Most of us in the fire service went into the EMS business with reasonably clear expectations for the future. While some of those expectations have been met, we've also encountered serious challenges and difficulties that we didn't bargain for. In some cases the unintended consequences of our service expansion are placing tremendous strains on our organizations, employees and taxpayers. The time has come for us to evaluate where we stand with fire-based EMS and open a new dialogue regarding our vision for the future.

For many of us, this all began when we were either pushed into — or voluntarily began to accept — a role in providing Basic Life Support first-responder service, usually to shore up the increasing response times of private and third-service ambulance providers. Today, instead of supporting someone else's system, many of us are the system, and we're struggling with the same systemwide issues and complexities that vexed the organizations we overtook. These challenges present fire officers of all ranks with difficulties that their predecessors might never have imagined.

It's no secret that our maiden voyage into EMS was marked with mixed feelings; to many this was the most incomprehensible dissolution of our attention to the traditional fire mission. To others it signaled a timely opportunity to shore up declining run statistics in a world where the fire problem had all but disappeared from the political radar.

Both views had some validity. There's no doubt that many fire departments have been able to justify new positions and additional resources based on their EMS mission. At the same time, by expanding our attention to address complex EMS and ALS issues, we have diluted our attention away from fire missions. Perhaps even worse, for many of us, EMS is placing considerable stress on our organizations.

Consider the following example: A middle-aged woman develops abdominal pain over the course of three days. On a Saturday afternoon she calls her doctor's answering service and requests that the doctor call her back. Twenty minutes later the doctor calls her back and listens to her situation. Since the doctor's office isn't open on weekends, he advises her to go to the emergency room. She tells the doctor she has no way to get to the hospital, so he recommends an ambulance. The patient calls 911.

The closest-due engine company, which had been in the middle of conducting a hose drill, is dispatched along with a fire department medic unit. Within four minutes, this $300,000 fire engine staffed with four firefighters arrives at her front door. Three minutes later, the $125,000 fire department ambulance staffed with two paramedics arrives at the door. Neighbors stand in their front yards, watching the excitement as six people pile into the house.

The ambulance transports the patient on a 20-minute ride to the hospital. Prior to transport, the paramedic follows protocol for any adult with abdominal pain and starts an IV. The paramedic turns the patient over to the receiving nurse, completes paperwork, re-stocks the medic unit, and after 20 minutes at the hospital, the ambulance marks back in service. Total out-of-service time for the ambulance is one hour.

After waiting in the ER for an hour, the patient is seen by the physician, who diagnoses a moderate case of pelvic inflammatory disease, prescribes antibiotics and releases the patient. The patient, unable to find any other ride home, eventually calls her ex-husband to take her home.

What's wrong with this picture? Imagine the response you might get if you met with your local elected officials, and recommended to them that the local government create a primary health care system for all citizens. This free system would be administered by employees of the locality, and the locality would guarantee a response to each citizen's home at any hour of the day within eight minutes of a phone call for help. Your elected officials may scoff at this notion, and yet in many cases that is exactly what we are offering.

The problem isn't that too many people call ambulances for non-emergencies, but that many of us aren't geared up to deal with non-emergencies. All too often we're locked into a specific course of action based on protocols designed to reduce our liability. But at what cost? It's not just financial; the heavy call loads can wear down our people and our equipment. There's also the obvious problem of our engine and medic crews being tied up with non-emergencies when the occasional true emergency call is received.

Modern EMS systems have been designed around meeting specific response time criteria, usually the American Heart Association guidelines for early intervention on cardiac arrests. This means getting a BLS- or AED-equipped first responder on the scene within four minutes, and ALS within eight minutes. As a result, we operate with an all-emergency approach. Everything we do is designed with the worse-case scenario in mind and rightfully so.

But when it comes to providing medical care, we're the only branch of the health care community that operates this way. Even in hospital emergency departments, patients are triaged carefully, and only those with certain conditions are seen immediately. Many emergency departments even have fast-track clinics where patients with non-emergency and minor medical complaints are seen by a physician's assistant instead of a doctor and released more quickly.

In the fire service we usually don't follow such a model. In most systems, every 911 caller with a medical problem gets an ambulance (and often an engine company) dispatched immediately. Even when we send an ambulance without lights and sirens, we are still providing a very high level of response and committing significant resources to the caller's need.

Many departments' EMS dispatch protocols are designed to avoid a failure to recognize an emergency. Because of our fear of liability, almost every call gets a full emergency response. Many systems are either unable or unwilling to use the phone call itself as an effective screening device to determine the degree of emergency. This is made more difficult when using a combination police-fire-EMS dispatch center, where call-takers may lack the training or experience to interview the caller in detail.

Both our dispatch procedures and field interventions are influenced to a great extent by the civilian medical director, a physician. Since the medical director is expected to be an advocate for medical care only and isn't held accountable for the operation's efficiency, there's usually no incentive to seek any balance between cost and benefit. Too often, fire departments are abdicating their policy-making ability to these civilian medical directors. At their urging we're expected to spend almost any amount to achieve the most marginal benefit. It's a problem we need to be aware of, even if we can't do anything about it.

All across the country, engine and truck companies assigned to areas with heavy EMS call loads stay very busy. Although we're likely to add more ambulances in areas where there's a high demand for EMS services, it's typically a harder sell to obtain the funding to add additional fire units in those same areas. As a result, fire protection in areas with high EMS call demand may be compromised. These are often lower-income areas, the same communities where we know we have a disproportionately higher fire problem.

In addition, fire crews that respond to a lot of EMS calls have significantly less time available for training, pre-planning, rehab and physical fitness, but these are compromises that we accept, by virtue of our willingness to take on EMS in the first place. Most of us agree that sending fire trucks to EMS calls results in saved lives, but are we making more of a compromise than we expected by routinely tying up our most valuable resources on non-emergency incidents?

What about the impact on the medic crews? In many urban and suburban systems, our medic crews are running an incredible number of calls and spending much of their time on the street. Can a medic really be as sharp at 4 a.m. after running 12 calls as he or she is early in the same 24-hour shift?

We make rehab mandatory for firefighters because we know that they aren't inclined to ask for relief — do we do the same for our medics? In many cases the answer is no. Many fire departments are short-staffed on medics to begin with, so there's little opportunity to rotate providers. We can end up with poor morale, higher rates of turnover and poorer patient care.

How do we quantify these problems? It would be helpful to know what proportion of our EMS calls are true emergencies, but we can't even begin to collect this information. Take the standardized data collection method used in Virginia. The State Department of Health, Office of EMS, created a standardized Prehospital Patient Care Data Report. On this form, the EMS provider must choose a call type. Nowhere on the call sheet is there a spot where the provider can indicate whether the call was a true emergency.

The data management issue is made even more complicated because we tend to think of all ALS procedures as emergency treatments. In the example I gave earlier, the paramedic was required by protocol to start an IV, so this call would probably be recorded as an “ALS Required” call. In most systems, a review of call statistics would place this call in the true emergency category despite it being a routine medical problem.

In all fairness to the established systems of data collection, we can't even begin to think about making a distinction between emergencies and non-emergencies until we first agree on definitions for both. This hasn't happened in the fire service, although insurance companies and HMOS have made several attempts with varying success. We aren't going to be able to navigate our way through this problem until we collect the data to understand it in a quantifiable manner.

Sooner or later the city and county managers are going to realize that they've been funding the non-emergency health care needs of the community with what we have represented as emergency needs. Do your local elected officials know the degree to which emergency resources are being siphoned off to handle routine, general illness calls? Maybe it's a good time for us to evaluate our old assumptions and measure what we've accomplished while taking stock of our failures. Are we doing a good job of providing citizens with a system that is both effective and efficient? Are we taking care of our employees?

Maybe we need to back up a little and identify more clearly what our common goal should be for fire service EMS. Are we expected to handle all medical problems that occur outside the hospital, to include both emergencies and routine illnesses? If so, we need to identify ways to meet the potentially overwhelming medical needs of the community while preserving our emergency resources for emergencies.

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Tony McDowell is a career firefighter/paramedic with the Henrico County (Va.) Division of Fire and is a former budget and management analyst for Chesterfield County, Va. McDowell is the IAFC program manager for wildfire and holds a bachelor's degree from Virginia Tech and a master's in public administration from the University of North Texas. He can be reached at <mcd03@co.henrico.va.us>.