There are clearly those who feel every fire unit should be staffed with only paramedics. I can understand why this idea appears to have merit. After all, if every person on the unit is a trained paramedic, it would seem logical that the level of care would be much higher.
Yet, if we look at other professions, we do not see this type of professional overstaffing. You don’t see only doctors working in the Emergency Room. Yes, they are there, but so are many nurses and other technicians. If having only doctors on-duty in the ER would save lives and be more efficient, don’t you think it would be the norm or at least tried somewhere?
If every person on the unit is a paramedic, who makes the decisions on patient care? They can’t all do it. There has to be a hierarchy in place to make decisions as there is in every profession. Some people feel this decision should be based on rank. I believe patient care decisions should be made by the best-trained or most knowledgeable person available. This is not a group decision and shouldn’t be.
Strangely, I also believe the opposite can be true. I told my crew that on a medical response, if one of them felt we needed paramedics and they weren’t responding already, I would always request them. We were not going to sit on-scene and discuss whether or not we needed a higher level of care. The patient would not suffer if we could not agree. Right or wrong, this was a discussion for back at the station after the patient was treated.
No one likes to talk about the cost to staff only with paramedics, but it has to be part of the discussion. Beyond the initial cost to train them, which is much higher than firefighter training, are the higher salaries they require. Depending on where in the country you reside, the salary difference can be significant.
I would venture that the average paramedic makes about 15% more than a firefighter, and if that estimate is correct, then for every six to seven members who are paramedics, you could hire one additional firefighter. This means that if you currently staff with 24 paramedics, you could hire three additional members and keep the two or three paramedics.
How would you like to have an additional ambulance available for the same costs? Would this provide more or better service to your community?
There is also the cost to maintain their paramedic certification. While the fire service continues to discuss the need for re-certification, paramedic re-certification has been in place for almost 50 years.
The one person I don’t see in any discussion of how many paramedics we require on a unit is the doctor who’s medical license the paramedics work under. I would expect doctors to have a greater say in how many paramedics are on a unit. They are usually not in charge of the fire department personnel, but without their medical license there is no paramedic program.
The fire service continues to debate the need for re-certification, yet we already have an on-going in-service training program. Obviously, this training program is not the same in all fire departments—nor should it be—but it is present in most if not all fire departments.
My fire department’s mandatory two hours of training each shift was about all that could reasonably be done by all units. Between alarms, station and apparatus maintenance, building inspections, and meal time and rest, there was little time for additional training. This was at the average station while at the very busy stations even these items had to be prioritized, as there was not always time for everything.
Imagine adding re-certification at the paramedic level to an already busy schedule. I saw how difficult it was for our paramedics (who do not ride fire apparatus) to meet their requirements starting with X number of IV’s and X number of intubations each year. I can’t see how a department having all members trained as paramedics could possibly maintain their skill sets in both medicine and fire training at the appropriate level.
Talking about money also brings up the subject of equipment for all these paramedics. Having units with paramedics on board would necessitate having all the equipment found on a paramedic unit with the exception of a stretcher. Along with the equipment is the maintenance and availability of replacement equipment and supplies. These resources must be available to replace broken or expended equipment and supplies at a moments notice.
You can’t have a medic unit with a broken defibrillator or one that is out of IV fluids. This is a large cost and a nightmare to administer. And we have not even talked about the controlled drugs. Just to give you a comparison: My city of over 500,000 had seven two-person medic units. We also had 44 engines and trucks. Can you even imagine the problems of having 44 caches of equipment and controlled drugs accessible to over 1,000 members to account for? The costs are staggering but the maintenance is almost unattainable. With only 15 paramedics available each shift we were able to establish the highest cardiac save rates in the nation.
We talked about who will make the decisions when an engine has only paramedics on board, but what about the scenario when there is only one paramedic? Obviously the paramedic would make the patient care decisions, but what about the other members? We as a whole are dedicated civil servants, but in this scenario there is little to push us into maintaining our EMT skills. After all, the paramedic will be making all the decisions and telling us what to do, so why should we spend a lot of our time trying to learn and keep current with our EMS skills? We will never diagnose a patient on our own. We’ll still be there but only following orders and not making decisions.
There is also the issue of competence. It’s unreasonable to think every paramedic will be 100% proficient in all areas. This is where having another paramedic there to discuss the treatment options is a great benefit. Let’s face a simple fact: Not everyone is 100% proficient in every aspect of their profession. You may be great at diagnosing a heart rhythm but have trouble quickly converting an 8-year-old's weight to kilograms to determine the correct amount of a life-saving drug.
Having the ability to discuss treatment options with another paramedic is important and should not be disregarded. The added stress of having only one member always making the decisions is both bad for the patient and for the paramedic.
Another issue is the ability to accomplish multiple tasks simultaneously. You can easily see where one paramedic is starting an IV and a second is getting ready to put in an endotracheal tube or talking to the doctor. I believe this is one of the reasons some people think it is better to have all members trained as paramedics.
So there are issues to be addressed with either response model: all paramedics and only one paramedic. Perhaps the answer lies somewhere in between these two options.
Many jurisdictions try to hire people who are citizens of their communities in both the fire and police departments. Now there are many people in your community who are well qualified and have the ability to become a firefighter but who do not have the desire (for a number of reasons) to become a paramedic. Their reasons are unimportant. The fact that they can’t get hired within their community is important.
We hear many politicians saying they want their local fire and police departments to represent those who live in the city and then they hire only those who are or can become paramedics. Telling anyone they must become a paramedic doesn’t produce the same quality of paramedic as the one who actually wants to be one. It’s just human nature.
“I live here and I want to become a firefighter so even though I don’t really want to, I will be trained as a paramedic. Since everyone is a paramedic, all I have to do is pass all my tests and let the others do all the hard stuff. I just want to stay in my city and become a firefighter.”
Does this sound like the person you want to be there to try to save your life in a medical emergency? The best analogy I have heard is that maybe the police should make all their new recruits pass all the rigors of the SWAT team. In this way, they would not need to have a specific SWAT team. Just call any officer on-duty. Let’s see how that would go over in a police department.
When you hear your community leaders suggesting all you need is more paramedics on duty to have a safer city, you should beware. You may actually need more of them, but what is most important is having an actual Emergency Medical Response system in place. This system must be such that it can be regularly evaluated, regularly modified and or updated, and expanded as the need arises.
These changes should come from within the agency, not solely from community leaders. We go through a lot of time, trouble and expense to hire qualified fire chiefs. Shouldn’t we allow them to run their departments?
So when you review your department structure, perhaps a key question is if you should have more or fewer paramedics?