FIRE SERVICE EMS: THE CHALLENGE AND THE PROMISE

FIRE SERVICE EMS: THE CHALLENGE AND THE PROMISE

PART 1—AN OVERVIEW

The EMS/fire service relationship has been controversial and it has been “spotty,” in that some departments have been very successful in incorporating both functions, some departments have had great difficulties trying to integrate both services, and some departments have made no major commitment at all to delivering EMS.

The “constants” that have emerged from the research for this series, nevertheless, are that EMS began in the fire service, is an integral part of the fire sennee, and will always be part of the fire sendee. The EMS!fire service duo, however, is not a guaranteed match for the future. As in any relationship worth preserving, both parties must be compatible.

This series begins with an overview of the EMS/fire service relationship up to present times, with emphasis on the problems and challenges surrounding it, the societal and economic forces affecting it, and the ongoing initiatives of fire departments and fire service organizations to ensure that the fire service maintains its edge as the major national pro vider of EMS.

future articles will look at some of the systems fire departments commonly use to deliver EMS, strategies that have proved effective in departments rendering firefighting and EMS services, and the experiences of some individual departments that have incorporated or altered EMS programs.

Over the past two decades, the public has come to expect many more services from fire departments. In addition to fire suppression, departments are engaged in fire prevention and protection, public education, heavy rescue, haz-mat management and response, and emergency medical services (EMS). Of these functions, EMS has made the greatest demand on fire department personnel and time; some would argue, however, that the fire service has not allotted to EMS the same management and training priorities given to other functions.¹ As an example, Don H. Hiett,Jr., treasurer of the International Association of Fire Chiefs (IAFC) EMS Section and chief of the Atlanta (GA) Fire Department, cites the following typical fire department budget breakdown: 96 percent, firefighting operations/training; three percent, fire inspection/prevention; and one percent, EMS and other programs—despite the fact that “better than 64 percent of the calls are emergency medical calls.”²

The issue of EMS as a fire service responsibility has been controversial, and the inability of the firefighting and EMS systems to intertwine and function as one complete system in some departments has caused EMS to be less “consistent” than other fire department functions.³ The relationship of the fire service to EMS varies drastically on a state-by-state basis. “Each town or city, each county, each region or state seems to reflect the attitudes of fire officials who were influential at various turning points during the past 50 or so years,” observes James O. Page, publisher/editor-in-chief of JEMS and executive director of the Advanced Coronary Treatment (ACT) Foundation. Many fire departments, in fact, have completely avoided any significant involvement in EMS over the years.⁴

Despite this lack of centrality, however, most of the EMS services have developed in the fire service.⁵ Many departments have become involved in EMS, and their operations are professional and efficient. A 1981 study, in fact, showed that 73 percent of all American fire departments, career and volunteer, are involved at some level in EMS service.⁶

THE EMS VS. FIREFIGHTING DEBATE

The explanations offered for the disparity in reception given EMS by fire departments range from a philosophical difference stemming from the dichotomy between the old and the new, and the traditionalist vs. the innovator, to misunderstandings of^ workers’ job descriptions to career’ issues such as compensation and promotion policies. Yet, the consensus inside and outside the fire service is that since the common goal of the firefighting and EMS functions is to save lives, the two services should work as a team to successfully fulfill the public’s needs.^3,2

Basic to the EMS-vs.-firefighting mentality that has existed within pockets of the fire service have been the following factors.

Tradition. The mission of the fire service “has been the same since the burning of Rome by Emperor Nero: to prevent and suppress fire.” Relatively speaking. EMS is a newcomer to the fire service and is not bound by the same traditions.^7,2

The fire service, especially in large urban areas, “has always done things I in a certain w av,” notes Gordon Sachs, I EMS program manager for the L.S. Fire Administration. “Just as change is inevitable, it is inevitable that the old dogs will resist the new ideas of the young pups. When a new program is forced, rather than eased into, it can cause problems in delivery.”⁸

In some departments, EMS has been looked on as “a stepchild—a responsibility that the fire service faces reluctantly.”^8,30 Whenever the topic of incorporating EMS into these departments has arisen, fire officers have retorted with “Firefighters should fight fires.”⁹ Some of these departments have tolerated EMS as a “necessary evil,” since both EMS and firefighting provide lifesaving functions to the public.¹⁰ Proponents of this “old-guard” theory have looked on anything other than fire suppression as an intruder into the department.^8,30

Accountability to “outsiders.” Fire departments, traditionally closed organizations used to operating independently and without much scrutiny, sometimes have found it difficult to have to account to the “outside” agencies responsible for EMS, explains Page. EM I s and paramedics, for example, are licensed or certified by “outsiders.” Fire departments that provide EMS services, consequently, find themselves accountable to “outsiders” ranging from private ambulance personnel to doctors and nurses to hospital administrators to local and state health agencies.”

Included in the areas subject to the scrutiny of the medical community are education/training, advancement, and discipline. As Page points out, some fire officers, in resisting the incorporation of EMS into their departments, have “appeared uncooperative at best, and obstructive at worst in their contacts and relationships with the health-care community.” Some of them have even tried to override medical protocols established for EMS personnel. In addition, some volunteer fire departments and organizations have lobbied to have training, continuing education, and certification standards for EMS personnel relaxed; in several cases, fire service organizations have fought for the right to evaluate their members’ qualifications to provide emergency medical care instead of having the state health agency make the determination.^4,16

Stepchild mentality. With regard to ambulance service, some departments—especially those departments that had inherited the responsibility for it —began exhibiting a “stepchild” mentality toward it during the 1940s. No established mandated criteria for training ambulance personnel or courses beyond basic first aid existed at that time. “The job required minimal knowledge, few skills, a tolerance for blood, and a strong back,” recalls Page. “In many fire departments, assignment to ambulance duty became an unofficial form of punishment.”^4,14

Morale problems have existed in some departments because old-line chief officers and firefighters in those departments took on EMS without accepting it as an integral component of their organizations. They view EMS “as a temporary assignment taken on by an organization whose job it is to fight fires” and, consequently, see firefighter/paramedics as temporary personnel. As a result, these departments do not have promotional policies that incorporate the two services or provide additional compensation for cross-trained employees.^3,2-3

“If we do not manage our EMS operations, they will be managed by others.”

ISSUES OF CONTENTION

Major EMS-related issues of contention among firefighters have been the following:

• Some firefighters just want to be firefighters; they do not want to be EMTs. In some cases, firefighters have had to accept new EMS responsibil-
• ities or lose their jobs. The prospect of performing EMS can make some firefighters anxious, as was the case when the San Diego (CA) Fire Department first placed defibrillators on its engines.^8,30
• The workload vastly increases when EMS functions are brought into a department. During 1982, for example, one major fire department responded to 2,621 structure calls and 81,210 EMS calls, with at least one engine company and one paramedic rescue unit per call.”^11,31
• EMS work increases personnel exposure to many communicable diseases and often brings personnel in contact with human blood, vomit, feces, and body fluids.”^1,31

Firefighters/EMTs or firefighter/paramedics also have grievances, such as the following, that increase stress and lower morale:

• Inaccurate perceptions of EMS personnel’s functions and responsibilities have led to misconceptions that affect the image of the EMS worker, who has not always enjoyed the same positive image as the firefighter. One of these misconceptions is that being a member of EMS is relatively safe when compared with firefighting. This viewpoint, point out observers, is “ironic,” since many statistics citing firefighting injuries and illnesses include EMS workers who are part of the fire service.

This view of EMS as a “safer” career has been changing, however, for various reasons. EMS professionals face many of the same hazards as firefighters, including the occupational dangers related to lifting and bending and exposure to contagious diseases, including those that are incurable, such as AIDS. These personnel often find themselves at dangerous scenes involving violent crimes or domestic disputes. The high volume of run activity makes EMT personnel more vulnerable to vehicular accidents, which account for a large percentage of emergency service worker deaths and injuries each year.^3,4

In addition, EMS workers serving in a dual role also perform suppression functions, which subjects them to all the risks associated with firefighting. EMS personnel and firefighters are reaching parity in occupational risk levels, and the difference between what is perceived and what is occurring may cause strife or division between EMS workers and fire suppression forces.^3,5

• Many EMS workers do not want to be firefighters. “Many of them don’t want to drag hoselines, search buildings, and participate on the fireground, except for caring for victim(s) retrieved from a burning building.” This attitude, although not prevalent throughout the combined services, could lead to morale and political problems within various jurisdictions. In the combined services, many EMTs do not feel they should assist “smoke-eaters” in cleaning and restoring equipment so that it is ready for the next alarm. This attitude creates friction.^10,38
• Some paramedics or EMTs think of themselves as health-care professionals and do not care to fit into the quasimilitary fire structure. Others feel that firefighters are not qualified or motivated to give quality medical care.^3,30 Not all firefighter/paramedics agree, of course.

“I have seen just the opposite,” asserts Firefighter/Paramedic Paul Harvey, president of the Seattle (WA) Fire Fighters Union, International Association of Fire Fighters (IAFF) Local 27. “Its underlying military discipline means the fire service is inherently able to give quality control.” In Seattle, EMS functions are completely within the fire department. Some firefighters cross-train as paramedics who ride advanced life support (ALS) units. Paramedics maintain firefighting certification and occasionally ride fire apparatus * ⅜°

Chief Hiett of Atlanta agrees. “There is no group in the United States capable of enforcing EMS,” he says. And, he adds, there is no enforcement group overseeing on a momentto-moment basis emergency services given outside of a hospital. “The fire department,” he stresses, “is capable of such enforcement.”²

• Ambulance runs generally take longer than an hour per call. In the volunteer service, this time usually is time the worker would spend with family or pursuing personal activities. In addition, ambulance calls are much more numerous than fire calls in most fire departments.^10,38

OUTSIDE OPPOSITION

In many areas of the United States, the firefighting/EMS controversy within the fire service has become public and has created the impression that the fire service is “a house divided.” Since the ultimate product of EMS is patient care, the dissension has caused some influential physicians to become concerned about the negative impact the stress of the ongoing conflict can have on the EMTs and paramedics—and patient care, which, of course, is the bottom line.^11,37 Some observers have even been led to ask whether the fire service has any “paternal” obligations toward EMS at all.^8,28

For the most part, the fire/ambulance personnel seem to work out their differences before and after the emergency call so that the political ramifications behind the delivery of the service are not evident to the recipient of the services. As M. “Mick” Mastrino, a 35-year veteran of United Fire Company #3 in Frederick, Maryland, observes: “The political climate in most fire/ambulance stations can be in turmoil; however, when the alarm sounds, most leave the problems behind.”^10,39

Another argument critics have used against locating EMS in fire departments is that fire protection and EMS services are too diverse to combine. One of these critics, a “very respected” fire department physician, in 1974 charged that the fire service looks on fire department EMS services as a “bastard offspring” of rescue and medical care. He also cited “significant differences” in the training, education, and experience required for fire and EMS duties.”¹²

The negative attitudes of the fire service toward EMS led to government actions in 1980 that could have taken EMS out of the fire departments. The fire service, however, rallied as a unified force to maintain EMS. At that time, a study group was commissioned by the U.S. Department of Transportation (DOT) to evaluate the concept of “third-service” prehospital emergency medical services: local government public agencies other than fire or police departments that would have prehospital EMS as their sole function. Third-service EMS agencies already were operating in Austin, Texas; Pittsburgh, Pennsylvania; Wichita, Kansas; Cleveland, Ohio; San Francisco, California; and other locales. The DOT’S actions had no significant effect other than to bind the fire service together,^9,38 and its suggestion to establish EMS as a separate or third service was made to eliminate some of the conflicts.^12.49

Other members of the EMS community welcome the fire service’s involvement in EMS. Among them is Jerome M. Hauer, executive director of the Indiana State Emergency Management Agency. “You cannot separate EMS and the fire service …. Some of my colleagues are myopic when they say they don’t want the fire service (particularly the National Fire Academy) involved. It’s about time someone in Washington got interested.”¹³

Adding to the debate has been the question of whether EMS is a public health-care or public safety issue, adds Hauer. “I would argue it’s both. It’s the first step before entering the health-care system. If you’re not successful in defibrillating, the patient won’t enter the health-care system.” Addressing this recurring issue, Sachs (USFA) says that after consulting with a number of experts, the USFA has taken the position that “EMS is a public safety entity charged with delivering a public health service.”¹⁴

EMS AND THE FIRE DEPARTMENT: A NATURAL DUO

Despite the reluctance of some fire departments to embrace EMS and the opinions of some critics to the contrary, the fire service and EMS seem to be natural partners from several perspectives. Among them are the following:

• Image. The firefighter has always been perceived as a brave public servant who can help when there is danger. Traditionally, the one source of help that comes to mind when a situation appears helpless has been the fire department.^9,38
• Cost effectiveness. As an alreadyexisting and functioning service, the fire department provides a more costeffective means of providing paramedic service, points out Tim Butler, a fire captain/paramedic w ith the City of Anaheim (CA) Fire Department. The public gets two services for the price of one.¹⁵ Staffing and equipment are already available. Most fire stations already have in place the components— such as communications, dispatch, vehicle maintenance, training, rapid response, and personnel — needed for EMS; modifications can make them suitable for medical pur-
• poses.

Decreased workload. The decrease in the fire workload has left firefighters with more time between alarms for EMS activities.

• Improved response time. Fire stations are situated so that response time often is improved; the time difference between the arrival time of the fire engine and the ambulance in outlying areas can be dramatic.
• Noninterference with J’ire suppression duties. Most fire stations find that assuming EMS duties does not interfere with fire suppression, points out Chief Ricky Davidson, chief of EMS for the Shreveport (I A) Fire Department and the immediate past chairperson of the IAFC EMS Section. In many areas, the ever-increasing number of medical calls being handled by the fire departments already has caused them to assimilate EMS duties into their daily routines.
• Incident command system. ‘ITie fire department has another advantage in that it uses the standardized incident command system (ICS) to manage large-scale emergencies. The ICS provides a framework tor coordinating onscene and available resources so that actions at a chaotic scene are controlled, explains Butler.

SOME STEPS TOWARD IMPROVEMENTS

Hie fire service began to move gradually to reorganize its EMS programs during the 1980s. Some departments entered directly into EMS and instituted separate job standards and career ladders, as well as different pay scales for these personnel. They devised solutions to the problems that had been fostering discontent within the fire service EMS (some of them will be presented in a subsequent article). In some locales, for example, the job description for fire chiefs has been revised to require that future applicants have a significant EMS background. In jurisdictions such as Beverly Hills, California; Idaho Falls, Idaho; and Abilene, Texas, fire chiefs have served on the streets as EMTs or paramedics.

Such changes, of course, are not likely to occur everywhere. Some fire departments have been “captives of their own history and hiring policies; many of them do a bad job of fighting fires and a bad job of [rendering] emergency medical care,” observes Page. These are the departments, he predicts, that the emergency physicians, who will become more involved in prehospital care on behalf of the patient, most likely will pressure into dropping EMS so that it can be provided by a private or hospitaloperated ambulance service.

CHANGES ARE IN THE AIR

If the fire service is to be at the forefront of EMS in the future, indications are that it must be able to adapt to the many changes underway in our society. (See “EMS at the Crossroads …” on page 55.) Some of these changes were begun in the early 1980s when some communities began to see their possession of EMS programs challenged. Potential competitors began assembling data to show the economic and service advantages of a hospital-based. public utility, or private ambulance program. Hospitals throughout the country with a surplus of hospital beds, for example, are looking to the control (or ownership) of the ambulance service as a means of bringing a flow of patients to their hospitals. Some private ambulance companies are offering these hospitals “turnkey” contract arrangements that will provide the hospital with ambulance service overnight.

Changes in Medicare reimbursement policies and new hospital-financing approaches have produced potential competition for the local volunteer ambulance service. The changes being proposed in the national health-care delivery system and the fire service’s EMS-oriented initiatives now underway nationally and in Washington, D C. also w ill affect the overall EMS system. “It will be very’ interesting to see what’s going to happen when a new national healthcare delivery sy stem is proposed and implemented,” notes Bill Madison. deputy’ executive director of the IAFC and a registered EMT/P. “If everyone becomes covered under the plan, will our business go up? How will the new health-care plan affect EMS, and will we be involved in it?”

A reorganization of Medicare, Medicaid, and private insurance could help ambulance companies, which have trouble collecting their fees. Many American Ambulance Association (AAA) members are concerned that health-care reform might include rationing and price fixing, which if incorrectly administered could put many ambulance companies out of business.

In Congress, Steve Gunderson (RWI) has introduced H R. 4256, which would create a federal EMS office under the Department of Health and Human Services and would provide grant money for state EMS offices and for improving rural EMS services (see “News in Brief,” Fire Engineering, June 1993, p.26).

According to Toffler and other esteemed futurists, major societal and economic changes are occurring every two to five years. Unless those segments of the fire service still saddled with the “traditions of constancy” respond to the accelerated change timetable, they may find themselves “vulnerable” with regard to EMS, warns Page. A warning sounded in 1983 still appears appropriate; “W hile the current parents of EMS are treating it as an old shoe, others —just around the corner—are perceiving it as a glass slipper.”

EMS, THE “SAVIOR” OF SOME FIRE DEPARTMENTS

Many observers, in fact, credit the move into EMS with helping many fire departments to keep their fire suppression service viable. “We can only speculate on what the fire service would be like today without the public and budgetary’ support it has reaped from its EMS role,” noted a 1984 JEMS report, which posed the following question: “Could a singlefunction fire service have endured the economic pressures of two oil shortages, double-digit inflation, taxpayer rebellions, and the longest of postwar recessions?”

In many areas, EMS is the function that has been winning public and political support for the fire department and providing the productivity needed to keep the engine and truck companies adequately staffed.

In departments where personnel are cross-trained in firefighting and EMS, there seems to be less of a tendency to eliminate positions; twothirds of all calls to these departments commonly are for emergency medical assistance. In addition, the departments also enjoy strong public support. Where sampled, public sentiment has shown that the public ranks EMS as the most valued public service, Page notes. The tax-concerned public, on the other hand, showed little concern over whether a threefirefighter pumper is as effective as a five-firefighter pumper, he points out.

“How can one justify a multimillion-dollar budget if the system doesn’t get used?” asks Madison.

It’s a matter of time before costefficiency comparisons will be made.” These analyses, he adds, will reveal fewer calls for fire suppression, more expensive fire suppression equipment, and escalating firefighting personnel costs. The progressive fire departments, he says, understand that EMS runs are one way to resolve the budget problem. Fifty percent of the ambulances sold in this country are sold to fire departments, something every’ fire chief has to look at closely, Madison notes. His department, in Norfolk, Virginia, took over EMS from a third service.

Providing EMS services seems to be a natural way for fire departments to build rapport with community residents. In one study based on an estimated total of 30,000 fire departments, 21,900 of them were shown to provide EMS in one or more of 26 distinct profiles of service (to be discussed in a later article). If each of those departments provides EMS to only two patients per 24 hours yearround, in a year’s time nearly 16 million people would have received fire service EMS. Theoretically, that means that fire department EMS personnel will have contact with every man, woman, and child in the country once every 12.5 years. No other public agency has such an opportunity to provide valuable service while establishing a relationship with taxpayers, stresses Page.

These factors have led some advocates to encourage the incorporation of EMS into the fire service. Harvey, of the Seattle Fire Fighters Union, says the question should not be “Should EMS be in the fire service?” but rather “How can a fire department meet the demand of EMS?”

The truth, say others, is that many fire departments believe they have no other choice but to take on EMS, since it no longer may be realistic to continue to support two departments with duplicate expenses for leadership, administration, and training staffs, as well as individual training facilities for similar responses.

Looking on EMS as “the emergency treatment for ailing fire service budgets” seems to be a logical position for many departments. Keep in mind, however, that many other critical factors in addition to the economic benefits must be evaluated when considering whether to add the EMS function to a department. Also, keep in mind that not all fire departments are ready to provide a full scope of services. Moreover, departments in cities and counties that have private or third-service EMS providers might not welcome the suggestion of a budget-saving fire-EMS merger.

Whether local fire departments should provide EMS depends on factors such as the community’s needs and wishes, the resource capability of the locality, the political impact of the decision, and the attitude of the fire department that is to undertake the additional responsibility. As Lieutenant Harold C. Cohen, EMS director of the Baltimore County (MI)) Fire Department and head of the Fire Rescue Academy, points outs, a department in which management “vehemently resists” EMS is not conducive to quality EMS.

Jim Thornton, a firefighter with the Department of Fire and Paramedical Services in Norfolk, Virginia, agrees: “Cross-training of firefighters for any level of EMS certification should never be forced.” Norfolk’s third-service EMS provider was merged with its fire department in May 1991; it is operated by cross-trained firefighters who want medic certification. “Some firefighters are not good at the EMS angle, and not everyone in EMS can do fire suppression,” Thornton explains.

While it appears that most fire officials accept that there is a legitimate role for the fire service in EMS, some are wrestling with decisions such as what the nature and extent of the role should be.

FIRE AND EMS IN THE FUTURE

Despite the problems, challenges, and competitors, the future of fire service EMS appears to be bright. Even those who believe that creating combination fire/EMS services throughout the country was “a mistake that will forever be a problem” also believe that “the political process will prevent their dissolution and that good management can prevent or minimize the friction that will be persistent between the services.”

Even in the 19B0s, when many of the problems associated with fire service EMS came to prominence, statements such as the following appeared in various fire service publications.

It “seems safe to say that fire departments, the public, and perhaps a large segment of the medical community have come to accept the fire service as a major EMS provider …. There certainly is no suggestion that the fire service should not continue to play a leading role.”

“I feel no community can run a truly effective EMS system without the involvement of the fire departments on some level …. Some of the best EMS services in the country arcprovided by fire departments …. The reason they perform so well is that they understand that EMS is different and demands a different type of thinking. Fire departments bold enough to look beyond themselves and their traditional approaches to fighting the ‘enemy’ will achieve their full potential of excellence.”²⁰

There have been warnings in these publications as well. One is that the fire service will have to work harder to keep EMS services in the future than many departments have had to work to acquire them. In a nation flirting with bankruptcy, other sources point out, decisions affecting the fire service and health-care arenas will be based on “cold-eyed analyses of quality and cost.” These factors keep in the forefront the question. Can the fire service maintain its role in EMS in such an environment?^9,40

Fire service EMS will encounter various challenges and obstacles in the future, observes Kevin Brame, battalion chief in charge of strategic planning and legislation with the Orange County (CA) Fire Department. Among those he cites are the following: the medical establishment’s mandating of local standards of care without giving any consideration to how they will be financed; overregulation; changing social environments that will place the fire service on the front lines of providing the first, if not the only, access to cumbersome and bureaucratic systems of health care; labor concerns relative to the increasing dangers within the work environment; political processes that tell the fire service how to do its job, based on the need for votes or political contributions; and a continuing medical community belief that members of the fire service are still “just firefighters.”²¹

NATIONAL EMS INITIATIVES

Indications within the fire service are that EMS is and will continue to be an integral component of fire departments, as evidenced by the IAFC and IAFF Joint Resolution on Emergency Medical Services, issued on January 9, 1991. The document recognizes prehospital emergency medical care as a major service provided by fire departments and maintains that the “fire service must continue to provide emergency medical care.” The document also urges “all elected officials, professional associations, and health care providers to recognize and support the provision of emergency medical care by the fire service.” In addition, the IAFC has established an EMS section; the Congressional Fire Services Institute (CFSI) has formed an EMS advisory committee;^21,32 and the CFSI has hired Michael Smith as its EMS coordinator, as of November 1, 1992, with the aid of a S25,000 grant from the AAA —his duties will include facilitating the flow of information from the CFSI to Capitol Hill staff members and members of the Federal Interagency Committee on EMS (see Fire Engineering, June 1993, p.22).

The USFA has committed itself to increasing the efficiency and effectiveness of the management of the overall prehospital emergency medical system. “Patient care is the top priority in EMS,” stresses Sachs. He points out that 80 percent of the fire service provides EMS and that, therefore, EMS management is a critical part of fire service management. The goal of the USFA, Sachs says, is to promote unity throughout the EMS community.¹⁴

A significant portion of the agenda for accomplishing this objective was developed at the National Forum on EMS Management, held in February 1992 in Arlington, Virginia. Leaders of all major national EMS organizations and federal agencies involved in EMS met to discuss various issues related to EMS, including the scope of the role the federal government should play. A report on the forum was being prepared at press time.²²

To increase coordination and cooperation between the federal agencies and the EMS community, the Federal Emergency Management Agency (FEMA) has reassigned the chair of the Federal Interagency Committee on EMS to the USFA and expanded its role. The chair’s functions now’ include maintaining a liaison with national EMS trade and professional organizations and associations.²²

At the NFA, Jeff Dyar, director of prehospital education at Creighton University in Omaha, Nebraska, has been hired to supervise the development of the NFA’s proposed comprehensive EMS management program. EMS leaders at the February EMS forum and participants in the National Highway Traffic Administration’s Public Information, Education and Relations conference in January 1991 had recommended that the NFA expand its curricula to include EMS. Among revisions the NFA will be making is the replacement of its current twoweek EMS management course with a new Advanced EMS Leadership course.²²

PROSPECTS FOR EMS

The fire department’s role in KMS in the 1990s will vary with each department. No single model will fit the needs of every community. In rural areas, for example, the fire department may be the only provider of EMS. In cities, on the other hand, the fire department may provide basic life support with another city agency or an outside (third-service) agency providing advanced life support and/or transportation to the hospital.

Fire service EMS is a complex, vital, and controversial issue whose future prospects invoke both “euphoria” and cautiousness in fire service members such as Brame of the Orange County (CA) Fire Department, who on the one hand is celebrating that “the fire | station light has come on, waking everyone up to the realization that fire service EMS is here to stay,” and, on the other hand, is warning that j without proper attention, EMS will become a “nightmare.” Brame emphasizes: “EMS management is a must, for if we do not manage our EMS operations, they will be managed by others.”^21,32-33

ENDNOTES

1. McKeen, D.K., N. Rynning, B.J. Weaver, K.M. Smith. “The Illusion of Gorgeous Uniqueness of the Fire Service Toward EMS.” Research Project, National Fire Academy, Jan. 7-18, 1991, 1.
2. D.H. Hiett, Jr., treasurer of the International Association of Fire
3. Chiefs EMS Section and chief of the Atlanta (GA) Fire Department, telephone interview, May 10, 1993.

Harley, G., I). Johnson, G. Kantak, et al. “Fire/EMS—A Marriage in Trouble. Research Project, National Fire Academy, Aug. 6-17, 1990, 1.

Page, J.O. “Trends in Fire Service EMS.” Fire Service TODAY, 50:2, Feb. 1983, 14.

1. Hunter, K., J. Holt, D. Saunders, et al. Improving Attitudes of Firefighters Towards EM.S Management of Emergency Medical Services

Course, National Fire Academy, Feb. 1-12, 1988, 1.

1. Newman, M. “Born of Necessity and Thriving: A Survey of Fire Service Involvement in Emergency Medical Services “JEMS, 1982 Almanac, Jan. 1982, in “Trends in the Fire Service,” as cited in No. 4 above, 16.

Alguire, W.J., J.C. Cosby, D.B. Jackson, et al. Patching up the marriage between fire service and EMS. Research Project, National Fire Academy, Apr. 11-22, 1988, 3.

1. Benson, K., “EMS in the Fire Service.” Emergency, Nov. 1992, 30.
2. “Fireman, Save My Child!” Staff Report, JEMS, June 1984, 38.
3. Mastrino, M. “EMS & the Fire Service: Has It Hurt Delivery?” Firefighter’s News, Oct./Nov. 1992, 38.
4. Page, J.O. “Understanding the Fire Service.” JEMS, June 1984, 34.

Gratz, D.B. “EMS in the fire service TIME OUT! Eire Chief Nov. 1983, 48.

Hauer, J.M. executive director, Indiana State Emergency Management Agency, phone interview, Feb. 1993.

1. Sachs, Gordon, EMS program manager, USFA, telephone interview, April 1, 1993.
2. Butler, T. “Call the Fire Department.” Emergency, Dec. 1989, 45.
3. Madison, Bill, deputy executive director, IAFC, and nationally registered EMT/P. Telephone interview, Jan. 27, 1993.
4. Washington Watchdog. Congressional Fire Services Institute, Nov./Dec. 1992, 7.
5. I.and, D.W. “Integration of Fire and EMS Delivery System, NFA executive development program, Nov. 1989, 9.
6. Peterson, W. “Improving Public Support for the Fire Service Through EMS.” Eire Engineering, Nov. 1983, 55.
7. Dernocoeur, J. “A Bold Approach to Fire Service EMS. JEMS, June 1987, 8.
8. Brame, K. “EMS Perspectives”: Fire service EMS comes of age.” Eire Chief May 1991, 33.
9. NASEMSD SCANNER, National Association of State Emergency Medical Services Directors, Fall 1992. 7.