Marriage Counseling Part II: The Dysfunctional Fire/EMS Relationship

Read Part I: Marriage Counseling: The Dysfunctional Fire-EMS Relationship

Marriage Counselor: Okay, we’re here to work through your issues. We want to create an honest and open dialogue here. Within the confines of this room, I want you both to feel as though nothing is off-limits. We can air our feelings in a mutually respectful, non-threatening environment. So, who would like go first?

EMS: FD doesn’t appreciate me! I feel like a second-class citizen in my own firehouse! I contribute eighty percent of the work, yet I’m treated as if I’m not an equal partner in this relationship!

Fire Department (rolling eyes): All I ask is that EMS does its job just like every other fireman. Learn how to fight fires, keep the equipment maintained and cleaned, and follow orders from superiors. How hard is that? Every other firefighter does it!

EMS: But that’s just the point! I don’t want to fight fires! I want to take care of patients! Why can’t I just do that? Why do I have to take hazmat and vehicle rescue classes when my ACLS card has been expired for two months?

Fire Department (smugly): See what I mean? EMS wants to dictate the terms. EMS wants to be treated like an equal, yet it refuses to do equal work. If it’d just do the same work as the other firefighters, we’d have no problem letting EMS do its little EMS classes. Time permitting, of course.

EMS (indignantly): ‘Little EMS classes’? See what I mean? Tell FD it’s being unreasonable!

Marriage Counselor (in his best Cool Hand Luke prison guard accent): What we have here is a failure to communicate.

Reconciling the disparity in the respective roles of fire suppression and EMS first require that we gain a greater understanding of those roles. Paramedicine and firefighting are two fundamentally different things — not worse or better, but different. On the surface, one might say that EMS deals in preserving human lives while firefighting deals with preservation of property, but in reality it’s more nuanced than that. EMS, despite our PR propaganda, doesn’t actually save all that many lives. And while firefighters may occasionally be involved in the preservation of human life, those instances usually trend heavily toward rescue operations, not pure medical care.

Last I checked, the typical paramedic program runs around 1200 clock-hours or so. College-based programs run substantially longer, and the trend is moving toward an Associate’s Degree as the minimum education requirement for paramedics.

Now, while a college education isn’t always necessary to become a firefighter, an Associate’s Degree in Fire Science becomes more of a necessity if you want to move up the promotional ladder. Even a Firefighter I certification represents a substantial time investment.

All this is to say that neither job is easy, and the educational programs for both are designed to achieve just minimum, entry-level competency. True mastery of either job will take a host of specialty certification courses and three to five years of on-the-job training. Even those fire departments with their own EMS training academy customize their programs toward how EMS is practiced at that particular agency. It’s more of an indoctrination into their departmental culture than formal education. Sadly, the EMS culture of many of those departments includes practicing medical care that is 15 years behind current standards.

There comes a point when we have to ask ourselves which profession we will serve. Because we can’t all be ACLS, PALS, PHTLS, AMLS, PEPP and GEMS certified paramedic fire suppression hazmat high-angle confined space swift-water rescue technicians, and still be able to maintain proficiency in all of them. Yet, in this setup, the best we can hope for is minimum competency — and we have to ask ourselves — do our potential patients and property owners deserve minimum competency or mastery?

Of course, a number of members of dual-role agencies made comments on my previous column and on my blog, defending the way their respective departments approach EMS care. Many of them actually do emphasize EMS education, rather than just the lip service seen in many of the major metropolitan dual-role agencies such as FDNY, Washington DC Fire/EMS, San Francisco Fire Department and others. The pattern seems to be that the dysfunction is at its greatest in departments where EMS and Fire were forced to merge — usually at the whim of elected officials — in an ill-advised attempt to save money and increase efficiency.

Except, of course, that merging rarely does successfully result in increased savings or efficiency. Costs usually multiply, response times suffer, and morale goes into the toilet when unwilling firefighters and paramedics are forced to coexist within the same department. Members are either forced to cross-train in a specialty that does not interest them, or they start resenting others because one segment of the work force is held to a less rigorous (in their opinion) set of hiring, certification and training standards – with pay and benefits equal to everyone else. It’s a perfect recipe for departmental dysfunction.

There are, of course, departments that do it right. One commenter pointed out that his department, when faced with budget cuts, opted to lay off a fire suppression/rescue instructor’s position rather than the EMS instructor’s position. The same department employs a full-time nurse with captain’s rank, whose job is to audit run tickets and do CQI. While I do wonder why a nurse was hired to perform such a function rather than a paramedic, I do have to give props to such departments that have their priorities in order.

Another commenter – an experienced firefighter/paramedic from Texas - pointed out that mutual respect in his firehouse wasn’t an issue, because every member of his department was required to be dual-certified as a firefighter and an EMT, and that all paramedic-firefighters received an extra $125 per month in incentive pay.

On the face of it, that sounds like a good thing…until you consider that not every firefighter wants to be a paramedic, nor does every paramedic want to be a firefighter. At some point, you have to decide where your heart lies, and you focus your time and energies there.

I replied with this little analogy:

Imagine you have an accountant named Murray. One day, you come to him and say, "Murray, you're a darned fine accountant. I don't know how I'd manage my finances without you. But I'd like my household to run a bit more efficiently, so I need you to handle my legal matters as well. So I'm going to send you to Shysters R Us law school at night. Once you graduate, you'll still be handling my taxes. But you'll also be handling my real estate holdings, my estate planning, representing my adolescent son in his drug possession case, suing the police department in my unreasonable force case, getting me a cash settlement for my OTJ injury and my Dad's mesothelioma and asbestos exposure, and handling my divorce. So you'll need to be an expert in estate law, criminal defense, personal injury law, family law, and juvenile addition to being the darned fine accountant that you already are.

By the way, this extra work is going to quadruple your workload, and you can expect to do 80 percent lawyering and 20 percent accounting. And to show you what a generous guy I am and to show you how much I respect the legal work you do...I'll pay you an extra $125 a month."

Do you think Murray might be just a little resentful, and do a less-than-stellar job as an accountant or a lawyer?

Certainly, EMS and Fire Suppression can coexist peacefully within the same department, although that is often not the case. As posed in the original question, what steps can be taken for paramedics to gain equality in their own firehouses? In Part III, we'll propose some answers to that very question. Feel free to suggest some answers of your own in the comments section!

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