Emergency medical services may soon be the core responsibility of U.S. firefighters, as traditional fire-based calls dropped significantly in the last decade, from 1.8 million in 1999 to 1.4 million in 2008, according to the U.S. Fire Administration. With fire-call volumes down, now is the time for fire departments to expand existing medical-response services. But departments first must determine how to fund such efforts while convincing their communities it's a worthwhile, value-added service.

Firefighters began providing first-response EMS beginning in the 1960s, according to Dennis Compton, a 40-year fire veteran and co-chair of the Fire Service-Based EMS Advocates. Even back then, many pre-hospital EMS providers were firefighters who had additional medical-services training, Compton said. Today, nearly every U.S. firefighter receives at least some medical training. In fact, out of the 200 largest U.S. cities, 97% have fire service-based pre-hospital EMS, as reported by the International Association of Fire Fighters.

"There are a lot of fire departments who have fully integrated EMS into their system — that is not unique," Compton said. "Now almost all fire departments do at least first response."

Cross-training firefighters in EMS makes sense based on how fire departments are positioned throughout communities, Compton said, i.e., fire stations already are strategically located and response time-modeling for EMS is similar to fire suppression. In addition, firefighters are trained to save life and property in high-stress, hazardous situations, which makes them well-suited for additional life-saving skills.

"There's a natural fit there," Compton said. "You're simply using existing resources in a much more cost-effective way."

Fire departments in cities such as Miami already have an integrated EMS system, Compton said. In those markets, firefighters are expected to be certified paramedics as a prerequisite for employment. But most fire departments don't want to pay for training or commit to the administrative process to keep paramedics certified, and that applies whether it is a city or a community department, he said.

"So most community and city fire departments don't have everybody as a paramedic," Compton said. "But a lot of them do have at least an EMT and one or two paramedics on their response units."

To pay for emergency medical services, Compton suggests that departments seek approval through federal, state and local channels to charge a fee for transport services.

"You charge a fee unless the community itself was willing to subsidize service — which is not common," he said. "They may subsidize part of it, but [officials] would expect, in most cases, a fee to offset costs."

Volunteer-Based EMS

Volunteer departments have a separate challenge, said Steve Austin, who co-chairs the Fire Service-Based EMS Advocates alongside Compton. Austin acknowledged that fire calls have declined while EMS calls have increased. As a result, volunteer departments need to think about deploying a fire-based EMS system, he said. Having a robust emergency medical component built into a fire department, whether first responder or paramedic, is what the community needs. Such capability also lets the department offer an all-risk response.

Austin said many of the nation's volunteer firefighters have at least been trained as first responders. But departments already struggle with tight budgets, so to add on the expense of paramedic certification is a lot to ask.

"It's unfortunate because fire departments deployed to the area often are located closer to a victim compared to a private EMS provider," Austin said. "If someone has a heart attack, fire departments can get there quicker and stabilize the patient."

First-responder training is a good place to begin the migration toward full EMS, Austin said. Volunteer departments can start small and build up to providing services. But providing services also means creating a salary-funding model. He said many volunteer departments already support a quasi-paid status, where EMTs and paramedics are hired and compensated when on duty.

"That becomes a combination fire department," he said. "But there are successful models where departments are doing that because there is a demand for having the station fully staffed 24/7."

Volunteer departments need to consider a minimum EMS fee and bill for services in order to recoup equipment and personnel costs, Austin said. Transport charges can range from $100 to $300, and fees are most often paid through insurance providers, such as Medicare and private insurers.

"The fee can get the department started on procuring the right equipment, training and salary budget to have people on duty all the time," he said.

Austin said volunteer departments must involve community members and discuss what implementing fire-based EMS would entail, both the costs and the benefits.

"There's no doubt about it," Austin said. "Good fire protection and good emergency services are a quality-of-life issue. If fire departments step up to provide medical services, it is going to improve the quality-of-life in that community."

Regional Look: The Capitol

Some cities pay for fire-EMS services mostly through tax dollars, said Dennis Rubin, fire chief of the District of Columbia Fire and EMS Department. Rubin said D.C. is one of the nation's busiest emergency medical districts, serving about 850,000 residents and more than 1 million visitors daily. In fact, the department responds to about 140,000 medical calls annually, he said.

D.C. citizens demand the service, and the fire department is in the perfect position to provide it, Rubin said. EMS calls can be serviced from 34 fire stations spread throughout the city, including 33 land-based engine companies and one fire boat. Since it started providing medical services, the department has built up a fleet of 80 ambulances, 40 of which are in service: 25 are basic life support units and 14 are paramedic units, with one ambulance held in reserve. As a result, EMS-trained firefighters can arrive quickly to provide the help victims need, he said.

"With the modern-day training and capability of a firefighter, being a paramedic enhances our ability and extends the emergency room out into the streets of D.C.," Rubin said.

The department provides fire recruits with six months of training that includes fire, EMS technician basic, hazmat and basic-rescue technician. However, most firefighters recruited already are certified paramedics.

"For the most part, because there are so many on the market, we've been able to directly hire folks that are nationally certified as EMTs/paramedics," he said.

However, when budgets are available and staff is interested, the department will offer firefighters an opportunity to become paramedics, a two-step process.

"Once [firefighters] have the national registry under their belt, we train them for two months, and then they are in the field working as a paramedic under our medical director," Rubin said. "In those two months, they learn the D.C. way: they learn our protocols, procedures, the hospitals' locations and how our paramedic companies operate."

D.C.'s fire department has a robust emergency medical team that is headed by an emergency-room physician and field-managed by EMS liaison officers (ELOs). An ELO is a firefighter who tracks EMS operations from patient pick-up to delivery at one of the 13 hospitals inside the city limits. ELOs take patient information from the on-scene paramedic, rate the injury by priority and analyze incident location data to help determine the fastest route to the hospital, with consideration given to hospitals' patient loads, the city's layout and the predicted rush-hour traffic hurdles, Rubin said.

In addition, the department has four hospital liaison officers (HLOs) who are in constant communication with the ELO, Rubin said. HLOs are assigned onsite to the four busiest hospitals in D.C. and communicate hospital status updates to the ELOs, such as available bed counts. Voice transmission is deployed over a special radio channel that was established for the ELO. Communications between ELOs and hospitals are maintained mostly by radio and telephone contact, he added.

"So based on the information the paramedic provides, based on the hospital status, based on the location, the ELO then determines where the best hospital is to transport the patient," Rubin said.

HLOs also ensure that D.C.'s onsite ambulance crews complete their electronic patient-care reports at the completion of a run, Rubin said. Incident data are transmitted to the department's computer-aided dispatch system via transport vehicles' onboard computers, while a fire administrator can view the same data remotely using the iMobile application.

Part of Rubin's goal is to keep the ambulance turnaround time — the time a unit arrives at the hospital until the time that ambulance goes back into service — to 35 minutes. Such improved services are a value-add for citizens; yet, the department currently is losing money on its emergency transport services. The department bills an average of $30 million annually for medical services but only collects a little more than half of what it is owed. For example, in FY 2009, $19 million was recouped — about 65% of billed services.

Rubin said the inability to recoup costs is partly due to the city's policy of soft billing. He said when the department responds to a call, a third-party biller receives transport data in near real-time. The billing agency determines whether federal programs, a private insurer or the individual should pay the bill. Bills then are sent. But if they are not paid after a third notice, they are written off. Part of the problem is the fact that citizens simply can't pay for the service.

"We're an urban city with indigent folks and those who are elderly and on a fixed income," Rubin explained.

The department is looking for ways to offset costs by improving services and efficiency. Beck said although they do not offer emergency transports, they do transport non-emergency patients to urgent-care centers rather than hospitals. By diverting patient traffic based on medical need, the ambulance bottleneck at hospitals during peak times dissipates. Re-directing medical attention to the urgent care centers, which are often less crowded, also increases the response times of ambulances to other life-threatening emergencies, he said.

Regional Look: The Southwest

Many mid-sized departments are experiencing a rising demand for emergency medical services while servicing an expanding coverage area. In Mesa, Ariz., fire departments must serve a 128-square-mile coverage area and at the same time keep response times down, said Harry Beck, the city's fire chief. The 471-person department protects more than 453,000 residents with 18 fire stations that house 24 advanced life support and firefighting units. It is an all-ALS fire department, and medical calls consist of more than 75% of total calls, he said.

"We decided to take all of our firefighters and train at least two per unit to be paramedics," Beck said. "We [provided] the extra training to improve our capabilities and our quality of service on a per unit basis."

The department has transitional response vehicles (TRV) that can serve both fire- and medical-based calls. Firefighters deliver service from a two-person ambulance-style unit. The vehicle is equipped for basic life-support services and is frontloaded with two firefighters, one of whom is a firefighter-paramedic, while the other is a firefighter/EMT. In the event of a large incident, the TRV has turnout gear on board so the unit can respond as part of firefighting efforts, he said.

However, a rising medical-call volume didn't result in more funding resources to help the department deliver services. In addition, there currently isn't a fee-for-service billing plan in place to pay for EMS, so the department does not charge for its services. Beck explained that in Arizona, fire departments need a license from the state to provide emergency transports and charge insurance companies for such services.

"So we really are not in a position to charge for services," Beck said. "Ambulance companies can because the state allows them to, but they don't allow us to. We see having the ability to do some cost recovery [in the future] depending on legislation."

As a result, the department is struggling to serve rising call volumes, Beck said. So during peak times of the year, the department staffs a two-person BLS unit with firefighters on an overtime basis, including a physician's assistant provided via a partnership with a local hospital for units in areas that run a high percentage BLS calls. Such units increase the availability time of an engine or a ladder company by almost 10% and reduces response times by a minimum of 4 to 6 seconds, Beck said.

"These units have picked up the slack; improved the availability time of advanced life support and firefighting units, and improved response times," Beck said.

The department is looking for ways to offset costs by improving services and efficiency. Beck said although they do not offer emergency transports, they do transport non-emergency patients to urgent-care centers rather than hospitals. By diverting patient traffic based on medical need, the ambulance bottleneck at hospitals during peak times dissipates. Re-directing medical attention to the urgent care centers, which are often less crowded, also increases the response times of ambulances to other life-threatening emergencies, he said.

Even if departments can't figure out a way to fund EMS, Beck encouraged chiefs to continue to pursue ways to provide such services. Specifically, chiefs need to continue to pursue the delivery of EMS because medical calls are rising nationwide, he said.

"Rising medical calls will continue to be a growing trend throughout the nation's fire service," Beck said. "We need to continue to pursue EMS as a primary service provided by the fire service."

In the Field

According to the American Heart Association, the national goal is to complete an angioplasty in 90 minutes starting when a person arrives at a hospital. The Colorado Springs Fire Department (CSFD) claims it often helps hospitals beat that time by integrating pre-hospital providers directly with the hospital staff and specialty physicians under the STEMI (ST-segment Elevated Myocardial Infarction) alert system. STEMI tracks patients from the time the CSFD arrives at the patient's curb to the time the patient is successfully catheterized, i.e., or "curb-to-balloon" time. The CSFD claims that it meets of exceed the national average about half the time.