Although some departments have been organized to provide emergency advanced life support (ALS) care from engines, this concept is still not fully understood or accepted by many agencies. This article will discuss the reasons for and the benefits of adding ALS care to the duties of the modern fire company.
Since it was founded in 1903, the Dothan Fire Department has provided fire protection and emergency services to the community. The citizens support the department and are interested in the matters of strategic direction. In fact, several times per month a member will make a formal presentation to a civic group and talk about the department's future plans.
In 1977, Dothan's first paramedics were trained at the University of Alabama at Birmingham. Back home, they were placed in service on a small rescue truck. At the time, this was a ground-breaking event.
The department operates out of six fire stations with an all-career roster of 144 members. Three fire stations are under construction with a completion date of late October 1997 one station is to replace a dilapidated, poorly located company and the other two are new locations. At that time, the force will be increased by 30 new hires for an assigned strength of 174 members. Each station will operate with a four-person engine that will be converted to a paramedic unit as time allows. Four new rigs have been received or on order. Five existing engines will be retrofitted to deliver paramedic care. This will let the department maintain one spare paramedic engine along with a reserve fleet of three other basic life support (BLS) engines. (The department also has two ladder trucks, various support vehicles and an on-duty battalion chief to supervise each tour).
Why The Change?
The fact that attracted the senior staff to consider and study the change to paramedic engines was the need for rapid delivery of advanced emergency medical care. Under the previous system, three rescue trucks delivered ALS citywide. This system served the city well for many years but response times crept upward as the city became more populated and larger through land annexation. In 1995, the department was able to arrive on location in less than six minutes on only 66% of the calls for emergency medical service.
The immediate fix was to outfit all existing engine companies with BLS equipment and dispatch them to nearby emergency medical alarms. This was easy to accomplish, in that nearly all members were nationally registered as basic EMTs. The difficulty was procuring the needed equipment and changing the computer-aided dispatch system.
By letting all six stations participate in EMS responses rather than only three of them, the average response time dropped by more than two minutes. Once the system is fully implemented, the department will set a goal of a six-minute response time citywide 95% of the time.
The department targeted the American Heart Association (AHA) model of delivering medical intervention within four to six minutes to prevent permanent brain damage. The AHA standard identifies the range of six to 10 minutes as the window for irreversible brain damage. Beyond 10 minutes, death is reported as imminent. The department wants to be able to intervene and stop the dying process (if humanly possible) within six minutes. The only way that this can be accomplished is by having paramedic units strategically located throughout the city increasing the three ALS locations to eight service delivery points. (This information went a long way toward securing the political and financial support to implement these changes.)
Another benefit of entering into the world of paramedic engine companies is the unity and harmony of the work force. Over the years, two classes of people had developed "fire medics" and "suppression men." The cultural value was that there would be only limited crossover opportunities. In fact, the department had organized by divisional lines to have a fire medic division of just 18 people. The separation was supported to the point that different shoulder patches were worn by the two groups.
By ensuring that all members are cross-trained to participate with all aspects of the workload, the department began to unify. All members are allowed to and encouraged to compete for promotional positions, rather than being stuck in one role or the other. Emphasis is placed on qualifications and capabilities for upward mobility purposes. Past practices would limit a member's potential based on divisional lines. For instance, some of the older medics tell stories about never being able to be promoted or leave a rescue truck assignment due to the shortage of paramedics. The new system blends them into one division with only one shoulder patch boasting equal opportunity for all.
The next advantage is the increase of on-scene personnel at 80% of incidents. Like most fire departments that provide EMS care, the call load breakdown is about 80% medical and 20% fire and other alarms. By en-suring that all members participate in the entire range of service delivery calls, Dothan has two additional sets of hands to help.
No one has been forced to become a paramedic but there is a pay incentive of 9%. The EMT-qualified members handle the BLS support care for the medics. The confidence levels of the EMT members have increased based on the opportunity to deliver this level of medical care much more frequently. This change has renewed many members' sense of purpose and belonging. Also, they are able to have a greater level of contact and interaction with customers in need of their help.
Program Costs
As startup costs were evaluated, the apparatus and equipment upgrades had the highest price tags. Each paramedic pumper cost just over $200,000 and the additional ALS gear was purchased for $15,000 per company. The five engine conversions will cost about $20,000 each.
This may sound like a lot of startup funding but the bottom line will be a substantial savings. Each paramedic engine will replace one rescue truck, reducing staffing by two members per unit per shift. The recurring cost of these positions, with benefits and equipment, is $700,000. But keep in mind that the on-duty shift strength will increase with the addition of two more four-person paramedic engines (eight additional members). This is a win-win proposition for the department and the city. The staffing will grow to include promotional slots with an overall cost savings by the better use of resources.
Another driving force behind this plan was a reduction of the department's ISO classification. The department had enjoyed a class 3 rating for a long time; with the last rating, the city went to a class 3/9 split rating. The areas in the city that were beyond five miles from a fire station or beyond 1,000 feet from a fire hydrant ended up in the class 9 district. More than 290 of the city's nearly 23,000 homes fell into the class 9 area. The three new fire stations will provide the required coverage.
Well over 40 miles of water lines are being installed by our city's water and electric department. The city realized a significant savings of several hundred thousand dollars by having the water and electric department perform most of the design and supervision of the water extension. Once the water line is in and the fire stations are operational, the ISO will be asked back in to re-evaluate our fire protection rating. A uniform rating of at least class 3 citywide is desired. By maintaining the ISO rating of class 3, the department will be able to save over $14 million per year in insurance premiums. Couple the news of monetary savings with better and quicker service and you have the ingredients for overwhelming public support.
Fire apparatus was designed with the delivery of fire and ALS service in mind. Once the basic concept was put to paper, several trips to the manufacturing plant were in order. The stock rigs used for a similar purpose were described as "rescue engines." They were larger (longer and higher) than we wanted. Also, this style engine was beyond the target budget cost per unit.
After spending several days designing and redesigning, the department had a specification that would work for it. The major modifications were a large, locking ALS equipment box added in place of the crew cab bench seat (four members can be seated and belted in the crew cab rather than the designed six). Right-hand high side compartments were included in the blueprint to provide much-needed storage space. Several dozen other design changes were made.
Members were asked for input to design these paramedic engines based on need and function. As much as possible, their input was included in the final design of these vehicles. The belief was "…apparatus designed by the members, for the customers." By giving the members significant input into this major project, the acceptance level has been very high for the change to paramedic engines. And the quality of the decisions has been better based on the team approach rather than the closed "chief-only process."
Conclusions
With any significant change, there are concerns and questions. For Dothan, there had been little change in the way it delivered EMS in the previous 20 years, so one can imagine the unsettled views that were held by some members. These concerns were addressed and brought to resolution for the vast majority of the department. The system will not be able to move ahead of the people, so getting the issues addressed took priority.
The first item was the overall response time of standard-size apparatus vs. smaller rescue trucks. The department enforces a policy of never driving more than 10 mph above the posted speed limit. Also, apparatus must obey stop signs and red lights and ensure that all other vehicles are accounted for before proceeding through an intersection drivers never make up response time on the roadway.
The cost issue surfaced several times, with contentions that the paramedic engines will waste money. This is not true. The initial startup costs are only slightly higher than the costs to outfit an engine. The city needed to buy four engines to open new stations and update a broken-down reserve fleet. The extra money for paramedic equipment is about $15,000 per unit. The cost reduction in not buying and maintaining two vehicles (an engine and a rescue truck) is a significant savings in tax dollars. However, the real savings come from the proper utilization of personnel. By letting capable and willing paramedics participate in fire duty and the reverse for firefighters answering medical alarms, the city saves a small fortune.
The last issue that surfaced dealt with the claim that fire companies are too busy to take on the extra EMS work. This too is unfounded. The busiest fire companies in this country are tied up on emergency responses about 10% of their time. By no means will Dothan's companies come close to this average; they are closer to the national average of 3% to 5% of the time being engaged in response to alarms. In fact, it only makes sound business sense to use this available resource to provide ALS care.
The concept of switching over to paramedic engines is based on the need to add more firefighting resources with the least cost impact. The direction to make the change to paramedic engines is based on providing a better service to the department's customers at a lower cost.
Informing the community of the reasoning behind the decision and the cost savings directly to them has served us well. We have the support that this needed to make nearly $6 million of capital improvements in an 18-month time frame. The long-term savings to the community will far outweigh this startup cost. I'm certain there are a few firefighters who are not happy about this transition. But allowing the members to have as much input as possible and giving them detailed information about their future have kept the vast majority of them solidly behind these changes.
Fire departments must take risks to seek opportunities to better serve their customers. Better utilization of resources in its principal area of responsibility seemed like the most logical avenue for the Dothan Fire Department to follow. The one thing that is certain about the future is that there will be change.
Dennis L. Rubin, a Firehouse® contributing editor, is chief of the Dothan, AL, Fire Department.
