Three years in, Fla. fire says its advance life support efforts are a success
The three year experiment to let the fire department run ALS calls is still a point of controversy despite good results
By Greg Stanley
The Naples Daily News
NAPLES, Fla. — A 92-year-old man sat in a nursing home bed with his head bowed, resting in a nurse's right hand.
The nurse turned as two firefighters arrived — the first paramedics to respond to the 911 call — and the man threw up into a bag she held above his lap.
His name is Jack, the nurse said.
"Jack, can you hear me?" said Rob Loewel, a North Naples firefighter, as he grabbed Jack's right hand.
He could hear, but he hadn't been able to speak since he had a stroke two weeks earlier, the nurse said. He was paralyzed on his right side and had been released from the hospital just a day earlier.
Two minutes passed until an ambulance arrived and two more paramedics from Collier County Emergency Medical Service entered the room.
The four medics loaded Jack into the ambulance, where two stayed in back with him as the driver navigated through rush hour traffic down U.S. 41 to NCH Downtown Naples Hospital.
The patient's family didn't notice it in this case, but that two-minute gap between firefighter and ambulance arrival has been the source of a decades-long fight over the capabilities of paramedics at the scene of medical emergencies in Collier County.
Limits on firefighters, who often arrive first, have sparked investigations and allegations of misconduct between competing officials in charge of local fire departments and county paramedics. The fights also have helped spur merger talks between the unincorporated county's seven fire districts.
While Jack's condition may not have required immediate advanced life support services in the minutes before the ambulance arrived, care in that time window can be critical for some patients — the difference between life and death.
Fire paramedics say they should be able to perform those live-saving procedures. But only one fire district in the county has the full freedom to do so — North Naples Fire Control and Rescue District.
After three years in practice, North Naples' track record of quicker response times and good patient care is proof that fire districts can effectively run emergency medical services in Collier County, said Jorge Aguilera, North Naples deputy chief.
"I think we've proven that it's not a capability issue," Aguilera said. "We've shown that we will be there as that safety net for patients who don't have to worry if we sent a vehicle with the capability to meet the needs of the emergency."
Collier EMS officials couldn't speak to the level of care provided by the fire district, but they admit it hasn't necessarily been a problem.
"There aren't problems with the way it is now, but in a perfect world a consolidated county-wide system would be the best approach to provide 911 services," County EMS Chief Walter Kopka said. "With two different medical directors now, we do not have a consolidated system."
Less is more?
Until recently there have only been two ways Collier County firefighters, even trained paramedics, could practice the full gambit of emergency procedures, including running an IV, injecting epinephrine and other drugs, or regulating air-flow.
A fire district could get a certificate of need from the county, which is difficult to acquire but the option fire chiefs prefer because it allows the district to use its own trained firefighters. Or a fire district could participate in a swap program with county EMS, where the county sends one of its employees to work on a fire engine as a trained paramedic while the district sends an employee to the county to work as a limited EMT.
Fire districts don't like this because they often have to use overtime to fill in for the shifts they lose to the county.
After several years of participating in multiple versions of swap programs with the county — all of which eventually turned sour between county and fire administrators — North Naples fire got a certificate of need from county commissioners in 2011. It has since been operating under its own medical director, Dr. Jeffery Panozzo.
But county EMS officials and medical director Dr. Robert Tober have long argued that it's better to have relatively fewer advanced paramedics. That way they stay sharp through repetition, knowing how best to administer drugs that can be life-saving, but also can cause harm. Too many paramedics means too little practical experience for each.
In most cases, the urgent care that's needed in early intervention to save a life — CPR, automatic chest compressions, administering oxygen — is basic support that any county firefighter can provide, Kopka said.
"No paramedics go running in with needles in hand, ready to inject somebody with lifesaving medicine," Kopka said. "All protocols start with basic life support — splinting, bandaging and assessment."
Proper assessment must be done because paramedics can always give more medicine if needed, but can't take excess drugs back once in a person's system, Kopka said.
Despite those arguments everyone involved admits the North Naples experiment has proved helpful to patients and county EMS crews in at least one critical way: Collier ambulance crews only have two responders — and one has to drive. So any North Naples firefighter who starts an IV or other procedure involving drugs or a needle is required to stay with the patient during the ride to the hospital.
"That does a couple things that are good for us," Kopka said. "It gives us another set of hands to take care of the patient. And also there is a continuity of care on the medical side."
A natural evolution
While local county government, by state law, has a say in who can practice paramedic procedures inside the county, the statewide trend has been to run ambulances and paramedics through fire departments.
As of 2011, about 70 percent of the state's population was served by medical response teams run through a fire district, said Darrel Donatto, a regional director of the Florida Fire Chiefs Association.
"We've been seeing a natural evolution to fire-based care really because fire departments are usually best positioned in the community to provide it," Donatto said. "And we're seeing it become what we call an all hazards approach -- when you call somebody for an emergency, the people who arrive are trained to deal with whatever the problem is, whether it's a medical issue, hazardous material, a carbon monoxide leak or a car accident."
Sarasota County, with a population of nearly 400,000, has used a fire department-based emergency medical service for more than 30 years.
The biggest benefit for patients is that both ambulance and fire paramedics are cross-trained, Sarasota Chief Mike Tobias said.
"We get a double bang for our buck," Tobias said. "If I have a fire today I can pull people from surrounding zones who are on ambulances. And if I end up with a huge accident I can pull people on fire trucks because I know they're trained."
The key to a working system, he said, is training.
Collier fire officials say they're not aiming to replace the current system but want to support it by providing a safety net. It's cost effective, they say, because a large percentage — usually about half — of a district's firefighters are already trained paramedics.
The safety net comes into play when the closest ambulance is busy on another call.
North Naples firefighters beat county paramedics to Jack's nursing home because the county ambulance in the district was already in use, transporting another patient to the hospital.
"Now while that medic unit is out, if there's another call in our area, another unit from a farther place has to replace that one," firefighter Loewel said. "Whereas, we can go and be done with a call and be ready to respond."
The issue of simultaneous or back-to-back calls is amplified during emergencies in rural areas west of Collier Boulevard, where the second closest ambulance may be 10 miles or more away.
That's one reason why Big Corkscrew fire consistently beats county ambulances to the scene of medical emergencies. Last year, Big Corkscrew firefighters took less than 7 minutes, on average, to respond to emergency medical calls, according to data provided by the fire district.
The county's response goal for the same area was 12 minutes and county ambulances only made it within 7 minutes less than half of the time, county data shows.
Big Corkscrew firefighters must wait for an ambulance to arrive from another district on 16 percent of their medical calls, which adds up to between 120 and 130 calls a year, Chief Rita Greenberg said.
The Big Corkscrew district unsuccessfully applied in January for the same certificate of need as North Naples to let its paramedics practice all services.
Commissioner Fred Coyle voted against the application, saying the fire districts were more interested in taking control over emergency services than providing patient care.
"The fire districts don't want to abide by the procedures of our medical director, so they try to hire their own and it results in different standards for different parts of the county," Coyle said. "They want control and they're not going to be happy until they get control.
Commissioners voted Big Corkscrew's application down, 3-2, and approved a compromise instead.
The county hired three paramedics to work on Big Corkscrew fire engines and approved nearly $1 million in ambulance and staff upgrades to cut down response times in rural areas.
The paramedics started at the fire station Monday. Big Corkscrew fire engines now have one paramedic who is certified to use advanced treatment on each shift.
It's a variation of the county's swap program, only where the fire district isn't required to send the county any of its employees.
Eliseo Chao, a Big Corkscrew fire commissioner who adamantly fought for the certificate of need, said the compromise should work.
"It helps without a shadow of a doubt," Chao said. "I'm glad that it's here and it's great for the people who are better served and protected."
Still, Chao said, it would have been cheaper and more efficient to allow Big Corkscrew paramedics, who were already trained and on staff, to practice paramedic procedures and hire the three new paramedics to serve other parts of the county.
"As appreciative as I am, if the county would have given us the certificate and used that money somewhere else, we would be providing more care for more people for the same amount of money."
(c)2014 the Naples Daily News (Naples, Fla.)
Distributed by MCT Information Services
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