Firehouse World in Los Angeles is the West Coast’s premier stop for high-quality training and education. For those who can’t make it to the show this year, we’ve compiled information from some of the educational sessions. Seek out additional information from the show at Firehouse.com or on social media using #FHWorld19.
EMS & Public Health: A Forced Marriage or Natural Union?
By Marc Eckstein, MD, MPH, FACEP, FAEMS
EMS call load has increased exponentially over the past few years and is projected to continue. Fire departments’ traditional responses have been to send more ambulances and engines to address this call load. This is model is inefficient and unsustainable.
The Los Angeles Fire Department (LAFD) is one of the largest providers of acute, unscheduled healthcare, receiving over 1 million 9-1-1 calls and responding to nearly 400,000 prehospital medical incidents annually.
A recent growth in calls for help includes disproportionate use of EMS among low-acuity 9-1-1 callers, vulnerable adult super-users, patients with acute mental health needs, patients with substance use disorder, and a growing cohort of seniors. The underlying drivers of 9-1-1 use for many of these groups include social isolation, undiagnosed mental health problems, poorly managed chronic diseases, lack of access to primary/preventative care, tenuous personal savings and housing status, and difficulty navigating a highly complex system of social resources, even at a time when more patients actually have insurance and are eligible for additional services that can keep them healthy at home. These increasing demands are really in the realm of public health, as opposed to the traditional focus on time-critical emergencies.
EMS provider agencies need to be creative in their approach to these growing public health demands.
There are innovative programs currently working to provide the right resource at the right time and deliver those resources to these vulnerable patients. These programs allow departments to keep their fire resources and paramedic resources available for the time-critical emergencies for which they are trained while helping a growing segment of society in need.
The first-ever LAFD SOBER Unit—the Sobriety Emergency Response Unit—was implemented in November 2017. It is staffed by a firefighter-paramedic, a nurse practitioner and a case worker. To date, over 750 public inebriates have been medically cleared in the field and transported to a free-standing Sobering Center. At the Sobering Center, these patients can safely metabolize the alcohol and are offered a variety of services, including detox and transitional housing.
The Advanced Provider Response Unit (APRU) is a novel prehospital resource that is staffed by a firefighter-paramedic and an EMS advanced provider (a nurse practitioner or physician assistant). The APRU medically clears patients with behavioral emergencies and transports them directly to a Mental Health Urgent Care Center, where these patients receive immediate professional mental health counseling.
These are just two examples of a paradigm shift, whereby the LAFD is sending a specialized resource to meet the needs of this growing number of vulnerable adults. The traditional model of dispatching fire companies and paramedic ambulances to patients with chronic medical problems, substance abuse and mental health crises is not sustainable and does not provide the right care for these patients. With these public health calls comprising a growing number of EMS responses, fire departments must think outside the box and devise new delivery models to best suit the changing needs of the community.
Dr. Marc Eckstein is the medical director and the commander of the EMS Bureau of the Los Angeles Fire Department. He is also a professor of emergency medicine at the Keck School of Medicine of University of Southern California. A former New York City paramedic, Eckstein has 30 years of experience in EMS and he is the recipient of numerous awards recognizing his efforts and innovations, including the Firehouse Thomas Carr Community Service Award.
The “Occupied” Vacant
By Brian Butler and Xavier Ricci
Fires in vacant buildings are dangerous jobs that have resulted in the death and serious injuries of many firefighters across the country. Vacant buildings were always thought to be an inner-city problem, but we are now seeing many vacant and abandoned residential and commercial properties in suburban and metropolitan areas.
Most of these vacant buildings are abandoned, derelict, dilapidated or damaged from prior burns, with current occupancy and interior conditions unknown. These jobs require some alternative tactics, especially during entrapment of squatters, vagrants and other trespassers.
There are many signs of illegal occupancy present when arriving to a burning vacant—information that will have a significant impact on strategy and tactics.
First-arriving officers must make it a priority to note the major on-approach size-up indicators that the building is giving you to help with decision-making. Most derelict structures have long reflex times, and if there’s entrapment, there’s very limited time, if any, to attempt a rescue. A proactive rapid-intervention team (RIT)/firefighter assist and search team (FAST) should be ready to go as soon as entry is made.
If the building is illegally occupied with credible evidence of entrapment on arrival, a rescue attempt must take place, whether it’s a methodical, cautious attempt in a structurally sound single-family home or a creative, unorthodox attempt in a dilapidated commercial building. Accomplishing that while ensuring firefighter safety, gaining entry to fortified properties, and locating any victims inside will be a major challenge. In addition, lack of resources or staffing, coupled with unknown hazards inside, add difficulty to the task.
Some major concerns when arriving to a burning vacant structure include life hazards, collapse and forcible entry challenges. There are many unknown interior dangers waiting inside for advancing firefighters, such as holes in the floors, drug needles, hoarding conditions, blocked secondary egress routes, and vertical fire spread, to name a few. Firefighters must be prepared and aware of the challenges when arriving to a fire with entrapment in these buildings. There is no one-size-fits-all strategy for these jobs, and critical decision-making must be addressed quickly.
Additionally, firefighters must understand the effects of urban mining (scrap, theft, vandalism) and its impact on vacant and abandoned structures. This cannot be ignored, as it contributes to fire spread, accelerated collapse, open vertical shafts, and other interior dangers that injure firefighters.
In the end, the keys to successful operations include conducting relevant size-ups, operating multiple saws, using what I call “CHASE [Collapse Hazard and (Structural) Stability Evaluation] reports” and watching for interior dangers, all combined with aggressive and safe searches for trapped illegal occupants.
Brian Butler is a fire captain in the city of Trenton, NJ. He is also a member of King of Prussia, PA, Fire Rescue in suburban Philadelphia. Butler serves as a rescue/hazmat technician with the Southeastern Pennsylvania Regional Technical Rescue Task Force and Hazmat Response Team and is a level 2 fire instructor.
Xavier Ricci joined the Stockton, CA, Fire Department in 2008. While spending most of his career on the truck and the rescue company, he now drives Engine Company 9 in Midtown Stockton. A member of the USAR team since 2009, Ricci is an alumnus of Sacramento State University, where he majored in organizational communications.
Tactical Decision-Making
By Phil Jose
Discussing tactical decision-making is probably the best part of being in any firehouse around the country. Sit at any beanery table, throw a magazine down or put a video on the TV, and the discussion will begin. Each of us brings a unique outlook to a tactical discussion based on our department, our education and our experience. The great thing is that decision-making is a skill, and like any skill, it can be sharpened with practice and review.
Each firefighter relies on experience as the basis for making first-in decisions. Decisions at the strategic, tactical and task level rely on the “slide tray” of the decision-maker—the visual memory and subconscious recollections from past experience. First-in decisions are, by nature, recognition-primed decisions (RPD). Some characteristics of RPD decisions are:
· They are based on limited information
· There is some, maybe a lot, of uncertainty about critical information
· The decision-maker experiences time pressure
· The situation itself is dynamic
· The outcomes represent high-risk for both civilians and firefighters
These are the decisions you make every day. Recognizing RPD as a skill, you may ask yourself how to practice this skill every day?
To practice RPD decisions, create a decision-making training environment. You can do this by selecting a video, photo or even a whiteboard drawing representing the type of fire you wish to be the focus of your decision-making exercise. Let’s use a video as an example for setting up an RPD decision-making scenario for a garage fire.
Select a video of a one-story, single-family residence with a garage fire. Collect a couple of like-minded firefighters or officers around the screen and designate one person to be the first-in decision-maker. Now, start the video, let it run for a few seconds, then stop it. Simulate the arrival process, providing a short window to collect information from the video. Now, have the first-in explain tactical deployments for the first couple of units. Take note of their decisions. Then go back to their first decision and discuss the strengths, weaknesses, information collected and any missing information.
Use this format to discuss among the group, digging into the information or decisions so that you better understand the decisions and how they were made. Then do it again with another video and another first-in decision maker.
A regular pattern of conducting tactical discussions breeds a depth of understanding, builds trust, and fosters effectiveness across your fire department. Recognition-primed decision-making (RPDM) is a skill. Use this method as a template to develop your ability to train this skill. Take the opportunity to learn from others as you create a learning environment in your department.
Deputy Chief Phil Jose is a 30-year member of the Seattle Fire Department. He teaches nationally on reading smoke, tactical decision-making, instructional craftsmanship, and air management. He co-authored “Air Management for the Fire Service,” and was awarded the Tom Brennan Training Achievement Award.
