What are the greatest challenges of being part of a fire-based EMS system, and how are the EMS personnel integrated into the fire system in your community?

Alec Jensen: One of my pet peeves for years has been the lack of standard cost accounting in fire-based EMS. I mean the lack of consistency between one provider and another in terms of how they determine whether or not user-fee-based systems are making a profit, breaking even or being subsidized. I think that creates some public policy challenges for individual agencies, and in a competitive arena, for those of us who have the displeasure of having to participate in RFP processes, it really puts us at a competitive disadvantage.

Larry Matkaitis: It takes on a different connotation for us. We're running probably the second largest fire department in the country with 5,000 members — 700 single-function paramedics, roughly 300 cross-trained firefighters/paramedics, about 2,000 firefighters/EMTS, and about 2,000 firefighters/first responders. Our goal after we started with fire-based EMS service nearly 28 years ago was to integrate the entire system. For a number of years we didn't do that, but for the last five we have been moving ahead rapidly. In the future in many of the smaller departments, they may require many of the people to be EMTS or paramedics to take the test to become a firefighter.

All of our firefighters who were candidates on the list prior to two years ago were not required to have medical training and are now required to pass EMT training before they come out of the academy. In addition to that, we have 12 BLS ambulances now, we run 71 on a daily basis — 59 ALS and 12 BLS. All of our new candidates that are coming out now man those ambulances, and we started that over the last three years.

Ultimately, our goal is that everyone on the department is going to be cross-trained so it's not an us-or-them situation. We have been pretty successful with it. Last year we responded to 300,000 EMS calls that were ambulances alone, and about 150,000 with our fire apparatus, a total of 450,000 calls that were EMS-based. We only had 44 people who complained about service and as a result of investigating those, we had to take disciplinary action on only 14 and most of those were attitude and not medical care.

We are really customer service-based. We have made sure that James Joyce, our current fire commissioner, has told everyone that fire-based EMS is the future — it's here now, it's been here for a while, get used to it. If you don't like it, you're in the wrong place. We have been tremendously successful with it in Chicago. We have a waiting list that goes out the door and we don't have trouble with retention at all.

Bill Metcalf: I would echo some of what Larry has had to say. The biggest challenge is truly integrating EMS into the fire department, actually having everyone recognize that it's an organization that is providing both fire and EMS. They are both integral to the mission of the organization — you're not just a fire department that tacks on EMS. EMS is truly integrated into the mission and the day-to-day activities of the organization.

In response to the second portion of that question, we have taken a similar strategy to what Larry described in that there's no us and them. Our entry level for paramedics is that they come in with firefighter certification as well as paramedic certification. On the fire side, where we are recruiting firefighters, they have to come in with basic EMT certification, and by the time they finish the probationary year, they also have to complete the intermediate EMT certification. As Larry described in their system, on most calls we have a fire engine and ambulance and they are working together side by side, whether they are fire calls or EMS calls. The two types of service that we provide in the community are truly integrated, they are working together all the time, and there's no major distinction in the organization, either structurally or if you look at the organizational chart. There isn't an EMS side of the chart and a fire suppression side of the chart, it all goes together.

Matkaitis: We run 99 pumpers out in the field, of which 35 are ALS equipped and ALS manned. There's at least one paramedic and one EMT-B on each one of those. We are going to expand that by two by the end of the year, probably another five next year. We have 60 ladder trucks and we are probably going to be putting on ladder trucks out as ALS equipped also. All of our new apparatus are coming in with ALS compartments in them, so that at some point in time they are all going to be ALS equipped or be able to interface with them. They are working together all the time, whether it's from the same firehouse or whether it happens to be in any part of the city.

Leeanna Mims Raw: I'm with Seminole County Fire Rescue here in Florida and we have been an integrated system for a while. Looking at it now, the biggest challenge that we are facing is maintaining a balance. We are full-service EMS, which is everything from initial response to the transport. We provide a helicopter service, we have hazmat, we have fire suppression and all the other things that go with it. In the course of a given day, trying to maintain the balance of calls and dealing with personnel issues is really becoming a challenge. We are starting to look now at how to make it easier, including putting additional units on that can be used when people are in training. But I don't come from a system that was ever split, it's always been a fire-based EMS system. We are operating out of 17 stations in Seminole County and with that we are on a first response system with all the cities in our county.

Jensen: My sense is that you have is pulled together some fairly progressive organizations here, and we live in somewhat of a privileged world where the culture is one that EMS is integrated with the fire-based system. The fact is that EMS, despite 20 to 30 years of a track record of being part of a fire-based delivery system, still resides in the background or resides as a second-class citizen within an organization. The greatest example of that is the lack of dedicated resources to support the EMS function. It comprises in a contemporary fire service organization more than 70% of the emergency response activity, but when you look at the allocation of chief officer time, training time, risk management time and so forth, you find that you still have the allocation of the minority of the organization's resources.

I'm not speaking for anybody who is participating in this call today, but I think that most of us would agree that on balance, we have not come very far. I get to talk at conferences to fire chiefs and ask them how many of them have EMS systems that are run by somebody with a gold badge, and it's only the minority of people who will respond in the affirmative.

Matkaitis: Well, I happen to have a gold badge, but I've got 33 years as a paramedic and am still active. Conceptually, I don't disagree with you. I also go to a lot of conferences where I run into the same thing. We are fortunate not to have that with the Chicago Fire Department, including with the fire commissioner, who was the deputy commissioner in charge of EMS for a while, and he is EMT also. We have a fairly progressive department where almost all the gold badges up here run operations. I happen to be an assistant deputy commissioner in operations, it's not defined as EMS operations, although that is one of the areas that I cover. The resources are on the top and I agree we are progressive. There are many places, meantime, where EMS is doing 70 or 80% of the workload and doesn't get the resources. When you are talking about gold badges it certainly does ring a bell with me. Leadership has to come from the top, not the bottom.

Metcalf: I think that's an issue that has crossed over with what Alex said and what Larry has talked about. Very often the blame for failures or difficulties in fire-based EMS systems is laid in the wrong place. It will get blamed on the union or firefighters or somebody else, and in most cases, in my experience anyway, the unsatisfactory fire-based EMS systems are related to failure in leadership from the top.

You can have all the support you want from the folks on the line, but if there isn't support at the top it's not going to happen. In most of the failed systems or experiments in fire-based EMS, and there are some big ones that are struggling at this minute, the problems can be traced back to failure in leadership.

I think that's where fire chiefs need to make a decision about what they are going to do and what their organization is doing. Is it truly an integrated emergency services organization that is providing both types of emergency services — both fire and EMS — or not? If they aren't prepared to make that commitment and not prepared to truly integrate those services together in their organizations, don't even start because you are going to cause a whole lot more pain and trouble than it's worth.

Matkaitis: I agree with you there. If the desire isn't there, then you are better off leaving EMS as a third service if it happens to be there. Unfortunately, what it will come down to in the future is that the third service will be competing with the fire department at the budget table. The budgets won't be unified. There are too many advantages to fire-based EMS, dealing with the delivery of emergency medical care, coordination with fire companies, hazmat and everything else rather than bringing in a third service. If leadership comes from the top, it'll be done regardless and you'll get participation from your union as well.

Is there a paramedic shortage? Is there a way to make due with EMT-BS considering most area hospitals are only a few minutes away?

Metcalf: In some parts of the country they are experiencing a paramedic shortage right now. I think that we are hearing that from the mid-Atlantic, both coasts actually, and the Sun Belt area. There are a number of places that are having real difficulty filling all their paramedic slots to the point where they have to shut down or take paramedic units out of service. I think in many cases we don't know why people are struggling with that because the “why” comes before the solution.

There's a lot of speculation that the pool of eligible applicants is shrinking, and as I travel around the country I know that I am hearing that fire departments in general are seeing a big decline in the number of people who are applying for jobs.

There is some speculation that the educational requirements have exceeded the compensation that comes later, what it takes to get into the business and what you are going to get paid once you're in it, one is starting to outweigh the other. I think there's some speculation that because of the type of work that it is — it's physically demanding, it's emotionally demanding, with very few people getting rich off of it — that we're not attracting the current generations, the X and Y generations, and what they're looking for in a career.

I think that this whole business of “what kind of organization are you going to be working in, are you going to be respected for what you do, are you going to be working in a good work environment?” — I think that's been speculated to play a part in it. So is there a shortage? I think there is. The solution is going to depend on the why and the industry in general is trying to sort out the why right now.

What about in the volunteer sector?

Jensen: I think there's a shortage of paramedics, but it begs the question, have we trained enough paramedics? I believe we have trained enough. So if there's a shortage, what happened to them? Why didn't they stick with it? There are a couple of things that come into play, one of which is burnout and workload equity within an organization. I don't think that organizations have done enough to recognize that. The bell goes off a dozen times a shift for a paramedic crew and less than half a dozen times a shift for somebody else. You have internal equity issues.

Another issue is the career ladder. I'm constantly exposed to organizations where people are cross-trained as paramedics and firefighters and as soon as he or she promotes to company officer, they can no longer function in their paramedic role. I don't want to enter into a debate of whether that's good or bad. I can tell you at Tulattin Valley Fire and Rescue, most of our battalion chiefs are paramedics and they carry ALS equipment and they respond on calls and it transcends all ranks within the organization.

You started your question by implying that maybe community standards was an issue as it relates to advanced life support versus basic life support, I don't think we have time to get into that. I do think there are a lot of communities that overstaff and over-deploy, so communities' standards may have something to do with the perception of whether or not there are enough paramedics. If you are staffing everything as ALS and you are putting two paramedics on all of your rescues and ambulances, and you can't meet that standard, it begs the question of whether that is a reasonable standard.

Matkaitis: In Chicago, I don't have that problem. They continue to come on and they stay. We don't have a retention problem at all. I think part of it has to do with a number of things that we touched on before: being recognized as an equal, pay parity happens to be here also. There are a number of departments or separate ambulance services that are not paid up to the level of the firefighters in the community. As a result, they don't retain the status and a number of other things that go along with it.

Should a paramedic be able to refuse to transport a patient? What about the public abuse of the EMS system?

Metcalf: Define abuse for me. I suspect conversations about system abuse are the loudest in communities where there is a fairly narrow definition of what's appropriate use of the system. I think that it goes back to how we look at the service we provide. Have we invested in the huge amounts of dollars, infrastructure and people, only to respond to immediately life-threatening injuries, or does the EMS system serve a role in the community as one of several points of entry into the health care system for the citizens? I suspect if you use the first definition, then there is a ton of system abuse that goes on out there. If you go with the second definition, you would be hard pressed to identify abuse. So I think it depends on the perspective of how we look at the service that we are providing.

Personally, I think that people are using EMS as point of entry into the health care system — they're our customers, that's what we're there for, and that's what we do. If that is diverting resources or causing us to need more resources to provide more service, that's fine. That's what our customers are asking us to provide. I tend to have a fairly broad definition of what is legitimate use of our service, therefore I don't see a lot of abuse.

Raw: When we talk about the issue of being able to refuse to transport, I think there are some things that we have to do there. Until we find a way to reduce the liability, increase the way that we are using technology to get us to that point, and recognize that the reason we are being used is because there's a fault in the overall health care system, that's where we are being pulled in. I'm sure that you are seeing the same things that we are. The long waits at the hospital — we have units that sit at the hospital for an hour and a half because there are no beds and the patient that they brought in probably could have gone to a lesser type of facility, but we don't have the flexibility to do that.

There was something that was put out by Medicare a few years ago — it was way ahead of its time — in which they showed the doctor in the ER and a video link with the paramedics in the back of the ambulance. The doctor made the call right there as to what needed to be done for that patient. I think that we have doctors in the initial receiving facilities that would make that same call if they could see the patient. They are just a little too leery to take on the liability at this point.

Jensen: Leeanna touched on something that I think is critical in this discussion. The discussion has centered on the whole notion of pathway management and the limitations within which EMS personnel function and when she referenced Medicare that's really, in my view, the heart and soul of this. As we all know, there are almost no provisions under which Medicare will reimburse for the care of a patient, unless that patient is transported to a tertiary facility. So the federal government has created a restricted environment in which we function and that is perceived as abuse.

Is the EMS system over-regulated, particularly in light of the new Health Information Portability and Accountability Act? How is this going to impact EMS?

Matkaitis: It's going to make it more difficult for us. The interesting part of it is that this was supposed to simplify things for all the providers and everyone else out there. I think it's about 2-inches thick, when you look at the regulation itself. Quite honestly, this is real tough reading. It probably started out as a good idea, but it may be that a lot of organizations that have waited for this are going to take a look at it and say they're going to have a hard time complying.

Maybe it's easier for smaller organizations but it's going to be difficult for a larger organization, like us. We are going to have to do a lot of things differently than we have in the past that we have been successful at. It's going to put a dent in our budget and make it more difficult to comply. The penalties are pretty severe, so we have to. When it comes to the other end, the goals and objective, I don't see that the goals and objectives translate into easier and better.

Jensen: My concern about HIPAA is what it's going to do to quality improvement. We've all conducted quality improvement with an eye toward respectful confidentiality. But the imposition of the HIPAA provisions are going to have profound impact on our ability to share information internally, but more importantly, between organizations.

Matkaitis: It may be difficult for a shift paramedic to go out there, go into a hospital, start talking and wonder whether someone has overheard him, and turn around and get sued because he let out privileged information. I think there are gigantic holes in this that have not been filled yet.

Metcalf: I don't disagree with what anyone has said, I think it's going to have a significant impact whether you are large or small. To me this is a classic case of those of us in this field, who tend to get interested or concerned about this stuff at the wrong time. The legislation is passed, the regulations are out and complaining about it now is like complaining about the weather.

As we take on the EMS role, and as EMS becomes more and more recognized as a piece of health care systems in our communities, there are going to be more things like HIPAA, which was a law that primarily focused not at EMS, but at hospitals and physician's offices and the more generic health care system. The things that are done in those arenas have a huge effect on us and we need to be at the table, pointing out the problems that it's going to cause for EMS. We need to be actively involved in the dialogue on the front end rather than when it's staring at us in the face. I think far too often that has been our approach — we are silent until the thing is done and then we try to figure out what we are going to do about it.

Bill, we know that you are involved with the IAFC'S EMS section. What is the IAFC'S position, or what actions are they taking, on the HIPAA regulations?

Metcalf: I think that we certainly monitored the process as it went along, but I'm not sure that anybody, whether it's the IAFC or the American Ambulance Association or the IAFF or any of the other constituent groups, were particularly active at the table in trying to get the regulations to deal with some of the unique aspects of EMS. So what we have is a generic set of guidelines that deal with patient confidentiality and they're being forced to fit for everybody. Now we have the huge task of educating everybody on what it means. I think that most fire agencies and EMS agencies and most fire chiefs don't have an idea of what HIPAA means. They have read about this April deadline that's out there, they've read about it somewhere and they know it has implications, but I think that probably most systems are far behind the curve in the amount of work that has to be done between now and April.

Raw: When you ask what are some of those things that can be done to make it easier for the EMS system and this particular issue, where we weren't who this was developed for, it's one of those things that gets pushed to us versus when you talk about things that are directed towards the fire side of what we do — those are developed for us. It's a little bit easier to manipulate it or make changes in such a way that it benefits us.

But we get hit with stuff like HIPAA time after time; when it's gone there will be something else next year. The system doesn't recognize EMS as its own entity. It's bad enough that our cities, our counties and our states don't, but if we take it up to the next government level and they don't either, that makes it difficult. Florida has a very active advisory council, but a few states doing it is not enough.

Does the fire chief have the obligation to inform the authority having jurisdiction if their department is not fulfilling the acceptable level of risk in the community?

Metcalf: I think that we have an ethical obligation to be completely honest about what we are doing and what we are not doing. Now, given individual politics not everyone may agree with that, but just from a purely ethical perspective, we should be up front with our customers or constituents.… I would rather deal with it proactively than have to play catch up or react to a newspaper story.

Matkaitis: I agree 100%, but that comes back to leadership and management. If we have someone saying that we evaluate our system on a day-to-day, month-to-month basis, then what resources do we need and what do we need to do? We have already set our standards, this is what we need to meet them, and if we need to add resources, we add resources, it's as simple as that.

Jensen: The practical reality though is that people need to realize that fire chiefs are oftentimes placed in an untenable situation and we all know of our contemporaries who have lost their jobs because they have been put under pressure by a city manager, mayor or city council to keep quiet. I don't know what the solution is but the question is rooted in some very tragic experiences.

Metcalf: I'm almost divided in two places. I think you're absolutely right that a city manager may not want a fire chief expressing their misgivings, concerns or failures to the public at large but if the phrase “the authority having jurisdiction” means what I think it does, then the fire chief has an obligation to make sure that, although he has order to the contrary, at least make sure that the city manager is aware of what the truth of the situation is.

Matkaitis: Or what the ramifications could be. I'd like to make two recommendations in the meantime that are backed solidly by facts and statistics. It goes up as saying “We recommend this because these are standards that we believe that the city fathers, mothers and everyone else wants.” If you expect a three-minute response time, if you expect us to be there with hazmat teams and everything else within X amount of time and we are running 450,000 calls a year and you average that out, you just have to figure it out. There are decisionmakers that go up all the way up to the mayor and the city council, they are elected by the citizens. They have to make their decisions based on what their constituents want and what we can provide. If they want a 10-or-15 minute response time, so be it, we can do that for them as well. What do you want from us? Do you want us to have a first-class fire department? Do you want us to have an ALS? It comes down to the voters.

Jensen: It's all a balancing act. The cynical side of me wonders if the root of a question like that is not born in one party wanting to see implementation of four-person engine companies in their community versus a fire chief who has been comfortable in his position relative to other staffing standards. These things are often politically driven. Is a fire chief under some obligation, now that we have passed NFPA 1710, to go to his or her city council and report that they are 30% underfunded even though he or she may believe that the status quo is acceptable?

Metcalf: It starts with understanding how well you're performing today. It absolutely amazes me the numbers of EMS agencies, including fire agencies, who can't tell you how they are performing. In many cases, I think it's “Don't ask the question if you don't want to know the answer.” I think it's a responsibility for each EMS agency to have a very clear understanding of how they are performing and how they compare to the benchmarks. It's only by doing that can you and your policy — makers make informed decisions about what you are doing with your system. I think a lot of folks just work day by day and have no idea how the system is actually working.

EMS on the table

Alec Jensen is the executive officer for Tualatin Valley (Ore.) Fire and Rescue. Before joining the fire service almost 12 years ago, he was the operations manager for Buck Medical Services, now AMR Northwest. Jensen has been an EMT, paramedic, military medic, paramedic educator and, for Oregon's Health Division, an EMS regulator.

Larry Matkaitis is currently the assistant deputy fire commissioner in charge of EMS operations for the Chicago Fire Department. He's a member of the Illinois Terrorism Task Force, the Illinois Department of Public Health's Bioterrorism Task Force, the Executive Council of the Illinois Emergency Medical Response Team, the Illinois Fire Chiefs EMS Committee, the Illinois Fire Service Association and a member and responding chief for the Mutual Aid Box Alarm System of the State of Illinois.

Bill Metcalf is the assistant chief for the North Lake Tahoe Fire Protection District in Incline Village, Nev. He currently serves on the executive committee for the International Association of Fire Chiefs EMS Section. Metcalf also is a frequent writer and speaker on fire service leadership and emergency medical topics.

Leeanna Mims Raw is the assistant chief of Seminole County (Fla.) EMS Fire Rescue, promoted to the position after serving as battalion chief of planning. She has served on several boards including the Florida Association of EMS Providers. Raw is a 1999 graduate of the National Fire Academy's Executive Fire Officer Program and a Florida-certified paramedic.