Enter the No IAFF Spin Zone

The issue of DC hiring single-role paramedics has been in the news recently, where a lot of opinions have been presented as facts in the media.  Following up on the All Hazards Myth, most of those opinions are Fire-Service Based EMS Advocates talking points.  With a dwindling number of fires and increasing number of medical calls, taking over single-role EMS services is a way to protect threatened firefighter jobs.  Armed with lots of money and political clout, but lacking a shred of evidence, this group proclaims that the fire service is better positioned to deliver EMS than the other models.  Unfortunately their recommendations benefit IAFF members more than patients and taxpayers.  This August AP story about DC appeared on EMS 1:

A shortage of ambulances, inadequate training and a poor strategy make the district “one of the worst EMS systems in the country when compared to other major metropolitan areas,” said Lori Moore-Merrell, assistant to the general president of the International Association of Firefighters.

No argument from me about that, but from there on we disagree.  The take home message is that there are not enough as many paramedics (and employment or overtime opportunities for IAFF members) in DC as there are in other cities, and that more paramedics are better.  The article fails to mention that communities with high cardiac arrest survival have a low paramedic to population ration, not higher.  This appeared in a 2005 USA Today article:

Most cities opt for more paramedics, despite the expense and evidence that the approach does not necessarily save more lives.

Of the cities studied by USA TODAY, Seattle saves more cardiac arrest patients — 45% — with 1.48 paramedics per 10,000 residents. Boston has the second-highest survival rate — 40% — and the lowest paramedics ratio at 0.86.

Many of the other cities have substantially lower survival rates and markedly higher numbers of paramedics per 10,000 population. Nashville, for example, has an 8% survival rate with a 3.33 paramedics ratio. Omaha has the highest ratio at 4.70 with a 16% survival rate.

So it’s not as much about the number of paramedics in DC as it is how they are trained, utilized, and monitored.

Back to the AP article about DC:

Successful urban fire and EMS departments tend to follow one of two models. One is where firefighters are trained as paramedics, and vice versa, so that they can respond to any emergency. In the other, the ambulance service is separate and employees are more specialized.

The District of Columbia has combined aspects of both systems into an unwieldy whole.

Rather than present a fair and balanced article about cross-trained vs. specialized EMS, only fire chiefs were interviewed who proclaimed the mythical benefits of the fire side.  Deputy FEMA Administrator and retired Boston EMS Chief Richard Serino, for example, would not have been hard to find to interview to present the other side.

And then there’s paramedic response times.

The (DCFEMS) department aims to have a paramedic on the scene within 8 minutes and an ambulance within 12 minutes. The National Fire Protection Association calls for a paramedic within 6 minutes and an ambulance within 10.

I’m not sure where the reporter got this, or even if they quoted it right.  Response times measure output, not outcomes.  The only response time that is proven to affect outcomes is 5 minutes for CPR and defibrillation for cardiac arrest, which make up about 1% of responses can be do not require a paramedic to do.  But don’t take my word for it, here’s what the 2007 US Constortium of Municipal Medical Directors had to say about response times in the most comprehensive, peer-reviewed, EMS system benchmark paper to date:

Overemphasis upon response-time in- terval metrics may lead to unintended, but harmful, consequences (e.g., emergency vehicle crashes) and an undeserved confidence in quality and performance.


Traditionally, managers of EMS systems that focus on response-time interval goals often determine that they must either add paramedics to the system or in- crease the efficiency of EMS units currently being deployed. As more paramedics are added to a particular system, however, the frequency with which each individual paramedic has the opportunity to assess and manage critically ill or injured patients in the primary or “lead” paramedic role may decrease. Pragmatically, considering that ALS cases constitute a small minority of all EMS 9-1-1 responses, adding more paramedics into the system may actually reduce an individual paramedic’s exposure to critical decision-making and clinical skill competencies.

and finally….

With the exception of basic CPR and AED response (in the case of cardiac arrest), there is in- sufficient evidence to strongly recommend a specific ALS (paramedic) response-interval target as part of an evidence-based model for performance evaluation of an EMS System.

The NFPA “standard” benefits firefighters, not patient outcomes or taxpayers. And speaking of undeserved confidence, back to the AP article about DC:

“We can put a paramedic on the scene of any emergency within about 4 minutes,” Memphis Deputy Fire Chief Gary Ludwig said. “We’re starting to say Memphis is the safest place to have a heart attack.”

Seattle and King County, WA have been the safest place to have a heart attack since the 1970’s, and they have gotten even better since the USA today article.  In 2012, their cardiac arrest survival rate was 57%, by far the highest in the country.  Some paramedics in King County are single-role and others are with fire departments.  But the fire department paramedics in King County complete twice as much training as what is required nationally.  There are only a few of them, they do almost exclusively medicine, they are closely monitored, and only respond to potentially life-threatening calls.  This gives each paramedic a lot of experience managing critical patients and performing invasive skills. King County also has an extensive community CPR and AED program, which  Memphis apparently does not have.  Seattle regularly publishes their survival statistics, but I was unable to find Memphis’s anywhere.  Sorry Chief Ludwig, but unless you have Seattle’s numbers, you’re better off having a heart attack there.

Cardiac arrest survival is associated with paramedic experience level, as well as intubation experience with mortality.  High performing  Wake County EMS and MedStar, in Fort Worth, TX send one paramedic on every call, but send and additional Advanced Practice Paramedic to critical ones for this reason.

Memphis has about 500 firefighter-paramedics, and 1,100 firefighters are also EMTs. Since 2008, every firefighter hired by the department has been required to become a paramedic.

More flawed logic, but don’t take my word for it.  Mickey Eisenberg, Seattle’s medical director, literally wrote the book on cardiac arrest survival.  In Resuscitate!, he states:

”Dual training an individual to be both a firefighter and a paramedic, then expecting stellar performance in both jobs, reflects a hope based on what is probably a flawed concept…The point is that paramedics must be allowed to learn the skills they need and then to hone them as professionals. This is not to say that they can not work within fire departments, but only that, except in emergencies, they should not be asked to perform the duties of firefighters.”

A large number of paramedics who rarely get the opportunity to manage critical patients are difficult oversee and train.  It is easier for incompetent ones to be covered by someone else and slip under the medical director’s radar.  It is also difficult to adopt new treatments, such as 12-lead ECGs or airway devices, when hundreds of paramedics must be trained and few will use them.

Back to the DC AP article:

Phoenix began cross-training its firefighters as paramedics in the 1970s, and more than one-third of its 1,750 firefighters are paramedics.

“We recruited people into the fire department that were inclined to be paramedics,” said Dennis Compton, a former assistant chief in Phoenix and former Mesa, Ariz., fire chief. “The other thing we did is pay them for it.”

I believe that EMS and firefighting require different personality types.  There is overlap between the two, just like each has with law enforcement, and room for joint tactical teams.  In my experience, most firefighters do not want to be paramedics.  They become one in order to get hired by a fire department, or because they signed an agreement to become one after being hired by a fire department, or to get promoted on the fire side.  Then they get, what I hear some some describe as “stuck on the ambulance.”  Having a large number of firefighter paramedics to rotate between ambulances and fire trucks means that each one spends less time in the role they don’t want, not for the benefit of patients.

Fire departments that do EMS well do so in spite of cross-training, not because of it.  It is really, really hard to be a good paramedic if you’d rather have another assignment.  Paramedics need to want to learn in order to become good, which requires wanting to be one in the first place.  Very few EMS patients are really sick.  Paramedics must manage a lot of them in order to get good at it, or do hospital clinical time and simulation training as a substitute.   Ones who spend part or most of their work week on a fire truck hardly see any, and must split training time between fire and medicine.

If you want a good EMS system, do what the services that measure success on patient outcomes do, not just output.  A lot of paramedics on fire trucks who arrive quickly makes sense, but has not been shown to improve patient outcomes.  Using a small number of  specialized paramedics has.  Promoting anything else is just self-serving spin.

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