Many things have changed throughout my journey. My work setting has changed dramatically several times, but what has remained consistent is me. Sure, I have certainly grown and matured throughout my career, but my work ethic, professionalism and level of care has pretty much stayed the same.

In every setting I have seen exceptional care-givers and I have seen exceptionally bad care-givers. Every place I worked at had their strengths and weaknesses. Sometimes I agreed with their practices, and other times I didn’t. Over the years I have developed an opinion on what I feel is the “best” way to run an EMS system, and I know that there are plenty of people out there that disagree and most likely have equal – if not better – ideas than I do. I know that I’m never going to be 100% right, and neither will anyone else. What remains the same, is that we both care enough about the profession to share ideas and try to improve the industry.

One thing that has really stuck with me, was something my boss said to me before leaving my job at the metropolitan ambulance service: “No matter where you end up, don’t ever lower your standards”. I didn’t fully grasp what he was saying until I started both of my new jobs recently. During classroom orientation at the hospital, I quickly learned that the management practices are much different than what I’m used to. Not in a good or bad way, just different. Once I got onto the floor and started training, the human factor set in. Both places offer plenty of training resources, good protocols, and top-of-the-line equipment. And just like both places, there are those who choose to take advantage of it, and those that don’t. Most people care about the quality of care that they provide, but unfortunately, some people just do enough to stay out of trouble and bring home a check.

Now let’s look at the other side of the coin. The small, rural ambulance service I work for reminds me a lot of my first EMS job. Both companies don’t have the resources of the large hospitals or the metropolitan EMS systems. They may not have bleeding-edge technology, but their equipment is good, functions well and serves it’s purpose when caring for patients. Most of the EMT’s and Paramedics working on the trucks (a new term I picked up working out here in Texas) use the long transport times and limited resources as an opportunity to improve their skills and actually do some real hands-on patient care. And of course, there are the few that choose to use the setting as an excuse for “not being able to do their job”. Once again, completely different settings, essentially the same people working.

I guess where I’m going with this, is that it doesn’t matter what setting you work in. Whether it be fire-based, private-based, non-profit, 3rd-service, or volunteer, the decision to provide quality patient care is up to you.

Good patient care isn’t measured by your protocols or resources. It’s measured by compassion, competence, and the willingness to do what’s right for the patient. It doesn’t matter if you show up in a brand-new ambulance with all the latest equipment and aggressive protocols, or if your on the side of the road in your private vehicle with nothing but a first-aid kit. You can still provide quality care to the best of your abilities.

So, back to the previous statement about “not lowering your standards”. It doesn’t matter what system you work in, the decision to provide quality care is yours. Just because a service doesn’t require you to attend airway training doesn’t mean you shouldn’t practice on a dummy frequently. Your service might be very conservative on the amount of medications and procedures that are allowed in your protocols, but that doesn’t mean you can’t do a thorough assessment and treat your patients to the best of your ability. The same goes for appearance. You should always present yourself in a professional manner, regardless of the mandatory dress code or lack thereof. You may be able to get away with wearing a worn-out, faded uniform – hell, it may be all that’s available to you – but that shouldn’t stop you from ironing it every day and at least looking like you give a damn about your job.

If there is one thing that I have learned throughout my years in healthcare, it’s that management simply cannot force good or bad patient care. They can certainly influence it one way or the other, but the final decision rests with the provider on the ground.

As I was doing my daily read of the most recent EMS-related news headlines, I stumbled across this interesting article. To be honest I was taken back at first, because I have always wondered why all of the cities around the OC / LA area insist on responding so many paramedics to every call. The fact that they run ALS engines isn’t what gets me, it’s the fact they use private ambulances for transport and FORBID them from providing any ALS care. This of course requires a fire-medic to ride in to the hospital and have the engine or squad follow them to pick them up at the ER. Maybe I’m just ignorant, but it seems like they are doubling their work.

To me it seems that it would make more sense for the fire department to just provide the ambulance transport themselves. Staff a paramedic who doesn’t split his/her role with any other function on the ambulance and an EMT to drive. I will never be convinced that having 4 paramedics treating 1 patient is a good idea.

This particular article is intriguing because for the first time (that I have seen), they actually want to get away from their current system and let a private ambulance staffed with a single paramedic and EMT handle the patient care. While I typically endorse this kind of change, I think the city and county need to be fair to the tax-payers. Chances are, the citizens pay some form of tax to pay for the paramedic service that is currently in place. While such a move will certainly save money, it kinda screws the tax payers. If they go ahead with a switch to private-level service, then they either need to remove that tax, or reduce it accordingly. The whole purpose of contracting to a private pay-for-service model, is the savings in tax dollars to the public, not the general fund.

I thought that this was actually a viable option until I read that the city doesn’t attempt to collect on uninsured parties, and they would expect the private service to do the same. I can say with 100% certainty that this kind of policy WILL NOT WORK without government subsidies. If they are expecting that some private company is going to come in and willingly operate at a loss, then they have another thing coming.

I personally don’t think that such a change is going to happen without some fierce resistance. I applaud their ability to think outside of the box, but I have my doubts that they will actually make this happen.

http://www.jems.com/article/news/more-worries-over-florida-coun

If you haven’t been following this story, you should. The North Naples Fire District had their ability to provide ALS on-scene care revoked by the local medical director because of poor performance and their training not meeting his standards. OK, maybe there is more to the story then what the media tells us, but this sounds pretty simple to me. It’s his license. Either provide care and train to his standards, or don’t provide care.

I would think that the department would have taken this message and headed straight for the classroom. Instead, they spent their time raising their voices and eventually found a way to provide ALS service by bypassing the local medical-control system. Nope, let’s not fix the problem, we’ll just find a medical director who will let us do what we want.

I would be interested to hear what the people of that community have to say.

I’m usually all for private ambulance service as it saves tax dollars and is staffed with paramedics who don’t have their duties divided between fire fighting and medicine. I’m not really sure how a private fire service would work. I’m assuming they would rely on billing insurance companies for structure fires but what about everything else? Would they receive subsidies? If so would that defeat the purpose of switching to a private-based system?

This truly is a topic that I know nothing about. I’m really interested to learn more. If anyone has any experience working with private-based fire, please let me know. I would love to hear all about it.

http://www.omaha.com/article/20100908/NEWS01/709089874/1003154

Cost

Private-based EMS is the most cost-effective solution for any municipality. Ambulance companies operate at no cost to the tax-payers unless they actually use the service. In times of financial hardship, it just makes sense.

Contracts

Exclusive operating contracts comes with requirements that must be met in order to continue providing service. These include response time compliance, complaint resolution, QA programs, community service programs and in some cases, minimum staffing. There is a good argument that there is actually more oversight for private companies than public services.

Single Medic

Private ambulances typically run 1 medic per ambulance. This means that each medic does more skills, has more responsibility and runs more calls on their own. For skills like intubation, paramedics need to be performing it as frequently as they can. I do realize that single-medic systems are not unique to private-based EMS, but it is more common amongst those types of systems.

Single Function

One of the biggest reasons that I prefer a private-based ambulance service, is that paramedics employed by these companies are only working as medics. Their roles are not split up by other jobs like firefighting or law enforcement. On top of that, I don’t think that being a firefighter should be a prerequisite to being a paramedic in a 911 system.

I have a few articles out there arguing for private-based EMS systems. If you are interested, check them out.

privates-to-the-rescue

two-paramedics-are-not-always-better-than-one

Private EMS – The Stepchildren of public safety

So here it goes, my list of the “pros” to fire-based EMS.

Training

For the most part, fire crews are running less and less fire calls and more medical calls. This being the case, they typically do a lot of training for medical-related emergencies and drill often to try and keep their knowledge and skills up. This is something that many private providers have lacked for a while.

Funding

Fire departments have done a wonderful job of securing funds at the state, local and federal level for a long time. This allows for high-quality equipment, better salaries and more resources. In areas where the fire service also provides ambulance transport, they are able to bill for their services as well to increase revenue.

Selection

With high pay, good benefits and an unbeatable retirement package, fire departments have qualified applicants lining up for miles for a job opportunity. This of course allows the department to be more selective when they hire personnel.

Health and Fitness

Firefighting can be a very physically demanding line of work. So naturally, fire personnel must work hard to stay healthy and physically fit. Regular exercise is something commonly seen amongst the profession. This leads to better concentration and less chance of injury.

Non-profit

In order to write this section, I must take some time to lock my stubbornness in the other room so it doesn’t interfere….so hang in there a minute.

…..ok still there? Good, here it goes.

I will admit that there is benefit to making decisions concerning equipment purchases, in-field practices and system management when making a return on your investment isn’t a priority. This is why you will commonly see fire services take on new procedures and protocols with open arms. They don’t typically have to worry about reimbursement.

So there you have it. My list of pros to fire-based EMS.

Lately I have participated in many discussions regarding fire-based EMS. As we all know, there are very good arguments to both sides as to whether EMS should be run exclusively by the fire department. So rather than argue about whether or not it should be done, I am going to express my opinion on how fire-based EMS should be run.

Having worked in a single-medic service for my entire career, I tend to favor that type of system. I truly believe that 1-2 paramedics for each call is really all you need. Any more than that and you are just wasting resources. At minimum 1 paramedic on the ambulance would be sufficient. Depending on ambulance availability I suppose having a medic on the engine would be beneficial too. You can refer to my article “Two paramedics are not always better than one” for more on that subject.

I believe that the paramedics assigned to ambulance duty should play a single-function roll. It is very difficult to keep up your skills as a paramedic if your job responsibilities are split between patient care and firefighting. I also say this because I don’t believe that paramedics should have to become firefighters in order to practice in a 911 system.

One big problem with having multiple paramedics on scene is establishing who is in charge. It needs to be made very clear in writing who runs the show. I feel that this responsibility should be given to the transporting paramedic. If they are going to care for this patient all the way to the hospital and have to answer to the doctors and nursing staff, then they should have the final say in how the patient will be cared for.

Being the conservative that I am, I don’t really believe in “special taxes”. Having said that, I do believe that if a community wants to vote to impose such taxes to provide fire-based EMS services, then more power to them. If a special tax is imposed to provide the service, then the department should not be billing the patients. Departments that tax and bill their patients are just asking to be shut down and replaced by a private ambulance service who collects no tax dollars.

I truly do believe that efficient and effective service can be provide by fire-based, third service or private-based EMS, it’s just a matter of doing it right.