When the vehicle you're driving begins drifting to the left or right, you may suspect a problem with your front-end alignment. You also may find it takes more effort to keep on track. In the same way, several obstacles now appear on the road traveled by EMS that may hinder the departmental mission. Many fire departments are having their budgets scrutinized, and fire chiefs may be scrambling to determine if their operations are traveling the right route to successful service delivery.

The fire department operating budget is the lifeblood of the organization. Maintaining equipment and human resources for emergency response is an expensive proposition, and in the face of NFPA 1710 it will become more costly. The cost of long-term capital expenses to city government and the funds necessary to maintain the physical plant constantly catch the eye of city management. Can they be confident that those monies really will make that big of a difference when saving lives?

I'm confident that it does make a difference. For example, in Frank Capra's masterpiece It's A Wonderful Life, what if George Bailey's injury had never occurred? What if a person never sustained an injury from a fall, or a child in a bicycle accident didn't receive an injury because of a helmet and protective pads? If a fire chief were to apply a cost-benefit analysis of reducing the probability of having the injury occur versus increasing the capacity in an expensive emergency response system, injury prevention would make considerable sense financially.

EMS systems need to establish a comprehensive relationship with the fire prevention resources in their department or community. The relationship needs to be redefined to encompass fire and injury prevention by employing an epidemiological model. Some fire service leaders propose that for every dollar spent in operations, a dollar should be spent in prevention activities. Modern fire departments are embracing the idea of staffing a full-time public educator. I suggest that half of the job description include injury-prevention activities outside of fire-related scenarios.

Injury prevention activities potentially could be assigned to the operation side of the house. For example, the concept of empowerment at the station level has become well-accepted management practice. Consider asking company officers to conduct an injury-prevention needs assessment for their first-due district. Companies covering a retirement village may see the need for fall prevention, whereas companies covering high-end residential areas may make drowning prevention a priority.

Information from your department's EMS database and Centers for Disease Control and Prevention statistics will provide rough estimates on injuries in the community. If a fire company identifies an injury prevention problem, they should have a major role in developing the solution. The National Fire Academy's efforts on public education are now being directed at high-risk groups identified by National Fire Incident Reporting System data and the National Fire Protection Association. Those groups are identified as children and the elderly in low socioeconomic areas. The NFA and NFPA have prepared curriculum to educate the fire service on how to work with high-risk populations.

For example, if a fire company spent a few minutes in the afternoon conducting a fall prevention campaign in their first-due district, the need to be summoned for an elderly person who has fallen in the middle of the night might not be necessary. Medicare statistics show that 25% of hip fracture patients will die within one year and 40% will require nursing home care. Surgically repairing a fractured hip is an enormous expense for the health care system, with costs averaging $37,000. The extended cost for rehab and family medical leave accelerates the cost.

As we start a new budget-planning cycle, it may be time to consider implementing an injury prevention coordinator to the fire prevention or EMS divisions of your department. Departments with smaller budgets should consider hiring part-time staff to execute the program. For example, think about employing a schoolteacher over the summer months to encourage the use of helmets and safety equipment. The financial outlay may be considerably less than one closed-head injury to a child in your community. Often health maintenance or community organizations grant monies for such activities, and this approach may lessen the financial impact to public safety organizations.

Another option may be to implement a college internship program under the supervision of the EMS or fire prevention division. Internships can be paid or non-paid and usually provide a practical experience for the intern. University or college health education programs have students fully prepared to develop injury prevention campaigns. Interns will need to be supervised and evaluated on their performance in exchange for college credit for the work. Providing an internship serves as an excellent recruiting tool, and an extremely successful program may help justify a full-time position.

To locate programs that have internships available, contact your local higher-education institutions. Community health students often are found in the education college of most universities conducting teacher training. Injury prevention also has become popular in nursing schools and health care administration programs. The American Association of Health Education and the University of California at San Diego operate a Web site with information related to health education projects.

The resources to accomplish injury prevention public education can be put into place through the use of collaborative agreements and partnerships. It's common to see fire departments and the local Safe Kids coalition teaming up to do child safety seat checks. If your local trauma center is rated as a Level One facility, it's required to provide injury prevention education and outreach programs. The trauma care coordinator also may be a valuable partner in the development of an injury prevention program. Through a collaborative approach, the R Adams Cowley Shock Trauma Center at Johns Hopkins University operates an injury prevention program through the National Study Center for Trauma with EMS and fire departments in Maryland.

The use of local fire companies has advantages and disadvantages. Law enforcement's use of community policing has shown that placing officers in a neighborhood in direct contact with citizens on a day-to-day basis has reduced crime. We have an opportunity to reassert ourselves in the community and engage in activities designed to reduce injuries. The disadvantage is that resources must be available for service calls during prevention activities. One model that may prove useful is the conducting of injury-prevention activities in combination with fire inspections and school drills. A safety inspection also could be conducted on a prearranged schedule.

Public education at this level presents a strategic realignment of the department's mission. To ensure the cost effectiveness of your activities, the EMS division needs to be able to tie its call volume data to the Uniform Minimum Data set. For example, Mrs. Smith's hip fracture may be coded as a 200 in the EMS data set. The number 200 would also be the same code the hospital puts into the records system for insurance purposes. The surgeon and rehabilitation centers also would document Mrs. Smith's hip injury as a 200. When Mrs. Smith's HMO receives all of her bills, it will tally the total cost for that injury.

The HMOS employ disease management coordinators for a variety of maladies, such as asthma and diabetes. The disease management coordinate for geriatrics may identify several cases similar to Mrs. Smith's that occurred in a certain ZIP code of the HMO's service area. It may be your local fire department that services that ZIP code area, and the HMO may see it as cost effective to fund a fall prevention campaign through the fire service in that area. Providing printed materials, wages and public service announcements would be more cost effective than funding one surgical repair of a hip fracture.

While this example deals with fall prevention, you can determine exactly what the majority of injuries and/or fatalities in your area are by accessing the CDC's Web-based Injury Statistics Query and Reporting System. The WISQARS system collects information from death certificates for each state by age and type. WISQARS also lists the top 10 causes of death for each age category and presents certain sub-categories by mechanism or disease process. The colored categories on the database are further subcategorized to identify the cause of death under certain classifications. For example, the blue unintentional injuries and adverse effects box on the fatality chart can be double-clicked to show a breakdown of categories ranging from motor vehicles to poisoning.

A second database is available to query non-fatal injuries per 100,000 people. The 1999 data collection is just being completed, and the site has a tutorial to aid in the navigation of collecting the statistics.

As the economy slows and budgets tighten or are diverted to security issues, it's an appropriate time to reassess organizational priorities. A realignment of the organizational goals may require a shift to injury prevention to compensate for restricted operational expenses. If you're convening a strategic planning meeting in the new year and meeting with city/county management, it may be an opportune time to align your operation and focus on an injury/death prevention program.

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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 a master's degree in public administration from the University of Nevada and an associate's degree in fire management.

For further information

CDC fall prevention programs
<www.cdc.gov/ncipc/falls/default.htm>

CDC WISQARS data
<www.cdc.gov/ncipc/wisqars/default.htm>

Injuryprevention.org
<www.injuryprevention.org>

American Trauma Society
<www.amtrauma.org/prevent/troo.cfm>

American College of Emergency Physicians
<www.acep.org>

University of Maryland Trauma and Emergency Medical Services
<www.umm.edu/shocktrauma/trauma_nsc.html>

American Association for Health Education
<www.aahperd.org/aahe/aahe_main.html>

NFPA's program on fall prevention
<www.nfpa.org/catalog/product.asp?pid=br%2D36a&src=nfpa&ms>