A review of international best practice of firefighters responding to emergency medical incidents within the community. By Station Officer Andrew Emery 2018 Churchill Fellow United Kingdom – Ireland – USA – Canada March – April 2019. “The discoveries of healing science must be the inheritance of all. That is clear: Disease must be attacked, whether it occurs in the poorest or the richest man or woman simply on the ground that it is the enemy; and it must be attacked just in the same way as the fire brigade will give its full assistance to the humblest cottage as readily as to the most important mansion….to ensure that everybody in the country, irrespective of means, age, sex, or occupation, shall have equal opportunities to benefit from the best and most up-to-date medical and allied health services available” Winston Churchill. 1948.
Transcript
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A review of international best practice of firefighters responding to
emergency medical incidents within the community.
By Station Officer Andrew Emery
2018 Churchill Fellow
United Kingdom – Ireland – USA – Canada
March – April 2019.
“The discoveries of healing science must be the
inheritance of all. That is clear: Disease must be
attacked, whether it occurs in the poorest or the
richest man or woman simply on the ground that it is
the enemy; and it must be attacked just in the same
way as the fire brigade will give its full assistance to
the humblest cottage as readily as to the most
important mansion….to ensure that everybody in the
country, irrespective of means, age, sex, or
occupation, shall have equal opportunities to benefit
from the best and most up-to-date medical and allied
health services available”
Winston Churchill. 1948.
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THE WINSTON CHURCHILL MEMORIAL TRUST OF AUSTRALIA
Report by Station Officer Andrew Emery – 2018 Churchill Fellow
To review successful international service delivery models of firefighters responding to emergency
medical incidents within the community
I understand that the Churchill Trust may publish this report, either in hard copy or on the internet or both, and
consent to such publication.
I indemnify the Churchill Trust against any loss, costs or damages it may suffer arising out of any claim or
proceedings made against The Trust in respect of or arising out of the publication of any report submitted to the
Trust and which The Trust places on a website for access over the internet.
I also warrant that my final report is original and does not infringe the copyright of any person, or contain
anything which is, or the incorporation of which into the final report is, actionable for defamation, a breach of
any privacy law or obligation, breach of confidence, contempt of court, passing-off or contravention of any
Firefighters Responding to Medical Incidents in Australia Page 9
London Fire Brigade Page 12
Dublin Fire Brigade Page 19
Boston Fire Department Page 24
Brockton Volunteer Fire Department Page 28
Toronto Fire Services Page 32
St. John’s Fire Department/Goulds Volunteer Fire Department Page 36
Winnipeg Fire and Paramedic Services Page 40
Los Angeles Fire Department Page 45
Conclusion Page 49
Recommendations Page 52
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Acknowledgments
Thank you to the Churchill Trust, the Churchill Fellows Association of Tasmania and the Tasmanian
Regional Selection Committee for seeing the need and immense community value in my project and for
entrusting me to represent the Churchill Trust and to uphold the Churchill Fellowship ethos as a 2018
Churchill Fellow.
In 2016, I was lucky enough to be in a forum to listen to the then NSW Fire Rescue Commissioner, Mr.
Greg Mullins, speak. Within a time of great change within the Tasmania Fire Service, Mr. Mullins made a
statement, although made with a hint of humour, it has resonated with me since that day. Mr. Mullins
said: “Historically, there are two things firefighters struggle with: the way things are…. and change”.
Most of Winston Churchill’s words are still relevant five decades after his passing. In preparing for my
Fellowship and the writing of this subsequent report, I came across a quote which gave me great strength
in undertaking this research subject; a subject that is often met with fear, trepidation and a hesitant
reaction with firefighters;
Mr Churchill said, “To improve is to change, so to be perfect is to change often.”
The reason I make these two references to change is that the following pages contain information,
statistics and anecdotes of the successes of the different service delivery models where firefighters
respond to medical incidents. If such models were to be adopted within Tasmania, it would be the single
biggest change to our firefighters’ job role in the history of this state. This will be undoubtedly similar in
all other Australian jurisdictions.
Over the months that I was preparing to embark on my fellowship journey, numerous firefighters
approached me with encouragement and their view that the research I was undertaking was needed and
welcomed. I would like to acknowledge and thank those firefighters, the ones who are prepared to
embrace potential large-scale change for the more efficient, effective and financially responsible
protection of the community that we serve without personal gain.
I want to thank all of the kind and courageous people who I met during my trip, who were so generous
with their time. Thank you for letting me chat with you, work among you and observe the good and the
deficits of your roles. These people are too numerous to mention but all belong to the firefighting and
emergency service family that I am so lucky to be a part of. The experience, wisdom, care and
professionalism which they imparted to me will never be forgotten and I am lucky to now call the
majority of these people my friends.
Thank you to Victoria CFA’s Deputy Chief Officer Mr. Gavin Freeman, who has constantly been a sounding
board and source of encouragement during the Churchill Fellowship application process and during my
career.
Gavin’s ability to give feedback, both positive and negative on this topic from the positions of being the
previous Tasmania Fire Service Deputy Chief Officer (who do not have a formalised model of medical
response) and now the Country Fire Authority Officer (responsible for the management of their successful
medical response program) has been nothing short of invaluable.
Thank you to Tasmania Fire Service Chief Officer Chris Arnol, for both supporting my Fellowship journey
and for realising the need for, and the benefits of, this international research. It has been a privilege to
follow in his fellowship footsteps.
Finally, I want to acknowledge the support of my amazing, patient and tolerant partner, Amy and my
beautiful daughter, Elvina. Thank you for your endless support, encouragement and enthusiasm. It was
not easy to be away from home for several weeks, but your support for my passion for my job, my
community and this fellowship made it all possible. Thank you so very much.
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Abbreviations
ARFF – Aviation Rescue Firefighter
BFD – Boston Fire Department
CAD – Computer Aided Dispatch
CBFD – City of Brockton Fire Department
CFA – Country Fire Authority
CISD – Critical Incident Stress Debrief
CISM – Critical Incident Stress Management
COPD – Chronic Obstructive Pulmonary Disease
CPR – Cardio-Pulmonary Resuscitation
DFB – Dublin Fire Brigade
EAP – Employee Assistance Program
EMR – Emergency Medical Response
EMT - Emergency Medical Technician
GVFD – Gould’s Volunteer Fire Department
IAFF – International Association Firefighters (USA/Canada)
IEC – Immediate Emergency Care
LAFD – Los Angeles Fire Department
LAS – London Ambulance Service
LFB – London Fire Brigade
MFB – Metropolitan Fire Department (Victoria)
MPS – Metropolitan Police Service (London)
NFPA – National Fire Protection Authority (USA)
ROSC – Return of Spontaneous Circulation
SJRFD – St. John’s Regional Fire Department
TFS – Toronto Fire Service
WFPS – Winnipeg Fire and Paramedic Service
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Executive Summary
According to statistics provided by the Victor Chang Cardiac Research Institute, around 20,000 Australians
suffer cardiac arrest outside hospital every year. The current survival rate for cardiac arrest outside
hospital is currently only 10%, meaning 9 out of 10 people who suffer a cardiac arrest will die. The type
and level of intervention a patient has in the first 3-5 minutes of these sudden cardiac events holds the
key to survivability.
The immediate cause of sudden cardiac arrest is usually an abnormality in the hearts rhythm, known as an arrhythmia. The most common cause of cardiac arrest is ventricular fibrillation, an arrhythmia where rapid, erratic electrical impulses, cause your heart chambers or ventricles, to quiver uselessly instead of pumping blood.
When looking at those statistics from the Victor Chang Cardiac Research Centre, there is a disconnect
between the medical research and the changing of patient outcomes to more favourable ones. The
research indicates that while when somebody will suffer a cardiac arrest is unpredictable, generally we
know why it occurs and what must be done to intervene to save the patient’s life. The agreed initial
solution across the world to increase the chance of survivability is to immediately enact the “Chain of
Survival”.
The medical Chain of Survival metaphor is widely accepted in all medical circles as the catalyst for saving
the lives of patients who are suffering from cardiac arrest and other emergency medical conditions. The
chain involves early access to a patient/s, early CPR, early defibrillation and early advanced care. There
are several community programs across Australia that recognise the important aim of providing the
patient with this chain, in particular early defibrillation and early CPR in order to give a patient suffering
from cardiac arrest the best chance of survival. However, there is room for more to be done.
Defibrillators were only once available to emergency services, those with a vested interest (pre-identified
conditions) or groups more susceptible to suffering cardiac arrest i.e the elderly or those who undertake
strenuous physical activity. Now, as defibrillators are becoming more and more common in people’s
homes, workplaces and public areas, and CPR and basic lifesaving skills and training becoming more
widespread, we have seen a rise in survival rates from cardiac arrest.
The idea of someone untrained, being able to source an easily accessible defibrillator, and to be talked
through the process by the automated voice of how to provide lifesaving first aid, is a major step in the
right direction and should be encouraged. However, the need for trained, better equipped and confident
people to quickly respond to the scene is also of the upmost importance and needs to increase. There is a
need to bridge the gap with advanced resuscitation techniques between civilian first-aid being instigated
and the advanced care of paramedics being rendered. This ‘gap’ is an ideal place for appropriately
trained and well-equipped firefighters to fill.
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This report presents the findings of my 2019 Churchill Fellowship. Over a seven-week period I was
fortunate enough to visit the UK, Ireland, USA and Canada with the aim of researching, by means of
interview and observation, the world’s best practice of firefighters, who already respond to medical
emergencies in their respective communities.
Australian fire agencies, who currently do not have a formal medical response in the community can use
this report, if they wish, to inform themselves of what service delivery model, or parts thereof, could suit
their move into providing an appropriate emergency medical service to the community they protect.
What also needs to be acknowledged is that emergency service agencies working in silos, cannot provide
the best service to those we protect - the community.
The findings contained in this report are relevant at a national level and to all Australian fire agencies.
However, the research and subsequent report focusses mainly on the potential success of an emergency
medical service to be provided by career/fulltime firefighters in urban or suburban areas. The scope to
research and present findings on volunteer firefighters in regional areas would be unachievable and too
ambiguous due to the vast differences between each individual response area covered by different fire
services. In saying that, larger metropolitan areas served by volunteer firefighters may gain benefit from
some or all of the research and subsequent recommendations of this report.
In all, six recommendations are made. These relate to (if a fire service was to implement a Firefighter
EMR program) the minimum process/consultation standards that should occur, the minimum welfare
requirements which would need to be adopted and recommendations to ensure an efficient medical
response service. This report does not aim to identify a single service delivery model of Firefighter EMR
which should be adopted by Australian Fire Agencies.
This report highlights the immense value of firefighter EMR to the community and the organisation which
provides it, including statistical data and anecdotal evidence showing the benefits of such a program.
This report also urges caution to those responsible for fire agencies in Australia who are moving, or
considering a move towards, a formalised medical response by firefighters no matter how large or small.
Fire agencies must acknowledge the potential negative outcomes that this type of response will have on
the mental health and well-being of the responders. It may also create issues in maintaining their
current response capability without changes to current response, training and welfare practice as well as
the potential resourcing implications.
It is expected that both this document and related reports, which have been undertaken in Australia and
across the world, can underpin a broader dialogue in the case for the adoption (or opposition to)
Firefighter EMR as part of the core business of fire fighters.
In making these recommendations, this fellowship report aims to inform the need for Australian fire
agencies to meet the communities needs into the future and to diversify to meet these needs, with the
aim of better serving the needs of the public. As times change and scrutiny becomes greater,
governments need to be more financially responsible with public monies as well as value adding to their
government agencies. As the following pages suggest, firefighter emergency medical response is an
effective way to do this in some instances, however, it needs to be emphasised that without adequate
funding, cooperation of all stakeholders and attention to the four-pillars of welfare, training, equipment
and industrial relations, a move into firefighter EMR could see more negatives than positives for both the
agency involved, and more importantly, the community.
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Introduction
The Need for this Fellowship
Emergency Medical Response by firefighters is still broadly in its infancy in Australia, however several
highly successful models have existed across the world for several years. In 2016, I instigated, with limited
results, preliminary investigations into the current service delivery models within Australia of firefighters
undertaking ‘Medical First Response’ responsibilities. Due to the uniqueness of Australia’s geography,
demographic, culture and different fire service structures and governance, it was discovered early in this
Australian research that a comprehensive international study needed to be undertaken into successful
international service delivery models in this area.
The intent of the Fellowship is to not make recommendations in regard to which specific service delivery
model would suit certain fire agencies who have an interest in branching into a medical related discipline,
its intent is to educate and inform discussions amongst stakeholders and to make recommendations on
what facets of the models witnessed should be taken into consideration and which should not.
Fellowship and Report Structure
The scope of this fellowship was to visit several international fire services/departments that have
adopted (or in the case of London Fire Brigade) trialled formalised medical response programs to provide
medical care to members of the community. The different fire agencies were chosen in order to provide
a diverse range of experiences and to collect data in relation to the history, advancement, success and
hurdles that each service delivery model have encountered in the areas including, but not limited to:
• Response
• Levels of Training
• Fire Fighter Welfare
• Industrial Issues
• Program Success
During my Fellowship journey I was fortunate enough to, not only interview respective organisation
managers and those with medical services as their functional area of responsibility, but importantly work
with and speak candidly with responders themselves about issues which they encounter daily when
undertaking the medical side of their role.
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Firefighters Responding to Medical Incidents in Australia
In a more informal secondary sense, all fire agencies in Australia, both career and volunteer regularly
respond to medical cases and provide medical care to members of the community in a range of
capacities. In the absence of more advanced medical personnel, firefighters are often required to provide
initial treatment to victims of trauma, such as those sustained in car accidents, industrial accidents and
fires. All fire services in Australia also regularly assist paramedics with lifting bariatric patients and assist
with the extrication of patients in circumstances where excessive manual handling is required, or access
or egress of a patient needs to be facilitated.
Increasingly, firefighters are being sent to medical cases where an ambulance may not readily be
available in a timely manner, or the required number of ambulances/paramedics may not be available.
Within Australia, there are currently 3 organisations with career fulltime firefighters, who respond as part
of a primary response to emergency medical incidents. These are:
Metropolitan Fire Brigade – Melbourne Victoria,
Country Fire Authority – Victoria
Air Services Australia - Aviation Rescue Firefighters (Responsible for 26 of Australia’s airports)
The Melbourne Metropolitan Fire and Emergency Services Board (MFB) was the first fire service in
Australia to implement a service-wide emergency medical response (EMR) program in 2001. The EMR or
"first responder" program provides training for fire fighters in treating cardiac arrest during a medical
emergency. The closest fire fighters are dispatched at the same time as the closest ambulance. In 2016,
Country Fire Authority Victoria undertook an EMR trial with great success, seeing it rolled out across all
CFA Career and Integrated Stations soon after. This saw CFA career firefighters join MFB career
firefighters as the only career firefighters with urban responsibility in Australia with a formalised Medical
Response program.
Victoria’s Emergency Medical Response is a collaborative program between Ambulance Victoria,
Metropolitan Fire Brigade and Country Fire Authority designed to improve survival from cardiac arrest.
CFA and MFB firefighters co-respond with the nearest ambulance and can manage unconscious, non-
breathing and pulseless patients by quickly providing access to life saving emergency medical care. As a
direct result of their program, MFB claim to have successfully resuscitated over 300 patients since 2001,
and since beginning their program, CFA statistics show that firefighters are directly involved in saving a
life every 8 days and every 11 hours, they get a person to hospital care who otherwise would not have
reached it.
Along with alarm calls, medical assist responses make up the majority of Air Services Australia’s aviation
fire rescue service responses - particularly at Sydney Airport. Selected airport employees inside the
airport who are first-aid trained triage a medical incident and then, if deemed serious enough, Aviation
Rescue Firefighters (ARFF) firefighters respond at the same time as Ambulance Service Paramedics. It is
reported that this isn’t always the case with the civilian first-aid personnel more often than not, calling
ARFF firefighters to triage less serious cases for them. ARFF personnel do not attend medical
emergencies outside the airport boundaries unless specifically requested by NSW Ambulance and
approved by the on-shift commander. Due to the proximity of the service delivery locations to the
terminal, patient contact is generally made within 3 minutes of receiving the initial call, thus giving ARFF
firefighters a substantially higher rate of success with patients suffering cardiac arrest. In some cases, as
high as 40-50%.
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Itinerary
March 2019 - London Ambulance Service
London Fire Brigade
March 2019 - Dublin Fire Brigade
March 2019 - Boston Fire Department
Brockton Fire Department
March 2019 - Toronto Fire Services
April 2019 - St. John’s Regional Fire Department (Newfoundland)
including Goulds Volunteer Fire Department
April 2019 - Winnipeg Fire and Paramedic Service
April 2019 - Los Angeles Fire Department
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Report author – Tasmania Fire Service Station Officer Andrew Emery
Parliament Square, London.
March 2019.
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London Fire Brigade (United Kingdom)
Response In February 2016, London Fire Brigade initiated a 20-month co-responding medical trial in the boroughs of Lambeth, Merton, Newham and Wandsworth to improve patient outcomes. The trial involved crews in the pilot boroughs being mobilised to calls where a patient’s condition was immediately life-threatening, as a result of cardiac or respiratory arrest. This trial was needs-driven due to London Ambulance Service not being able to effectively meet their response times.
Over the trial period, LFB firefighters attended over 2,250 incidents, approximately 8.5% of all callouts. Of those 2,250 approximately 400 were categorised as “cardiac arrest”. There are slight anomalies with the reported results, however they range from 71-78 occasions where LFB crews were directly involved in Return of Spontaneous Circulation (ROSC). This accounts for ROSC in approximately 20% of all medical based callouts. The instance where LFB firefighters were involved in being able to perform CPR and other life saving measures on a patient, and where that patient was transported to hospital and later had a positive outcome could not be recorded, but would have also contributed to the reported success of the trial.
When compared with post-trial data, statistics as well as feedback from the firefighters, has shown that during their co-response trial, London Fire Brigade made a significant contribution to the resuscitation rate of patients.
Fig 1 - Graph showing the number of medical calls (by month) LFB firefighters attended.
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The initial predicated call volume prior to the trial was for a combination of 28 calls per week across the participating stations. The actual number was 36. As the graph shows, there is a gradual decline in the number of calls throughout the duration of the trial period. This can be attributed to reduction of mobilisation determinants as well as stricter monitoring and ‘policing’ of the calls that LFB were dispatched to as the trial progressed. When speaking with firefighters involved in the trial, they reported that they didn’t feel as if they were “over-run” by medical calls. During the trial, a fire appliance supplemented one ambulance response, which would ordinarily have been dispatched prior to the trial. After the initial “mission creep”, firefighters were satisfied that they were usually only being sent to code red emergencies - medical cardiac arrests or respiratory arrests only. In the first year of the trial, after 5 months, it was decided to remove firefighter co-response to calls involving patients under 9 years old. The explanation for this was that these types of patients generally required immediate advanced care techniques and transport (described as “scoop and run”) which firefighters could not provide.
Fig 2. Meeting with London Ambulance Service and London Fire Brigade Interoperability Development Officers
London Fire Brigade’s Training and Equipment
At the commencement of the co-response trial, London firefighters held a First Aid qualification with
basic trauma life support content. When speaking with firefighters, it became inherently clear that the
training they initially completed to undertake such a role was lacking. The firefighters reported several
instances of not having the appropriate training and thus confidence, to deal with patient conditions in
situations to which they were sent. A common theme was:
• No training in bystander management
• Not having the training to diagnose death (e.g- Rigor mortis, hypostasis, trauma not compatible
to life.)
• Scenario based training lacking or non-existent.
• An inability, due to lack of training, to better diagnose patients (e.g- Unconscious patients due to
being drunk and drug affected, a case where firefighters administered oxygen to a patient
suffering chronic obstructive pulmonary disease blunting hypoxic drive was mentioned).
Firefighters also took issue with an external provider, who don’t necessarily have a background in emergency services, or understand the idiosyncrasies of how they and their role operates, delivering the training.
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Interestingly, after taking part in the trial, some firefighters who were initially dubious to take on the role, became passionate about the new role. Some even expressed a willingness to study further either as Emergency Medical Technicians and/or Paramedics. Since the trial, London Fire Brigade has developed an “Enhanced Immediate Emergency Care” course,
which has been designed and developed in close collaborations with London Ambulance Service. At the
time of reporting, a very significant number of firefighters had already undertaken the enhanced training.
Specialist teams also train to undertake casualty treatment and recovery alongside colleagues from
London Ambulance Service (LAS). These teams would deploy if a terror attack resulted in large numbers
of injured. All firefighters undertake an annual refresher training course for Immediate Emergency Care
(IEC),
According to the Harris Review into London’s preparedness to respond to a major terrorist incident, the
strategic planning of training delivery has allowed an early and encouragingly high level of confidence in
firefighters with enhanced medical skills, who are available to save lives in the event of further terror
attacks in London.
Aside from nasopharyngeal airways, London Fire Brigade carries what would be considered a reasonably
standard medical equipment cache on its responding appliances including an oxy-resus/airways kit, basic
trauma kit and semi-automated external defibrillator. Those interviewed agreed that the equipment they
had was sufficient to successfully provide for the medical role they undertook.
m Fig 3. Fig 4.
Fig 5.
Fig.3 London Fire Brigade immediate emergency care (IEC) pack.
Fig. 4 London Fire Brigade “Zoll” Automated External Defibrillator (AED)
Fig 5. London Fire Brigade O2 and airway managemnt kit.
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Fig 6. Meeting with London Fire Brigade (Clapham) Firefighters who took part in the Co-response trial.
Fig 7. Meeting with London Fire Brigade (Battersea) Firefighters who took part in the Co-Response trial.
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London Fire Brigade’s Firefighter Welfare Program
Prior to the co-response trial, London Fire Brigade firefighters had access to the London City Employee
Assistance Program as well as to the Critical Incident Stress Management Peer Support workers. Prior to
the Grenfell fire, the firefighters interviewed reported that, although they knew the welfare systems that
were available, they felt they had to be driven entirely by themselves. They all acknowledged that, since
the Grenfell Tower Fire, support was freely available. They all felt that welfare support for London Fire
Brigade Firefighters was more “reactive than pro-active”. In saying that, 6-months into the trial, London
Fire Brigade Management introduced an additional trigger mechanism (‘Tango’ messages) to enhance
trauma support and intervention from LFB’s counselling & wellbeing department.
At the time of my visit, mental health issues were the leading cause for absence from work of LFB
firefighters. Due to confidentiality requirements, statistics on the detailed reasons behind the absences
could not be disseminated. However, anecdotally, it is generally accepted amongst all those interviewed
that the Grenfell Tower Fire tragedy would, by and large be, the leading cause of this.
Interestingly, in the areas covered by the co-response trial, personal leave absences either stayed the
same or reduced through the duration of the trial. No correlation with this and the co-response trial
could be made.
Of those interviewed with regard to their welfare specifically related to the co-response trial they
undertook, some felt distressed due to:
• No follow-up on patient condition afterwards
• No Opt-In, Opt-Out System
• Felt councillors didn’t understand their role.
• Crews “filling-in” for from stations not involved in the trial felt initially uncomfortable.
• No specific trauma councillors were available.
• No clarity on the ability to cease response to a medical call to attend a fire-call.
• Immunisations were an afterthought, which caused distress to those potentially exposed to infection and disease.
All firefighters agreed that the Fire Brigades Union and London Fire Brigade were now working together and increasing support to them.
London Fire Brigade Industrial Issues
London Fire Brigade Firefighters have been involved in a long-running pay dispute with the government.
In the firefighters’ claim, there is no pay rise or conditions directly attributed to co-responding.
The Fire Brigades Union were contacted multiple times through several avenues in order to interview
them during my time in London, however no reply was received. It seems to be agreed that another trial,
or full roll out of a co-response program in London would not occur until this dispute was finalised.
London Fire Brigade’s Co-Responder Trial Success
From the important community protection perspective, London’s Firefighter Co-Response trial was a
resounding success. It could be argued that having only 1 successful patient resuscitation would warrant
the trial to be labelled a successful one, however over the 20 months, the trial saw that London’s
firefighters played a part in 1 in 5 patients returning to spontaneous circulation.
A major issue that was identified was that all the emergency service agencies in London (Police, Fire and Ambulance) all operate different Computer Aided Dispatch (CAD) systems. This has resulted in a 90 second delay between the ambulance receiving the call and a fire crew being alerted to the incident. When a patient who is suffering cardiac arrest’s chance of survival decreases by 10% for each minute they are without defibrillation, this was an alarming and unacceptable time lapse. Positively, the Multi-Agency
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Information Transfer (MAIT) system was soon scheduled for completion. This system is a link between LFB and LAS control rooms and will allow incident information to be transferred in real time, thus speeding up mobilisation and giving attending crew and control staff the necessary updates required to make swift and informed decisions.
Once anecdotally strained, the relationship between London Ambulance Service crews and firefighters has improved dramatically and the Ambulance Service has been highly complimentary of the LFB’s professionalism and were grateful for their assistance at co-responding incidents. The benefits of the trial were also significant to firefighters, with some firefighters who were reported to be dubious before the trial, were now converts to the benefits having experienced first-hand the success of the program. Some also were happy to extend into other areas of medical intervention in the future when/if the program is implemented again. Firefighters interviewed reported that the exposure to these medical incidents has given them more confidence to operate at mass casualty incidents to which they have been called (terrorist attacks etc). To that end, Lord Harris’ Harris Review into London’s Preparedness to Respond to A Major Terrorist Incident (recommendation 47) states “It is important that agreement is rapidly reached for the current LFB/LAS co-responding pilot to be expanded to all London boroughs as quickly as training resources allow”.
Overall, it appeared that the trial was implemented without appropriate consultation leading to several issues. It was agreed by the firefighters that most of the issues were “ironed out” towards the end of the trial, and others (such as the lack of public advertising on the program which created confusion when firefighters arrived first, or firefighters having to buy their own universal precautions) were to be fixed in consultation before any re-instatement of co-response within London Fire Brigade. It was also the opinion of the firefighters that were interviewed that busier stations may not be suited to undertake co-response such as Soho Station which goes to over 3000 calls a year and has large scale traffic issues when responding and returning. It was mentioned that stations like this could be utilised for those who require respite from medical calls.
Generally, the 17 London Fire Brigade firefighters and officers I interviewed who were involved in the trial were happy to undertake the role but agreed that a few things (not including the pay dispute) needed to be rectified before the program is reinstated either in trial form or permanently.
London Metropolitan Police (MPS)/London Ambulance Service (LAS) Partnership
In July 2017, an initiative led by London Ambulance Service and Metropolitan Police Service saw defibrillators added to over 700 police response vehicles and police stations across London.
This is a dual-response initiative, which looks to improve a person’s chance of survival when in cardiac arrest. If an emergency call received into London Ambulance Service’s control room meets a set criteria, both the LAS and the MPS will be dispatched to the incident at the same time.
The response by the police is additional, and does not replace an ambulance response. London Ambulance Service continue to respond to any call as quickly as possible, even where a police officer is dispatched.
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Fig 8. London Fire Brigade Headquarters – Union Street London
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Dublin Fire Brigade (Ireland)
Dublin Fire Brigade Medical Response Since 1862, Dublin Fire Brigade (DFB) has provided fire and Rescue Services to the Dublin Community and its visitors. This service was enhanced in 1898 by the addition of an emergency ambulance service with Dublin Fire Brigade being the only Brigade in the country which has a fully integrated Fire Based EMS service. Dublin Fire Brigade has 12 strategically located fulltime fire stations from which 12 emergency ambulances and 19 paramedic first response fire appliances respond to medical emergencies. There are currently over 900 active firefighter/paramedic personnel within Dublin Fire Brigade. DFB deals with about 135,000 callouts each year, of which approximately 80-85% are ambulance related incidents.
The Dublin Fire Brigade control centre receives the emergency calls for the Dublin area. The emergency medical dispatcher in the control centre will ask the pertinent questions to enable him or her to code the incident and assign it a particular response depending on the acuity of the call. An echo-coded call (cardiac/respiratory arrest, choking) would have the highest priority simultaneously activating ambulance, fire appliance, and advanced paramedic vehicles and will get the following response:
• The nearest available emergency ambulance;
• The nearest available fire appliance;
• An advanced paramedic vehicle, when available.
Fig 9. Blue Line denotes Dublin Fire Brigade Boundary
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Dublin Fire Brigade Medical Response (Cont’d)
Fig 10– Shows the percentages of which emergency assistance is first on the scene of life threatening
incidents within Dublin Fire Brigade.
Dublin Fire Brigade’s Training and Equipment All new Dublin Fire Brigade recruits, during their initial training, complete nine-weeks in the classroom to
prepare them for the National Qualification in Emergency Medical Technology (NQEMT) Paramedic
assessment. They are then entered onto the professional register as a Paramedic Intern.
During the Paramedic Undergraduate Internship, each intern completes a field clinical placement on a
Dublin Fire Brigade Emergency Ambulance and Paramedic First Response Fire Appliance under the
direction of experienced Firefighter-Paramedics. Interns work alongside medical and nursing staff in adult
and paediatric emergency departments, coronary care units and maternity hospitals as well as a
placement on one of the brigade’s advanced paramedic vehicles.
The undergraduate internship is a minimum of 18 weeks plus 1 week Trauma Life Support course. Interns
then begin a further year-long internship during which they complete three competency assessments and
professional development modules. On successful completion of the program, each student then enters
the professional register at ‘paramedic’ level and receives a diploma from the Royal College of Surgeons
(RCSI). The entire program takes two years to complete.
Dublin Fire Brigade runs 12 emergency ambulances and 19 paramedic first response fire appliances that
respond to medical emergencies. Aside from quantity and equipment on the designated ambulance such
as bed and inbuilt oxygen systems etc; all portable emergency equipment is very much the same on both
Dublin’s Emergency Ambulances and medical response fire appliances. They both carry defibrillation,
resuscitation medication and other trauma equipment for Echo-coded calls. Those Dublin
Firefighter/Paramedics interviewed agreed that the equipment they had was sufficient enough to
successfully do the medical role they undertook.
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Fig. 11
Fig 12.
Fig 11. Dublin Fire Brigade Emergency Ambulance.
Fig 12. DFB intravenous cannulation equipment
Dublin Fire Brigade’s Firefighter Welfare Program Dublin firefighter/paramedics are supported by their own peer-led Critical Incident Stress Management
Program (CISM). Like most other international fire services that run a CISM program, it is responsible for
managing the initial impact of critical incidents on its firefighter/paramedics and dispatch (999) centre
staff.
As employees of the city of Dublin, Dublin’s call-takers and responders also have access to an Employee
Assistance program (EAP) run by a private provider for the City of Dublin.
The firefighter/paramedics who were interviewed felt, as a whole, they were well supported mentally by
both of these programs. However, they did mention a reluctance to use the EAP program due to
confidentiality issues.
The firefighter/paramedics communicated that although CISM was a good program, they felt that the
best way to keep their mental health “in-check” in relation to exposure to traumatic incidents was
colleague based, informal debriefing.
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Dublin Fire Brigade Industrial Issues in relation to medical response
Aside from a push by Dublin City Council to have the call taking and dispatch function of the Dublin Fire Brigade ambulance service transferred to the National Ambulance Service (of which firefighter/paramedics interviewed believe would then result in detrimental changes to the way DFB is run), there didn’t appear to be any current industrial issues directly related to the Dublin Fire Brigades fire based EMS. As Dublin Fire Brigade and its firefighter/paramedics have been performing the dual fire and medical role for over a century, from a remuneration perspective, their pay and conditions are packaged together and thus there aren’t any specific allowances made for one role or the other.
Fig-13. Receiving a gift from Dublin’s Chief Fire Officer Dennis Keeley
Dublin Fire Brigade’s Fire-Based EMS Program Success Dublin Fire Brigade’s fully integrated Fire Based Emergency Medical Service is the envy of the country.
Some of the advantages being:
• All firefighters trained to paramedic level;
• All call-takers and dispatchers undertake dual purpose fire and medical role;
• Shared infrastructure;
• Simultaneous dispatch of required resources;
• One management structure;
• Increased patient outcomes;
• Well entrenched as the “norm” for over a century;
• Firefighter/Paramedic’s role in the community is revered, as is the Dublin Fire Brigade’s standing.
Between 2003 and 2008, a study conducted by MATER Medical Researchers found that Dublin’s improved
quality of emergency pre-hospital care has impacted on survival from out of hospital cardiac arrest,
particularly from ventricular fibrillation. These improvements were most likely due to dispatchers
beginning to give telephone assisted CPR, reduced time to arrival on the scene of an arrest and reduced
time to defibrillation.
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Fig 14. Graph showing percentage increase in hospital discharges of patients who suffered ventricular
fibrillation cardiac arrest
Although Dublin’s Fire/EMS model is an excellent example of a cost efficient and multi-value emergency
service, it has anecdotally some inherent issues, which were raised by firefighter/paramedics. The
constant theme being “burn-out” whilst working on the ambulance, and paramedic response to low-
acuity patients.
In Dublin, like worldwide, demand for ambulance services has increased, with rising population in major
cities, such as Dublin being partially to blame. It was communicated by DFB’s firefighter paramedics, who
were interviewed, that ambulance services were also often utilised for low-acuity patients, which saw
low, to no down time for firefighter/paramedics working long shifts. This has resulted in
firefighter/paramedics getting promoted to “get off the ambulance” (once promoted to Sub-Officer,
firefighter/paramedics aren’t required to undertake operational work on the ambulance). Fatigue and
frustration at not being listened to, were also major concerns.
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Boston Fire Department (USA)
Boston Fire Department Medical Response The Boston Fire Department provides fire protection and first responder emergency medical services to approximately 700,000 people in the city of Boston, Massachusetts and is the largest municipal fire department in New England. Along with fire and other emergencies, Boston firefighters co-respond with Boston EMS (a combination of Basic Life Support and Advanced Life Support Ambulances) to “Priority-One” medical calls. As with all of their calls, Boston Firefighters are able to respond, on average within 4 minutes or less. This is due mainly to the unavailability of ambulances, and the strategic location and sheer number of Boston Fire Stations. In 2018, Almost 60% of Boston Fire Department calls were medically related.
Fig 15. Locations of Boston fire stations and Boston EMS stations
Boston Fire Department’s Medical Training and Equipment Boston Firefighters are required to hold an Emergency Medical Technician (EMT) level of training. In an Australian context, EMT equivalent would be a combination of advanced first aid and advanced resuscitation techniques training and qualification. EMT’s provide what is considered basic life support and are limited to essentially non-invasive procedures. Boston firefighter EMT’s can typically also administer certain non-prescribed drugs including oxygen, oral glucose, epinephrine autoinjector and nasal naloxone. However, strict clinical practice guidelines are in place.
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Massachusetts has one of the strongest veteran’s preference programs in the country. Veterans, who are disabled or who served on active duty in the armed forces during certain recognised periods, or in military campaigns, are entitled to preference over other qualified candidates from the lists of eligible applicants. The benefit of employing ex-service men and women is that they generally already hold the equivalent or better medical qualification, and have already been exposed to trauma and other first-aid events in their previous national service occupation.
Aside from oral glucose, epinephrine autoinjector and nasal naloxone, Boston Firefighters carry what would be considered ‘minimum standard’ for a medical co-response in a Semi-Automated External Defibrillator, Oxygen Resuscitation Equipment and a generic trauma pack. All firefighters interviewed expressed that they felt that the training and equipment provided was sufficient to allow them to undertake their role satisfactorily.
Left: Fig 16. BFD Oxygen Resuscitation Equipment.
Right: Fig 17. SAE Defibrillator with Naloxone Spray
Left: Fig 18. Naloxone Hydrochloride Nasal Spray for Opiod Overdose
Right: Fig 19. Boston Fire Semi-Automated External Defibrillator
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Firefighter Welfare Boston firefighters, as City of Boston employees, have access to the Boston Council’s Employee Assistance Program (EAP). The Employee Assistance Program is a free and confidential program focusing on the wellbeing of employees and their immediate family members. The EAP provides a wide range of services including assessment, referral, supervisory and management consultations, brief treatment, case management, advocacy and crisis intervention. They can also assist in the prevention, recognition, and treatment of drug and alcohol dependence.
Alongside this, Boston Fire Department also has a peer-led, in house Critical Incident Debriefing (CISD team and a full-time chaplain.
General consensus amongst the firefighters interviewed was that although the CISD and Chaplain programs were not overly utilised, they were welcome. Firefighters expressed a reluctance in regards to utilising the Boston City EAP program due to the program’s requirement to report some instances to the employer. i.e. alcohol and drug abuse etc. which they felt was a breach of confidentiality.
Boston Fire Department industrial issues in relation to EMS Co-Response For approximately the last decade, the union representing Boston Fire Department’s firefighters has been making a push to have firefighters increasingly respond to more medical calls in the community. Over this period, Boston Fire Department has seen an increase in the category of the medical incidents they respond to. This is in response to the reduction in traditional fire-calls and an inability for Boston EMS to reach their response time goals due to an increasing workload. Firefighters, although they said they have the upmost respect for the city’s EMS, described this as a “turf” battle with firefighters in a position to respond to more incidents to help the public, as well as wanting to value-add to their position. They believed Boston’s EMS and paramedics saw this as an encroachment on their role.
Boston Fire Department Co-Responder Medical Program’s Success At the time of writing this report, statistics on patient outcomes directly attributed to Boston Fire
Department Co-Responding with Boston EMS were not available. Anecdotally however, Boston
Firefighters reported numerous successful resuscitations both autonomously and in conjunction with
Boston’s ambulance provider. Although the firefighters reported that there was some “mission creep” in
that they were frequently sent to medical incidents to assist when they were either not needed, or the
incident was outside their scope of response or training, they communicated that “there are a lot more
beneficial jobs we go to than not”. Although medical response is the largest portion of their response
activities, they were more than happy to have this as part of their role.
As an added factor to Boston’s continual advancement, higher levels of training and exposure to medical
incidents, firefighters feel they are better suited to undertake a medical role at the more traditional
incidents which they attend such as car accidents, structure fires and rescues.
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Left: Fig 20. With Boston FD Ladder 11 Captain Joseph Minehan
Right: Fig 21. With District Fire Chief EMS Gerry Cahill
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City of Brockton Fire Department (USA)
Brockton Fire Department Medical Response With a city population of just less than 100,000 people, The Brockton Fire Department is the busiest department per-capita in Massachusetts. In 2018 the Department responded to 26,316 incidents in the city. Approximately 80% of these calls were of a medical/rescue nature. Brockton’s emergency services are extremely busy due to a combination of a number of factors including a low-socio economic population, a large number of illegal immigrants, high amounts of drug and alcohol abuse and a large homeless population. These factors also result in a high crime rate.
Brockton Fire Department is responsible for emergency medical services in the City of Brockton, however it contracts out emergency medical and patient transport services to a private provider, which is not an uncommon practice in the USA. To supplement the firefighter response, the private ambulance provider “American Medical Response” provides the City of Brockton with Emergency Medical Technicians (EMT) manning 5 Basic Life Support Ambulances, and fully qualified paramedics manning two advanced life support ambulances. All medical calls in the city of Brockton are a co-response with the fire department and ambulance provider. This two-tiered operation is intended to provide better coverage of multiple calls and the option to provide the appropriate level of care based on the (emergency medical dispatch) assessment at the start of the incident.
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Fig 22. City of Brockton response statistics for the six years to 2016.
Brockton Fire Department’s Medical Training and Equipment Brockton City firefighters are all required to hold a minimum level of America’s National Fire Protection Authority (NFPA) Emergency Medical Technician (EMT) qualification. Like Boston, Brockton Fire Department participates in the Veteran Preference Program. It also gives preference to those already trained and experienced as EMT or greater.
Again, similar to Boston Fire Department, City of Brockton Firefighters carry equipment considered ‘minimum standard’ for a medical co-response in a Semi-Automated External Defibrillator, Oxygen Resuscitation Equipment and a generic trauma pack. Due to the broad range of incidents that City of Brocton firefighters respond to, they also carry some obstetrics related equipment and more comprehensive trauma equipment such as splinting and heavy trauma pads.
Left – Fig 23. Brockton Fire Department Central Fire Station Right: Fig 24. City of Brockton Fire dispatch
centre
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Brockton Fire Department industrial issues in relation to EMS Brockton City Council reports that it is operating during difficult economic times, and as such, firefighters reported feeling that they were required to “do more with less”. However, there was no reported formal industrial issues/action directly related to the provision of emergency medical services.
Brockton Fire Department Firefighter Welfare Brockton Firefighters referred to a constant, ever increasing work load in the area of medical calls, some even referring to being “burnt out” and stressed.
All of Brockton’s firefighters have access to Brockton City’s Employee Assistance Program, provided by a private provider, AllOne Health. The purpose of this program is to encourage all employees experiencing physical illness, mental illness, emotional distress, financial hardship, marital or familial difficulties, substance abuse or addiction or any other concerns, to seek appropriate help. AllOne health provide services such as:
• Mental Health Counselling
• Life Coaching
• Work/Life Resources
• Student Assistance Program
• Legal/Financial Resources
The Brockton City extends the same offer of assistance to the immediate families of all permanent employees.
Although Brockton doesn’t run its own Critical Incident Stress Management Program (CISM/CISD), they have access to other programs run by fire departments in the state of Massachusetts and supported by the International Association of Firefighters (IAFF) if required.
Fig 25 – Brockton Firefighters (Central Station)
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Brockton Fire Department Medical Program’s Success All Brockton Firefighters interviewed stated that, in the context of cardiac arrest, they have all been
involved in incidents where they were directly involved with a patient who had a return of spontaneous
circulation on occasions “too numerous to count”. Although this in itself is not a measure of success, and
a fair assumption considering the sheer amount of these types of incidents that Brockton firefighters are
exposed to, Brockton’s firefighters anecdotally use this as a measure of satisfaction that their role in
providing emergency medical care to the community is a valuable one. The formal arrangement which
sees Brockton firefighters co-responded with an ambulance, sees regular exposure to all types of medical
incidents, which, in turn gives them the confidence to operate in all medical environments with limited
equipment.
Fig 26. Deputy Chief Joseph Marchetti
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Toronto Fire Services (Canada)
Toronto Fire Services Medical Response The City of Toronto Fire Services (TFS) provides fire protection and first responder emergency medical
assistance to Toronto, Ontario, Canada. The Toronto Fire Services is currently the largest municipal fire
department in Canada.
Toronto Firefighters and Toronto EMS (TEMS) operate under what is sometimes referred to as a tiered
response system. However, it is more appropriate to describe it as a “co-response” type arrangement,
where fire and ambulance are both automatically dispatched to Delta and Echo calls, (the two most
serious classes of patient). Police also attend Echo calls, and all three services attend highway accidents.
For less serious calls — Alpha, Bravo or Charlie — dispatchers can make a judgment call. The system is
designed to ensure speedy responses to potentially life-threatening situations. In the case of Toronto
Firefighters responding to medical calls, it is always strictly as a co-response to support the ambulance
response and never as a primary response.
As Toronto’s EMS system is faced with the challenge of providing care to, not only an increasing and aging
population, but a high number of residents who abuse substances, its capacity to provide such care is
often stretched to the limit. Often this translates to extended patient contact time for Toronto Fire
Services crews as paramedics may be delayed while waiting for hospital beds (ramped/stacked), or
traveling longer distances to calls. While paramedics may be more fully equipped to handle medical
incidents, Toronto Fire Services often beats ambulances to the scene, mostly reflecting the department’s
greater resources, number of strategically placed resources (stations were historically situated close
enough together that a horse and carriage could dash to any scene without running out of breath) and a
dramatic shift in its caseload over the years, away from fighting fires and toward an all hazards approach
to community protection.
Toronto Firefighters saw their main role in the emergency medical system is to stop the clock, providing
initial first-aid treatment and then providing support to Toronto Paramedics as required for the duration
of the incident. Although they felt that they could not always perform the necessary medical
intervention, they can assist in other ways, from gaining entry to buildings to holding elevators for
paramedics, to dealing with bystanders who may hinder operations.
Fig 27 and 28 – Toronto Firefighters assisting in co-response with Toronto EMS (TEMS)
In 2018, Toronto Fire Services Firefighters responded to 132,365 incidents. Of these 132,365 incidents
68,089 were deemed as “Medical Emergencies” which accounted for 51% of all incidents.
Fig 29. Graph Showing percentage of all Toronto Fire Services Responses in 2018.
Toronto Fire Services Medical Training and Equipment
Toronto Firefighters receive a total of approximately 120 hours of Emergency Medical Response (EMR)
training during their initial recruit class. This training encompasses basic trauma and life support
management including, but not limited to, anaphylaxis, childbirth, foreign body airway obstruction,
hypothermia, advanced resuscitation techniques including hypothermic patients and neonatal patients.
The training is developed by Sunnybrook and Women's College Health Sciences Centre, whose staff teach
defibrillation and other medical services to Toronto Fire Services instructors.
The training, licensing and subsequent medical directives are overseen by Sunnybrook Medical Director.
Effectively, Toronto Firefighters operate under his/her personal medical license and authority. This
includes the administration of Oxygen, Epinephrine Auto-Injectors and Naloxone nasal spray.
In the last 2-3 years, Toronto has seen a large increase in responses to Opioid-Affected patients (mainly Heroin or Fentanyl). Due to this, in October 2017, Naloxone Nasal Spray was placed on all Toronto Fire Services vehicles, which respond to medical emergencies. Firefighters said that even though the rate of opioid overdose witnessed by them is very high, Naloxone is rarely administered by firefighters due to the presence of Toronto EMS, or patients not meeting the strict administration guidelines set out in the TFS medical directives guide. Toronto firefighters also showed a complete understanding of how to operate specialist equipment of Toronto EMS, such as stair-chairs, bariatric equipment and ambulance beds as well as how to package/prepare patients ready for transport. It was conveyed by firefighters that they learn this “in the field”.
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Fig 30: Toronto Fire Services Semi-Automated Defibrillator Kit, including Paediatric and Adult Epinephrine
Auto-Injectors (Epi-Pen)
Toronto Fire Service Firefighter Welfare Like the majority of other larger North American Fire Departments, Toronto Fire Services runs its own
Peer Support and Critical Incident Stress Debriefing Team which is called upon to deliver welfare support
to firefighters after a serious or critical incident. Interestingly, when compared to other Critical Incident
Stress Management Programs here in Australia, the definitions of a “Critical Incident” differ. Due to the
high daily rate of which most Toronto Firefighters are exposed to death, serious or traumatic injuries,
these types of exposures seem to be considered more “normalised” or understated than they would in
Australia and don’t see automatic instigation of CISD or EAP. Instead, it seems that more onus is put on
supervisors and colleagues to debrief after incidents as they see fit, as well as educating firefighters in the
support mechanisms available. CISD is automatically instigated at mass-casualty incidents, incidents
involving infant or juveniles and visually traumatic incidents to name a few.
Of the firefighters interviewed, all expressed that although they do not readily use the systems in place,
they were happy that they knew how to get support if they felt they needed it and felt that those
supports were adequate.
Fig 31. City of Toronto Employee Assistance Program (EAP) poster
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Toronto Fire Services industrial issues in relation to EMS Tiered/Co-Response
Like many, if not all other North American Fire Departments, Toronto Fire Services are facing budgetary pressures and are required to provide continual evidence of the need for their high-operating costs. As a part of this, Toronto Fire Services come under continued scrutiny from those who suggest merging fire and ambulance services, as has been done in other Canadian and U.S. municipalities with varying levels of success, in order to reduce duplication of services which in turn will reduce administrative operating costs and staffing requirements. The most documented issues referring to a one-service system like this is show that “turf wars” make integration like this extremely difficult, as do different workplace cultures.
Toronto Fire Services Medical Program Success
Having taken part in a year-long International Firefighter Exchange Fellowship with Toronto Fire Services
in 2013/2014, I was able to be involved in, and witness first hand, not only the challenges but the overall
immense success (measured in value to the public) of the Toronto Fire Services Emergency Medical Co-
Response Program. During my time in Toronto for both the firefighter exchange fellowship and this
Churchill Fellowship, I attended a combined 29 VSA (Vital Signs Absent) incidents, of which 20 patients
required firefighter-led cardio-pulmonary resuscitation and defibrillation. Of those 20 patients, 4 had a
return of spontaneous circulation, and several others were transported to hospital whilst still being
manually ventilated and perfused. On a more negative aspect of the program, firefighters interviewed
referred to a mission creep in that they are dispatched to incidents where they could do little apart from
reassure the patient. Most firefighters said that this wasn’t an inherent issue as jobs like this aren’t the
“doom and gloom” of the regular medical responses however it was becoming more and more common,
and they felt the time between their arrival and Toronto EMS arrival at these lower-acuity patients was
becoming greater. All of the firefighters interviewed believed that all that matters is that someone gets
to the scene quickly to begin basic life support.
Fig 32. Left. With Toronto Firefighter Chris Pallister
Fig 33. Right – Responding with Toronto Fire Service to Vital Signs Absent (VSA) Opiod Overdose
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St. John’s Regional Fire Department (Newfoundland, CA)
St. John’s Regional Fire Department Medical Response
St. John’s Regional Fire Department medical response is provided from 7 Fire Stations, 6 of which are
staffed by paid, full-time firefighters 24 hours per day, and 1 Fire Station (Goulds) operated by paid, full-
time firefighters 8 hours per day (Monday to Friday) and volunteers for evenings and weekends.
As First Responders, St. John’s firefighters administers basic first aid and perform ventilation,
cardiopulmonary resuscitation and defibrillation. In the case of a medical emergency the nearest St.
John’s Fire Department firefighters are dispatched at the same time as the nearest ambulance (either
private or public owned) and work on the patient under instruction from the paramedic on scene. This
system is what is widely referred to as “co-response”. St. John’s firefighters do not have the capacity to
transport patients.
Fig 34. Central Fire Station – St. John’s, Newfoundland.
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St. John’s Regional Fire Department Medical Training and Equipment
Prior to joining the St. John’s Regional Fire Department, applicants for firefighter positions are required to
already hold Emergency Medical Responder (EMS) qualification by completing either an “Advanced First
Aid for Firefighter’s” Certificate or “First Responder” (through St John Ambulance or Red Cross), or an
active Paramedic certification or equivalent (as recognized in Newfoundland Labrador). This course
allows firefighter candidates to undertake the basics in providing pre-hospital care for medical
emergencies.
Upon successful appointment to the role of Firefighter with St. John’s Regional Fire Department, recruits
undertake a more organisational specific first-aid “refresher” where they are trained in the specific
response needs of the department including the use of the specific equipment which is carried as well as
patient and bystander management in-line with city and provincial specific protocols.
St. John’s Regional Fire Department firefighters carried what was considered “minimum standard” for
North American departments however unlike other departments visited, Sty. John’s had a stronger
emphasis on physical trauma injuries and as such, appeared to have a more comprehensive kit to enable
them to better manage these types of injuries. There seemed to be a heavy emphasis on fractures with a
various limb splints and femoral traction device (traction splint) making up some of their medical
equipment. St. John’s fire appliances carried Naloxone (Narcan) nasal spray for opiod over dose and
dextrose oral gel (insta-glucose).
All of the firefighters and officers which were interviewed felt that the equipment they carried was
sufficient to undertake the medical role which was required of them.
Fig 35. Dextrose Oral gel Fig 36. Narcan Nasal Spray
Fig 37. Traction Splint Fig 38. Leg Splint
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St. John’s Regional Fire Department Firefighter Welfare
The St. John's Regional Fire Department in partnership with its Local 1075 IAFF members have recently adopted a vital program to the Department called “Road to Mental Readiness (R2MR)”. This course was originally developed by the Canada Department of National Defence and it is aimed at supporting the mental health and wellbeing of its first responders and enabling full productivity of its employees who work in all areas of the Department.
The SJRFD has developed a number of resources to provide to its employees in the aim for proper support and assistance for mental health and wellness. Its involvement includes the hiring of a Behavioural Health Coordinator who assists in the Peer Support Program (PSP), Critical Incident Stress Management (CISM) Teams, and now the R2MR Program.
The high majority of members have been trained and involves all Divisions within the Department (Suppression, Fire Prevention, Training, 911/Fire Dispatch, Administration, and Mechanical).
St. John’s firefighters welcomed the R2R program, but acknowledged that the way that most of them best deal with workplace stress and critical incidents is to undertake informal debriefing with their peers.
St. John’s Regional Fire Department industrial issues in relation to EMS Response
St. Johns’ firefighters were generally happy to undertake their role, and saw the immense benefit in it.
There appears to be some kind of merger or standardisation in progress in regards to Ambulance Services
in greater Newfoundland, as well as severe “ramping” issues. “Ramping” or “stacking” involves abulances
not being able to off-load their patients at the health care facility due to lack of resources to accept them.
This issue was common in every city which was visited. Related to the fire departments provision of
emergency medical services, there were no reports of any industrial issues directly
Gould’s Volunteer Fire Department
The Fire Chief of the Goulds Volunteer Fire Department reports to the Fire Chief (Director of Regional Fire and Emergency Services) and is responsible for the effective and efficient execution of the duties and responsibilities of the Department. The Goulds Volunteer Fire Department is responsible for providing a wide range of fire and emergency services to the Goulds geographical area. Volunteer firefighters respond to incidents from 4:00pm – 8:00am Monday to Friday and during weekends. Incidents that occur during the remaining hours in the week are responded to by full-time, paid staff. All fire and emergency incidents are supported by full-time/paid firefighters from adjoining SJRFD Stations. While this Division operates with a considerable degree of independence, the operations of the Department are integrated with the SJRFD and form an integral part of the fire and life safety service within their geographic area of responsibility.
Fig 39. – Total incident numbers attended by Gould’s Volunteer Fire Department by category and by year.
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Fig 40. Total incident numbers attended by Gould’s Volunteer Fire Department by category and by year.
St. John’s Regional Fire Department Medical Program Success
Statistical data to analyse the numerical success of St. John’s Regional Fire Department’s emergency medical program was not available.
Anecdotally, all firefighters and officers reported being directly involved with one or several patients who experienced ROSC in the absence of paramedics. Firefighters interviewed also spoke of the time between their arrival and paramedic arrival, and the felt like they were making patient contact 50% of the time in the absence of an ambulance. This in itself is not an accurate measure of the program’s success, but a safe assumption that the overall goal of saving the lives of those patients suffering an out of hospital cardiac arrest, has been aided by St. John’s Regional Fire Department emergency medical program.
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Winnipeg Fire and Paramedic Services (Canada)
Winnipeg Fire Paramedic Service Medical Response Winnipeg Fire and Paramedic Service comprises of approximately 860 frontline staff across 31 service
delivery locations. In 1983 the Winnipeg Fire Department introduced the use of first responders
(firefighters) to start assisting the Winnipeg Ambulance Service on medical calls. Beginning in 1990,
Winnipeg began an amalgamation of both its fire and paramedic services to create an Integrated Fire-
EMS model to serve the city of Winnipeg. As of 2000, both departments amalgamated to form
the Emergency Response Service of Winnipeg, which was later renamed as the Winnipeg Fire Paramedic
Service. The service uses a dual response system in which the Winnipeg Fire Department has a licensed
Primary Care Paramedic on most fire apparatus who can assist the paramedics on ambulance. WFPS
operates what is commonly known as an integrated service model, which unites fire and ambulance
service under one employer and one response team.
Winnipeg Fire and Paramedic Service Medical Training and Equipment WFPS applicants either apply for a position as a paramedic, a firefighter or a firefighter paramedic.
To enter as a firefighter, candidates are required to already hold a Canadian recognized Emergency Medical Responder (EMR) Program Certificate (minimum). Preference is given however to applicants who have acquired a Canadian Medical Association (CMA) Accredited Primary Care Paramedic Program (PCP) Certificate and Province of Manitoba Technician-Paramedic Licence.
Entry to the WFPS as a firefighter paramedic requires the candidate to hold a province of Manitoba Technician-Paramedic Licence (minimum) and entry as a Primary Care Paramedic only requires the candidate to already hold a Province of Manitoba Technician-Paramedic Licence (minimum) or Province of Manitoba Technician-Advanced Paramedic Licence provided by Manitoba Health.
As vacancies occur, applications are called for firefighters who wish to cross-train to firefighter paramedic level.
Cross-trained Firefighter/Primary Care Paramedics were unanimous in their view that their cross-training provided them with the necessary skills to effectively respond to emergency medical calls, and firefighter only personnel said that they were comfortable with their level of training (combined with the support from Firefighter/PCP’s) to effectively and efficiently do their job
All Winnipeg Fire Department firefighters are recognized Emergency Medical Responders (EMR). They have undergone training to prepare them to respond and assist at emergency medical scenes, supporting paramedic personnel. The function of an EMR is to provide emergency patient care, cardiopulmonary resuscitation (CPR), patient immobilization, oxygen therapy and basic assessments.
The Primary Care Paramedic (PCP) can be found riding on pumper trucks, rescues, or squads in the Winnipeg Fire Department as well as assigned to ambulances for Winnipeg Emergency Medical Services. The Primary Care Paramedic (PCP) scope of practice includes:
• Manual defibrillation
• Glucometry
• Pulse Oximetry
• IV Maintenance
• Administer drugs including: ASA Epinephrine Glucose gel Nitroglycerin Salbutamol
The function of an Advanced Care Paramedic (ACP) includes all the responsibilities of the Primary Care Paramedic and is further enhanced with additional training and skills. The Advanced Care Paramedic (ACP) is a graduate of an accredited training program, many of whom graduated from the Winnipeg Fire Paramedic Services own accredited training division. Paramedics in Winnipeg attending the WFPS Training Division must undergo a two year program to be recognized as an Advanced Care Paramedic. This training involves hundreds of hours of clinical, didactic and ambulance field preceptorship time. Upon the completion of their first year of training students are recognized locally as an Intermediate Care Paramedic (ICP) that has no national comparator. Intermediate and Advanced Care Paramedics (ICP and ACP) are exclusively assigned to EMS units with Winnipeg Emergency Medical Services.
The Intermediate Care Paramedic (ICP) scope of practice includes:
• Synchronized cardioversion
• 12 ECG interpretation
• Intravenous therapy
• Intraosseous infusion
• Direct laryngoscopy and foreign object removal using Magill forceps
• Administer additional drugs including: Amiodarone
To compare these qualifications and responsibilities within an Australian Paramedic context, a Winnipeg Advanced Care Paramedic would be closely comparable to Australia’s regular paramedics in their skill-sets and scope of practice.
WFPS vehicles carry what would be expected of a full-service paramedic response in that in addition to basic trauma life support equipment, they carry licensed treatment drugs as well as technologically advanced ECG machines inclusive of defibrillator which automatically analyse the ECG and diagnose cardiac events.
WFPS have, as part of their operational fleet, two squad trucks/vans. These are manned each by a Lieutenant and Primary Care Paramedic and are designed to attend lower acuity patients where they attend a call, provide medical care and assess the patient to decide whether an ambulance is needed, or if police are required to attend. Due to a major drug and alcohol abuse problem, and homeless population in Winnipeg, the incidents which these squad vehicles are sent are generally unconscious or drug affected patients out on the street, or out in the elements. These squad vehicles allows patients to be treated inside the privacy of the vehicle, and away from the elements. Although these vehicles aren’t specifically designed for transporting patients, firefighters reported that they have, in some instances, utilised the vehicle to transport patients to the Intoxicated Persons Detention Area (IPDA Centre), which supports intoxicated or drug affected individuals into sobriety using a Harm Reduction approach, close monitoring and a supported release.
Winnipeg Fire Paramedic Service Welfare Systems Winnipeg Fire and Paramedic Service firefighters are supported by both a CISM peer support team as well
as Winnipeg City Employee Assistance Program. Although firefighters interviewed said they were
comfortable with the level of support available to them, they were welcoming of the pending results of
further research into a larger, more holistic approach to firefighter welfare which was being developed by
the International Association of Firefighters.
Winnipeg Fire Paramedic Service Industrial Issues The integration of Winnipeg’s Fire and Ambulance Services caused, and continues to cause industrial
issues within the organisation. The move to integrate both services, although undoubtedly creating
business efficiencies, resulted in years of labour strife, which was finally settled in 2007. It also created
animosity and poor working relationships in the service. The two major issues were the cultural
differences between the services, and labour relations. These labour relations and working relationships
are reported to have mended, and anecdotally, do not affect the end result of providing an extremely
effective and efficient emergency medical service to the community.
Fig 44. With Winnipeg Fire and Paramedic Services Chief John Lane.
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Winnipeg Fire Paramedic Service Integrated Fire/EMS Model Success. Today, Winnipeg considers itself, and is generally considered by other fire agencies, as a leader in
integrated fire and medical services to the community in the areas of organisational and response
efficiencies.
Undoubtedly, having cross-trained firefighter/paramedics increases efficiencies and provides better
service by having both fire and paramedic support available in crisis situation, and by having dual-role
personnel value adds to both the individual and agency.
Approximately 80% of all WFPS call-outs are of a medical nature. In 2016, firefighter/primary care paramedics dealt with an entire incident without an ambulance 10,500 times, leaving ambulances available for patients with life threatening conditions.
All Winnipeg firefighter paramedics and primary care paramedics are trained in the STEMI protocol. The protocol allows all primary care paramedics/firefighters to assess a heart attack patient in their home using an ECG machine with 12 electrodes. Using the ECG and the symptoms, the paramedic can diagnose the patient who is having the most severe kind of heart attack called an ST-segment elevation myocardial infarction or STEMI.
Once the diagnosis is made, the ECG is wirelessly transmitted to a doctor in real time, and the paramedic will call the doctor to determine the next step. Together, the doctor and the paramedic will decide between three options. In the case of the patient suffering a STEMI, they would go directly to the cardiac catheterization lab where the blocked artery would be reopened. The paramedic may also administer a clot-busting drug on scene. If the patient is not having a STEMI, the ambulance would transport the patient to the nearest hospital.
Since 2008, 200 patients on average have been treated each year using the protocol. The Winnipeg Fire Paramedic Service and the Winnipeg Regional Health Authority said the mortality rate for pre-hospital STEMI patients has dropped from one in 10 in 2007 to one in 30 in 2015.
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Los Angeles Fire Department (USA)
Los Angeles Fire Department Medical Response The Los Angeles Fire Department (LAFD/LA City Fire) provides emergency and medical services to the city of Los Angeles. The LAFD is responsible for approximately 4 million people who live in the 1,220 square km area of responsibility. The LAFD is the nation’s second busiest provider of EMS in the nation, behind the New York Fire Department (FDNY).
LAFD is a fully integrated fire and ambulance service in that both fire and medical services in LAFD jurisdiction are provided by LAFD uniformed firefighters and paramedics.
Every day, the LAFD responds to more than 1,112 emergency responses and the department’s rescue ambulances transport more than 571 people to area hospitals each day.
LAFD has total of 1,018 firefighters including 270 dual-role Firefighter/Paramedics.
The LAFD's 3,246 uniformed fire personnel protect life, property and the environment through their direct involvement in fire prevention, firefighting, emergency medical care, technical rescue, hazardous materials mitigation, disaster response, public education and community service.
LAFD run what is commonly known as “tiered response” in that once a medical call is received by LAFD 911 dispatch centre, the type of incident is triaged and the response is dictated by patient acuity.
Either a fire appliance, basic life support ambulance or advanced care ambulance is dispatched. In the case of serious medical emergencies, the dispatch can involve a combination of all three.
LAFD also has dual role fire and medical call takers, who swap between undertaking call-taking duties, or
dispatch duties for both fire and medical related calls.
Fig. 45. LAFD Incidents by category and incidents by year.
Los Angeles Fire Department Medical Training and Equipment All applicants wishing to join the LAFD as either a firefighter or firefighter/paramedic are required to
already hold a valid Emergency Medical Technician (EMT) qualification. Firefighters are either employed
as firefighter/paramedics or as EMT firefighters. EMT Firefighters can choose to diversify into the
paramedic role once employed. Firefighters must have two years as an LAFD firefighter and pass
the paramedic school entrance test. They are then placed on a merit-based list and wait until the next
paramedic class is held.
Los Angeles Fire Department provide several types of medical response vehicles to support and manage
medical incidents within the community. Aside from basic “fire engines” (containing firefighter EMT’s)
which can respond to less serious calls and in cooperation with either BLS or ALS ambulances, LAFD
utilises rescue ambulances, called 'rescues' for short. These ambulances are either advanced life
support (ALS), or basic life support (BLS). Advanced life support (ALS) ambulances are staffed by two dual-
role firefighter / paramedics. The departments basic life support (BLS) ambulances are staffed by 2
firefighters trained to Emergency Medical Technician (EMT) level.
Depending on the available resourcing, firefighter/paramedics work either on a fire appliance, or on an
ambulance and have the ability to swap between the two if personnel numbers allow.
Both LAFD firefighter EMT’s and paramedics have the knowledge and skills to transport patients and
provide them with emergency care. The biggest difference between them is the skillset they hold and
what they are allowed to do for patients (scope of practice).
Both Los Angeles Fire Department BLS and ALS ambulances carry what would be considered ‘standard’
pre-hospital care medical equipment whilst fire appliances that respond to medical incidents carrying
firefighter EMT’s carry enough equipment for them to work within their scope of practice, including
oxygen, defibrillator, naloxone, epinephrine auto-injector (epi-pen) and oral dextrose.
Fig 47. Left - Inside an LAFD Basic Life Support Ambulance Fig 48. LAFD Sobriety Emergency Response (SOBER) Unit
Los Angeles Fire Department Welfare Systems As considered ‘standard’ in North American Fire Department which were visited, Los Angeles Fire Department personnel were supported by both a city council provided employee assistance program (EAP) and a Critical Incident Peer Support Response Team. The EAP program is provided to LAFD personnel as City of Los Angeles employees and offers councelling and support services in relation to, but not limited to the following:
• Marriage, family and relationship issues • Stress and anxiety • Depression • Grief and loss • Anger Management • Domestic Violence • Alcohol and drug dependency • Other emotional health issues
All of the members of the employee’s household are eligible to receive this service.
LAFD also employs chaplains and a fire psychologist. The fire psychologist is responsible for the behavioural health and welfare of the Los Angeles Fire Department’s (LAFD) uniform and civilian employees. As the sole director and clinician of the LAFD’s Behavioural Health Assistance Program, the Fire Psychologist is responsible for managing, supervising and evaluating the Behavioural Health Assistance Program and the Critical Incident Peer Support Response Team.
Of the firefighters and officers interviewed, they felt supported by all of the welfare systems available to them. However, the did communicate a reluctance to use the Los Angeles City’s EAP program due to potential confidentiality issues. The firefighters also referred to several outside firefighter support organisations (which are supported but not funded by LAFD) who offer family support and relief services to LAFD firefighters and their families.
Fig 49. Left. With LAFD Battalion Chief Doug Zabilski - Commander of EMS Training and Administration at
City Hall.
Figure 50. Right. With LAFD Captain James Vlach at LAFD Fire Station 4.
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Los Angeles Fire Department Industrial Issues Like most departments which provide medical services to the community, Los Angeles Fire Department
firefighters spoke of the “unrelenting” strain on ambulance resources. This has led to a push for further
resources, but is not categorised as an “industrial issue” in the context of this report.
An issue which was bought up several times during interviews with LAFD personnel is that they felt that
due to the ever-increasing pressure and reliance of LAFD’s ambulance services, that the monetary
emphasis was being focussed on that discipline of their response, sometimes to the detriment of the
fire/rescue budget.
Los Angeles Fire Department Fire Based EMS Model Success. Like Winnipeg Fire and Paramedic Service, the benefit of being able utilise dual-trained
firefighter/paramedics and firefighter/emt’s cannot be argued against, in particular, as 85% of incidents
responded to by the LAFD are medical in nature.
Due to the sheer volume of medical calls that Los Angeles Fire Department attend, being able to gather
sound statistical data on “successful” patient outcomes due to the intervention of firefighter/emt’s and
firefighter/paramedics could not be achieved as it would be too ambiguous. Anecdotally, all
firefighter/EMT and firefighter/paramedics interviewed said that they were exposed to positive outcome,
either ROSC or providing life-saving intervention “on a daily basis”.
All agreed that part of the relative success of the LAFD’s medical service stemmed from the speed and
ease of the initial call-taking and dispatching (Tiered-Dispatch System) which LAFD’s 911 centre use. All of
LAFD’s call takers and dispatchers are trained in all facets of both call taking and dispatching and work
both between fire and medical disciplines. The integrated environment in which this takes place allows
for seamless answering of the call, triage and simultaneous dispatch, saving important seconds. It also
allows for shared infrastructure and cost-benefits by reducing duplication.
Fig. 51 – Left. The dispatch area of LAFD 911 centre
Fig. 52 – Right. Los Angeles City major incident management room.
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Conclusion
When someone suffers a cardiac arrest, blood is no longer being pumped around their body and they are clinically dead. With each passing minute from the time of the arrest, the probability of survival declines about 7%-10% - making early access critical. It has been found that chest compressions and ventilations, and early defibrillation are the only factors proven to increase the survival of patients with out of hospital cardiac arrest and are key elements in the chain of survival. These resuscitation efforts are labour intensive. Firefighter emergency medical response is designed to support this universally recognised and adopted chain of survival, in particular but not limited to, early Cardio-Pulmonary Resuscitation (CPR) and Early Defibrillation. Chain of survival depicts the critical actions required to treat life threatening emergencies including heart attack, cardiac arrest, stroke and foreign-body airway obstruction. This is proven to increase survival rates and extended perfusion resulting in higher rates of successful organ donation. It could also be argued that a quicker initial response by trained and equipped personnel can have a positive effect on the grieving process of those present in the case of a negative outcome.
In co-response locations, Firefighter EMR is all about having the quickest response to time critical medical
emergencies, such as cardiac arrest, in order to instigate life-saving medical intervention. It’s not about
replacing ambulances or paramedics. If areas were to have 100 extra ambulances on the road tomorrow,
a place for firefighter emergency medical response would still be present, albeit with a lower rate of use.
Response time is the absolute priority for medical emergencies. With an ever-increasing scope of work
and workload for ambulances, firefighters are in the best position to respond quickly and to provide vital
services until their arrival.
In all service delivery programs scrutinised around the world, where firefighters responded to medical
emergencies (either as a primary response, or as a co-response) it was concluded that the benefits to the
community in a life-saving context were irrefutable. The statistics and anecdotes from firefighters who
already undertake such a role contradict any argument that firefighter medical response or fire based
EMS “does not work”. There is a huge place for it in a modern day, progressive community
service/emergency response organisation and the life-saving benefits to the community are undeniable.
In some areas, fire departments in the United States and Canada have been responding to medical
emergencies for over 50 years now, and in the case of the Metropolitan Fire Service, Victoria -over 20
years. The success of the total integration of emergency medical and fire services has been extensively
documented by the United States. In the US, 51% of fire departments provide emergency medical
services and of the 200 largest cities, 97% have fire service based emergency medical response.
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Unlike most cities in Australia, North America has a relatively large number of fire stations, fire trucks and firefighters across small geographical areas. This contributes to the success of their programs. Due to the diversity and complexity of all firefighter medical response service delivery models, any
costings were not completed during the scope of the fellowship. In general terms however most of the
proactive costs associated with Firefighter EMR seemed to be attributable to remuneration, equipment,
training, inoculations and welfare services. Unless someone develops a formula on how much an
accidental death costs, it will prove very hard to conduct an accurate cost benefit analysis on Firefighter
EMR programs. However, due to the national and international success of such programs, a safe
assumption would be that the benefit would far outweigh the costs involved.
If the purpose of fire agencies is to respond to fire and other emergencies and governments have a
responsibility to provide protection to its citizens, then it makes sense to take an existing group of
employees (firefighters) and train them to respond to as many types of emergencies as possible in either
a primary or support role. This paradigm shift however, needs to be properly resourced and
appropriately planned and executed. For fire agencies which do not already have a formalised response
model of firefighters who respond to emergency medical incidents in the community, firefighter
emergency response should be treated with a “not if, but when” attitude. The earlier that both
firefighter representative groups and fire agencies sit down together and collectively embrace the
benefits of this more effective, efficient and financially responsible approach to community protection
and agree on the “rules of engagement”, the sooner that this valuable service to the community can be
provided to the people who they are employed to protect.
Unfortunately, some Australian career firefighters have an overwhelming lack of confidence in their
respective state governments’ ability to implement such a program with appropriate attention to detail,
consultation, satisfactory training, remuneration and welfare support. Although, as a whole, they are
always open to developing their skills and value in the community, the mere mention of Firefighter
Emergency Medical Response is generally met with fear, trepidation and uncertainty. These fear and
concerns are also compounded by misinformation on what firefighter medical response entails. There
exists an antiquated view of the role of a fire service/firefighter in the community and a reluctance of
firefighter representative groups to be proactive and enter into discussions with fire agencies for varying
reasons.
To that end, instead of waiting for and being reactive to a push from Governments to have firefighters
enter into the emergency medical response sphere, firefighter’s representatives (unions and associations)
should be pro-active in accepting both the value of emergency medical response to the community and
accepting emergency medical response as the “new norm” in a firefighters ever diversifying role.
Firefighter unions/associations need to, in conjunction with paramedic representatives begin developing
their own minimum acceptable standards of any implementation of such a program within their own
organisation. These minimum acceptable standards should fall under pillars including but not limited to:
• an appropriate response model and how that response model will be governed;
• appropriate level of training and equipment;
• appropriate welfare systems;
• appropriate remuneration;
It’s important to note, that all of the respective fire agencies visited, adopted their service delivery model
based on what suited their community’s need and their legislated emergency services structure. It needs
to be acknowledged that any service delivery model of firefighter medical response cannot be adopted in
a “one-size fits all” approach. As the recommendations suggest, implementation of firefighter medical
response should not be dressed up as “modernisation” or “improvement” in lieu of ambulance/health
care budgetary or resource shortfalls. i.e.- untrained firefighters should not replace paramedics, rather
complement their response and support them.
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In the instance of Winnipeg Fire and Paramedic Services and Los Angeles Fire Department, their medical involvement is commonly called “Fire-Based EMS” where firefighters are either co-trained as paramedics, or separate firefighters and paramedics both operate within the same organisation. This arrangement has efficiencies, especially from a managerial perspective. By having cross-trained firefighter/paramedics leads to arguably a better service by having both fire and paramedic support in the one role. However, the common theme with these particular organisations is that the integration was extremely difficult and in some cases caused severe damage to relationships between firefighters and paramedics as well as poor workplace culture. Fire-Based EMS offers many outstanding “promising practices” in service integration that could be applied by other cities around the world. Ambulance and fire integration in some form should not be ruled out within Australia. There is always a place for a proactive improved offer of service to the community when the need arises. Rather than seeing this possible expansion of the role of firefighters as a negative, it should be seen as part of the ongoing cooperation between the emergency and health care services to deliver faster, and improved emergency assistance. Australian firefighters have always provided first aid when required, eg for people injured in a fire and have always been ready, willing and able to assist other emergency services, including the ambulance service, when requested. This is another opportunity for them to contribute to the well-being of their community but not at the expense of, or to replace the excellent service provided by paramedics. Fire Services should strive to improve capability and service delivery and should aim to increase the value that communities place on their organisation by lifting its profile and by meeting the community’s needs. Today’s paramedics deliver advanced, definitive care at the scene of an accident or illness and have skills to diagnose and monitor patients, administer drugs, through a variety of routes and provide other high level interventions. In-line with this expansion of skills has come an expansion of education with a shift away from on-the-job vocational training to tertiary level qualifications. Paramedics complete a three year degree before beginning their full ‘on road’ experience.* By introducing firefighters to undertake the more physical elements of a resuscitation attempt (e.g- moving a patient to a suitable area, CPR, ventilating. defibrillation) which they are already trained and arguably more suited to than paramedics in some instances, it allows paramedics to be free to undertake the more technical and clinical roles involved in resuscitation attempts and to potentially expand treatment options for a patient faster. * * *Ruth Townsend and Michael Eburn
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Recommendations:
Due to the diverse nature of Australia’s fire agencies including geography, areas of responsibility and management structure, specific recommendations are not given as to which service delivery model or parts of would suit each individual organisation. Instead, the recommendations combine an initial process towards adopting a formal medical response, a minimum requirement of any move to a firefighter emergency medical program and recommendations in regards to creating efficiencies.
Recommendation 1 – Due to the diverse nature of Australia’s Fire agencies and communities, I believe a comprehensive needs analysis be conducted including, but not limited to, comparing ambulance and fire service response times and call rates in areas covered by career firefighters to identify areas where firefighters may be able to assist. This would allow informed discussions on whether in fact, a firefighter based emergency medical response would be beneficial or even needed within individual communities.
Recommendation 2 – Due to a somewhat ‘taboo’ approach to firefighter medical response by some Australian firefighters and firefighter representative groups, I believe it is imperative that all stakeholders, in particular responders, are in full receipt facts and implications of the implementation of such a service. The high majority of the apprehension appears to be driven by lack of education or lack of communication, or both.
Recommendation 3 – It became clear upon returning from travel, the high level of interest in the fellowship findings and a real interest of firefighters to open discussions about branching into an emergency medical based discipline. There appears to be a real trepidation amongst firefighters to speak openly about this support due to a loud minority of firefighters who are against a move towards any variation to their areas of responsibilities. To that end, firefighter representative groups (unions/associations) should anonymously survey their members and allow a ‘conscience vote’ to inform the inclination of their members to enter into a formalised medical response role to ensure they are truly representative of their wishes.
Recommendation 4 – One major finding from my travel was that any move towards any service delivery model which sees firefighters respond to emergency medical incidents is that it needs to be done cooperatively, and with complete transparency. I believe that the easiest way to do this is for fire agencies looking towards this type of implementation establish a working group with representation from the relevant fire agency, relevant Ambulance Service, Australian Resuscitation Council, Firefighter Union, and Paramedic Union to establish minimum standards of Firefighter Emergency Response to ensure a safe, efficient and financially responsible service to the community is developed. These minimum standards to be agreed on should include, but not be limited to:
•An appropriate response model and how that response model will be governed; •Appropriate level of training and equipment; •Appropriate welfare systems; •Appropriate remuneration (if any);
I strongly believe that any firefighter first responder program developed must be based on community needs and expectations with a scope to provide appropriate, safe, timely and effective medical interventions in response to medical emergencies for critically ill or injured patients.
Recommendation 5: Particularly during London Fire Brigade’s emergency medical response trial, there seemed to be a great deal of confusion in the public arena about the fire fighters additional role and the program itself. I believe it’s important that prior to the implementation of any firefighter emergency medical response model, a comprehensive public media campaign be run to educate the public on the new program to remove confusion during response.
Recommendation 6– London Fire Brigade’s Emergency Medical Response trial encountered several hurdles across the trial period. By having this trial and fluid approach, these issues were able to be rectified during the trial period to finish the trial with a well-rounded efficient and effective service. I believe it is imperative that if a formalised firefighter medical program is to be implemented, a comprehensive (1-2 years) trial be undertaken at identified service delivery locations.
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Recommendation 7 – The importance of firefighter mental health and burnout, particularly in fully integrated Fire/EMS departments, was the single most common theme spoken about with the responders. They were all in agreeance that to maintain a safe and enjoyable work environment, any EMR program to be an “Opt In-Opt Out” program for all responders.
Recommendation 8- As mentioned in the previous recommendation, firefighter welfare was paramount for both managers, supervisors and firefighters themselves. Although it appears that a combination EAP/CISM welfare support was consistent and deemed suffice across all destinations visited, I believe before the instigation of any firefighter first responder program, mental health first aid training for all responders and managers should be undertaken. Compulsory initial psychological assessments (benchmarking), as well as at regular intervals should also be considered. This recommendation is due to, in part, the common thread that although formal welfare programs were available to every responder, they were rarely used and that firefighters felt the best way to debrief or identify issues with themselves or their colleagues was done more informally around the workplace.
Recommendation 9 – During visits to fully integrated Fire based EMS agencies, it was clearly apparent both by interview and witnessing the working relationships at operational incidents that the benefits of having dual trained firefighter paramedics was extremely beneficial. It was also apparent that most firefighters who worked in departments who held a lesser firefighter-EMT role were passionate about developing their knowledge and skills beyond the EMT level to value-add to their role and the department, as well as provide more advanced assistance at medical related call-outs. To that end, it seems important to harness the passion of these types of people and fire agencies who take-on a formalised emergency medical response should facilitate and encourage responders to train to whatever standard (above minimum) they wish. E.g.- a firefighter wishing to train to paramedic level.
Recommendation 10– Although most facets of fully-integrated ambulance and fire service and Fire-Based EMS appears to be “world’s best practice”, due to cultural and governance hurdles, it is unlikely this will be adopted in Australia. If a move is made towards having firefighters respond to emergency medical incidents in the community and to be able to harness some of the benefits of this type of service without full integration, I believe it is important that a system be put in place to facilitate firefighters who wish to conduct ’ride-alongs’ with paramedic crews. To either actively assist, or as an observer to gain experience.
Recommendation 11: Outside operational response, major efficiencies were witnessed in seamless call taking and dispatching of crews within fully-integrated fire agencies. On the opposite end of the spectrum, London Fire Brigade saw unacceptable delays both call taking and dispatching crews due to ambulance and fire services who work independently of each other. I believe it’s vitally important that if firefighter emergency medical response is adopted, the integration of a state’s ambulance and fire communication facility and operations (including cross training staff) should be considered. In smaller states, further fire and ambulance Service integration to some level should also be considered . This should be looked at in areas with pre-existing arrangements where ambulance and fire already share infrastructure.
