Fire Based EMS Not Efficient? Really?

Thanks to the folks in the recent Santa Clara County Grand Jury, we now have positive proof that fire based EMS delivery using fire trucks is inefficient.




I was worried we would never discover the problems draining tax payer dollars.  Did they know we've known this for nearly 20 years?  All they had to do was call me, or just google it even.  Instead tax dollars were used to show tax dollars are being used inefficiently.

I guess all the murders, robberies and other court cases are all finished there in Santa Clara.  Good thing they don't have a baseball doping case to worry about.

What the grand jury failed to do, perhaps it is not in their interests, is look beyond the "retirement costs" and perhaps look at the system and how to deliver what our pal Chris Kaiser dubbed EMS based EMS.  Looks like Santa Clara needs to stop and rethink things, then start from scratch.  Someone suggested that once...but I digress.

This grand jury report will be cited by every union basher come election time in an effort to privatize public safety accounts and likely not lead to any changes in the delivery of first response EMS in Santa Clara County.

The report fails to mention that the local private provider does not have enough resources to completely cover the district for first response ALS.

So now what?

Oh, I covered this topic 2 years ago.  What, you missed it?

Top 10 New Responders without the Fire Department

and then

Top 10 New Responsibilities of the Fire Department


Poking fun at a serious topic for sure, but until we get away from a fee for transport model, this thing will never work guys.  Fire based, mailman based, if we base our service on what we can get paid instead of how best to serve the community, the system will never work properly.



[...] Happy Medic's eminently reasonable take on the issue. [...]
[...] in theory people only call 9-1-1 when they have a true emergency that needs immediate response. Ask Justin Schorr or Michael Morse if that’s [...]
Too Old To Work said…
Just a point of order. Civil Grand Juries are not the same as Criminal Grand Juries. It seems to be an oddly California thing and as I recall you're not a native of the state so you probably never heard of them. In fact, I'd guess that a lot of natives don't know the difference.

I never did get how long you've been with the FD, but a Civil Grand Jury looked at SFFD and EMS back in 2004 and made a number of recommendations. How many of those were actually carried out I never could find out.

I'd not hold my breath waiting for EMS to move from a fee for transport model to, uh, something.

As I point out in my post on the same subject, if the problem is not enough ambulances, then put more ambulances on the road. Sending fire fighters to medical calls because they have nothing else to do isn't the answer.

Oh, on your list of new things the fire department can do between fires is building inspection. Since in my experience every fire shift has at least one plumber, one carpenter, one electrician, and one HVAC expert, who better to do inspections during construction? ;)
the Happy Medic said…
I am well aware of the concept of the Civil Grand Jury, but it still requires municipal attorneys, facilities and time that could be spent on actual needs of he jurisdiction.
I used to be a big fan of ALS engines, but that was when I was rural and had a 20 minute response time, passing firehouses who waved to us.
The problem, as we all know, is not that we have too few ambulances, it is that we are not allowed to make good decisions regarding who goes to the ER ALS and who does not.
An ALS engine is wasteful.  A BLS and ALS ambulance both responding to the same call is wasteful, sending PD code 3 to do nothing but radio ahead that yes, she's not breathing, is wasteful.
And on the note of building inspection, my last 3 departments have been very busy with building inspections when it comes to fire safety, but my crew has no one in the trades.  We're seeing a generational shift to higher education in the fire service instead of decades in the trades.  Perhaps an the exception to the rule?

I was indeed in the SFFD when the Civil Grand Jury reported on the issues with EMS within the dept.  One of our medics was even ON the jury and many of the issues there have been addressed with few improvements because the false belief of BLS before ALS sends an BLS engine, then an ALS engine, then an ambulance.  Waste, waste and overkill on over half of our calls.

We have a long way to go.
because we do cardiac arrests (the whole point of EMS) and toe pain (not the point of EMS), EMS will always be inefficient, no matter who provides it. as you said, until we start telling lame patients (no education, no common sense) to drive their own butts (no car, no transit) to the neighborhood clinic (no more clinics) to see their primary care docs (no insurance, no docs), changing response models isn't really going to do a whole lot.

no matter what we do and who responds, someone has to make it so that CPR and a defibrillator arrive in 4-6 minutes. in this sense, fire-based EMS works relatively well compared to the alternatives. for everything else not known as cardiac arrest, it's inefficient.

of course, if anyone had the spine to do little things like teach CPR in school or put AEDs in sensible locations, those are other ways to beat the 4-6 minutes. but, there's no wealthy lobby advocating for CPR in schools, and librarians (as a real-life example in an unspecified location) and other people/staff who should have AEDs with them resist AEDs, so we're stuck with what we have now.

i'm with you - change is needed. we actual providers have plenty of suggestions, but everything we always talk about or think is a good idea never gets implemented. so far.
Timothy Clemans said…
I disagree with the implication that higher bystander CPR rates lead to higher survival rates. The paper Cardiac arrest survival as a function of ambulance deployment strategy in a large urban emergency medical services system. showed:
Suburban Houston had a 63% bystander CPR rate but only a 4% discharge alive rate. However downtown Houston had a 46% bystander CPR rate and yet had 24% discharge alive rate. The stats were for bystander-witnessed VF.

I think fire engine first response can be used both efficiently and effectively. For example Wake County (43% discharge alive rate for bystander-witnessed VF) sends the fire department only to calls where the caller states the patient is not breathing normally or the patient is unconscious. 

I'm surprised you didn't mention that EMS should be transporting non-emergency patients to the waiting room. Many call 9-1-1 because they don't want to wait.
no matter what we do and who responds, someone has to make it so that
CPR and a defibrillator arrive in 4-6 minutes. in this sense, fire-based
EMS works relatively well compared to the alternatives. for everything
else not known as cardiac arrest, it's inefficient.

Which, to me, seems to point to a need for Police based EMS.  Or, at the very least, a program to stick AEDs in squad cars (and train the cops appropriately, and do routine checkups on the status of the AEDs, of course) would seem to do a lot.  I have to admit ignorance of other cities, but here in ABQ, if you call 911, you'll get a cop car, then a fire truck, and then an ambulance, in roughly that order, every time.  (Well, if you say you need an ambulance, you will, anyway.  :) )  If the cops are going to get there first... give 'em the tool and show 'em how to use it.  I bet you could up the save rate for cardiac arrest quite a bit that way.
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