Fire Based EMS vs. Private EMS

“In Germany they first came for the communists, and I didn’t speak up because I wasn’t a communist. Then they came for the Jews, and I didn’t speak up because I wasn’t a Jew. Then they came for the trade unionists, and I didn’t speak up because I wasn’t a trade unionist. Then they came for the Catholics, and I didn’t speak up because I was a Protestant. Then they came for me – and by that time no one was left to speak up.”

- Rev. Martin Niemoller

Yesterday an Action Care ambulance covered my station while I was at a training. Action Care is the local private ambulance service. I know, the name always seemed a little silly to me. If a super hero ever created an ambulance service, he would most certainly call it Action Care. I joke about the name, but they’re the real deal. If you’re going to work as a private service EMT, you could do worse than Action Care.

I’m glad we have Action Care. They help cover our district when we are low on resources. They are always professional and polite on scene. They give good care.


Sometimes, working with a private ambulance service on scene can be challenging. There are conflicts. There always are. Occasionally a private ambulance service medic will assume that I’m an idiot because I’m wearing fire gear. Sometimes, that can be amusing and sometimes it can be frustrating. Sometimes a fire medic will assume that the private ambulance medic needs her hand held because, well, she works for a private company after all. I’m sure that’s frustrating for them as well.

I know that most of these biases are made up. When I was in the private ambulance service, I advocated for the advantages of private ambulance service and denounced the fire service as bad for EMS. When I became a fire fighter I suddenly saw things differently and the flaws of private, for profit medicine became more evident.

I’ve certainly seen both sides of the equation. Which, recently made me consider an interesting question. While driving back to my station, thinking about how much I appreciated having our local private service available for our district, an interesting thought occurred to me.

What would happen if we advocated for each other?

I know, it’s a crazy thought. The very idea of a fire fighter / paramedic extolling the virtues of private ambulance service medicine and a private service medic understanding and advocating for the benefits of fire based EMS seems insane. But consider it. Go crazy with me and ask yourself, “What if..?”

What if firefighters saw private EMS as good for our industry and supported the efforts of their private ambulance brothers and sisters?

What if private services recognized the important contributions of fire based EMS systems?

What if, instead of being threatened by each other, our service were public advocates for the others needs?

What if I told members of the community that our local private service was an essential part of our response plan and an excellent example of everything private services can be?

What if my private ambulance counterparts explained why my fire based service was the right design for the community and a good model of what fire based EMS can be?

What if we spoke up for each other?

What would happen next?

You tell me.

Comments

  1. Being in a similar spot, I think if we start supporting each other folks will wonder why we need both. Coke or Pepsi is our culture, never mind 7up or Dr Pepper.
    If private EMS works, then why is it doing so poorly?
    If public fire based EMS works, then why are privates taking over?
    Neither is the solution, in my mind. We need to start advocating for what is best for our patients: A non-profit, non fee based service that offers medical advice, care and, IF NEEDED, transport.
    EMS based EMS funded the same way other public services are.
    I know, I know, “Why shouldn’t someone be able to profit on your injury?” Because we all may need it and out of pocket cost should not be a concern.
    We don’t get billed by the cops, or the highway dept, or the FD, why does EMS bill?
    Off topic slightly, sorry, but the profit margin will be the downfall of private EMS and the fire dept the downfall of public EMS. And I’m an optimist.

  2. I agree with Happy on a non profit EMS, and for EMS by EMS. Remember that many fire based EMS systems are still for profit. Medicine for profit in general seems wrong, but that’s another argument. It all comes down to whats best for the public. And if we are talking about just resources, then I think a municipal or government service, like fire or 3rd service EMS is the way to go. At least for 911. Private can still be there for transfers, and 911 back up if needed. trouble is, privets will still try to under bid a muni system, which then goes back to the whole for profit thing. What if we advocated for better EMS, regardless of Fire vs Private. Then what?

  3. Wow that’s a million dollar question. Or is it a concept? Advocating for each other, It seems so simple doesn’t it? I think that’s the number one problem in EMS – no one seems to be able to get along. Paid vs Volunteer, EMT vs Paramedic, Fire vs EMS, back in the day vs change, not to mention the battles with management and hospital staffs. I work for 3 ambulances. One hospital based, one fire based, and one private, and what I’ve found is that it’s just the same everywhere. It’s the culture of EMS. It’s bad, it has to change, but it’s very difficult to change. It’s simply accepted. Until that culture is changed progress in any direction remains difficult.

    It is my windmills.

  4. It is not a question, we should all get along, however, I see the evolution of fire based EMS a necessary need for efficiency, effectiveness and cost savings…Why not have EMS firefighters do both…60% of the calls are EMS and on large fires you have more FF to handle the big ones…I have never seen it pencil out to do anything differently….It’s better for the taxpayers financially and we provide a better service…Some people, I fear, are stuck in the mud that FF’s are not EMS people…hogwash…just another train of thought…Here’s to a Great Summer, Randy

  5. There’s no perfect model.

  6. I work inside the volunteer side of EMS. My squad does NOT charge for our service, nor do we get stipens from the town. We cost the taxpayers nothing and support ourselves through fund drives. Now when it comes to what everyone is talking about I believe we should all advocate for one another. Its what makes the PD and the FD so strong, they advocate for each other. It seems to me in EMS we have so much infighting we are a detriment to ourselves. If we can be professional among our own how can the public look at us AS professionals.

  7. When I try to picture fire-based EMS in my area, it is somewhat difficult. Fire in my county is more community based, while EMS is a county wide affair. There are probably 2-3x as many fire stations in the county as EMS stations, but dispatch keeps everywhere covered fairly well. On possibly life-threatening medical calls fire usually arrives first, starts high quality BLS care, and transfers to ALS when they arrive (all trucks have at least one medic). The EMS system generally runs like clockwork, providing quick response times on every call. I just don’t think you could run fire based EMS in my area.

    That said, I can see where it would be ideal. Large cities that have high fire and EMS call volumes could benefit by having joint stations placed ideally around the city. If you don’t have far to go, response times aren’t an issue.

    For me, an ideal system would be the city or county running both fire and ems systems alongside their public safety department. Depending on an areas geographic distribution, EMS could be standalone or paired with fire.

    I do have to agree though that its in everyone’s best interest for public safety to advocate for other public safety workers.

  8. Sean Fontaine says:

    Way to stir the pot on this one. I’ve worked both private and fire based EMS, both agencies alongside one Steve Whitehead. Both systems had their strengths and faults. I haven’t been employed by a true third party system, but I’ve worked in one as a paramedic student. I believe as well that all parties involved in pt care need to advocate for and support one another; my snotty caveat to this however is that I believe both within my agency and those outside of it should not only be trained to the highest standards, but should maintain their skills to the highest standard at all times. This stems from my belief that the pt doesn’t care that you don’t have high acuity/call volume or that you run 2 calls/day or that home life has been hectic and you couldn’t reread your cardiology about fasicular blocks lately, when they need your help they’re depending on you to recognize and treat what is causing their Sx, not just give them a high speed taxi ride w/an IV.
    That soap box aside, people dial 911 and don’t expect anything more than top level medical care, they don’t look @ the graphics on or color of our rigs they just know that someone shows up to help them.
    I like Justin’s idea of non-profit EMS, because I hate patients trying to refuse in the face of death due to not being able to pay and my explanation that I could care less about finances and only about getting them the care that they need at that moment, the reality is I don’t see the bill either way, they do, so what kind of a bastard am I selling this story. The reality I’ve seen over the last 10 years though is that, medicine needs money, there is poor at best state/government remittance on services rendered. Our systems need to operate more seamlessly from one to another, but where does this dialogue begin and how I don’t know. Far from an answer my idea of the perfect system (which just by calling it that creates faults within it) is one w/progressive protocols, a pt forward/advocate position, takes pt finances into account when billing, and has a seamless flow from BLS-ALS (if needed)-transport (if needed)-receiving facility and trust from one level to the next throughout that chain to avoid the 2 steps back @ each hand off.
    This is a great topic, one filled with more uncertainty than answers.

  9. We need to return EMS to Emergency Medical Services. People legitimately need rides to the hospital. either they are unable to do so themselves or have no other way to get to where they need to go. Sending a rescue vehicle with lights, sirens and all the bells and whistles like we do in Providence is a waste of time, money and a danger to the community.

    In my opinion, Fire Departments are the best answer for emergency response, simply due to the strategic placement of qualified help. Transport is another service altogether.

    Proper triage is the answer. And proper resources for either non emergency transport of critical care. Taxpayers should not be on the hook for every ride to the hospital. The public needs to know the difference, and be confident that the proper response is on the way when they call for help. I’m tired of taking non critical, or even barely injured or sick people to the ER while critical patients wait for a help because all of the available responders are busy taking intoxicated people to the ER for the tenth time this week.

    So, to sum up this rambling rant, Fire Department for crisis, not because we are any better than anybody else, we are not, but because we are in better position generally to get to the victims faster, and private companies for transports. Some privates are better equipped for critical care transports, that is their forte’ and they should get the call.

    Thanks for putting me in the July Roundup, I appreciate it. I’ve been waiting to put my two cents in here, but time flies and before I knew it a week had gone by.

  10. I don’t have any answers, but I think two things are important: 1. Places are different – so there probably isn’t a system that will work best in both Prairie City, SD and Manhattan. They have different needs in terms of coverage, response, call volume, etc.
    And 2. I think it’s important the people be allowed to do what they want to do. I know some fire-EMS services require everyone to be fire and everyone to be EMS, which means working shifts on engines and working shifts on rescue. I think that’s bad for EMS. Now, if someone whats to be a ff-emt, or ff-medic, that is awesome, more power to them, but if you just want to be a ff and you get stuck working rescue once every two weeks, that means for that shift, some patients are not getting the best care. It also means if i want to work EMS, they’re going to have fool behind a hose. I a not interested in fire science, and don’t want to learn about it, and wouldn’t make a good fire fighter because of that.

  11. I have to agree with what AJ is saying. Whether you want to admit it or not, there are plenty of fire fighters who only view EMS as a necessary evil. That, in my opinion, is what keeps fire based EMS from ever being the perfect model. Do you really want someone who views EMS as job security for their “real job” taking care of your loved ones?

  12. Sean Fontaine says:

    Drew,
    I admit it there are those guys, I’ve worked w/them and I’m one of the firefighters who happens to love medicine. However, I’ve also worked w/medics who only went to p-school to get a raise due to poor pay in private EMS. There are also the ones in both fire based or private EMS that no longer care, but don’t move on and find another job. The unfortunate reality is that there are the ones who only do it for the pay every where, and there in lies the faults in all the systems.

  13. Joshua Barkley says:

    I see it as a limited point of view. x or y..In our area, neither is sufficient. I find it amusing that Private paramedics are viewed as Privates while they are certified and regulated by the state. I find in concerning that Private Corporations have free reign over taxpayer money. Fire Departments that are delivering emergency transport are losing money across the board. Fire departments generally do not view EMS Transport as part of thier job and the “continutiy of care” position was over before it started. Both are on scene at the same time and it’s not a matter of continuity of care, its a matter of manpower and resources. The days of the 1.5 million dollar truck with chrome rims, repsonding to grandma’s fall injury are nearing the end. I would think, for the best interest of all, the whole system should be scrapped and realigned. EMS should have it’s own government Branch, as does Fire and Police. The money should be regualted and put back into the system for improved performance. Standards should be raised and Providers should have the same or better benefits than the people the work on. EMS is it’s own culture and it gets pulled on from all sides, strictly to use the revenue to support less needed but more expensive programs and services. County wide systems with good oversight, ALS ambulances with State certifed medics recieving a prevailing wage and benefit package. Good working relationships with Fire Departments that respond in appropriate vehicles with appropriate manpower.

  14. The fire based EMS model could work, but normally it doesn’t. The idea is great, but look at whats going on. Talk to the firefighters that are being “forced” on the ambulance. If you don’t know any, read the discussions by firefighters in a fire-based EMS system at firehouse.com. The problem is simple, fire departments are so caught up in absorbing the ambulance service for their own security, they forget the most important part…making it work.

  15. Save a couple of wonderful exceptions, EMS systems are driven by the EMT’s. Fire brass, ambulance managers. Not exactly Wharton School of Business/Mayo Clinic doc kinda people. I’ve worked military medic, private ambulance medic(3), fire service, and hospital RN. And Pizza Hut manager while in college. Guess which gave me the best skills in system management? Extra cheese please. First and foremost, civil authority must regain control of the fire services. They are wildly independent and self serving. So, no I can’t kumbya. The fire chief must report to the mayor every morning, hat in hand. Christ, in my city the Batt Chiefs carry guns. No commission/permits. They just do it…get my point?

  16. First, I would like to say that the article is well done and stimulates good discussion. My opinion of the purpose of this well written essay was to shed light on the fact that the public and private sectors serve or could serve vital rolls on their respectitive EMS system. That they may be even being able to work together. In fact, they do and should under any model in order to fulfill our purpose to the sick and injured.
    There are hundreds if EMS models that are currently in place and most that participate in those EMS models would show some form of bias as to which is better. The fact is when profits, union jobs, tax subsidies, fees for service, and contractual agreements are involved, the complexities of where one would stand on these issues is certainly relevant. After reading the article and the responses to the article it still leaves me with the tone that it will be difficult for change because there are two camps. The fire unions vs. privates. Both have their deep seated motives to advance their cause. I know in our system it would in the best interest of the fire based EMS professionals to work with the private services. The tax payers have had enough, the tax wall is a pond us, so now what. One other little tid bit that should be brought out from my team position. In our area the 911 areas are exclusive to one service designation. The non-profits charge, the fire services charge and the private’s charge. I hope you see my point here. The non profits and fire services are no different than the privates. In a sense, they are full scale competitors, ALL after MONEY. My camp often here’s this, “those dirty private profiteers. making money off sick people”. Come now, really! My emotional come back could be. “How much does your exact same service cost, that’s right, three times more”.
    I will end with this. This article suggests that we all can work together. I agree with that to a point. There are currently more needs for service than any of us can provide. Another words, there is plenty of business for all of us. We can argue forever who is better, has a better response time, the best price, and so it goes. I vote for both advocating a working relationship amongst all parties involved. This puts us all on the side of the angles when being there for some in need of ambulance service.

  17. Considering the overwhelming majority of medical calls vs. fire, why is it so important fire absorbs EMS? The solution is to downsize fire and scene stabilization to be absorbed by EMS. Have a group employed by the Emergency Medical Service who’s sole responsibility is scene stabilization. It is important to put egos’ aside, as well as the desire to prove one’s worth in life, and ask what is needed by the modern community. Structures are not made of matchsticks anymore. Since scene stabilization is conducted primarily for the access to provide medical treatment to the patient, the reigns should be in the hands of medicine professionals. This is what is needed by our patients. And the thought that EMS should be free is ridiculous. There’s no such thing as a free lunch. Patient’s refusing transport usually aren’t refusing transport only because of the cost of transport, but because of the cost they will receive at wherever they are transported to. Medicine is moving along at a very fast rate. The technical college educated paramedic will phase out and be replaced by a university educated professional. Most other countries are already leagues past the US regarding this. I understand the wonderful comradeship that goes along with fire department, but it is time to adapt.

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