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Home > EMS Products > Consulting, Management and Legal Services
November 04, 2008
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The Ambulance Driver's Perspective
by Kelly Grayson

Marriage Counseling Part III: Détente in the Dysfunctional Fire-EMS Relationship

By Kelly Grayson

--> Read Part II: Marriage Counseling: The Dysfunctional Fire-EMS Relationship

Marriage Counselor: OK, I’m sensing a lot of resentment from both of you. EMS, you feel stifled, and you blame FD for holding you back and not giving you the respect you deserve. FD, you seem to feel that EMS is ungrateful and undisciplined, and should just accept their assigned role in the department structure — is that it?

FD and EMS (in unison): Yes!

Marriage Counselor: Have either of you considered the possibility of compromise? It seems that both of you have valid concerns. Adults strive to work out their problems and often compromise is necessary to achieve harmony in a relationship. Obviously, you both can be good for one another, so how can you find some common ground?

EMS (petulantly): FD can start by letting me just do emergency medical calls and not fight fires! And he can pay me more than the firefighters! After all, I do most of the work!

FD (stubbornly): EMS can shut up and do the work, just like any other firefighter!

Marriage Counselor (sighing and reaching for his flask of tequila): Dad was right. I should have run off to join the circus when I was a kid.


I’ve spent a couple of columns bashing dysfunctional fire-EMS departments, but it is only fair to point out that not all fire departments do EMS poorly. The general trend I see is that the most dysfunctional relationships are within large municipal fire departments where EMS and fire were forced to merge unwillingly. In many cases, they took a functioning EMS system and a broken fire department, and tried to combine the two in the name of cost-savings and efficiency. What they got instead was a system that resembled efficiency, just like Frankenstein’s monster resembled a human being.

More than a few readers have replied to me personally by e-mail and here on EMS1 to inform me that their respective departments not only provide quality EMS care, but manage to do so with parity in salaries and overall funding with their fire suppression brethren.

I applaud the departments that do it right. It’s apparent that many suburban fire departments have found a winning formula in providing dual-role EMS and fire suppression. The question is how do we make their approach catch on elsewhere?

Let’s face it — the public face of dual-role departments across the country is the major cities. San Francisco, Philadelphia, Los Angeles, Dallas, DC Fire and EMS … heck, the FDNY “brand” is downright ubiquitous. You can see it on T-shirts worn by volunteer firefighters from right here in rural Podunk Parish, Louisiana. It’s nearly as popular as their own departmental logos.

And when the general public — small town public officials included — looks for a departmental model to emulate, they often look to those cities, right or wrong. And it’s most often wrong.

DC Fire and EMS has problems providing EMS care, and the recent adoption of an “integrated, all-hazards agency” hasn’t done much to quell the discontent among their crews. Philadelphia FD has chronic response time problems. Los Angeles FD not only has had some well-publicized snafus in delivering EMS care, but apparently has no QI system in place for detecting and correcting such problems. FDNY has had its share of growing pains, and they’re still suffering from them 12 years after the merger.

The antipathy is even played out here in the comments on previous columns, with epithets like “stretcher ape” and “hose monkey” being tossed about.

So, how do we answer the original question posed in Part I: What will it take for medics to achieve equality in the firehouse?

Well, for starters, I’ll stick with my original premise and advocate doing away with the dual-role model altogether. I firmly believe that fully serving two masters is both counterproductive, and an impossible goal for most medics and firefighters. However, there are some lessons we can learn from the smaller departments that have embraced the dual-role model and attained a measure of success with it. Here are some of those lessons:

  • Pay parity and equal hiring standards: And no, I don’t mean everyone gets paid the same. Some jobs are harder than others, some qualifications more difficult to attain. What I mean is, everyone should start with the same base pay and the same basic qualifications — EMT-Basic and Firefighter I within six months of hire, for example. Beyond that, there should be a graduated compensation scale for department members who choose to take different paths — incentive pay for paramedic certification and the various EMS alphabet soup courses, and similar incentive pay for the various firefighter specialty certifications such as hazmat and technical rescue courses.
  • Equal promotional paths: If we scrapped the dual-role model, it would result in two separate promotional pathways with each culminating in the role of a chief. While I don’t think having separate fire and EMS division chiefs would be a bad thing, for many of the fire department old guard, such an idea is tantamount to heresy. All it would take to work is having both division chiefs answer to one overall departmental chief — one with equally strong fire and EMS credentials.

    This is a fundamental organizational tenet that has been ignored in many fire/EMS mergers, with senior medics magically attaining battalion chief status with little real-world experience in fire suppression. While this is wonderful for the newly-minted chiefs, it does little to foster cooperation and mutual respect between EMS and fire suppression crews.

    In a dual-role department, promotional pathways should at least be based on competitive testing. And the promotional exam should be non-task specific, biased neither for, nor against, fire suppression or EMS.
  • Allow lateral transfers: If a medic grows tired of life on the ‘bolance, allow him to apply for openings on the fire suppression side — provided he is willing to attain the necessary qualifications. Allow the same for firefighters. Most importantly, ensure that the education to attain those certifications is readily available to crews from both sides of the firehouse.
  • Flexible rank structure: I’ve heard it said many times, “There is no room for improvisation on the fireground.” While such a statement is largely true for fire-suppression operations, EMS care, by its very nature, requires frequent improvisation. The responsibility for patient care ultimately lies with the highest trained provider on scene, not necessarily the one with the most seniority or number of promotions. Nothing is more corrosive to EMS morale than a battalion chief with an EMT-B certification who feels qualified to dictate treatment decisions to a paramedic simply because the medic occupies a lower rank on the departmental ladder.
  • Strong medical direction: The oversight and medical direction of the EMS side of the house needs to be handled by a physician who is not subordinate to the chief. Make him a co-chief if you want or make him answerable directly to the governing body of that municipality, but emergency medical operations need unfettered oversight from a trained medical doctor.
  • EMS ratings: How does a citizen know that their fire department provides quality EMS care? How do you, as a member of that department, know how you stack up against departments across the country?

    The answer is simple in concept, but difficult in execution. We need to devise objective national benchmarks for measuring the effectiveness of a department’s EMS care. Fire departments are already objectively rated by property insurance associations on their fire suppression capabilities. Citizens benefit from fire departments with higher ratings by receiving lower insurance premiums. Why not rate EMS the same way?

    For those fire departments that do EMS really well with quantifiable results, the citizens they serve should get discounted health insurance premiums. That gives citizens incentive to clamor for better EMTs, and gives fire departments incentive to give EMS the budgeting it deserves. Departments would also have tangible results to point out to taxpayers come time for renewal of tax millage.

There, see how easy that was? If both parties can learn to bend a little, I think this EMS-fire marriage can be saved.

Of course, by “bend,” I mean, “adopt all my suggestions without question.” I’m stubborn, even for a stretcher ape. Then again, I may also be totally full of manure. What do you think? Tell me so in the comments section below!

About the author


Kelly Grayson, NREMT-P, CCEMT-P, is a critical care paramedic in Louisiana. He has spent the past 18 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is a former president of the Louisiana EMS Instructor Society and board member of the LA Association of Nationally Registered EMTs.

He is a frequent EMS conference speaker and contributor to various EMS training texts, and is the author of the popular blog A Day In the Life of an Ambulance Driver. The paperback version of Kelly's book is available at booksellers nationwide. You can follow him on Twitter (@AmboDriver) or Facebook (www.facebook.com/theambulancedriverfiles), or email him at kelly.grayson@ems1.com.

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