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Tuesday, August 7, 2012

Getting The 4-1-1 On 9-1-1 Emergency Response

Bystanders sit in the shade at the scene of a shooting inside a Sikh temple in Oak Creek, Wis., Sunday, Aug. 5, 2012.  (AP Photo/Jeffrey Phelps)

Bystanders sit in the shade at the scene of a shooting inside a Sikh temple in Oak Creek, Wis., Sunday, Aug. 5, 2012. (AP)

The fire chief in Oak Creek, Wisc. is praising his crews for their response to Sunday’s shooting at the Sikh temple that claimed six lives. More than 60 paramedics and EMTs rushed to the scene in 22 fire trucks and ambulances, and several other units were standing by.

But that was during the day.

The Aurora, Colo. theater shooting took place at midnight last month. And while police were on the scene within minutes, some ambulances remained idle, and police were begging dispatchers for more units.

Scot Phelps, a professor of disaster science at the Emergency Management Academy, says the ambulance system in the U.S. is a public policy disaster.

Phelps says much of the country depends on a patchwork system holding ambulance services together, and many cities are failing when it comes to ambulance services.

For example, in Philadelphia, there are so few ambulances that police end up transporting as many as a third of shooting victims to the hospital in their squad cars.

And in Detroit, last New Year’s Eve an ambulance broke down in the middle of a gun battle.

Part of the problem is that communities are relying on a whole array of medical response services: privately-owned ambulances, publicly-owned ambulances and, increasingly, paramedics who arrive on the scene in fire trucks instead of in more costly ambulances. And coordinating all of these different response teams is difficult.

Phelps says fire departments should dedicate more of their resources to medical response rather than fire suppression, since they’re spending more of their time on medical emergencies.

Phelps also believes ambulances should be reimbursed for the real cost of care they provide, instead of just for transporting a patient to the hospital.


  • Scot Phelps, professor of disaster science at the Emergency Management Academy

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  • D Docwww

    It is a flagrant waste ofmoney & personnel to send out several tonnes of equipment and several firefighters to stand around with an oxygen tank waiting for the EMTs to arrive to give insulin to a diabetic having an hypoglycemic seizure.
    Solution: 1.reduce the number of fire stations and firefighters 2. increase the number of EMTs and ambulances 3. A call that is for an illness our injury is answered with only the ambulance & EMTs.
    Remember that a firefighter died in a crash a couple of years ago when his vehicle ran into a daycare centre. This will also save a great deal of wear and tear on these very expensive vehicles.
    Bill from Boston

    • Hncpac

      I agree with your basic premise but, actually if you give insulin to a diabetic that is having a hypoglycemic seizure you will kill him.  On the other hand his seizures will stop and he won’t be using any more health care resources…

  • Jess

    My father is a Fire Cheif and I grew up surrounded by the fire service. While I appreciate Mr. Phelps critiques and assessment that some fire companies may be overstaffed and we need to rethink how we staff and coordinate emergency resources. I think it is unfair to say that because there are generally fewer fires we must need fewer firefighters. These individuals respond to and are trained for all sorts of emergency situtations  - car accidents, rescues and extractions of injured persons both on land and water, hazmat incidents, earthquakes, tornadoes and all sorts of other natural disasters. To minimize their role to “only” fighting fires is dismissive and won’t go far in starting this important conversation about how to effectively allocate scarce public resources to best serve the public and keep people safe.

  • http://profile.yahoo.com/7RTLDWGHIM6NU7OXFL664JAXNA yahoo-7RTLDWGHIM6NU7OXFL664JAXNA

    In Eugene, Oregon, there are no private ambulances. A subscription service called Fire-Med takes care of much of the cost. For about $62 per year, my wife and I are covered for ambulance service at home or in our cars. The Fire Dept runs the ambulance service here. I am surprised more communities don’t have a subscription service. I don’t need it til I need it, like any other kind of insurance including medical and auto insurance, but when you do, it is there.  

  • Guy Howd

    One glaring point that has yet to be addressed is that Medicare and Medicaid not only decide when to pay but have a schedule of how much to pay. With ausually relatively slim operating margin, providing the highest level of care to a patient may incur a degree of financial loss to whomever is providing care.

  • EMT-B

    Scot is exactly right. We have plenty of fire suppression vehicles but far too few ambulances nationally. I am an EMT and volunteer with a fire service and constantly see excuses being made protect the budgets and jobs of union fire people. Fire is often 25-30% of municipal budgets for a shrinking danger – less than 20-30% of calls. Many firefighters, although clearly not all, do not take medical roles as seriously. Fire and medical calls are very different and to expect one person to honestly do both proficiently is nonsense. We need to standardize EMS services and support them as their necessity is increasing. If fire wants to play a role, that is great, but it has to make sense. Don’t drive a $200,000+ vehicle at a cost of $30/mile to every call because fire simply needs to prove their value. An ambulance costs a third of most fire vehicles and operates at 1/6 the cost. Use and develop resources based on facts not politics. Stop scaring the public that an “all hazards” response is needed or even justifiable.

  • IdClare

    Regionalization is the only way Fire and EMS can survive but few departments are willing to give up local control.  Until this happens, communities will continue to struggle.  Another solution is that they all operate as a system of medical transportation which includes non-emergency transports that help offset emergency response costs. Private companies do little emergency work and if they do, non-emergency patient transfers cover those costs.  Buy or run out all the private or non-profit companies, separate Fire from EMS, then all patient transport monies go to fund the system as a whole.  Bet you can’t get your fire heads around that can you?

  • Eric Liddy Sr.

    Being both a firefighter AND an EMT, and having worked for Detroit Fire Department as a Medic for more than a decade, I can say without a doubt that monies are improperly allocated for EMS.

    Millions of dollars were spent on Fire apparatus, annual payroll, training, and supplies, for fire service in Detroit, while EMS suffered in silence…voices suppressed by administration and management. Paramedic units so badly in disrepair and all too frequently broken down, it’s amazing that patients received any prompt response. In many cases they did not. Detroit Fire Department EMS Division responds to approximately 140,000 calls for EMS versus the department’s Suppression Division response to approximately 28,000 calls for fires…many turn out to be false runs.

    The cost of sending a Fire Truck versus an Ambulance is like comparing Oranges to Torpedoes. The price of a brand new Engine Company can be as much as $250,000.00 to $500,000.00 and the maintenance costs of these specialized pieces of equipment can be astronomical! The price of a brand new, fully equipped Advance Life Support Ambulance, is around $100,000.00 to $180,000.00. 

    Post 9/11, Detroit received millions in federal funds via grants that were misappropriated, that was designed to train and equip Police, Fire and EMS for a terrorist attack. (I spoke on this a few years ago on NPR live on the air on the Diane Rhem Show. The discussion surrounded National safety and security, in the case of  emergency preparedness.) Instead, huge quantities of personal safety equipment was warehoused that was meant for EMS, minimal EMS training was given, and monies were spent on Fire and Police for God only knows what.

    Today, Detroit EMS has, on a perfect day, about 14 Ambulances in operation. The trucks are in disrepair, break down often, and many are barely running. The amount of rigs and personnel have dropped from 29 Paramedic units and 303 personnel, to less than 160 personnel and 14-18 Medic units. The administration has downgraded many of the ALS units to Basic Life Support units, and have refused to replace the aging fleet with new, modern rigs. One of several reasons that I resigned my sworn job with Detroit EMS.

    On the other hand, many fire departments, most are paid on call, are responding to both fires and EMS calls…many, but not all have transport capabilities. These departments came to the realization as far back as 2 decades ago, that fire calls were diminishing and EMS calls were on the rise. The average cross trained fire department responds to 70-80% EMS related calls and 20-30% fire related calls. Yet with many full time departments, namely those in Urban/Suburban centers, a heavy emphasis is placed on suppression and very little given to EMS. In 1988 when I first came into Fire Service, my Deputy Chief, Jim Porter, told me that, “As a firefighters, we are putting ourselves out of business with all of the fire safety classes and “Learn Not To Burn” programs. EMS is the wave of the future in fire service.”

    I took what he said to heart and began my medical training in conjunction with my firefighting training. 

    At Bill From Boston: EMT’s and Paramedics do not give insulin to Diabetics, they can only give a solution of Dextrose, 50%. Insulin is contraindicated in hypoglycemic patients. (Sorry, not trying to burn you, just better educate you.)

    An increase in EMS is drastically needed in this nation, and it is my belief, that much like law enforcement and firefighters, there needs to be a nationally recognized set of protocols that are used nationwide, and every EMS agency in every state, should have the same training in the most up to date techniques. 

    To Mr. Phelps, you are absolutely correct that EMS in the U.S. is a complete disaster in public policy. Those in charge at the national level should be ashamed.

    Eric Liddy Sr.
    Detroit EMS (Retired)
    Montcalm County Emergency Services-Rescue 20
    Amble Volunteer Fire Department
    President-Michigan EMS Memorial
    Author-The E.R. Loading Dock; Real Life EMS Stories From Around The World

  • Fxtrt479

    I saw the rise of EMS being taken-over by Fire Departments from the 1970′s thru 2000. The most prevalent reason was due to private companies (Hospitals, Funeral Homes, for-profit-providers) typically delivering a very uneven & typically trustworthy EMS care—the public demanded “better, consistent standards”. The Fire Service–with typically equally-distantly-spaced stations in a given area—could easily expand it’s “Rescue” component–& those fellows were routinely “training”. 

    ‘Medical Transport’ is often the label thrown about, but the truth is in whether one is dealing with incipient emergency treatment & response (& transport), or “other” sorts of scheduled patient movement.  When one can end the lawsuits (good luck), and be rewarded for not using-up one’s funds’ allotment (“Annual Budget” in city terms) every fiscal year, then you’ll have a better, more acceptable & uniform services’ delivery (sorry, private enterprise in this case tends to be more like business security cops, not front-line daily state police forces.) 

    Last, but not least—the Fire Department’s quality & performance determines largely one’s “Homeowner’s Insurance Policy,” to say nothing of Business Casualty Insurance premiums.  EMS needs to be better addressed, despite the “free-loaders” that use & abuse the system–this seems to be the true, behind-the-scenes anger & “get-even-itus” that unfolds by ‘those’ saying, “Well, EMS isn’t paying it’s way; use the 7 trucks,  instead of having 10 ready-to-go as is needed.”

    Scot’s right—ambulance service, emergency-first-response & treatment & transport is a patchwork mess.  Might as well accept it….or do you demand better?  More “taxes”, to cover those that don’t pay the annual subscription service premiums? Hmm, good luck with that.

  • wmvt

    I am a professional
    firefighter/paramedic.  In the city I work, we operate a fire based EMS
    system.  We provide to our citizens the highest level of pre-hospital
    emergency care available today.  When it comes to quality, professionalism
    and customer service, fire based EMS systems are unmatched.  The
    firefighter/paramedics I work with are dedicated city employees who have made
    it their career to serve our community.  We have established relationships
    with the citizens we serve.  When the fire truck and ambulance arrive,
    those stepping off the truck are familiar faces.  Our citizens have been
    in our firehouses and have come to know us.  And when they are
    experiencing a medical emergency, a familiar face provides great comfort.


    Our citizens (tax payers) have
    invested in our department and have come to rely on the unmatched level of care
    and service we provide.  They also recognize that a fire based EMS system
    reduces taxes.  There is no need for an additional EMS department within
    city government, additional infrastructure, additional administrative staff as
    well as employees.  And there is no need to contract with outside third
    party for profit companies who are here today and gone tomorrow.    


    W. Moran

    IAFF Local 3671   


    • IdClare

      Fire based EMS systems reduces taxes?  Where, on Mars? Keep buying $150,000 ambulances when you could have 3 for for the same price.  I’m a taxpayer and most people know that’s how you waste money.  Like everyone else in this economy, you need to start doing more with less.

  • I’m just Sayin…

    Taking the problems of Detroit (the most downtrodden metro area in the US today) and applying that lens to the nation as a whole is a mistake. You also have to separate how metropolitan and rural ares (yes Virginia people still live outside of cities in the US) operate. Attempting to apply a national standard, one size fits all requirement would be detrimental to many areas.

    The reason the US is served by a “patchwork system” is because there is a patchwork of needs. If a local EMS system is not performing, it is a local crisis, not a national one. The citizens have the ability to vote in the local politicians to make changes until the system is fixed. Should some cities have a separate EMS service separate from the fire service? maybe. Should all fire departments have to carve out a separate system because Detroit’s system is failing? No.

  • Eric Liddy Sr.

      IdClare: One thing you don’t understand, is that the moment you put the EMS or Fire Department label on something, the price doubles or triples. You can not find a brand new Ambulance for under $100,000.00. Even the Van style units are in the 100k range, if not over that, fully equipped.

    WMVT: Since I left my “Fire Based” EMS system, Detroit EMS, I now work for a County operated system that does extremely well without fire services. They are professional, extremely well trained, high quality and customer service friendly. There are a number of municipally operated EMS systems that are not well organized, and poorly managed…Detroit is the worst in the nation.

    To say that paid on call or volunteer members in EMS or Fire Services are not professional, is a slap in the face to all that respond. We are ALL professionals that have the same levels of medical licensure or fire service training. 

    And yes, I was a member of a unionized system, however, we are all equally professionals and to discount those that do the job part time or on a voluntary basis, is a a discredit to all non-unionized emergency services. After all, Benjamin Franklin was the God-Father of volunteerism in our nation. In fact, there are many of these systems that are better trained than some of our nation’s finest of full time systems, and volunteer/paid on call departments and agencies out number full time, unionized systems.

    The point of this article, is that as a nation, we are NOT well organized and some sort of national policy needs to be put into place when it comes to EMS.
    Eric Liddy Sr.

  • TFLD

    I see 2 major problems here:
    1. The US health care system is a disaster, and directly impacts the funding of field EMS.
    2. Many fire departments, especially back east, have never seen themselves as logical partners in the provision of field EMS, and have totally mucked things up as a result.

    My solutions?

    For #1, that’s above my pay grade, but the status quo and its insurance megacorporation-controlled market is clearly not working.

    For #2, look to the west!

    Most larger western fire agencies are understaffed, but many have always been an integral part of EMS response. There has never been a line between fire and EMS in many western metro areas (as well as in some other lucky cities nationwide).

      The best of all, IMO, is in the Pacific Northwest. Seattle’s Medic One model has now spread to most of western WA, and it is efficient, logical and proactive. As the linked article indicates, it actively involves the public as first responders. It also provides opportunity for private ambulance enterprise, as they get the lucrative non-emergency transports, saving ALS (Advanced Life Support-paramedic) ambulances for the most critical calls.
     Seattle Medic One is and has always been fire department-based, and it is one of the most beloved tax-supported entities in my state. Most surrounding counties that have adopted the model have kept the fire-based structure, and their public support is similarly stellar.

      I am not an insider cheering for Seattle Medic One. I live in a WA metro area not covered by such a service, but instead held hostage by a large corporate private ambulance provider that regularly runs out of ambulances on busy days. Here, most fire agencies must maintain ALS (paramedic) status on their engine companies, as they often provide all necessary ALS care and have the patient package LONG before the ambulance arrives. 

      I worked for one of those ALS fire agencies for 3 decades, and longed for a better system, to no avail.  Any attempt to open public dialogue about changing to a different model results in an immediate avalanche of lawyers and lobbying cash. (see #1 above)

  • Info

    Dear NPR,
    When you would like to hear the other side of the argument, give the American Ambulance Association a call.

  • Redshelly

    I found Mr. Phelps assessment of the EMS/FIre system biased.  It appeared that he definitely had an agenda.  Mr. Phelps is correct in that 85-90% of emergency calls are EMS based, however, his assessment of the reasons for the divisions in funding is incorrect.  While fire departments do receive a larger piece of the funding pie, the equipment is necessary for extrication, fire suppression, industrial rescue, collapse, hazmat response, etc.  The number of fires each year has dropped, but when a fire occurs equipment & personnel is needed to put that fire out.  Mr. Phelps failed to address this need.  He makes the comment that “cutting fire personnel is a political non-starter”, apparently oblivious to the cuts in personnel & equipment in every major city in America.  NPR, itself, did a story on the reduction of pay to minimum wage of fire & police in Scranton.  While this was eventually remedied, concessions were made.

    Using Detroit as an example of fire based EMS is self serving.  There are many fire based EMS services that are stellar.  Milwaukee County in Wisconsin has predominately fire based EMS that dove tails with several ambulance companies and consistently has save rates above the national average.  The paragraph above questioning the response to the Oak Creek shooting, should it have occurred at midnight, was ill informed.  The response, per county protocol, would have been the same regardless of time of day, time of year, or location in the county or surrounding counties. It is poor form to use a tragedy to further a personal agenda.  If there were issues in Aurora, solve them.  Don’t use a broad brush and paint all fire based EMS as failures.

    In actuality,  it is a good use of resources to cross train fire personnel to perform EMS duties.  Firefighters are there for entrapment, fire, etc.; eliminating fire personnel endangers the public in those times when disaster occurs.  Let them respond to medical emergencies.  Ambulance personnel do not possess the training & equipment needed to deal with hazmat spills, industrial entrapment,  or fire when they occur, regardless of frequency.  Successful fire based EMS retains some ability to transport & plays well with others, allowing ambulance services to do their job as a member of an efficient team.

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Robin Young and Jeremy Hobson host Here & Now, a live two-hour production of NPR and WBUR Boston.

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