BY BILL ADAMS
Alan Petrillo’s article, “More Departments Choose Smaller Fire Apparatus to Handle Typical Runs” (December 2017) showcased some of the smaller apparatus fire departments purchase “to handle emergency medical services (EMS) runs and nonstructural fire calls to lighten the load that’s been placed on first-due engine and truck companies.” It is a topic worthy of further discussion, particularly when addressing the impact providing EMS has on the fire service.
Disclaimer: There is no intent to disparage the work performed by fire-department-based EMS providers. They have rightfully earned the respect and admiration for the services provided—likewise for those in the private EMS sector and the independent volunteer ambulance and rescue squads.
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I am not a proponent of volunteer or career fire departments providing EMS, believing it should be delivered by career medical professionals as their primary vocation. The cost of providing a separate career “EMS-only” service is probably beyond the financial capabilities of most governmental entities. Hence, the obvious service provider is the fire service.
In some instances, providing EMS can be detrimental to the goodwill, morale, and discipline of the fire service. That could be troubling. Equally unsettling is the possibility that providing EMS may inadvertently decrease the fireground capabilities of some fire departments. Frightening is when the powers that be refuse to acknowledge it.
Fire prevention programs, community education curricula, alarm systems, smoke detectors, and automatic fire sprinkler systems have drastically cut down the number of actual “fire” responses. However, the general public will forever crash their automobiles, have on-the-job and at-home accidents, become sick or get very old and die, or fall and get hurt and require medical attention—although not all are actual life-threatening emergencies. Usually a fire station is but a few miles away, and the public knows when they “pull the hook,” help is just around the corner.
1 One of Tucson’s Alpha Trucks, a pickup truck staffed by an EMT and a paramedic designed to take the heavy EMS work load off of suppression companies. These rigs have short wheelbases with two-door extended cabs and short beds with caps. [Photo courtesy of the Tucson (AZ) Fire Department.]
Some in the career sector look at EMS as a means of ensuring job security. Some in the volunteer sector reluctantly accept EMS as part of their community service. Sometimes both can regret assuming the responsibility—not all, but some.
In volunteer organizations with staffing issues, especially during weekdays, an EMS run may tie up a department’s available (and qualified) firefighters, possibly temporarily putting it out of the fire suppression business. The increase in EMS responses in that sector has forced many volunteer departments to either discontinue providing the service or hire part-time or full-time personnel to provide it.
The method of staffing an EMS response on the career side can be a contentious issue for the very small career and combination departments with limited resources. Some departments may cross-staff a fire suppression company with an EMS response vehicle. Cross-staffing in this instance means one or the other responds—it’s either the EMS rig or the fire truck. Others may dispatch the nearest suppression apparatus to EMS runs—regardless of the size, cost, or functional importance of the apparatus.
2, 3 Typical chief’s buggies that could be outfitted to be job-specific as EMS squads. (Photos 2-3 courtesy of Miles McLaughlin, Empire Emergency Equipment.)
In both instances, the suppression apparatus is out of service for the duration of the EMS incident. If the fire department transports with the EMS vehicle, the out-of-service time can be extraordinary. Cross-staffing an ambulance with a department’s only ladder truck may not be a wise decision—neither is taking half (or most) of the crew of a department’s only staffed engine company. However, the latter may be the lesser of two poor choices. Consequently, the smaller career departments can also find their suppression capabilities diminished when providing EMS.
A concern for some career and volunteer departments is that EMS training requirements can be very rigorous and time-consuming. The higher level of expertise required, the longer and more intense the training that is required. Annual refreshers may be obligatory. Volunteers may not have the time. In some departments, a certain level of EMS training may be a mandatory requirement for employment or membership. EMS responses themselves can be physically and emotionally trying for first responders. They can easily burn out from the stress. While providing EMS is a noble cause, it may not be physically possible for every member.
A major concern is the financial cost to provide EMS. Because the labor to provide the service can be either career or volunteer, it is not addressed in depth here. However, it should never be discounted on the career side because labor is the most expensive factor. Fire department personnel and police always seem to be targets for cutbacks with cash-strapped and vote-conscious municipal officials. “Do more with less” is the mantra of some politicos when addressing personnel. The next obvious place to reduce cost is with the apparatus itself.
EMERGENCY FIRST-AID, EMS, AND “MICKEY MOUSE” CALLS
Years ago, fire departments started providing EMS by establishing first-aid or emergency squads. Merely providing first aid has morphed into a highly sophisticated calling requiring specialized training.
For the remaining discussion, the presumption is regardless of the entity doing the transporting, the fire department is providing EMS prior to the arrival of the transport vehicle. Or, as a practice, the fire department responds to every EMS call.
Fire departments can wear out their full-sized suppression apparatus by dispatching them to every request for EMS and, in particular, to those I categorize as “Mickey Mouse” calls. They could include a stubbed toe, a stomachache, a headache, or a call to a familiar address for a known “frequent flyer” who is just looking for a free ride to the hospital rather than paying for a taxi cab.
There is an expectation that 911 operators have the training and expertise to categorize nonlife-threatening emergencies. It is no different than determining a noncritical fire call such as a vehicle lock-out or a chirping carbon monoxide detector. Caution: An expectation may not always reflect an actuality or a reality.
THE TUCSON (AZ) FIRE DEPARTMENT
To save conjuring up particulars, reference is made to an almost five-year-old online City of Tucson, Arizona, report describing its fire department EMS (https://bit.ly/2swBkr0). I interpret the report as showing the Tucson Fire Department (TFD) is a very EMS-oriented organization that is supported by the city.
An interesting paragraph from the report is: “In an effort to save money and free up fire crews for more serious calls, the TFD started an Alpha Truck program in 2007. Pick-up trucks, manned by two emergency medical technicians (EMTs), were purchased to respond to less-serious medical situations. Besides medical care, the EMTs had special training to help people get information about social services assistance. The underlying goal of this continuing successful program is to provide resources to help repeat 911 callers connect with senior programs, homeless shelters, outpatient clinics, and other social services that will keep them from overusing ambulances and emergency rooms for non-emergency calls.”
My simplistic description for Tucson’s Alpha Truck is an “EMS Squad.” It or a similar vehicle may be beneficial for many career and volunteer fire departments in addressing EMS. There is some interesting data that could be used to justify the use of the Alpha Truck program, also found online in the fire department’s 2017 annual report (https://bit.ly/2PVCT9M). It states that 90 percent of the fire department’s approximately 92,000 2017 runs were requests for EMS.
The “Emergency Vehicle Management” section of the report shows the average mileage on the city’s pumpers was 117,632 miles, ladder trucks was 90,253 miles, and the medical fleet averaged 157,054 miles. The department tries to replace apparatus with 100,000 to 125,000 miles or between 12 and 14 years of age. Of the almost 82,000 EMS runs, about 52 percent required an advanced life support (ALS) response and about 48 percent a basic life support (BLS) response. Interestingly, under the heading “Patient Conditions Found,” the most common condition found was categorized as “sickness”—13,000 times. Sending a full-sized suppression apparatus to a sickness call could be a misuse of resources.
Petrillo interviewed Tucson Chief Jim Critchley, who stated a paramedic and EMT staff the Alpha Trucks. They have their turnouts and self-contained breathing apparatus (SCBA) in the back under the cap and some minor fire equipment such as irons. They primarily respond to EMS calls but are available to be called to fire scenes if not actively engaged in an EMS run.
ARE EMS SQUADS VIABLE FOR ALL DEPARTMENTS?
Not every community is as large as or has the resources of Tucson. Smaller communities may not be able to afford a two-person response vehicle where the sole or primary function is responding to EMS calls. It is likely both volunteer and career firefighters share firefighting and EMS duties. And, it is more than likely they use a single rig to perform them.
EMT is used to describe just one level of the training expected of a first responder providing EMS. What is the most efficient way for the fire department get two EMTs from the fire station to the incident? Sending a $1 million aerial ladder to a sickness call may be a misapplication of resources. Likewise, so is having a half-million-dollar pumper carting two EMTs to a nonlife-threatening EMS call such as a stubbed toe. Common sense should be a factor in determining an efficient use of resources.
An EMS squad cross-staffed by personnel from a suppression company, staffed by a couple members of a suppression company, or as the second piece of a two-piece suppression company may be a reasonable solution. If the intent is to deliver two EMTs with basic EMS equipment to an incident to either assist an ambulance crew or provide EMS prior to an ambulance’s arrival, an EMS squad vehicle could be similar to a chief’s buggy whether it be an SUV-sized vehicle or a pickup truck.
There are a couple of considerations to be addressed prior to implementing the concept. The first is to squash the propensity for fire departments to overload their apparatus. Regardless if the function is solely to provide medical care prior to the arrival of transport, if there is room on the rig, most fire departments will find something to load onto it. They’ll find room for a couple more extinguishers, a toolbox or two, or maybe even a battery-powered auto extrication tool. They’ll be strapping backboards and Stokes baskets to the roof and maybe even an attic ladder. Only medical equipment should be carried.
One caveat could be carrying personal protective equipment if the crew is also to perform fire suppression duties. Going overboard with custom-built slide-out equipment trays, tool boards, and equipment mounts may lessen the financial advantage of a simple vehicle to transport two first responders and basic life support equipment to an incident scene. Bear in mind the trend to keep possibly contaminated turnout gear and SCBA out of crew cabs. That should be taken into consideration.
The next factor is how to staff an EMS Squad. If a career suppression company has three or four personnel assigned, it may be possible to send the two EMTs out on the squad and keep the balance back to minimally staff the suppression rig. If a back-to-back call comes in while the EMS Squad is tied up, at the least a minimally staffed suppression apparatus can do a size-up and perhaps perform some basic tasks prior to the arrival of the next staffed apparatus. It may be an acceptable alternative to having no apparatus available.
4 Two basic slide-out storage units mounted in the bed of a four-door pickup with a cap. One could be “environmentally sealed” to carry turnout gear, if applicable, while the other could be used for medical equipment. Some slide-out units can be very elaborate. (Photo courtesy of Empire Emergency Equipment.)
The same concept could be followed in the volunteer scenario. If more than two or three people show up for an EMS call, send two out with the EMS squad and keep the rest back with the real fire truck(s).
A cross-staffed EMS squad, or one running as the second piece of a two-piece company, may not be feasible in every situation. In career or combination departments with limited staffing operating from a single station, whatever personnel are on duty in the fire station might be the only people available. In that situation, it might be advantageous to keep them on one rig capable of multiple functions.
Staffing can be more complicated and definitely not guaranteed with volunteers. If people are not available to staff the squad and provide a driver for the suppression apparatus, the concept will not work. Keeping them all together on a multifunction apparatus may be a necessity.
An EMS Squad may have merit regardless if it is a pickup truck with a cap or an SUV-type vehicle. It will only work if it can be staffed without compromising (too much) the fire suppression capabilities of a fire department. A cost-conscious authority having jurisdiction (AHJ) may see merit in running the tires off a $60,000 rig rather than one that costs more than a million; however, a serious study similar to a cost benefit analysis should be done.
An AHJ should determine the actual expense to operate a full-sized suppression apparatus, replacement costs, and the projected total cost of ownership (TCO) with and without using an EMS Squad. Although the EMS Squad concept sounds logical, it may not be financially feasible based on the TCO projections, including the projected number of responses.
The EMS Squad may not be the panacea to the increasing number of EMS calls a fire department may face; however, it is a concept that may be worth investigating—open mindedly.
BILL ADAMS is a member of the Fire Apparatus & Emergency Equipment Editorial Advisory Board, a former fire apparatus salesman, and a past chief of the East Rochester (NY) Fire Department. He has 50 years of experience in the volunteer fire service.