This is a longer post than most, but this is complex subject that required a full-throated rebuttal. This post does not necessarily reflect the opinions of my employer.
No doubt you have been aware of the conflict that has arisen again in Ontario between paramedics and fire fighters. At issue is a proposal from Ontario Professional Fire Fighter's Association (OPFFA), the fire fighter's union, to the Ministry of Health (MoH) that outlines a pilot program to introduce a full suite of "symptom relief" medications to front line fire fighters. Medications identical to those carried by primary care paramedics in order for "fire medics" to start treatment before the arrival of paramedics.
This has paramedics in Ontario steamed for many practical reasons but I think what has us really mad is the success that the OPFFA and their president Carmen Santoro have had in selling this to the media and the public. Fire fighters have a lot of cultural and political power, and we don't like it one bit.
It is important to note that I believe this plan will fail because of one simple fact: over the past 50 years Ontario has invested heavily in a comprehensive pre-hospital response system that is meeting its goals, at least in the urban centres targeted by this plan. It is important to note that fire fighters currently respond to calls with a risk of cardiac arrest with CPR training and automatic external defibrillators (AED) and epi-pens for deadly allergic reactions. However that is the extent of the evidence we have for their response in the Ontario pre-hospital system.
Granted, in other jurisdictions there are fire-based EMS systems that work well, but in Ontario, pre-hospital medical care is provided by upper-tier municipalities, from first response to critical care transport, and that is not likely to change any time soon. We hear constant rumblings from the gossip jungle that fire is going to take over EMS, but as fire is a much more fractured system being provided for the most part by local townships, this is not likely to happen. Why then are paramedics so angry?
First, it has to do with the gulf that exists between the OPFFA plan and modern medical care. Paramedics have increased their scope of practice over the past 25 years: we autonomously perform more controlled acts than any other medical profession in Ontario, save for doctors, and while for many years the medical directives were largely based on expert opinion or theoretical evidence, there has been a real push to use the evidence-based medicine approach that has put the patient at the centre of practice and used science to guide decision-making.
The OPFFA proposal uses none of this. As is freely admitted in the OPFFA magazine The Intrepid (p.5), this proposal was born out of complaints by front line fire fighters at the 2014 general meeting of a loss of medical call volume due to changes in the tiered-response plans. As is noted in the magazine, it was because of these reports that the current Fire-Medic proposal was dreamed up. This plan would have five fire fighters and a pumper truck respond to every emergency medical call in their area, not just the rare cardiac arrests and pre-arrest scenarios.
The OPFFA has spun this as a public safety issue: that a "standing army" exists to deliver front-line symptom relief that will save lives and money. However, there is absolutely no evidence that providing anything other than CPR and defibrillation by an AED a few minutes faster than EMS will improve patient outcomes. The truth appears to be that the OPFFA, facing threats of staffing cuts, is waging a campaign at all levels of government and with the public to justify keeping expensive fire halls open in the face of decreasing call volume, and this year it's the work of paramedics they have their eye on.
Now, don't be misled: I think fire fighters hold an essential position in our public safety web. Despite better fire code and exemplary fire prevention, things still burn and accidents happen. We need fire fighters to run into burning buildings to save lives, decontaminate dangerous chemical spills and cut people out of their wrecked car, and until we train every citizen in CPR and have a defibrillator on every corner we need them to first respond to cardiac arrests.
The complex rescue and fire suppression tech requires constant training and upgrades to allow fire fighters to perform their jobs. Therefore it is imperative that we let them do these jobs: the irony of the Fire-Medic plan is that it may in fact keep them from doing many of these things because of one simple fact: there are a lot of emergency medical calls.
Let's look at the numbers. In the region that I work, we have over 75,000 calls annually, with approximately two thirds, or 50,000 of them requiring "lights and sirens" response. That amounts to about 10,000 emergency calls in my area. In that same area, there are about 11,000 calls serviced by the fire service in the same area. Now, while a portion of the medical calls are already serviced by the Fire Dept. this number grows every year with increased housing starts and an aging population. The extra calls will quickly approach the number of calls they currently run. Therefore, under the OPFFA plan, the call volume for the Fire Dept. will be sure to double quickly.
On top of this, EMS in most of these jurisdictions is arriving within minutes of the FD. Most of the jurisdictions targeted by the OPFFA plan are meeting or exceeding the targets set by the MOH and getting on scene between 8-10 minutes around 75 per cent of the time and most of the time we are there by 15 minutes. The FD sets a target of 6-7 minutes (given that they also calculate this time differently these numbers quickly become closely equivalent). This leaves only a few minutes for the FD to apply their directives. Even worse, only 2 per cent of those calls require any symptom relief at all. Given that it takes paramedics about 10-15 minutes to start symptom relief it is unlikely that the Fire Medic, with a few extra minutes before we arrive, will be able to start giving medications safely and appropriately.
Many of these jurisdictions also have 24-hour shifts for fire fighters. Tired workers make mistakes and get into accidents, and being up for 24 hours running medical calls will make everyone more tired. Given that Fire Medics have only a few minutes on scene before EMS paramedics arrive, that most calls do not require symptom relief, that fire fighters are going to have a high level of fatigue, and that there is no evidence that giving the medications a few minutes earlier will affect patient outcome, it seems hardly worth the risk to have fire fighters administer these medications.
What is even more incredible is that no one else in the province except the OPFFA wants fire fighters to have symptom relief drugs. In documents quickly leaked to the public, the Ontario Association of Municipalities, the Ontario Base Hospital Group Medical Advisory Committee that oversees pre-hospital medical direction, the Ontario Association of Paramedic Chiefs and the paramedic unions, all oppose this plan. Even the Ontario Association of Fire Chiefs denied knowledge of the OPFFA proposal before it was public, although it is hard to belief that the OPFFA did not get the chiefs' tacit approval.
But why is this? It is easy to see why the medics oppose it, but if it is going to save money (according to the OPFFA) then why would the municipalities and the EMS chiefs oppose it? It is because the plan is built upon a false economy. The total cost for the pilot project at one fire service is stated at around $30K in the plan, however there are some very costly items that are left out of the budget. The largest cost will be the shortened life of a fire pumper or rescue truck. Replacement cost for a modern fire apparatus is around 1 million dollars and it is expected to last 10 years. In a report by the Ontario Association of Paramedic Chiefs in 2011 (p.22), a fire engine responding to all emergent calls in its area would half its life span: that means that with this plan, expect to pay an extra $100K every year per engine in this plan: in Mississauga, a site in this pilot program, this would be an extra $1.8M a year or 60x the cost in the OPFFA plan. This plan is economically weak.
The plan also does not take into account an increased cost of worker injury and sick time, given the increased call volume, and it leaves out an analysis of the increased number of third party vehicle collisions, a side-effect of running lights and sirens through traffic and causing people to stop suddenly. It is insulting for the OPFFA to suggest that this plan does not threaten paramedic jobs as well. The OPFFA makes the argument that this proposal will help to control the increasing costs of Paramedic services. This means that the plan is designed to limit or lower the increasing infrastructure costs that come from trying to meet the response targets set by the MoH; costs that result in more ambulances and paramedics on the road. Also implicit in this argument is that EMS is not meeting these standards. In fact most EMS systems are meeting the provincial response targets, so not only is the plan an attack on paramedic work by attempting to limit the number of paramedics required in a service, it also invents a problem that does not exist to defend such a move. This plan is not only weak, it is indefensible.
The Ontario Base Hospitals Group oppose the plan because of what they see as its very inadequate training program: 20 hours is nowhere near the 1200 hours that paramedics spend training for their job to use the equivalent suite of medications. We certainly don't spend that extra 1140 hours learning how to drive someone to the hospital. In that time frame there is extensive anatomy and pathophysiology as well as 450 hours of clinical time where we learn to recognize who needs and does not need a medical intervention and how to administer drugs properly and safety. Even after that 1200 hours it takes a good year to get really comfortable with using these symptom relief drugs. Given that there is no evidence that administering these drugs any faster than we already do will have any impact on patient outcome, the risk of slinging prescription medications like a cowboy far outweigh any benefit that a Fire Medic would have on the road. It is a wonder they have found a physician who is giving them the permission to practice under his or her licence, and it is therefore no surprise that the Ontario Base Hospital Group is opposed to this proposal.
So we know the municipalities don't want it because it will cost a lot, and we know the physicians oppose it because it is an undue risk to the patient, but why do medics oppose it? We have already established that this proposal stands no chance of being approved and medics do not face a real challenge from the FD in Ontario, so why are we all so angry? The fact that the OPFFA, the fire fighter's union, has proposed this plan is just strange: such requests for expanded scope would be expected to come from the municipalities trying to meet targets or serve their citizens better. Not only did they put this plan together, but the fire fighter's union has been successful at convincing at least some people that it is a good idea. What is most galling to paramedics, in my opinion, is that the OPFFA and its parent organisation the International Association of Fire Fighters (IAFF) is powerful and organized (as an example, the OPFFA has owned the web domains names of "sendaparamedic" since 2012). Paramedics do not have anywhere near the same amount of power, organization and influence that the FF unions have and it is frustrating.
In Ontario, CUPE, OPSEU and the Ontario Paramedic Association have largely worked at cross purposes and with different agendas. The unions that represent us also represent a large and disparate workforce that do not always agree and we have been unable up until this point to organize ourselves enough to try to influence any politician effectively. One positive outcome of this current attempt by the OPFFA to move in on the work of paramedics is the rise of the Paramedic Working Group, a collection of the ambulance committees of the unions and the OPA that are finally going to create a united agenda and attempt to advocate for high quality, patient centred, pre-hospital care.
Despite the cool rhetoric from the OPFFA, this proposal is an obvious attempt by the OPFFA to defend the jobs of its members by edging in on the work of another union. This is the most galling part for me: in a job where we depend on all of our allied public safety and healthcare services to get the right help to the right patient at the right time, we are distracted by infighting and threats to our job. I believe fire fighters are committed and honorable public servants, who train relentlessly to run into burning buildings when everyone else is running out. However, the animosity that is building between Fire and EMS is going to continue as long as the union leadership at the OPFFA continues to place job security ahead of patient safety.
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