Craig A. Haigh
While attending a recent national conference, I had dinner with a group of chief officers from an east coast volunteer department. When asked about the number of personnel I have assigned to fire apparatus, I was immediately chastised about running only three-person companies (not five or six) and how this was dangerous and inefficient. I had been feeling pretty good about running with three people since so many departments in my area had been forced to reduce company staffing numbers, eliminate companies, shutter firehouses, or work with rolling brownouts.
I have often made the statement that, “In today’s economy, if I go home at the end of the day and still have three people assigned to each fire company, I had a pretty successful day.” I tried with no avail to explain to my new friend at the table that, although my community and elected officials are generally very supportive of the fire service, the village as a whole simply does not have a tax base that will support more than a three-member apparatus staff. I made little to no progress in defending my position, while he explained that money should not be a driving factor when it comes to the safety of residents and firefighters. Although I agree with the need for sufficient staffing and understand his position, I also understand the reality of tax rates and the costs associated with filling these spots.
Don’t get me wrong; I fully support and advocate for the National Fire Protection Association (NFPA) recommendation that each company should be staffed with a minimum of four personnel. I understand the workload and tasks assigned to each position and the Occupational Safety and Health Association-mandated safety aspect of “Two-in/Two-out.” I am aware that a three-person company will be delayed in entering an immediately dangerous to life and health atmosphere until additional help arrives (unless they have an immediate rescue) and, if they are attempting a rescue with minimal personnel, they are significantly increasing their overall risk. My problem is not in the number of firefighters needed per company; it’s with getting the dollars to pay for them.
Looking at the Dollars
Using my small Chicagoland fire department as an example, the cost to add one additional full-time career firefighter is approximately $95,000 annually. This number is calculated based on an entry-level salary along with the department’s cost for benefits such as health and life insurance as well as pension contributions. This cost increases to more than $125,000 in five years because of increases in the firefighter’s negotiated pay plan. Since my staff works a 24/48 schedule, I would need to hire a minimum of three additional firefighters to cover just one position 24/7. This makes my first-year payout $285,000. In my community, this amounts to a 1.7 percent annual increase in the fire department’s property tax levy. In five years, this number becomes $375,000, or a 2.1% increase.1 These numbers and percentage increases grow exponentially for each additional firefighter added to each fire company.
Making this even more challenging is the recent loss in assessed property valuation. My community has lost $184,070,658 in assessed value since 2009. This means that to maintain the same annual tax revenue, significant tax increases are mandatory. This happens before any consideration is given to adding additional fire department staff.
Attitudes About Fire
Most people believe that they will never suffer a fire at their home or business, and therefore will not support a tax increase for fire protection. In years past, people witnessed devastating fires and the loss of life, but through the efforts of the fire service in prevention education, installed protective systems, and construction changes, average residents are not nearly as worried about having a fire as they were 20 years ago. The United States has seen an overall 57 percent reduction in the number of fire responses over the last 34 years.2 In fact, only 35 percent of all fire responses are characterized as structure fires.3 Civilian fire deaths have also dropped, realizing a 42 percent reduction in the past 30 years.4 The bottom line is that our taxpayers are no longer buying the story that we need massive fire departments to protect their safety and wellbeing.
So what does this mean for the fire service? It means we need to find new ways to justify and fund our needs based on the realities of our environment.
Making a Different Argument
Looking at United States call volume data, 66 percent of all fire service responses are for medical aid. (2) Comparing this against my own department, 71 percent of our responses are medical in nature, with only about 2.3 percent being for an actual structure fire.5
When a structure fire occurs, it is imperative to have sufficient staffing readily available to address all of the tactical demands required to operate efficiently and safely at the incident. The name on the side of the rig still says “Fire Department,” and you must be able to carry out your mission when required. My problem was that when I attempt to justify the cost of providing heavily staffed companies for less than three percent of my incidents, the taxpayers begin to push back. So, I have a choice: I can operate with less and less personnel (which on the fireground is dangerous and inefficient) or I can try to justify a different staffing model based on the realities of the call types to which I most commonly respond. This brings me to my second conversation.
A few months back, members of my training staff were entertaining guest instructor Chief Bobby Halton at one of our area restaurants. As we ate, my chief of training made a comment about the number of medically trained personnel we amass at the scene of an emergency medical services (EMS) call based on our paramedic engine program. This is when the proverbial lightbulb came on!
I started thinking about all the changes we have made to our EMS protocols over the past several years and the reasons behind them. Modern EMS theory is to bring more and more of the historical emergency department treatment modalities to the field. EMS personnel have greater levels of diagnostic tools and equipment and preparatory treatment algorithms that allow them to better diagnose the problem so patients can bypass the emergency department and proceed directly to the appropriate hospital definitive care unit. Early ST-elevation myocardial infarction and CerebroVascular Accident (CVA) recognition with transport to specialized treatment facilities has become a mainstay of EMS. Pit crew cardiopulmonary resuscitation (CPR), 12-lead electrocardiograms, hypothermic treatment post cardiac arrest resuscitation, candidate physical ability test, capnography, drillable interosseous access, new medications, more advanced airway options, and any number of additional critical care procedures are all being implemented or pilot tested by aggressive medical directors, thereby stretching the capabilities and staffing needs of an EMS agency.
An amazing number of staff is involved when caring for a critical patient in an emergency department. Between the physician, nurse, and the ancillary care specialists, the numbers equal or exceed the number of personnel responding to the scene as part of a fire company and transport ambulance. This begs the question: if we are providing more and more time sensitive emergency department treatments in the field, how many players do we really need?
Take a cardiac arrest as an example. One person is required to manage the airway, one the cardiac monitor/defibrillator, one to initiate IV access and deliver medications, two are needed to provide pit crew CPR, and one is needed to set up and prepare the equipment needed to get the patient from the location of the arrest to the back of the ambulance. This totals six emergency responders. In many communities, a cardiac arrest is a routine call handled by a first responder engine or a truck company and an ambulance crew. It is easy to justify a six-personnel crew when talking about a cardiac arrest because your residents understand this situation. Many have had a close tie to someone who has experienced an out-of-hospital cardiac event and are sensitive to the need for optimal patient care. You can easily replace the cardiac arrest situation with any number of other medical emergency scenarios and still come up with the need for six, seven, or more personnel.
Interestingly, these are the same number of players needed to effectively stretch and operate a hoseline at a structure fire or staff a truck company capable of conducting a search or opening a roof. The beauty of fire service EMS is the cross-trained/duel-role personnel. It is relatively easy to conclude that to effectively provide the current out-of-hospital care we are espousing, we need heavily staffed companies. Likewise, when the structure fire occurs, we need the same company staffing levels.
Where Does This Take Us?
In communities with populations of 100,000 or more, 97 percent of U.S. fire departments provide some level of EMS.6 With this being the case, I believe that we need to begin arguing that EMS is an essential and integrated part of a fire companies duties and that sufficient staffing levels are required to not only lead out a hoseline or search a building, but also to be able to work a full arrest, operate at a traffic accident, manage a trauma, CVA or other critical medical emergency.
But, how do we pay for the staffing? The fire service in general has been very reluctant to charge for what we do. At our most basic level, firefighters enjoy serving others in their time of greatest need. We often struggle with the business side of our services and the economics associated with making it work. We don’t want to charge people—we just want to respond and solve their problem. Unfortunately, it takes dollars to make that happen and in today’s economy, these dollars are becoming harder and harder to find.
If we view EMS as not only an essential service but as a revenue source to fund our appropriate levels of staffing, we quickly find options that may not exist with strict reliance on property taxes. Insurance reimbursement rules vary from state to state, but it is commonly accepted that medical insurance plans will pay for prehospital medical services. If you operate a fire department ambulance transport service, the process of billing is relatively well defined. If you do not do the transports, but still provide a level of EMS service designed to integrate with the ambulance provider, you will likely not be able to bill Medicare or a private insurance carrier directly. In these situations, I know of several fire departments that have agreements where they bill back their services to the ambulance agency. The ambulance agency then establishes fees appropriate to cover the cost of the care provided, which includes the response of the fire company.
Another option is to look for other billable responses. For example, one department in northwestern Illinois has had good success billing for auto accidents and extrication services through the owner’s vehicle insurance carrier. This is especially helpful to its tax payers since a large number of those involved in vehicle crashes are not residents of their community. My community has adopted an ordinance that allows the courts to impose fines against DUI drivers for the cost incurred in responding to the incident they created. although not specifically EMS, my department bills for false alarm responses and for salvage services that involve the removal of smoke, water, carbon monoxide, natural gas, or similar from inside structures. A variety of other creative billing options/revenue generating tools likely exist if you spend some time focused on the services you are actually providing.
Finally, you need to not only make your bosses aware of your problems, but you need to bring them solutions. If a solution involves additional dollars, the funds may not exist using your old funding models. If you need to increase the size of the revenue pie, creatively figure out how to make this happen. Your old arguments don’t hold the same weight that they did in years past.
The service demands of your community have changed, and as a leader you need to adjust your service delivery models to meet the needs of today’s customers. It takes people to do the things you do. The question is how do you justify the numbers in a day and age of shrinking tax dollars, and how do you creatively find the funds to efficiently and safely provide the services needed? You are not just doing fires anymore; EMS has become a mainstay of the business. Therefore, start telling the entire story as it relates to staffing—we have a much better story to tell!
ENDNOTES
- R. Flakus, personal communication. August 20, 2013.
- Levesque, P. Trends and patterns of U.S. Fire Losses. Retrieved from http://www.nfpa.org/research/statistical-reports/overall-fire-statistics/trends-and-patterns-of-us-fire-losses. 2013.
- Karter, M. J. Fire loss in United States. Retrieved from http://www.nfpa.org/research/statistical-reports/overall-fire-statistics/fire-loss-in-the-united-states. 2012.
- Ragone, M. Emergency Service Departments: Formally known as fire departments. In C. A. Haigh, Emergency Service Departments: Formally known as fire departments. Symposium conducted at the Hanover Park Fire Department, Village of Hanover Park, Illinois. February 2011.
- Village of Hanover Park Fire Department. Annual Report. Hanover Park, Illinois: Village of Hanover Park. 2012.
- Dean, A., & Messoline, M. (n.d.). Fire-based EMS: The solution for an ailing system? Retrieved from http://emberly.fireengineering.com/articles/print/volume-164/issue-2/departments/fire-service_ems/fire-based-ems-solution-for-an-ailing-system.
Craig A. Haigh is a 30-year fire service veteran, chief of the Hanover Park (IL) Fire Department, and a field staff instructor with the University of Illinois Fire Service Institute. He has managed volunteer, combination, and career departments, served as interim village manager, and implemented intermediate and paramedic services. He has developed a variety of courses for the fire service and regularly presents at local, state, and national conferences and is a FDIC H.O.T. instructor. He has a master’s degree in executive fire service leadership and a bachelor’s in fire and safety engineering. Haigh is a graduate of the National Fire Academy’s Executive Fire Officer Program, a nationally registered paramedic, an accredited chief fire officer, and a member of the Institute of Fire Engineers.
