Last December, the Rand Corp. released a report that started a national debate. The non-profit think tank advocated the creation of a federal agency to oversee emergency medical services in response to the Gilmore Commission's inability to identify exactly what the state of EMS is in the nation. In fact, several credentialed EMS leaders have expressed a lack of cohesiveness in the national EMS efforts. A number of leaders have called for a national EMS administration to elevate EMS to an equivalent standing with fire and law enforcement.

The response among the EMS grass roots has been impressive. It appears that there is significant support from both fire- and non-fire-based EMS providers to move this effort forward, and this has the attention of several key congressional officials. Several of the agencies that have been leaders in changing EMS should ask themselves: What part of the customer service model have we missed? Is it just time to bring it all together?

The National Fire Academy consistently touches large numbers of EMS providers on a regular basis. Several years ago James O. Page, an EMS visionary, called for the NFA to incorporate EMS into its mission statement. However, repeated attempts to raise EMS to a more active role at the NFA weren't given an equal share of attention or budget. In true bureaucratic fashion, the academy stayed within its boundaries and its mission.

This isn't to say EMS is ignored by the National Fire Academy, but its courses, with the exception of Advanced Life Support Response to Hazardous Materials Incidents, focus on department management issues. What's missing are those courses that focus more on the management of clinical practice and research related to EMS delivery. For example, a course on developing EMS training programs or command and control of major EMS operations would go a long way toward helping the fire service strengthen its EMS programs and provide an opportunity to reach out to other EMS groups.

The NFA has always had the opportunity to become the leader for the delivery of such EMS programs because it provides an exceptional educational experience overall. If a more significant attempt was made to provide true equity in its partnerships with all EMS organizations, there could be a major improvement in the nation's emergency medical service. Perhaps when and if funding is allotted for a second classroom building on the campus, EMS would share a home with the National Fire Academy. That combined strength may provide an opportunity to gain the high ground on lobbying efforts away from law enforcement.

Elsewhere in the U.S. Fire Administration, some forward-thinking people have made some strides in the national EMS debate by developing the Federal Interagency Committee on EMS and incorporating EMS into the USFA Web site under “EMS/Rescue.” Unfortunately, line paramedics and most EMS supervisors and fire chiefs have never heard of FICEMS, and not much has come forward from the committee's activities. Also within the USFA, the folks reviewing the early FIRE Grant requests found a way to award some monies for EMS-related activities to local fire departments by thinking outside of the box and awarding EMS grants under the category of firefighter safety.

In other federal news, the National Highway Traffic Safety Administration has launched several major initiatives and continuously made significant strides in EMS practice, laying the groundwork for the EMS Agenda for the Future. In fact, the efforts of NHTSA over the past five years have been truly remarkable. The projects undertaken by NHTSA are longitudinal and almost always done through consensus-building. NHTSA also seeks out the experts, as evidenced by the group's awarding the development of the National EMS Instructor Curriculum to the National Association of EMS Educators.

What NHTSA suffers from is a lack of identity created by not having EMS in the organization's name. The operating expenses also get prioritized within a larger agency, and the sharing of funds does not allow for those direct grant monies to the agencies. The state level of bureaucracy adds another step in highway traffic safety grants being awarded directly to the municipal agencies, therefore few in the grass roots realize NHTSA's contributions. The Bush '05 budget has several targets earmarked for funding reductions, including yet-to-be-determined cuts at the Department of Transportation. The DOT's EMS programs would be safer located at the National Fire Academy under the Department of Homeland Security, which will continue to get full funding for some time into the future.

The International Association of Fire Fighters is another major stakeholder in EMS, and the union really deserves credit for pushing the fire service into EMS. In a strategic move, the IAFF has advocated front-loading fire apparatus with paramedics, which has increased staffing and provided for three- and four-person companies in some jurisdictions. Under the leadership of Lori Moore, assistant to the general president, there has been a balance struck between staffing and quality. The IAFF has launched a quality improvement program that has built on the NHTSA program and has become the gold standard.

What has been missed are those folks who are not members of the union. Private ambulance, volunteer EMS and third service workers have not had the opportunity to share in the same cutting-edge information provided by the IAFF. In the IAFF's defense, the union has never turned away a request for those who knocked on the door and asked for the information; in fact, most people never see the innovations and excellence that is being generated at the IAFF headquarters.

More notable is the fact that the IAFF has come out in strong support of Democratic presidential candidate John Kerry, while the owners in the corporate ambulance industry are supportive of the pro-business Republican administration. That pro-business slant has been evident in a shift in values to lesser regulation, changes in overtime and profit-driven operations. A change in the U.S. presidency may lead to a change in the way government does business, as well as an increase in support of a national EMS administration that also can affect private-industry EMS practices.

Even physicians groups have taken notice of the lack of a national focus on EMS. The National Association of EMS Physicians and the American College of Emergency Physicians, which originally focused on clinical issues and training, have developed a strong lobbying organization called the Advocates for EMS. U.S. Senate Majority Leader Bill Frist (Tenn.) is a medical doctor who, in a high-profile event, stopped and rendered assistance at an accident scene; he knows the value of EMS.

It can be reasoned that this lobbying group will be able to articulate its concerns to a congressional leadership that listens and understands issues brought doctor to doctor. Add to this a U.S. Surgeon General Richard H. Carmona, a former paramedic who has a strong EMS background and significant ties to tactical EMS, and you have a very effective lobbying group to support a national EMS administration. There has been some success in lobbying efforts already by inserting EMS into homeland defense legislation that had been exclusive to law enforcement and the fire service.

So what's next? When the bureaucracy of a large school district becomes so big that quality suffers and the constituent base is under-represented, it may be necessary to create a set of smaller of districts to serve the community and remain responsive to parents and the public. In multinational corporations, when services become too specialized or the bureaucracy becomes too big to react to industry changes or market forces, certain pieces can be spun off.

For example, in 1997 PepsiCo spun off its restaurant division as Tricon, which included Pizza Hut, Taco Bell and KFC, when the corporate leadership made a strategic decision to enable that aspect of the business to focus on the development of the restaurant chains. However, Pepsi is still served in those restaurants, and an alliance stands firm between PepsiCo and Tricon, now known as YUM! Brands. Similar to these three types of restaurants, there are equally as many provider types of EMS that need to be developed, yet the relationship with the fire service will need to remain intact.

The real question is if the government should create something new or simply reassign the resources of NHTSA, the NFA and certain aspects of the U.S. Public Health Service to the proposed U.S. Emergency Medical Services Administration/National EMS Academy. A lot of talented people have been working to move the process forward in all of the above-mentioned organizations. Careers and a lifetime of work have been devoted to the EMS Agenda for the Future. Fire chiefs need to support their EMS leaders and formulate a cohesive approach that is inclusive of EMS providers around the country. The effort needs to have one clear goal in mind — to provide the best delivery of EMS to the public.

At the heart of the problem is the very reason for the existence of the Gilmore Commission, to determine the state of security this country presently operates at. When so few EMS leaders are being supported by their fire chiefs to get out and weigh in on the national agenda with facts and a united front, EMS may just get new leadership.

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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 and an associate's degree in fire management.

Online Tools

www.rand.org/nsrd/terrpanel/links to the executive summary of the Rand Corp.'s report from the Gilmore Commission that advises Congress to move toward a federal EMS office. The full text of the Rand report also can be found at this location. This is a must-read for any fire chief, as it gives fire service leaders a glimpse of what's to come for the American fire service. Pages 36-37 in the full text download detail the specific recommendation for federal support of EMS.

www.projectusemsa.org is the home page for the national task force to establish the U.S. Emergency Medical Services Administration. Although the page is short on content, it does list contact information for the lead lobbyist.

www.advocatesforems.org/default.cfm/PID=1.28 is the Web page for the Washington, D.C., lobby group that is advancing EMS issues with the support of the American College of Emergency Physicians and the National Association of EMS Physicians. It's important to know who the members are and understand the influence they exert.