Recent debate in Washington, DC, and other places around the country centers on whether a fire-EMS system is best served by cross-trained, multi-role firefighter/paramedics or single-role paramedics who are not firefighters.
To understand the debate, consider making something from wood. I would not hire one person to carry the wood, another to measure the wood, another to cut the wood, another to hammer nails into the wood, another to hold the nails as they are hammered and another to sand the finished product. I would hire a carpenter, because hiring a carpenter who can do multiple tasks is operationally and financially efficient. The same can be said for a firefighter/paramedic. A paramedic who is also a firefighter is trained in multiple disciplines and is also operationally and financially efficient.
Utilizing cross-trained, multi-role firefighter/paramedics produces the highest level of EMS delivery, the most efficient use of resources, and the most beneficial system for employees, management and, most importantly, the public (your customers).
EMS is a system. The delivery of EMS is just not an ambulance showing up at someone’s door and taking that person to a hospital. It is an integrated design commonly referred to as a “chain of survival.†The first link in the chain is a dispatcher taking a 911 call, assessing the situation through an objective criteria-based protocol and then, if necessary, providing pre-arrival instructions to the caller. The second link is a first responder, often on a fire apparatus, showing up on the scene and providing definitive emergency medical care. This can be done with basic life support (BLS) such as controlling bleeding or splinting a fracture.
Many EMS systems, however, have transitioned to the delivery of advanced life support (ALS) care by the first responder. An ALS first response involves one or more paramedics assigned to an engine or ladder company who arrive before the ambulance, bringing equipment such as defibrillators, heart monitors and life-saving drugs. The earlier the intervention by a paramedic with life-saving equipment, the better the chance of reducing mortality and morbidity among critical injured or ill patients. That point is important to remember. Countless studies bear out this fact. The sooner you can “stop the clock,†the better the survivability of the patient. In essence, the paramedic with life-saving equipment on the engine or truck can deliver the same level of care and perform the same the procedures as a paramedic assigned to an ambulance, except for the ability to put a patient on the stretcher and transport him or her to a hospital.
The single-role paramedic who is not a firefighter represents a one-dimensional system with many disadvantages to the operation of an EMS system. The EMS systems I have seen that are one dimensional with single-role paramedics logged longer response times, huge overtime payouts, high injury rates, high sick-leave usage, low morale and disgruntled employees. All of these issues can affect the delivery of patient care and place financial constraints on the community or department. Employees are not policy makers; they are usually the instrument of that policy.
Experience around the country has shown me that there are demonstrated benefits to EMS systems in which paramedics are cross-trained and perform multiple roles. Besides working on the ambulance, a firefighter/paramedic can also be assigned to an engine or truck company. When everyone is a firefighter as well as a paramedic, there is continuity of administration and the same medical direction, operating procedures, training, quality-assurance processes, equipment and incident command system, which all results in continuity of care when the patient is transferred from the first responder on the scene to the firefighter/paramedic who is treating and transporting that person to the hospital. In many systems, if the patient is critical, the firefighter/paramedic from the first responder ALS engine company will supplement the paramedics transporting the patient to the hospital by going in the ambulance to provide another pair of hands.
Another key critical component of running a highly effective EMS system in an especially busy environment is the need to rotate paramedics off busy ambulances. Paramedics who are one dimensional and are not cross-trained as firefighters cannot work on engine or truck companies. Thus, historically in cities where a third-service operates, those paramedics seem to burn out more quickly and frequently.
Soon, it’s my hope, in communities where there is a fire-based EMS system and the paramedics are not cross-trained as firefighters, change will occur to allow that to happen.
Gary Ludwig, MS, EMT-P, a Firehouse® contributing editor, is a deputy fire chief with the Memphis, TN, Fire Department. He has 28 years of fire-rescue service experience, and previously served 25 years with the City of St. Louis, retiring as the chief paramedic from the St. Louis Fire Department. Ludwig is vice chairman of the EMS Section of the International Association of Fire Chiefs (IAFC), has a master’s degree in business and management, and is a licensed paramedic. He is a frequent speaker at EMS and fire conferences nationally and internationally. He can be reached through his website at www.garyludwig.com.
