On a Tuesday morning in a town served by a volunteer fire department, the dispatcher calls for a response to a possible cardiac arrest. Is the department prepared to meet the community's — and the patient's — expected level of service?

This is a situation that many volunteer and combination fire departments face today. Still others are trying to decide if they even should get into the EMS business. If we do, should we be primary or secondary responders in the community? How far should we go? Should we just render aid or should we transport? Should we provide Basic or Advanced Life Support? What level of certification should we require our members to have? Should we bill, or for that matter can we?

Why do most fire departments go into the EMS business? The answer to that question is simple. Most departments are doing a very successful job of putting themselves out of the fire business through effective use of the three E's of fire prevention: education, enforcement and engineering. This being the case, they are looking for work. Career fire departments must justify their budgets, and that's partially true for combination departments, but volunteer departments are looking for action. All of these departments need to maintain a high level of interest. More runs do that, and EMS certainly provides more runs. This, of course, is in addition to the fact that some communities do not have adequate EMS service.

If a department is thinking about going into the EMS business, it must first decide what level of service it's going to provide. A very honest and in-depth needs and resource analysis must be conducted by the department. Enlisting stakeholders and responsible community members to help with that analysis is essential. Some of the information that must be identified is:

• Level of EMS service currently provided.
• Level of EMS service desired by the community.
• Current and future EMS load in the community.
• Level of service that your department can provide.
• Available equipment that can be used to adequately provide the service.
• Personnel needed to provide the service.
• Time requirements of providing such a service.
• Available financial resources.

The next thing that needs to be done is a little soul-searching: Why does the department really want to go into the EMS business? Let's now consider the factors mentioned above one at a time.

Level of EMS service currently provided

The main thing to consider is when the chips are down, is the community being provided with the necessary mundane and life-saving emergency medical care in a timely fashion? This question can be answered simply by looking at national benchmarks for communities of your size and population.

Level of EMS service desired by the community

Is the community satisfied with current EMS service levels? Are people content with the current response time, from the moment they call for help to the moment help arrives? What level of care is desired, Basic or Advanced Life Support? Are they satisfied with the transportation element of their care, or how they are getting to the hospital and the care they receive on the way?

Current and future EMS load in the community

We are well aware of the fire load in our communities, but EMS load is vitally important to consider as well. What is the average number of EMS-related calls in your community? It doesn't matter how these calls are answered, only the number of requests for EMS services. How often does your community use the services of existing BLS and ALS service providers? Is your community growing? What is the demand placed on EMS services by facilities such as assisted-living complexes, nursing homes, ambulatory surgery clinics, doctor's offices, dialysis clinics and the like? Are there existing contracts between private providers and these facilities that won't place an EMS demand on your department? Are there future plans to bring such facilities into your community? All this directly affects call volume, or in other words EMS load.

Level of service that your department can provide

A decision must be made as to whether the department will be the primary responder, the agency that will be called first by the dispatcher and expected to respond on all EMS related calls, or the secondary responder, the agency that will be called as backup if the primary agency is tied up. It even can be arranged that you would serve as third or fourth responder on the EMS food chain. Will the department provide these services 24/7? Is the department going to transport patients to a receiving facility? Will the department provide first responder, or EMT-Basic or -Paramedic service? What are the current and future EMS mutual aid agreements?

Available equipment that can be used to adequately provide the service

Does the department currently have ambulances and all the required equipment needed to provide the level of service they have chosen to provide? If not, can the department obtain this equipment easily?

Personnel needed to provide the service

Are there enough people in your department based on the service level determined to meet the EMS demands that the department is committing to provide now and in the future? Is the department going to need paid personnel to ensure that the service commitment will be met?

Time requirements of providing such a service

Are department members fully aware of the time commitment involved in providing the determined level of EMS service? This time commitment includes the time involved in responding and completing the calls. It must be fully understood that the average EMS call is much longer then the average fire call, especially if transportation is involved. EMS involves many hours of specialized training that increase as the level of service moves from basic first aid to advanced life support. There also are regulations for recertification that vary from state to state. The certification and recertification requirements are ever-increasing, requiring more and more time to comply.

We all know that time is the biggest enemy of the volunteer fire service, and EMS takes a great deal of time, so it's imperative that before a department ventures into the EMS business, it seriously consults with its members to see that everyone enters into the business with their eyes open. Once a department commits itself to providing EMS, no matter what level, it is crucial that each and every member of the department become part of the team.

Available financial resources

Providing EMS service is a very expensive proposition. The equipment and vehicle costs can be astronomical. A vehicle replacement policy should be established because EMS vehicles take a great deal of wear. Even if the department isn't going to transport patients to receiving facilities, the engines will roll much more frequently. The cost of new equipment and the replacement of heavily used equipment as well as the cost of supplies can be expensive. Billing may or may not be the answer; there are complications to the billing process such as who pays, who collects and many more such considerations. A department certainly should not go into the EMS business as a fund-raiser.

If a department is already in the EMS business, there are few things that are essential for success:

• The community's acceptable level of risk,
• The obligations of leadership and
• Planning.

The community's acceptable level of risk

It is essential to fully understand what level of service that public officials, stakeholders and the community expect from the department. This can only be done with constant communication between the department, public officials and the community. It's not difficult to then determine what the department's report card would look like. A department that is providing EMS can't hide its head in the sand and pretend things are going well if they are not — lives are at stake, not to mention liability concerns.

The obligations of leadership

It's the responsibility of department leadership to accurately report to the authority having jurisdiction whether or not the department is fulfilling the acceptable level of risk. A leader must not necessarily consider it a failure if the department is not meeting that level. Many factors come into play in this area, such as demand simply exceeding supply. Community demographics can easily outgrow the capacity of the department to meet the ever-expanding needs of that community.

A department head cannot allow ego to enter into his or her decision to keep the authority having jurisdiction informed. Accurate and honest reporting is the only way that the affordable level of service in a community can be determined. Remember that once the authority having jurisdiction is clearly informed of a condition, the liability shifts. It's also important to remember to not let volunteer pride get in the way of the level of service provided.

Planning

This is the only way for today's volunteer and combination fire service to survive, especially if they are in the EMS business. The days of running a department one day at a time are long gone. A plan brings that ever-important element of continuity to a department. It's essential that a department have a clear vision of where it will be in five years, a mission statement telling how it will get there, common values that each member subscribes to, and clear goals and objectives that all can appreciate. It's also important to know how the department plan fits with the overall community plan. Alternative delivery systems must be investigated and evaluated as to how they apply to the individual department's current and future needs.

If, as a leader or a valuable member of a volunteer or combination fire department, your pager activates at 10 on a Tuesday morning with the announcement that a person with chest pain needs help, will you be the one providing EMS assistance to that person? If you are, will you be providing the level of service that person expects?

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Chief Mike Chiaramonte is a 35-year member of the Lynbrook (N.Y.) Fire Department and a past chief of the department. He's currently the chief fire inspector, where he is responsible for code enforcement and prevention education. Chiaramonte was a past-chairman and board member of the IAFC Volunteer and Combination Officers Section Board and New York State Director to the IAFC Eastern Division. He's also a National Fire Academy Instructor and an advisor to the National Fallen Firefighters Foundation. Chiaramonte is a state EMT-CC and an instructor at the Nassau County EMS Academy. He has as a bachelor's degree from the University of Houston and a master's degree from Hofstra University, both in communications education.