The Institute of Medicine's Committee on the Future of Emergency Care in the United States Health System was convened in 2003 to examine the state of emergency care in the United States, create a vision for the future of emergency care and make recommendations to help the nation achieve that vision. Their findings and recommendations were presented in three reports released in mid-2006, one of which is the critical Emergency Medical Services: At the Crossroads.

As momentum begins to build on a response to the report, many agencies, trade groups, labor, and a host of individuals and stakeholders in EMS struggle with how to find a unified voice. To date, all that has emerged from the generalities of the report has been a whirlwind of emotional proclamations, summits and seminars. It's as if EMS as a profession has realized — and suffers from the shock of realizing — that despite all of the problems identified in 1966, again in 1985 and yet again in 2006, we still have done nothing about them. Much like a disease that has to be rationalized, it's as if a cancer has returned and requires another course of chemotherapy. The unpleasant side effects and the potential futility of the whole episode can take a tremendous toll.

Questions still exist about the efficacy and value of much of what EMS does. Yet still fire departments push forward with ALS on every vehicle, despite what is being identified as lack of skill proficiency, lack of focus on medicine, and lack of cost effectiveness versus the opportunity to fund other EMS activities such as transport or alternative response vehicles.

It's important to note that the fire service and the medical authority are on a collision course. Over the last decade the International Association of Fire Fighters has motivated the fire service to enter into the ALS market with many of those agencies wading into the transport industry. The fire service now provides a major role in the majority of EMS systems and is the lead agency in most of the major metropolitan areas. Little science exists that identifies this as the most beneficial model for the best patient outcomes.

It's as if we have handed the keys to a sports car to a teenager driver, then are surprised to find an extraordinary number of miles have been racked up. When that first ticket arrives and it comes time to stand before the judge and be held accountable, we will find the cost puts us back into a vehicle that is much less attractive. Insurance, fines and time lost can be equated to what we will see from risk management, regulatory agencies and reduced staffing.

The point here is we have failed to be good stewards of the opportunity afforded to fire-based EMS. It is simply not good enough to deploy paramedics or become the primary EMS provider without ensuring that the level of service focuses on the medicine, outcomes and cost effectiveness. Even with all of the resources and the can-do attitude possessed in most fire service men and women, the same problems persist that existed in 1985 when private ambulance services reigned, and in 1966 when the local tow truck driver or funeral home operator provided the service.

The National Highway Safety Traffic Administration has moved forward with everything that the stakeholders have designed or requested. Money has been available from a variety of sources for proven services, and even more funds can be found for evidence-based practice and techniques or medicine that makes of difference. Will it take another bloated bureaucracy to solve the problem? Not necessarily, but fire-based EMS must begin to justify its effectiveness in terms of what's best for the patient to have a positive outcome.

The IOM's report on EMS provides the ammunition for just such a lead agency for EMS. The fact that the same problems exist today as did 40 years ago should tell us that a key to the successful delivery of EMS still has yet to be found … or at least not been proven. Supporting the IOM report is the continued failure of the fire service to make our case scientifically. At the American College of Emergency Physicians Scientific Assembly in New Orleans, fewer than 10 of more than 300 presentations were on EMS-related topics. A series of poster presentations was the EMS highlight of the conference. ACEP's EMS committee, while well-attended, still struggles to find a way to assert itself or create a program to provide real leadership to fire-based EMS.

The IOM report identifies the need for a board certification in EMS; what body of knowledge is needed or should be included has yet to be defined by experts in EMS operations, quality improvement, and issues of medical control and delegated practice. As the problems with EMS persist, the physician community, state EMS officials and federal agencies that have a vested interest in EMS will look for another model or design to correct the problems identified in the IOM report. That system may not necessarily be the fire department.

Virtually no valid scientific research exists on any aspects of EMS system designs in the United States. This forces researchers and authors of white papers to focus on what pseudo-science is being generated by those trying to make an argument of what's best for the patient. Repeated calls have come from fire-based EMS leaders for them to embrace and engage in EMS-related research and to generate some valid data about what we do. Yet still little research exists on fire-based EMS performance with respect to patient outcomes and identification of what might result in better outcomes for patients, based on who is delivering the service.

If you're involved with fire-based EMS, you should partner with a university, train your own people or simply start small with something you know works but hasn't been proved scientifically. For example, how many fire-based EMS units provide glucose or D50 to a diabetic and yet don't transport that patient to the hospital? How much does that treatment save the HMO, the patient and the health care system? Does treatment of insulin-dependent diabetics ever require further treatment, or does the ability to self-regulate insulin and blood sugar allow the patient to continue in his or her routine after the fire department response? Is Glucagon more cost-effective than D50 in most diabetics because it reduces the need for an intravenous solution and the possibility of an infection at the site of the intravenous line?

The responsibility for EMS research is as important as fire prevention or annual hose and ladder testing. You have to prove that it's safe, that it can be relied on when needed and that it will meet the standards set forth by the profession. Read the Institute of Medicine's report, Emergency Medical Services: At a Crossroads and discuss it with your EMS chiefs, field supervisors, medical directors and quality improvement staff. Start submitting to speak on fire-based EMS at national conferences, and not at the venues mainly attended by fire-based EMS providers. Present your ideas and information to the physician's groups, state and federal officials, and city and county managers. While we may be the 800-pound gorilla in the room at the moment, soon someone will figure out it takes a lot less bananas to feed a smarter and more-easily-taken-care-of chimpanzee.

Bruce Evans is the fire science program coordinator at the Community College of Southern Nevada as well as an adjunct faculty member for the National Fire Academy's EMS and injury prevention courses. A captain at the Henderson (Nev.) Fire Department, he has an associate's degree in fire management and a master's degree in public administration.