Sending fire apparatus staffed by three or more firefighters to medical calls is both outdated and a waste of taxpayers’ money. So says a Santa Clara County Civil Grand Jury watchdog report that recommends a major restructuring of fire and emergency response protocols.
Citing that about 70 percent of calls to the county’s fire agencies are for medical emergencies while only 4 percent are for fires—and that only one of every three fire crew members is trained to respond to medical situations and conditions—the June report states, “There appears to be a mismatch between service needed and service provided.
“Further, while a great majority of calls received require a medical-based response, most of the SCC [Santa Clara County] fire departments do not have apparatus that is built specifically for that purpose, i.e., an ambulance. Those fire departments that do … are not permitted by the county to use these vehicles in a first responder role. Conversely, the current EMS provider, AMR, is required by contract to subcontract with fire departments to serve as first responders.”
Santa Clara County, located in Northern California, includes the cities of San Jose, Santa Clara, Sunnyvale and Palo Alto. Some cities have their own fire departments; other areas are organized into fire protection districts that contract with other agencies, such as the Santa Clara County Central Fire District, for fire protection. On average, fire departments consume about 20 percent of city budgets, according to the report. “Taxpayers can no longer afford to fund the status quo,” it states.
The report questions the practice of sending out fire engines, which cost $500,000, while an ambulance costs $100,000. Reasons given by fire chiefs interviewed by the Grand Jury include making sure equipment is operational; exercising the crew; and over-responding in case it’s needed and the caller has given inaccurate information.
The Grand Jury also asked city managers and fire chiefs why fire departments haven’t changed with the times to become “emergency response departments.” “No truly defensible answers emerged,” the report states. Some leaders cited existing arrangements in which the fire department provides first response and then calls a private ambulance service to provide ambulance transport to the hospital, an “arbitrary separation of duties.”
Firefighter/paramedics are also “over-trained” to do a job that is mostly about responding to EMS calls. “Where most businesses operating with a view toward rightsizing their capabilities to meet demand would take a closer look at such an imbalance, analyze needs, and make adjustments if warranted, publicly funded fire departments choose to look the other way. Perhaps more two-person crews composed of paramedics and EMTs and fewer firefighters are needed. Perhaps true collaboration with the county EMS provider would produce better and more cost-efficient service to the community.” The report also calls for consolidation of departments to save costs.
The Civil Grand Jury is a watchdog body that is charged with making sure public funds are properly spent in the interest of the community.
To read the full report, go to scscourt.org/court_divisions/civil/cgj/grand_jury.shtml and click the link to “Fighting Fire or Fighting Change? Rethinking Fire Department Response Protocol and Consolidation Opportunities.”
Ambulance Diversions Lead to Unnecessary Deaths
A new study confirms what many in EMS have long suspected: Lengthy periods of ambulance diversion are associated with higher death rates among patients with acute myocardial infarction.
When the nearest emergency department was closed due to overcrowding for 12 hours or longer, mortality rates were about 3 percent higher at 30 days, 90 days, nine months and one year, according to the study, which appeared in the June 12 online issue of the Journal of the American Medical Association (JAMA). Researchers analyzed nearly 14,000 Medicare records for MI patients in four California counties (Los Angeles, San Francisco, San Mateo and Santa Clara) from 2000 to 2005. During that period, the average ED was on diversion for eight hours a day.
One of the reasons for diversions is that there are fewer EDs, leading to overcrowding. Over the past 20 years, more than one-fourth of the EDs in the U.S. have permanently closed, according to a study in the May 17 issue of JAMA. In 1990, there were 2,446 hospitals with EDs in suburban and urban areas. That dropped to 1,779 in 2009, while an aging population has contributed to about a 35 percent increase in visits.
And it’s not only crowding in the ED that can lead to diversions, experts say. When the rest of the hospital is full, EDs get backed up with patients waiting for inpatient beds.
“While the public sees ambulance diversion as a sign of ED overcrowding, those of us in emergency medicine have known for years that it actually reflects failed processes in the non-ED areas of the hospital,” explains Carl Ramsay, M.D., chairman of the department of emergency medicine at Lenox Hill Hospital in New York, who was not involved in the study. “How many people actually know that unbalanced surgical scheduling by stacking up Monday through Thursday OR schedules creates ED overcrowding, which creates ambulance diversion? This is only one in a chain of many dysfunctional links that leads directly back to the streets that carry patients to hospital emergency departments.”
An American College of Emergency Physicians task force has proposed some solutions, including:
- Moving admitted patients more quickly out of the ED to inpatient areas, with each department taking a few patients to more evenly spread the burden.
- Coordinating discharge of patients before noon. Timely departure from the hospital can significantly improve the flow of patients in EDs by making more inpatient beds available.
- Better coordinating the scheduling of elective patients and surgical cases. Studies demonstrate that the uneven influx of elective patients (heaviest early in the week) is a prime contributor to exceeding capacity. This often requires support services to be available seven days a week.
Chemical Suicides May Be Increasing
Chemical suicides—in which people mix common household detergents in enclosed spaces such as cars and closets to form deadly clouds of toxic fumes—appear to be on the rise, says New York State Office of Fire Prevention and Control Deputy Chief Jacob Oreshan, who has been tracking the cases.
Last year, there were 36 chemical suicides in the U.S. Since Jan. 1, there have been at least 27, Oreshan told the New York Times. Chemical suicides are still only a tiny fraction of the 34,000 or so suicides reported each year nationwide, and so far, injuries to responders have been minor, authorities say. However, the CBRN Committee of the National Academies of Emergency Dispatch, in recognition of safety dangers that can potentially be mitigated at dispatch, are reviewing protocols aimed at keeping callers and responders safe.
The trend, according to news reports, started in Japan, where a teen-ager attempting to commit “detergent suicide” sickened 90 people. Instructions on how to create the toxic fumes can be found on the Internet.
For more on how to handle suspected chemical suicides, visit colofirechiefs.org/ffsafety/Chemical_Suicides.pdf.
