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Flashpoint: Band-Aid solution: The fire/EMS debate

A former colleague of mine, now a deputy chief in western Canada, was the perfect guy to answer a question that was bugging me. I noticed in an annual report of a neighbouring fire department that it had purchased a number of public-access defibrillators (PADs). I wondered if the department had gone with a different strategy than the semi-automated external defibs (SAEDs) most departments use once they commit to providing this level of pre-hospital patient care.

Logically, if a PAD is effective in the hands of an untrained bystander in a bus terminal or hockey rink, it would be at least as effective in the hands of a trained firefighter. In addition, the cost of the equipment and the duration of the training would be less of a drain of the resources of the fire department.

So I asked my friend if some fire departments are putting PADs on their apparatus. He replied “Yes, some are, and it is a huge mistake! They will never get past that into symptom relief and IV maintenance.”

That also made sense. If a fire department had drawn the line of its service at PADs, then it would not likely commit to more advanced equipment and training. But the question has to be asked – what is the appropriate level of EMS that should be delivered by a fire department, given its response times, funding and staffing realities, and what existing EMS resources already serve the community?

Fire fighting in the 21st century is a very complex job, requiring current and complex levels of knowledge and skill in multiple areas: What flow rate is required if the local grocery store is 50 per cent involved in fire? What is the correct foam application for this chemical, and at what percentage? Will I have to call in mutual-aid resources or will I have enough if I run a tanker shuttle from the reservoir? What precautions do I have to observe at this trench rescue?

Adding the demands of EMS to this learning curve may not be realistic. A very good training officer, who has since succumbed to cancer after a decades-long fight, once showed me a draft of a training document on how to insert an oropharyngeal airway. Firefighters were instructed to insert the device into the patient’s mouth facing upwards “until resistance is met at the posterior oropharynx”, before rotating it 180 degrees and completing the insertion. My problem was that “posterior oropharynx”, while absolutely correct, was no more correct than “back of the throat”, which would have been much more easily understood by most firefighters.

There is a balance between keeping it as simple as you can while making it as technically correct as you have to. You can only stuff so much into the human brain. If you have a large enough organization and you can deal with this competency overload by dividing responsibilities into functional areas – a fire/rescue division and an EMS division – then is this really fire-based EMS or two services under one managerial infrastructure?

It turned out that the PADs had been ordered by the fire department on behalf of parks and recreation for installation in community centres. The fire department already had a budget line for defibs so the funds were transferred over.

We sometimes forget that we are part of a larger corporate entity. It will often be the case that the amalgamation of missions between operationally similar departments will result in efficiencies of scale.

The classic Canadian conundrum – “which level of government is responsible” – will rear its ugly head when dealing with provincial and municipal funding and control, but that is why the fire/EMS chiefs get the big bucks – to sort out these problems.

Aside from the tasks we perform, which are inherently unique, there are many support functions that are common to fire and EMS: both train and equip staff; purchase and maintain vehicles; and operate communications and dispatch centres in order to provide emergency and non-emergency service to the public. But the same can be said about the solid waste, water/waste-water, roads or public health departments. How come I don’t remember anyone talking about fire-based waste management?

The bottom line: if a patient can receive fast and appropriate first-responder care, including defibrillation if needed, and be handed off to advanced life support within the established time frames, then why would that patient care what shoulder flashes are worn by the medics? And, if all of this can be accomplished by separate services in a cost-effective manner, then why would the taxpayer care? The model that can most efficiently and consistently deliver excellent, seamless care is the one that should be chosen.

District Chief Peter Sells writes, speaks and consults on fire service management and professional development across North America and internationally. He holds a B.Sc. from the University of Toronto and an MBA from the University of Windsor.  He sits on the advisory councils of the Ontario Fire College and the Institution of Fire Engineers Canada Branch.