Up until the mid-1960s, “ambulance” operations in St. Paul, MN, were conducted either by the police department or the coroner’s office. In 1967, primarily because no one else wanted to do it, the St. Paul Fire Department (SPFD) took over the ambulance service in the city. Basic first aid was provided to the patient during transport to the emergency room in an adapted International station wagon. The extent of life-saving measures: driving fast to the hospital.
Although the department’s first step into EMS resulted because no one else wanted to provide the service, the SPFD embraced EMS and now strives to stay on the cutting edge of technology and care.
A super idea
Taking a cue from the Miami, FL, Fire-Rescue Department, which trained firefighters to become paramedics as far back as 1966—as well as from the once-popular TV show, “Emergency”—the SPFD sent three members to Long Beach, CA, in 1972 to be trained as paramedics. In 1973, SPFD provided the first ALS services in Minnesota when Medic 4 and Medic 14 went into service. SPFD’s goal was to provide ALS services on Engines 4 and 14 by “dual-staffing” the two apparatus. The four-person crew of the engine would move over to the medic rig when they received a medical call and respond on the engine when they received a fire call. This system stayed in place until 2009, when the concept of Super Medics was added to the system.
With a constant increase in medical calls, the city’s engine companies were found to be out of service more often due to the medic rigs being out on calls. The Super Medic program addressed this problem by staffing the engine company with six personnel: a captain, a driver and four firefighters (a minimum of two paramedics were in this configuration). A medic rig was assigned to the engine, and two of the firefighters (including one of the paramedics) were placed on the medic rig while four individuals stayed on the engine. When a low-acuity medical call came in, the medic rig would be dispatched, keeping the engine in service. If a higher acuity call came in, the engine would be dispatched with the medic rig. If, after evaluating the patient, it was determined that the medic rig didn’t require additional assistance, the engine could go back in service, once again keeping the engine in service more often. If, however, the call came in and it was a shooting, cardiac arrest or other very-high-acuity call, then six individuals went on scene to assist the patient, and as many as five individuals were in the medic rig during transport to the emergency room. As well, when the engine was dispatched to a fire, the medic rig would accompany with turnout gear and SCBAs. With both units assigned to the fire, there would be six firefighters on scene. The Super Medic program is an effective way to provide ALS services to the public while keeping engines in service more often.
Today, each of St. Paul’s 15 fire stations houses an assigned ALS medic rig. Three stations have Super Medic rig staffing; the other 12 run the dual-staff concept.
Focused on the future
In 2009, the SPFD launched its EMS Academy. Individuals ages 18 to 24 who live in St. Paul and meet income restrictions are paid to attend an EMT course. The goal: EMT certification. (The fire station where the students attend class is called Station 51, in honor of the station in “Emergency.”)
Because one of the first questions that any employer asks during an interview is, “What kind of experience do you have?” the SPFD established a BLS transport program, which utilizes the new EMTs to transport patients who are discharged from the hospital to their residence. This provides the new EMTs with experience and sets many of them on a path to careers in fire, EMS and law enforcement and to nursing and medical school.
The BLS program today includes two ambulances, with the capability to respond to a 9-1-1 scene and to transport BLS patients after they’re evaluated by an ALS crew. This allows the ALS crew to get back in service quickly. If the medic rig on scene was a dual-staffed company, the engine also is put back into service more quickly.
From the EMS Academy program, the Fire Medic Cadet program was developed. Here, individuals are hired full time and are required to get their paramedic, Fire I and Fire II certifications. This provides to them a pathway to become a sworn member of the SPFD. Fifteen graduates of the EMS Academy are members of the SPFD. Other graduates went on to become police officers, 9-1-1 dispatchers, private ambulance attendants and registered nurses. In 2019, one graduate received his white coat from the University of Minnesota Medical School. The EMS Academy program has been so successful that, in 2019, Ramsey County, which includes St. Paul, opted to partner with the SPFD to run a second EMS Academy each year. The addition of the second class allows not only St. Paul residents but all Ramsey County residents to apply to attend the course and to receive EMT training.
Responding to a shortage
In 2014, the SPFD experienced a shortage of paramedics. To solve this, the department converted the EMS Academy classroom into a paramedic classroom and put several of the department’s firefighters and some BLS EMTs through paramedic school. The SPFD purchased SIM Men, which still are used today, to keep up on intubation skills, ACLS, PALS and basic cardiac-arrest management. Not only did the department gain paramedics immediately, but every BLS employee who attended the course went on to become sworn firefighters on the SPFD.
In 2018 alone, the SPFD responded to more than 47,000 9-1-1 calls. The writing was on the wall. The department’s run volumes increased dramatically year after year, and there were no signs of it stopping. As run volume grew, the department’s fire apparatus spent more and more time out of service while attending to medical calls. In addition, every medical call was being responded to by an ALS rig, regardless of the acuity. In response, on Sept. 30, 2019, the SPFD put into place the operation of three BLS rigs, running out of fire stations, that would respond to low-acuity, or alpha, BLS calls. Today, each BLS rig responds to approximately 10 BLS calls per day, which takes the strain off of the ALS medic rigs and the associated fire apparatus. Although the staff who are assigned to the BLS rigs aren’t sworn firefighters, they are members of IAFF Local 21 and are considered essential employees. One of their most critical functions is responding to fires and setting up firefighter rehab under the supervision of the on-scene ALS medic rig that’s assigned to the fire.
Above and beyond
The SPFD has been blessed with an active and enthusiastic EMS program since it took over emergency transport from the St. Paul Police Department, but it doesn’t stop there. The SPFD has a medical director and three assistant medical directors. The medical director, Dr. R.J. Frascone, likes to brag that he has been the medical director for nine fire chiefs. During those years, he pushed the SPFD to grow.
Because of the medical directorship’s trust and unbridled energy, the SPFD has stayed on the cutting edge of technology and training and is a front-runner in studies. The department participated in the first and second study for the ResQPump and the ResQPod. These studies proved that negative pressure during CPR provides better blood flow to the brain, which significantly improves the outcome for the patient.
The department studied field lactate evaluation and its effect on sepsis survival and field EEGs during cardiac arrest. The SPFD was a primary agency in a study of extracorporeal membrane oxygenation, or ECMO, where individuals in refractory ventricular fibrillation cardiac arrest are taken into a cath lab. The results for this study are so dramatic, with survival rates upward of 40 percent, that it’s now a standard care in the Twin Cities, and a mobile ECMO vehicle is being developed.
The department’s medic rigs carry intraosseous infusion, or IO, equipment, Lucas CPR devices and C-MAC video laryngoscopes and perform rapid-sequence intubation in the field. Working under guidelines from medical direction, on-scene paramedics are allowed to use their discretion in activating the cardiac cath labs and stroke CT scans, bypassing ERs.
One of the directorship’s assistant medical directors, who is an emergency room staff physician at a local Level One trauma center, tells his new residents that if they can’t find something just call 9-1-1, and the SPFD will respond with it. Although he says this jokingly, the ER used the SPFD’s EZ-IO and Lucas device on occasion.
Because the SPFD encounters more than 37,000 medical patients per year, and because their medical directors work at a Level One adult and pediatric trauma center—which also is a stroke and cardiac center—the department continues to participate in studies that affect EMS.
The department also benefits from its robust relationship with the medical directorship, because two of the doctors also serve as medical directors for medical support to Minnesota Task Force 1, Urban Search and Rescue Team (MNTF1/USAR) and took all of the training for the USAR program, including crawling in a concrete pipe and being flooded out. One individual in the medical directorship office is on the SWAT Medic team, and it’s a natural fit. He developed one of the first tactical emergency medical services (TEMS) training programs in the state in the 1980s and provided TEMS support to the FBI, the Minnesota Bureau of Criminal Apprehension, the Minneapolis Police Department and the St. Paul Police Department.
Although the SPFD provides ALS and BLS ambulance coverage to St. Paul, they also provide numerous offshoots of the program and teams. TEMS coverage is provided to the St. Paul Police Department via a 14-member SWAT Medic team. This team was established in anticipation of the Republican National Convention that was held in St. Paul in 2008. The SWAT Medic team trains fire and police personnel in active-shooter response and supports the Mobile Field Forces during times of civil unrest. The SPFD also provides medical support to MNTF1 and is an integral part of the Minnesota Air Rescue Team, which flies with the Minnesota State Patrol and has statewide responsibility for Air Search and Rescue. This team performed many rescues throughout the state and recently was the first team on scene for a fatal Air National Guard helicopter crash. The SPFD also is the state Chemical Assessment Team, and where the hazmat team goes, so goes the SPFD medical support.
Although the SPFD provides many new and expensive tools that enable the department to do its job, the most valuable tool that the department has is its personnel.
Kenneth Adams
Kenneth Adams is a deputy fire chief with the St. Paul, MN, Fire Department. He has been the deputy chief of EMS Operations since 2019. His professional background in the fire and EMS service extends back 20 years. In his current position, Adams is responsible for operations oversight, policy/procedure development and administrative functions.
