One of the key recommendations from the Institute of Medicine's report on EMS was to put the medicine back in EMS. When was medicine removed? Or when did the perception arise that medicine was a second priority in the system?

In many parts of the country, fire departments struggle to find qualified personnel who are both well-trained and have medicine in their hearts. Finding support staff to help with other EMS functions such as quality improvement or EMS education also can be a challenge. But even more critical is the shortage of fire-based EMS medical directors and physicians who truly understand and champion fire-based EMS.

When the term “fire department medical director” is used, it often means the person who represents the department on paper. In most organizations paramedics rarely, if ever, see their physician medical director or even have a relationship with that person that makes an impact on their practice. It's the exception rather than the rule to find physicians in the field or in the fire stations actively performing EMS or in discussion with the line personnel about how to improve fire-based EMS. This lack of solid relationship and friendship between fire-based EMS providers and the medical director may be contributing to the increasing number of physicians' who have only a lukewarm support for fire-based EMS.

In the early 1970s the term “fire surgeon” often was used to describe a physician who ran calls or was assigned to a fire-based EMS projects. These doctor usually were surgeons who were interested in trauma, and many helped start the early paramedic programs. Drs. John Howard, Sam Seeley, Robert Kennedy and Oscar Hampton created the first American College of Surgeons' Orange Book long before emergency medicine was a specialty, coining the term “fire surgeon” in the process.

The fire chiefs of the early '60s and '70s recognized the value of physician involvement in the fire service. Dr. Eugene Nagel, one of the pioneering doctors in fire-based EMS, set the standard of physician involvement in EMS. He was medical director for the Miami Fire Department's rescue operation for a decade, spending countless hours in the fire stations and letting himself be used as a patient for new technologies. He also helped lobby for the EMS Act of 1974. Sadly, the days of the fire surgeon seem to have passed into the history books.

However, there is hope. If your department is a fire-based EMS agency located in an area where there's a medical school or large teaching hospital with an emergency medicine residency, you most likely have an untapped local resource. While most emergency medicine residencies programs focus on emergency department practice, several programs also have EMS fellowships. In fact, there are approximately 50 EMS fellowships in the United States, but most aren't filled due to the low wages and the additional year of school that's required. These positions pay only about one-third of a typical emergency room physician's pay, and most new doctors usually need to get to work immediately paying off student loans.

Metropolitan fire departments need to consider a partnership with these residencies and supplement or match what the medical school has provided as a salary to make the scenario more attractive to young emergency medicine graduates. This should be considered a prime opportunity to start growing a new generation of fire surgeons. A few EMS fellowships already are partnered with large metropolitan fire departments in Houston, New York, and Washington, D.C.

These doctors also should be afforded all of the regalia and traditions surrounding the fire service, including a coat, a radio, a call sign, and an ceremonial entrance and exit from the organization. After one year of residency, they should leave looking to engage a fire department in the community they ultimately reside in.

Equally important is that these residents are educated about the real issues of the street and the fire service. It is the fire service's responsibility to educate physicians on the due process involved with the labor union and EMS operations, how to use the Incident Command System and how to integrate into a large-scale disaster under the proper organizational structure and communication protocol. They also should be shown how to coach people on performance and build teamwork.

This is also an excellent time to make a physician acutely aware of the demands of firefighting and EMS, the physiology behind the demands of being in firefighter turnout clothing, and the emotional trauma that comes with the job. The ultimate benefit for the fire department is that it will have the backing of a medical doctor when it seeks funding for members' health and safety needs.

If you're looking for physicians with the highest credentials, the American Osteopathic Board of Emergency Medicine — the certifying body for doctors of osteopathic medicine — offers a subspecialty in EMS. To sit for the Certificate of Added Qualification in Emergency Medical Services exam, candidates must first:

• Have a valid, unchallenged, unrestricted license to practice in the state or territory where his or her practice is conducted prior to and during the examination for certification of added qualification process.
• Be a member in good standing of the American Osteopathic Association or Canadian Osteopathic Association.
• Be a diplomat of the AOBEM.
• Have completed an AOA-approved training program in emergency medical services.

In lieu of this last requirement, the board requires that candidates provide both:

• Documentation of a physician's involvement in emergency medical services for at least 60 months during the last seven consecutive years.
• Documentation that 20% of the physician's practice is dedicated to emergency medical service, or 2,000 hours over five years.

The physician also must verify involvement with operational, educational and regulatory components of pre-hospital medicine, specifically operational issues such as service delivery, medical direction and agency direction, and continuous quality improvement or quality assurance. Educational issues such as EMS education or continuing education also are taken into consideration. The candidate must demonstrate knowledge of other aspects of EMS research and involvement in EMS professional organizations, EMS medical directorships and publications.

The written continuous quality improvement in EMS consists of at least 150 questions administered over three hours. Each candidate is graded according to the directions of the examination committee, as approved by the board. Following review by the board, applicants are notified of the results of the examination within 60 days of completing the examination. Certificates are administered according to Article XII of the Rules and Regulations of AOBEM. The content of the written examination includes emergency medical services as it pertains to:

• History of EMS;
• EMS personnel;
• Medical command;
• Communications;
• EMS equipment and vehicles;
• EMS agencies;
• EMS receiving facilities;
• Aero-medical operations;
• Legal considerations;
• Mass-gathering/casualty incidents;
• Critical incident stress debriefing;
• EMS research;
• Hazardous materials; and
• Clinical care issues regarding assessment, treatment and supervision.

If your fire department doesn't have a physician medical director who is a strong advocate for fire-based EMS, you are missing one of the pillars of your service delivery. It can be argued that there isn't enough clinical sophistication or medical impact made in the system to justify cross-trained fire-based EMS providers. However, the real impact in EMS is made when a physician with critical-thinking skills, resources in research and the weight of the title of medical director begins measuring, monitoring and adjusting the clinical practice to make a difference.

The EMS battles between private and public models in the future will revolve around evidence-based practice. The well-supported medical director is the fire chief's weapon against attacks on fire-based EMS. A physician medical director who is only a name on the agency's permit and not engaged in the field is a wasted resource. If your people can't identify your medical director, and your medical director hasn't provided any recommendations for enhancements or feedback on the system's performance, you may look for a change or redefine the expectations of the position. This resource needs to be resurrected and nurtured to continue the fire department's EMS mission to serve the public with the best medicine possible.

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Bruce Evans is the EMS chief for the North Las Vegas (Nev.) Fire Department. He previously served as captain of the Henderson (Nev.) Fire Department. Evans also 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. He has an associate's degree in fire management and a master's degree in public administration.

Online Tools

www.saem.org/saemdnn

This site of the Society for Academic Medicine lists EMS residency training programs and provides resources for EMS physicians.

http://66.243.178.55/uploads/resEMSStandards.pdf

This page offers the Basic Standards for Residency Training in Emergency Medical Services, as set by the American Osteopathic Association and the American College of Osteopathic Emergency Physicians.

www.naemsp.org

The Web site of the National Association of EMS Physicians contains support materials for EMS-related activities for medical directors.