By Michael Kohrt, President-elect, Alexandria Professional Medics Association (File photo)
To the editor:
When a fire chief proposes a major restructuring of a department, it is often in response to a problem. A decade ago, after years of embarrassing and dangerous mistakes, D.C.’s fire department made sweeping changes to its emergency medical services system. But those changes failed to address the department’s true underlying problems and, as a result, it continues to make headlines today.
Now, Alexandria Fire Chief Robert Dubé wants to make some of those same changes here in Alexandria. He has proposed eliminating the positions of dedicated single-role paramedics, replacing them instead with paramedics who also are trained as firefighters. He also wants to decrease the number of these highly-trained medical providers on ambulances, in order to place them on fire engines.
The question that Alexandria residents and city officials must ask is why. What is wrong with the city’s current EMS system?
Dubé has yet to provide a satisfactory answer to this question. The arguments he has made for changing the system — to look more like the models in neighboring jurisdictions — do not hold up when compared to the evidence. Dubé has instead proposed a system based on outdated practices and fire service myths.
1. Adding paramedics to fire engines saves lives: The firefighters who staff fire engines and ladder trucks today are already trained as basic emergency medical technicians. The training to become an EMT is much shorter — and cheaper — than to become a paramedic, yet it still allows for EMTs to provide treatments necessary in the first few minutes of a life-threatening medical emergency, such as defibrillation for cardiac arrest.
The Seattle Fire Department and the Medic One system in King County, Wash., have some of the highest cardiac arrest survival rates in the nation, despite only having EMTs on their fire engines.
2. Having more paramedics is better: Adding paramedics to every fire engine in the city will require an increase in the number of paramedics in the fire department. It will also increase turnover, as firefighters who no longer wish to function in this role will allow their certifications to lapse and still remain in their positions as firefighter/EMTs. With more paramedics, training costs also will increase. Perhaps most significantly, having more paramedics will decrease the opportunity for each paramedic to perform advanced skills, such as inserting breathing tubes and administering medications.
Research in other medical fields has indicated that the more often a health care provider performs a procedure, the fewer complications that patients experience. Again, we only need to look at the Seattle Fire Department, which has seven paramedic ambulances — only one more than Alexandria — on duty each day. Seattle paramedics intubate approximately 40 people during their first year. In Alexandria, paramedics average fewer than two intubations annually — a number that will only decrease as the number of paramedics goes up.
3. Firefighting and emergency medicine are similar jobs: While it’s true that many firefighters in fire-based EMS systems now also operate as paramedics, the nature of both jobs has changed dramatically in recent years. More and more, EMS is becoming part of the health care continuum, which is a good thing for communities.
While some EMS calls are for true, life-threatening emergencies, the majority of 911 calls are for less critical medical conditions. In response, many EMS agencies across the country have created an integrated system of care, wherein patients get the right treatment at the right price — avoiding the emergency department when it’s not needed.
But people who join fire departments often are drawn to the adrenaline rush and the thrill of the rescue. It’s no wonder that many ultimately experience burnout when asked to staff ambulances, which respond to nursing homes or pick up mentally ill patients on a daily basis.
In Alexandria, where paramedics can be paramedics and firefighters can be firefighters, paramedics have never complained about having to work on an ambulance — that’s what they were hired to do. But in D.C. and in other fire departments that cross-train, being assigned to an ambulance can be seen as punishment or a job for the newest and least experienced firefighters.
4. Cross-training paramedics as firefighters will save money: The department’s administration has argued for several years, even prior to Dubé’s arrival, that converting each paramedic to a firefighter/paramedic will save money.
It’s easy to see why they feel that way — because of federal labor laws, civilian paramedics earn overtime after working 40 hours in a week. But firefighters are exempt from that rule, and do not earn overtime until after they have worked 53 hours. Alexandria’s plan to train paramedics as firefighters, and have them work an additional 14 hours each week (the difference between the current paramedic and firefighter shift schedules) for only slightly more than their current annual salary would, on paper, save hundreds of thousands of dollars.
But there are several problems with that proposal, the least of which is asking dozens of highly trained medical professionals to take on an additional skill set and increase their workload by a third without compensating them fairly.
Additionally, Alexandria’s firefighter and paramedic salaries have remained below those of their counterparts in the Washington area for many years — something accepted by many of the department’s paramedics because of their desire to focus exclusively on providing high-quality pre-hospital medical care. In order to compete with neighboring jurisdictions, Alexandria ultimately will need to significantly increase the pay for its own firefighter/paramedics — the same ones that Dubé now believes he is getting on the cheap.
5. Cross-training paramedics is the only way to offer them career advancement opportunities: Another argument made by the fire chief is that paramedics have limited career opportunities in the current system — that, as firefighters, they will have a much greater chance at promotion. This is certainly true, but there are many other, better ways to solve this problem.
In an agency where more than two-thirds of its responses are for medical emergencies, a firefighting background shouldn’t be a leadership requirement. Many EMS agencies and fire departments across the country already have created promotional ladders for EMS providers. And in an era where the majority of the fire department’s mission is medical, there’s no reason a paramedic can’t serve as its safety officer, training chief, or even department head.
Before Alexandria makes the most drastic change to how it provides emergency medical services in four decades — when the current civilian paramedic program began — city officials need to be honest about whether or not these changes will actually make a difference. Chances are, they will — they’ll lead to a less effective, more expensive and possibly more dangerous EMS system.