I get along great with the private ambulance company medics that I run in with.
I run in with them because we’re closer to some of their calls and we don’t stop at some line on a map if someone needs help.

As medics we all have to wade through the same blood and puke and put up with the same nurses and docs don’t we? So why the attitude?

How do medics benefit from being fire fighters, other than through the stronger union representation? How do fire fighters benefit from being medics other than a bit of perceived job security?

We shouldn’t cross-train people in unrelated fields. These two jobs are not complementary. Being a good fire fighter does not help you to be a better medic and being a good medic does not help you to be a better fire fighter.

I am not trying to bash fire fighters.

If my home is on fire, I want fire fighters to respond to put it out. I do not want somebody cross-trained in other unrelated jobs. My life, my child’s life, my neighbors’ lives may be on the line.

If there is a medical emergency affecting me, my child, or anyone else I care about, I want a medic to respond to provide medical care. I do not want somebody cross-trained in other unrelated jobs. My life, my child’s life, the lives of the people I care about may be on the line.

Cross-training is a way for taxing entities to save money. It is similar to Walmart putting pressure on suppliers to produce products more cheaply. Eventually the production will be so cheap that it is not worth the cost savings.

The problem is requiring that people be trained for roles that are not compatible. Fighting fire and providing medical care are not connected, except by the lights and sirens.

“The large number of medics needed to meet the “everyone is a medic” staffing criteria, seems to encourage those, who should be providing oversight, to overlook patient care instead of overseeing patient care.”

If I’m reading this right, that is a problem with the training program and the preceptors. Or there is someone who should be doing quality control that isn’t. Either way, I don’t see it as the medics fault. They need someone with experience to tell/show them the way it should be done.
The bad medic is a symptom of the disease the higher ups have.

Signed,
30 yrs and counting

In that part of my post you have understood the point I was trying to make.

The cost of providing well trained medics with aggressive medical oversight is more expensive than many wish to consider. ALS on the cheap is a bad idea, but that is the motivation behind cross-training. There are some people who will do well when cross-trained, but I do not believe that this is true of most people. You will end up with many who may be good at one job, but are dangerous at the other.

Do you want to go into a fire with someone who is a bad fire fighter, but the bosses need that person’s medic skills?

Do you want to be cared for by someone who is a bad medic, but the bosses need that person’s fire fighting skills?

If the person is not going to operate in the other role, what is the point of being cross-trained in the other role?

This is not a match made in heaven, except for some who may be very good at both jobs. This is calling out for an annulment, so that the various emergency services can specialize in what they are supposed to be doing.

Administrations pitting fire fighters and medics against each other is just a way to take attention off of the real problem. Doing the job right costs money and requires a focus on the job – not a focus on a couple of different jobs, or a few different jobs.

.

Comments

  1. Pissing off the pyromaniacs again I see ;)To the 30 yr FF:I am not sure what the logical rationale is behind believing it is a good idea to combine job titles a la cross-training. Just because dialing the same phone number (wakes-up) activates people in emergency services, it doesn’t necessarily follow that all responders to all emergencies be trained equally. Police are similarly summoned by the same three digits, why aren’t there police officer/firefighters? The answer, and incidentally the point I think RM is trying to make here, is that each job is unique and requires its own skill-set. Dilution of focus is a sure-fire (no pun intended) way to decrease the proficiency at any particular skill. You wouldn’t go to a Psychiatrist for your case of Chlamydia (unless of course your latent hatred for your mother caused you to engage in risky sexual behaviors…but I digress)you would see your primary care doctor- both are physicians and both have the training (in theory) to deal with your problem, but one is infinitely more practiced at it than the other. Another quick example and I will take my 98 cents change and go home.SWAT is, as I am sure you know, a specialized division of the police department. There is a lot of down time- fortunately they generally do not handle multiple calls every single day. This is offset by a very rigorous training schedule that involves constant honing of their skills, so when needed they will be able to execute with the greatest effectiveness and safety. Would you suggest that in an effort to save some money a given municipality cross train SWAT members to say, write parking tickets during their “down time”? Clearly not a capital idea!

  2. I love these conversations, because, in truth, I agree with them. I am a Paramedic-Firefighter. However, I am not a firefighter because I am a paramedic, nor am I a paramedic because I’m a firefighter.My career department is a BLS fire department that utilizes a local private with [intercept vehicles, fly-cars].My OTHER full-time job is as a Paramedic. This coincidentally happens to be with the private that handles the intercepts.Firefighters as a whole, do not necessarily make good paramedics. Paramedics, as a whole, do not necessarily make good firefighters. Some do.Departments that FORCE their FFs to become Medics, or Departments that only hire Medics create resentment, and a shitty scenario for most involved.This Paramedic-Firefighter is one of the exceptions. I love both, and I’m pretty good at both. I also make a mean mango-habanero salsa.

  3. P.S.: Right now I am neither. As explained previously, I am a paper-work pushing POG for the next 6 or so months.

  4. ParaCynic,I do not deny that there are peopled who can excel at two distinctly different jobs. I know some who are excellent at three or more unrelated jobs. As you state – this is unusual and not something to be expected on any large scale.

  5. Vince, There is one department that does have cross-trained PD/FD. Sunnyvale, CA. They claim to be happy with this. This cross-training has been in place for a couple of decades. I suspect that they get a lot of applicants from people who are strongly motivated to perform both jobs.

  6. RM, thanks for the reply. It seems though that you are clueless when it comes to firefighting. That’s OK, I’m ignorant of what it takes to be an air traffic controller. “This FF/EMT-P idea is bad fire fighting and bad medicine. Having fire fighters make medical decisions is as bad as having medics make fire fighting decisions.” I’m sorry, but I disagree to the point that I think you are flat out wrong.”Bad fire fighting” because I have a medic patch on right shoulder? WTF? How hard do you think fighting a fire is? It’s an ass kicker physically, but basically you put the wet stuff on the red stuff. It’s not a severe brain drain. Sure, there is ventilation, utilities, salvage, don’t eat the hazardous materials, etc., but once you learn it, you know it. Vince and you act like if I learn a new fire fighting technique, I’m going to forget the landmarks for a subclavian. “Oops, sorry for the pneumo mister, we just got a new saw and now I’m brain dead.” You didn’t forget how to drive just because you learned to read a 12 lead EKG did you? It’s kinda like that. “Having a person become a medic, because the person is already in the neighborhood performing another job, is a bad staffing decision.” What if that person WANTS to be a medic?? I’ve actually seen it happen. To me.No one is EVER, EVER ‘forced’ to be a medic around here. When you try to get on the job, you know up front that you need to be an EMT-Basic. (And if thats all you want to be that’s OK) It hasn’t scared anyone off. Every test for the last 20 years or so has had over 3000 applicants for about 75-100 positions.Taking the fire truck to EMS calls is taxing on the truck. On that I will agree. The upside is, if I go down in a fire, my buddies don’t have to call anyone in to save my ass – they’re already there. Vince said: “it doesn’t necessarily follow that all responders to all emergencies be trained equally”They aren’t. Some are basic, some are medics and some are flight nurses if you land a helo. “why aren’t there police officer/firefighters”. There used to be in my city. The problem is, during the patient interview, if someone tells you that they have some coke on board, (and more in their pocket), that is protected under Dr – patient confidentiality. The medic is working under a Docs license.(And now you know how to get the medics documentation thrown out of your DUI trial. You’re welcome)A cop is supposed to pursue the drug use. The fire medic has better things to do right then. “Would you suggest that in an effort to save some money a given municipality cross train SWAT members to say, write parking tickets during their “down time”? I wouldn’t but I’m not a cop or a city administrator. Some small rural towns do just that though. They don’t have the revenue to do it any other way and can’t wait for 45 min. to 2 hours for the County Mounties to show up. I do both jobs and do both of them damn well, thank you very much. Paracynic and I can’t possibly be the only ones.Stay safe, 30 yr FF/Medic(sorry for the freaking book)

  7. Sir…you are my hero. This post sums the inner workings of my heart and mind for the past year and a half. I work in a system that not only has FF-Medics, but REQUIRES them to be notified of ANY emergency medical call in the city.While they are, in general, great people and better firefighters, as a whole their medical skills are lacking. The medics aren’t terrible as a whole, but there are several merchant medics of death who continue to practice their deadly art. The EMTs are only EMTs because it’s required, and worse EMTs you have never seen.

  8. Anonymous said…”How hard do you think fighting a fire is? It’s an ass kicker physically, but basically you put the wet stuff on the red stuff. It’s not a severe brain drain.” And you were saying that I was critical of fire fighters. :-)Then you might make the case that there is not a good reason the top management positions should be dominated by fire fighter only personnel. That medics would be welcomed as chiefs in fire departments. I think you know that there would not be a warm welcome of medics as chiefs.The scene management is something that can lead to injuries and loss of life if handled poorly. The understanding of teamwork on a fire ground. The familiarity with the strengths of one’s coworkers.These are important and are not generally understood by government agencies.”Vince and you act like if I learn a new fire fighting technique, I’m going to forget the landmarks for a subclavian. ‘Oops, sorry for the pneumo mister, we just got a new saw and now I’m brain dead.'”No, there are enough poor providers in both services. We do not need people to have more requirements for continuing education/training, when the average provider does not do a good job of maintaining/improving skills as it is.Subclavian lines? Why? Water saves lives in fires, but rarely in a patient’s veins. You put the wet stuff IN the red stuff. “‘Having a person become a medic, because the person is already in the neighborhood performing another job, is a bad staffing decision.'””What if that person WANTS to be a medic?? I’ve actually seen it happen. To me.”And if you read my comments to ParaCynic, you will see that I accept that there are people who are unusual in being competent at two unrelated jobs. My congratulations to you. This is exceptional. The people imitating you, but lacking your abilities, may do a lot of damage to patients and coworkers.What if the person wants to combine two other unrelated jobs at one employer, should we set the system up to satisfy them, or set the system up to protect patients? If I want to be a helicopter pilot and want to be a flight nurse, should cross-train everyone so that I can have my dream job? I had a boss with this desire. He was a good boss. He did not get his wish.”No one is EVER, EVER ‘forced’ to be a medic around here.”Nobody is ever forced to borrow money from loan sharks, either. Many still seem to make this mistake. There are many ways of coercing cooperation from someone.In some places, if you want to be a fire fighter, you’d better want to be a medic – or pretend that you do, because it is the best way for you to get on the department. 7 years later you can demote to a real fire fighter job.”When you try to get on the job, you know up front that you need to be an EMT-Basic. (And if thats all you want to be that’s OK) It hasn’t scared anyone off. Every test for the last 20 years or so has had over 3000 applicants for about 75-100 positions.”This coercion has not scared anyone off? How do you know?Many people will put up with a lot to become a fire fighter. Kids dream of this job. That does not mean that it is not coercion.”Taking the fire truck to EMS calls is taxing on the truck. On that I will agree. The upside is, if I go down in a fire, my buddies don’t have to call anyone in to save my ass – they’re already there.”If you take an engine to an EMS call, your buddies will be with you on a fire scene?If you take a utility truck to EMS calls and rendez-vous with the fire apparatus at the fire and have automatic dispatch of medics to all working fires, the result should be better. “I do both jobs and do both of them damn well, thank you very much. Paracynic and I can’t possibly be the only ones.”I did not claim that you are the only ones, but I do claim that you are not at all typical. Stay safe, 30 yr FF/Medic (sorry for the freaking book)No problems with the book. That is one of the reasons I started blogging. You might want to blog yourself. There is not enough reasoned debate on this topic. Too many times one side, or both, become offended and it becomes personal, rather than about the merits of the debate.

  9. Witness,That is one of the problems with the cross-trained provider. It is difficult for almost everyone to be competent at both jobs. To excel at one job is uncommon. To excel at both jobs is much more rare.

  10. “And you were saying that I was critical of fire fighters. :-)”Ha!! Touche. I should show this to my North Shift Commander. “Subclavian lines? Why? Water saves lives in fires, but rarely in a patient’s veins. You put the wet stuff IN the red stuff.”You lost me on this one. A trauma pt needs some kind of blood pressure to make it to surgery. The IV is may not be first on the list of things important, but is is on the list. If the limbs are busted up, burned or missing and there isn’t a peripheral IV site handy, central lines work just dandy. IO’s with a pressure infuser just don’t give decent volume in my experience. Don’t ‘stay and play’ but enroute to 1 of our 5 trauma centers get done what needs to be done. Even with 5 centers, I’ve had transport times over 40 min. Urban sprawl at its best.”If I want to be a helicopter pilot and want to be a flight nurse, should cross-train everyone so that I can have my dream job?”Get your nursing license and your pilots license. Why would you train everyone? Your employer doesn’t have anything to do with it unless you want them to pay for it. Once you have the license you want, get the job you want. :)”If you take a utility truck to EMS calls and rendez-vous with the fire apparatus at the fire and have automatic dispatch of medics to all working fires, the result should be better.”We do have automatic dispatch of medics. They’re on every engine.I shudder at the thought of meeting the fire truck on the scene of a working fire. If the truck gets there first and the homeowner sees nothing being done because there is no crew, now what? If the crew gets there first, nothing is getting done because they don’t have any fire fighting equipment. I wouldn’t want to have to explain that one to the news crews or defend the video that will show up on YouTube. Witness noted: “The medics aren’t terrible as a whole, but there are several merchant medics of death who continue to practice their deadly art.”There are some turds floating in every punch bowl. (why I drink beer) If you see a turd, make whoever is in charge of EMS or training do their job and cleanse their mortal souls. We have had guys given the choice of dropping their patch or going through another medic training course from day one to graduation. Question… What are you guys seeing in the new hires quality wise?A disturbing trend I see is a lot of youngsters (say 19-24) haven’t had a real job yet. They’ve been in school, lived with Mom & Dad and now they get hired here. Some take to hard work and long hours like a duck to water because they have been blessed with parents that showed them what a work ethic was. A small but very visible minority have the attitude of “hey, I’d rather be…you know…like, at the lake on my boat.”By all means, take your boat to the lake. Maybe it will sink and backflush the gene pool of your DNA!Stay safe,30 yr

  11. 30 yr:I concede that learning another skill certainly doesn’t supplant a preciously learned one. But there is something to be said for practice. If firefighting is as simple as “putting the wet stuff on the red stuff”, you would have to agree that constant training and practice will make the firefighters safer and more effective. The same is true of being a paramedic. It is slightly more of a cerebral activity but obviously not impossible to learn. However, there is a marked difference in meeting the minimum requirements to wear a patch, and being the type of provider that is knowledgeable, skillful, experienced and essentially someone you would want to care for a loved one. The point is: while yes, it is possible for one to be a true Renaissance Rescue Randy, most providers will benefit from the singularity of focus. One of the problems that RM mentions is: in many systems, being a paramedic is used as a “back-door” to attain the “dream” firefighter job. I personally know at least half a dozen who became paramedics for this explicit reason. As you can imagine, entering into a field that you are ambivalent about- at best, may not lead to the best job performance. Unfortunately, in EMS, poor performance leads not only to lower pay raises, but impacts patients’ lives.If a member of my family required EMS, I certainly would chose the full-time professional paramedic over the firefighter-paramedic-locksmith-taxidermist-and part time DJ. This may or may not hold true in firefighting, but at least in the medical arena, specialization lends itself to a high proficiency of care. This model is well established among physicians. It is not a stretch to make the assumption that in any public service-emergency responder role the keys to success are initial training, experience, and continued training. Cross training negatively impacts these last 2 areas.

  12. “No wonder Ambulance Driver links you. He seems to dislike fire medics also.”Heh. Right on, 30.I woke up this morning with a mad-on for hosemonkeys, just like I have for every other day of my nearly forty years. Can’t stand those fire medics.That fire medic who taught me most of my initial paramedic education, man I hated his guts. In fact, every time I had dinner at his house, or invited him to mine, it was all I could do to keep from barfing in disgust.Those fire medics I hunt, fish and socialize with?Pure Sun Tzu, baby: Keep your friends close, and your enemies closer.All those protocols I’ve written, classes I’ve taught, and fire medics I’ve trained for a few dozen fire departments over the years…I was just being masochistic.Yep, nothing spells disdain for fire medics like training a bunch of them and perpetuating the breed…I point out the disparity in skill sets between medics and firefighters, and honestly question whether the two are a good fit, and suddenly I’m a hater.Usually, you have to enter politics to have your words so radically distorted.

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