EMS Programs Facing Regulatory, Fiscal, Other Problems in the ’80s
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—St. Paul Fire Dept. photo.
The new decade of the ’80s may be an era of growing pains for many of the fire paramedic programs born in the ’70s.
This vision appears from discussions with leaders of the nationally recognized EMS program developed and administered during the past decade by the St. Paul, Minn., Department of Fire and Safety Services.
Compensation, regulation, training, funding and new techniques are among the challenges facing St. Paul and other fire department administered EMS programs with a paramedic emphasis.
Uncertainty ahead
“The future of some of these programs, including our own, is by no means certain,” said Chief Steve Conroy, who started the St. Paul department’s EMS program in 1971 without an increase in manpower or payroll. “In so doing, we doubled the productivity of our department by providing a needed service,” Conroy explained.
In addition to full fire protection, St. Paul fire fighters provide 24-hour basic and advanced life support service and ambulance transportation to any one of 22 metro area hospitals. Last year, typical of recent years, they answered 6,633 fire alarms and 13,641 EMS calls in the city, which covers 55 square miles and has a population of 270,000. Meanwhile, the two private ambulance companies in the city answer more than 25,000 medical calls annually, according to a recent city planning study.
Of the approximately 445 St. Paul fire fighters, about 420 are EMT trained and 70 of these are paramedics, according to Assistant Chief Robert Pye, who coordinates his department’s EMS program under the direction of Conroy. Six more fire fighters recently volunteered and now are taking the 670-hour basic paramedic course, directed at St. Paul Ramsey Medical Center by Dr. Brian C. Campion, chief of cardiology; Dr. Robert A. van Tyn, chief of emergency medicine; and Dr. Linda Long of the cardiology section.
Response system
Ten of the city’s 16 fire stations are equipped with ambulances. Six of the 10 are advanced life support units and the other four are basic life support units.
The 10 double-duty crews respond with an engine or ambulance, depending on whether it’s a fire alarm or medical call. The next closest station provides fire and medical coverage during a run, and may be called in to assist if extra manpower is needed. Average citywide EMS response is 3 ½ minutes and fire response time is 2 ½ minutes.
The fire paramedic companies have a captain, engineer-driver and two fire fighters, but for a company to be in service, the fire administration says two of the four must be paramedics.
St. Paul Pioneer Press photo by Sully Doroshow
Citizens enthusiastic
Public reaction to the St. Paul EMS program has been enthusiastic, and going into the ’80s, it is regarded by citizens as the most valued service offered by the city. Whether due to personal experience, visibility, favorable publicity or other factors, St. Paul taxpayers have repeatedly demanded in letters and public statements that the paramedic service be continued at present or increased levels, even when other city services have been cut.
“In time of need, our citizens know they can have a team of doctor-directed fire paramedics in an advanced life support ambulance at their door in less than four minutes, day or night,” according to Pye. “They want us to make house calls—and we do.”
As a result of its perceived importance to the community, the St. Paul Fire and Safety Services Department has avoided significant cutbacks in manpower during the ’70s.
Future compensation
Appropriate compensation for the fire paramedic is a crucial second generation problem in St. Paul and other cities at the turn of the decade. No longer are enough fire fighters volunteering for additional paramedic duty.
Commented Pye, “Double duty work is very demanding in personal effort and responsibility. The glamour and personal satisfaction of being a fire paramedic are wearing thin.”
Solutions to the problem vary from city to city according to specific circumstances, but they include conscription, using non-fire personnel as paramedics, reducing paramedic service and providing extra pay.
Extra pay urged
“The St. Paul Fire and Safety Services Department has rejected negative approaches and recommends providing extra compensation for double duty in view of our increasing EMS workload,” Conroy stated.
Thus, the department currently is in the process of creating promotional civil service positions for paramedic and ambulance-related EMT work. In early 1980, fire fighters interested in doubling as paramedics should be able to apply for the new positions that provide additional compensation.
“Our paramedics, almost to the man, don’t want to be put into a separate division and no longer fight fires,” the St. Paul chief explained. “They’re proud to be fire fighters and want to be known as fire paramedics. But they do expect extra pay for the extra work.”
Standardization expected
St. Paul is preparing to meet a major national trend of the early ’80s: standardization of EMS programs and especially paramedic training through governmental regulation.
“Anyone who thinks we’re going to do business the same way as we’ve done in the ’70s is uninformed,” commented Campion, who also is an associate professor of medicine at the University of Minnesota School of Medicine.
The medical profession and the fire service are both moving toward the same objective of setting standards aimed at providing better patient care and quality control in the EMS field.
Van Tyn is a member of a joint review committee of the American Medical Association for paramedic training courses. The committee is developing national criteria for accreditation of paramedic training courses. The criteria are based on the United States Department of Transportation training curriculum.
—St. Paul Fire Dept. photos.
National certification
Conroy supports the idea of national certification standards for fire paramedics, but at the present time he is concerned about cost and other factors associated with the national paramedic certification test. He expects that when they are resolved, St. Paul fire paramedics will take the examination.
Campion reported that detailed emergency care standards for St. Paul and Minneapolis area hospitals already have been approved by a review committee, of which he is a member, and soon will he in the process of implementation. He believes, as do the others, that as more hospitals achieve an approved EMS status during the ’80s, fire paramedics will have a better guide for channeling patients to an appropriate medical facility.
Meanwhile, St. Paul also expects to be affected by national standards for EMTs, which the National Fire Academy is planning to develop in the ’80s. In addition, the academy may offer courses in EMS management. Conroy believes the St. Paul program may be cited as one of the best in the country.
The trend toward better control of EMS in St. Paul and elsewhere is a part of a systems approach which, Campion asserted, will have a significant impact on patient care.
Paramedic to EMT ratio
A question remaining to be decided in the ’80s concerns the “right” number of paramedics for St. Paul, and the proper ratio of paramedics to KMTs.
The St. Paul chief observed that medical calls are as unpredictable as fire alarms. He explained that “for the same reason we send a full assignment on most fire alarms, we think we should provide a paramedic response for most emergency medical calls. In both cases, the potential need outweighs other considerations.”
The number of paramedics and paramedic units continued to increase in St. Paul through 1979 because of the work load, according to the fire administration. However, the number is expected to level off before 1985.
Van Tyn cautioned that during the coming decade, various fire paramedic program administrators around the country may face pressures to modify or lower the ratio or number of paramedics due to cost considerations.
Sophistication increases
The St. Paul paramedic program, as well as others that began during the ’70s, has extended hospital emergency room techniques into the street. During that period, these techniques have grown more sophisticated, Conroy pointed out. For example, he explained, St. Paul paramedics started with oral airways and advanced to use of the esophogeal airway. Now, with added training, endotrachial airways are being used for intubating patients.
“This equipment is more expensive and requires more training, but is highly recommended by our medical directors,” Conroy noted.
On the basis of their EMS and fire service experience, Conroy said the St. Paul fire paramedics expect that the techniques they employ will become increasingly sophisticated and effective during the next decade. These techniques will be influenced by medical studies now underway, according to van Tyn and Campion. The studies cover such areas as ventricular fibrillation, chest pain and head injuries.
Campion commented, “Now we are finding that pre-hospital, or paramedic practice, has different goals than those in the hospital. For example, stabilization of a patient on the street has different objectives than in a hospital.”
St. Paul paramedics are entering the ’80s with portable, lightweight and weather-resistant medical equipment—quite a change from the heavy, cumbersome hospital-type devices they used through the mid-’70s. This trend is expected to continue over the next five years. After 1985, Campion believes, some new trends in equipment may occur as a result of developments in fire paramedic techniques.
Meanwhile, van Tyn urges that around the nation, more attention be given to judicious purchase of paramedic equipment. Some equipment, he said, is becoming quite fancy and high-priced compared to other less expensive equipment that may be just as effective.
Budget outlook
Conroy is proud that the St. Paul fire paramedic program has from its inception been based on a tight, cost-effective budget and has been locally funded, unlike similar programs in other cities.
“By continuing this dual emphasis,” the chief said, “I think we will be in a good position to meet the challenge of rising costs for salaries, training and equipment while still improving our emergency medical service in the ’80s.”
The secret, in Conroy’s opinion, is to continue to make it possible for the city’s fire fighters to double as fire paramedics.
“While the cost of this approach will rise,” he said, “it is less costly than other alternatives, such as separating paramedics from fire fighters.”
Meanwhile, van Tyn believes the fire paramedic programs that depend on federal funding may be endangered during the coming decade because he anticipates those funds will be curtailed.
