Response to the OPFFA fire medic proposal
I am writing this open letter in response to the OPFFA proposal to train firefighters to give potentially harmful medications to patients in addition to their standard set of skills. As both a resident of Ontario and a Paramedic, I am fervently against the allocation of resources for this initiative and believe you should take the same position. There are three reasons why I have taken this position. First, allocation of resources for additional medical training should be utilised for Paramedic services; second, there is a potential danger to the public; third, while the proposal seems cost effective, the proposal is much more costly than advertised.
OPFFA Proposal Rationale
Before I go into the reasons why their proposal is costly and dangerous, we should look into the rationale of the proposal. The OPFFA essentially states that Paramedic response times are inadequate, often attributed to increased call volumes and offload delays. The basis of their argument for additional resources is as follows: Firefighters have a 90th percentile response time of approximately 6:45. Paramedics have a 90th percentile response time of approximately 10:30. (OMBI, 2013) This means a 3min 45second difference at the 90th percentile. The big question is, are Paramedic response times really underperforming? According to the ministry of health, sudden cardiac arrest patients and CTAS 1 (Canadian Triage Acuity Scale) patients (e.g. those requiring active resuscitation) must have Paramedics arrive within 6 and 8 minutes respectively 50%-90% of the time (MOH, 2011) and nearly all Paramedic services in Ontario are currently meeting or exceeding that benchmark. (OMBI, 2013; OMBI, 2012) Many Paramedic services do have challenges with offload delays, but those offload delay times overall have plateaued or declined thanks to Paramedic services tracking triage and offload times, and putting pressure on ER’s to free up Ambulances quicker. (OMBI, 2013; OMBI, 2012) Paramedic services are even tackling chronically increasing call volumes by employing strategies like community Paramedic and CHAP EMS (Community Health Assessment Program by EMS) programs. Hamilton Paramedic Service, at their CHAP EMS pilot project Strathcona building, have seen a 32% drop in calls to that building since the onset of the initiative. (Frketich, 2013) While there is a strain currently on Paramedic services across the province of Ontario, resources are being effectively used and meeting current ministry standards.
A second unstated rationale for their proposal is that an AMEMSO study has found that firefighters are useful at about 2% of all medical calls, those calls likely being cardiac arrest and motor vehicle collisions. (Levy, 2011) Many municipalities in North America have attempted a merger of emergency services or a “fire-medic” model as proposed by the OPFFA. A District of Columbia fire chief has studied cultural differences between Fire and Paramedic services and found that “most (fire-medics) cannot wait to get back to firefighting. Most of the firefighters do not like performing the duties of a medic. They joined the fire department to fight fires.” (Gill, 2004) With a cultural shift as monumental as this, there is a possibility of an internal revolt and lack of support for medical services. The same study found, “the current (fire) leadership has been less than sensitive to the needs of the EMS system.” (Gill, 2004) It continues saying “interfacing EMS into the very traditional fire service or, in many cases ‘forcing’ EMS into the fire service has caused a number of operational problems and system breakdowns.” (Gill, 2004) Training firefighters to perform medical interventions beyond their traditional role may be culturally and logistically difficult. A feasibility study was performed for the city Toronto regarding the possible merger of Paramedic and fire services and it concluded “Significant evidence exists demonstrating that merging separate fire and emergency medical services takes significant investment and is often beset with challenges including substantial legal and labour issues.” (Fox, 2013) While this study was specifically drafted regarding merger of services as opposed to simply training “fire-medics”, history and studies have both shown that investing in medical responses is best invested in Paramedics.
Evolution and Benefits of Paramedics
The Paramedic profession has a short history in Ontario compared to firefighting, but its evolution has been quick. In the 1950’s and 60’s Ambulance drivers had no required training and ambulance services were run by a hodgepodge of operators. Responding to the need for more formal and organized ambulance delivery, the profession took on new skills. The original Ambulance and Emergency Care (AEC) program proved so successful that the course length quickly grew from a 6 month training course to a full year. In no time, these emergency medical specialists expanded their skill set to include things like cardiac monitoring, symptom relief medications, and defibrillation. With the knowledge and skill required to meet the Ministry of Health standards, the designation of Emergency Medical Care Assistant (EMCA) was coined and the definition of Paramedic in the ambulance act was changed to include certification by a base hospital physician and completion of the six hour EMCA exam. Eventually Paramedics expanded their knowledge and skill set so much that the Ministry of Health decided add the word Advanced to the EMCA certification (AEMCA). (Trillium College, n.d.) Today, Paramedics are required to complete a 1500 hour college course which includes an additional 500 hours of practical training. (Admin, 2015; City of Ottawa, n.d.) With this 2000 hours of training, Primary Care Paramedics can administer medications such as nitroglycerin, epinephrine, salbutamol and glucagon, to name a few. Primary Care Paramedics in many services, with additional training can perform controlled medical acts such as intravenous therapy, advanced airways and cardiac diagnostics. The Ministry of Health recognized the need for yet more emergency interventions, which led to a whole new class of Paramedic, the Advanced Care Paramedic. This course required yet another 1200 hours of didactic and practical training to be able to perform advanced medical interventions including dopamine administration, intubation and needle decompression. (Admin, 2015; City of Ottawa, n.d.) Even with all these advancements, the field of Paramedicine is still evolving. Initiatives such as community Paramedics and CHAPS EMS are being studied and are already making a huge difference in peoples’ lives. Paramedic services are studying new interventions thanks to networks such as ROC (Resuscitation Outcomes Consortium) and CPER (Centre for Paramedic Education and Research) so they can continue to serve their community better. Paramedics are proven medical professionals who work tirelessly for their communities. They have proven themselves in the ever changing field of evidence based medicine. When communities consider allocating resources for their medical needs, Paramedics have proven that they are worth investing in.
Danger to the Public
The OPFFA’s proposal is to train their members to perform delegated medical acts is extremely dangerous for multiple reasons. First of all, they are proposing 20 hours of training. As previously discussed, to reach the minimum standard per the Ministry of Health to perform medicals acts as a Paramedic is 2000 hours or training and passing a 6 hours certification exam (Admin, 2015; City of Ottawa, n.d.) That is a gargantuan difference from any standpoint. The knowledge required to perform the delegated medical acts proposed by the OPFFA is great and cannot be underestimated. Every medication that Paramedics deliver to their patients carry inherent risks and can cause adverse effects that are potentially life threatening. To prevent drug misuse, Paramedics must perform a thorough assessment, use diagnostic tools like the cardiac monitor and SpO2 monitor, obtain vital signs, and obtain a patients’ medical history including medications and allergies, and follow the ministry required Basic Life Support standards all prior to administering ANY medication. (MOH, 2011) With only 20 hours of training, fire medics won’t be able to perform those medical acts effectively or safely.
To ensure quality assurance and patient safety, Paramedics are overseen by three entities; The Paramedic service, Base Hospital, and the Ministry of Health. Review of thorough documentation completed by Paramedics helps to identify potential problems with medical delivery, identify areas of improvement, and aids in data collection for continuing medical education and skills development/advancement. In the proposal by the OPFFA, it is unclear what medical oversight, if any, they will have. This poses a great danger to the public. It also leaves the “fire-medics” unaccountable for their actions and potential mistakes. In fact, the Ontario Base Hospital group is now on record stating they have “significant concerns from a patient safety perspective.” (Lewell, 2015)
Paramedics are required by the Ministry of Health to have continuing medical education and recertification for ensure that their knowledge and skills are up to date, and that their skills continue to advance in the ever changing medical field. (MOH, 2011) In the proposal by the OPFFA, there is no mention of continuing medical education and annual recertification. This also poses and HUGE risk of harm to the public because the so called “fire-medics” may not have knowledge that is up to date, and their protocols may not follow current evidence based medical guidelines.
The final risk to public safety contained in the OPFFA proposal lies in the increased used and unavailability of fire trucks for actual fires. If the proposal goes ahead as planned, fire trucks will be utilised much more frequently than in previous years. A study noted regarding the disadvantages to merging Paramedic and fire services concluded “that the integrated model might encourage staff reductions, which could compromise the capacity to cover concurrent Fire and (Paramedic) surge demands” (Browett, 1999) Meaning staffing levels for fire calls will be reduced. This also means more fire trucks will be screaming down city streets, going through red lights and disrupting traffic on a much more frequent basis. Any emergency responder will tell you that going lights and sirens to any call is dangerous. On top of this the additional use of firetrucks could potentially tie up the “fire-medics” on medical calls for extended periods of time, preventing them from responding to their primary purpose, which is of course fighting fires. Fire response times will go up, property losses will increase and lives will be lost. The OPFFA also states that fire-medics will be trained “on shift” but they don’t specify exactly what that means. Likely those trainees will not be available for calls while they are in class, which means that less units will be available to respond to calls.
Greater Financial Burden on Municipalities
Finally, the OPFFA proposal claims that their training will be done on shift and will cost no more than approximately $30,000. I believe that this is a grossly underestimated number that is not representative of the true cost that they are taking on.
The medical field in North America is highly litigious. This means that the entire fire service will have to take on errors and omissions insurance and liability insurance. On top of that, court costs, lawyers, overtime for fire-medics who have been summoned, settlement costs are all unaccounted for. There is also the intangible loss of face in the eyes of the public when things go wrong.
The per response cost of a firetruck in Hamilton for example is $330, and by contrast a Paramedic response in Hamilton is $194. (OMBI, 2012) Undoubtedly, if fire responses increase, the cost to the municipality will increase. Wear and tear to the trucks, fuel use and maintenance costs will all increase. The National Commission of Fire Prevention and Control calls the practice of responding to medical calls with full-size apparatus, “an expensive and inappropriate use of equipment.” (Baker, 2014)
A top tier firefighters’ salary in Ontario is in excess of $90,000 (Wente, 2013) compared to a Paramedics salary of just over $75,000. (Admin, 2015) Bear in mind that each fire response crew has 4 people as opposed to a Paramedic crew which has 2 people. That’s $360,000/year compared to $150,000/year. Paramedic crews are undoubtedly much more economical. Consider as well that fire-medics are taking on additional responsibilities than traditional firefighters, which means that fire-medics will likely ask for a raise, once again increasing the cost to the municipality.
As previously stated, the fire-medic trainees, while in class, may not be available for calls while “on shift”. If they are not, that will likely mean that firefighters will have to be brought in on overtime to maintain service levels, a cost which also has not been accounted for.
The Firefighter profession is very well respected in all circles of society. They do very good work at fire suppression and fire prevention, which has contributed to a reduction in fire responses of 41.4% over a 16 year period. (Shum, 2015) This effectiveness has unfortunately caused the symptom of firefighters attempting to branch out into other areas of responsibility which are already being serviced and in which they are not fully effective. Given the safety risks to the public, the mounting costs associated with fires’ medical responses, and the growing medical expertise of current Paramedics on the road, municipalities would be best served investing resources intended for medical responses to medical professionals.
Thank you for your time,
Jonathan Buxton PCP, AEMCA, Paramedic Instructor
Disclaimer: The above is solely the opinion of the author and does not represent the position of Paramedic services, Colleges or Paramedics at large.
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