Fire department emergency ambulance services struggle with EMS staffing, ambulance workload, and response time. I revisit two cities where I did a deep dive long ago and consider why their wicked problems have returned.

What is a “Wicked Problem”?

The term “Wicked Problem” was introduced in 1973 by Horst Ritter and Melvin Webber in describing the challenge of addressing planning and social policy problems. Wicked problems of planning lack clarity in both their aims and solutions. Unlike the “clean sheet of paper” approach, wicked problems are subject to real-world constraints that prevent multiple risk-free attempts at solving them.

Rittel, H. W., & Webber, M. M. (1973). “Dilemmas in a General Theory of Planning.” Policy Sciences, 4(2), 155-169.

A Tale of Two Fire Department Ambulance Services

While an Assistant Professor of Emergency Medicine, I did a deep dive into Baltimore and Los Angeles City as they took different approaches to resolve the problems of staffing, ambulance workload and response time in 1999. Both departments use the same time-on-task measurements, and I had access to their data.

Baltimore: Underutilized Fire Companies and Overworked Ambulances

In 1999 Baltimore Mayor O’Malley asked the Greater Baltimore Committee and The President’s Roundtable to examine fire department operations. Using time-on-task analysis:

Baltimore engine companies averaged 1 hour 47 minutes in 24 hours working on incidents, while paramedic ambulances averaged 14 hours and 25 minutes in 24 hours on incidents. Over the past five years, structural fires declined 58% to 2,367 working fires in 1999. Half of the engine company responses (49,000) were to EMS calls. (1)

Baltimore staffed 40 engine companies, 21 truck companies, one rescue company, and 18 paramedic ambulances. Engine company average response time was 4:16 minutes, and paramedic ambulance response time was 8:44 minutes.

On May 10, 2000, the city started the process to close seven fire companies. Of the 140 firefighter positions affected, 100 will be moved to other fire companies to save $4 to $5 million in overtime, and 40 will staff 4 to 6 additional ambulances. After lengthy labor and legal negotiations – interrupted by a July 2001 chemical train fire in a tunnel that closed downtown for three days – the 2005 Baltimore Fire Department was comprised of:

• 32 Engine Companies – closed 4 companies and upgraded 4 companies
• 4 Squad Companies – engine companies upgraded to “rescue engines”
• 19 Truck Companies – closed 2 companies
• 22 Paramedic Ambulances – added 4 ambulances
• 1 Rescue Company
• 6 Battalion Chiefs – lost 1 battalion

The average time-on-task for all 22 Baltimore paramedic ambulances in 2005 was 14:40 hours:minutes in 24 hours, a system-wide Unit Hour Utilization of 0.61.

2021: Operational & Management Assessment by FACETS Consulting

Baltimore City engaged FACETS Consulting to perform a detailed fire department operations and management analysis. Their assessment showed an average ambulance response time of 8 minutes 31 seconds, with a 90th percentile of 13 minutes 56 seconds using 21 paramedic ambulances staffed 24/7. Paramedic ambulances are spending 14 hours and 54 minutes every 24 hours responding to, on-scene, transporting, and awaiting patient transfer to the emergency department. Engine company workload has increased to 3 hours and 36 minutes every 24 hours. Truck company workload has slightly decreased.

The workload among BCFD unit types is highest for the ALS and BLS ambulances (ranging from 39.27 percent to 71.07 percent). These numbers are exceptionally high, especially for caregivers working a 24-hour shift. 

Even the least busy ambulance exceeds the workload percentage recognized by many agencies for 24-hour shift durations by almost 10 percent. 

This level of workload can result in substantial employee wellness issues, does not provide on-duty time for essential training, and also leads to extended response times at the current level of resource deployment. Moreover, fatigue can negatively affect patient care and decision-making at incidents. (2)

Time-on-task for individual Baltimore paramedic and EMT ambulances in 2018-2019 ranged from 9:26 hours: a UHU of 0.39 to 17:03 hours:minutes – a UHU of 0.71. The caregiver on Ambulance 24 provided an over-the-radio perspective last September.

Los Angeles: Losing Paramedics Faster Than They Could Train New Ones

There needed to be more single-role Los Angeles Fire Department paramedics in 1999. Fourteen percent of the 435 authorized positions were vacant. A single-role paramedic made significantly more money than the fire chief, working five or more consecutive 24-hour shifts weekly. At that time, Los Angeles City lost paramedics quicker than they could hire replacements. (3)

One reason was the “force hire” that ordered paramedics back to work during their scheduled time off. In 1999 there were 60 unfilled LAFD single-role paramedic positions. If you wanted to make sure that you could get off to take a vacation, celebrate a holiday, or attend a family event, you needed to work 96 hours of voluntary “assigned hire” overtime in the previous month. (4)

Bad-outcome EMS calls highlighted in San Fernando Valley Secession Effort

LAFD established six rescue ambulances in the San Fernando Valley in 1957 to replace a private ambulance service in the 210-square-mile district. By 1968 eight LAFD rescue ambulances were handling 14,000 responses a year. (5 and 5a)

One of the 1957 GMC Suburban rescue ambulances assigned by LAFD to the San Fernando Valley. Restored by Lou Farah.

San Fernando Valley homeowners and businesses tried to secede from Los Angeles in the late 1990s. This effort by Valley VOTE was driven, in part, by a perception that San Fernando Valley tax payments were not used to provide city services in the valley. (6) Rescue ambulance average response time had increased to ten minutes, with over one-third of the rescue ambulances exceeding the department guideline of 350 responses a month. (7)  

The Valley VOTE campaign used high-profile, bad-outcome EMS incidents as examples of inadequate city services. While the secession vote was defeated, it was a driver of a significant five-year expansion of the Los Angeles Fire Department rescue ambulance and paramedic services.

EMS Resource Deployment Plan 2001-2006

By 2005 LAFD added 210 single-role paramedic positions, placed a paramedic in every fire station (on a rescue ambulance or a suppression company), and put a rescue ambulance in every fire station. The rescue ambulance fleet increased by 39% – 88 paramedic and 40 EMT ambulances.

Rescue ambulance workload is under 6 hours (responding to, at the scene, transporting, and delivering a patient to the hospital) in 24 hours. Paramedic Rescue Ambulance average response time is reduced to 6.5 minutes. The average Unit Hour Utilization for all 128 LAFD rescue ambulances in 2006 was 0.25.

2023: 15-Minute Wait for LAFD Rescue Ambulance to Arrive at a Cardiac Arrest

Michael Davis’s wife called 9-1-1 after he collapsed. It took about 15 minutes for an LAFD rescue ambulance to arrive. It is unclear in the Fox 11 news article if there was a fire company first responder. The three-month Fox 11 investigation uses anonymous paramedic sources that paint a picture of 10 to 20-minute rescue ambulance response times. (9)

The Ten Characteristics of a Wicked Problem

Rittel and Webber describe 10 important characteristics of a wicked problem:

1. They do not have a definitive formulation
2. They do not have a “stopping rule.” In other words, these problems lack an inherent logic that signals when they are solved.
3. Their solutions are not true or false, only good or bad
4. There is no way to test the solution to a wicked problem
5. The cannot be studied through trial and error. The solutions are irreversible so, “every trial counts.”
6. There is no end to the number of solutions or approaches to a wicked problem
7. All wicked problems are essentially unique
8. Wicked problems can always be described as a symptom of other problems
9. The way a wicked problem is described determines its possible solutions
10. Planners, that is those who present solutions to these problems, have no right to be wrong. Unlike mathematicians, “planners are liable for the consequences of the solutions they generate; the effects can matter a great deal to the people who are touched by those actions.”(10)

Fire-based EMS issues are challenging to solve because they involve complex, interconnected situations involving healthcare organizations and community populations. The environment of out-of-hospital unscheduled emergency medicine is constantly changing:

• New clinical best practices – including transport of 9-1-1 patients to specialty care centers (trauma, stroke, STEMI)
• Revenue or compensation opportunities
• Documentation requirements
• Emerging health issues
• Deteriorating hospital capabilities – increased “wall time” at emergency departments when delivering a patient
• Shrinking healthcare staff at nursing homes and assisted living facilities that generate more 9-1-1 calls
• Community population demographics

These problems often require creative solutions involving multiple stakeholders. Identifying the root causes and developing effective strategies to address them is difficult. Local government often lacks the resources or capacity to address these issues quickly or adequately.

Baltimore and Los Angeles invested financial and political capital in resolving the 1999 EMS crisis based on their resources, history, communities, and traditions. By 2005, they felt they had resolved the problems identified in 1999. Eighteen years later both cities are back in the news with staffing, workload, and response time issues.

Baltimore: Four Decades of Incremental Fire Suppression Reductions

Baltimore mayors have incrementally reduced fire suppression resources since 1984. Five quints were established in 1986 by combining an engine company crew and truck company crew of eight firefighters into a six-firefighter Aerial Tower company. Quint staffing was reduced until the unit was a 4-person truck company or eliminated. Fire stations have closed, and fire companies disbanded. (11)

Mayor Schmoke’s 1991 closing of three fire stations is a Harvard case study at the Kennedy School of Government. Case #1130.0 How to Bite the Bullet: Baltimore Mayor Kurt L. Schmoke and Fire Station Closings.

The 2005 final product from the Greater Baltimore Committee/The President’s Roundtable recommendations reduced fire suppression overtime costs. The four additional paramedic ambulances did not reduce the systemwide transport workload or improve ambulance response times as the EMS workload continued to increase yearly.

In 2012 Truck 15, Squad 11, and Truck 10 were shut down. In 2020 an effort was made to close Engine 4 (northeast Baltimore) and Engine 55 (Pigtown) to reduce the fire department Fiscal Year 2021 budget by $3.6M. Organized community effort delayed the closures pending the result of the FACETS report.

Los Angeles: Well-Funded EMS Expansion until the 2008 Recession

Los Angeles enjoyed political support and budget resources to expand the city’s emergency ambulance and paramedic services. A second five-year plan was issued covering activities through 2012. (12) The 2008 Recession halted the second five-year plan.

After three years of rotating closures of 15 engine companies and six ambulances, the 2012 Fiscal Year budget permanently closed 11 engine companies, seven light forces (a truck company with a pumper), and four EMT ambulances. Thirty command staff positions were eliminated. The 17 variably-staffed ambulances were closed.

Between Fiscal Year 2006 and Fiscal Year 2012, there was a net reduction of 228 firefighters and paramedics on duty each day. This is about a 17% reduction in the LAFD workforce.

A $15.4M Staffing for Adequate Fire and Emergency Response (SAFER) grant in 2018 allowed the reopening of four engine companies.

March 9, 2023: Los Angeles Fire Chief asks for 300 additional positions (13)

On April 21, 2023, Engine 8, with a paramedic/firefighter, responded to a drowning call where they encountered twin 4-year olds in cardiac arrest. They arrived within four minutes of the 9-1-1 call. Fire Station 8 is one of the eight LAFD fire stations without a staffed ambulance. Rescue Ambulance 107 is the closest ambulance with a six minute response time, but it was handling another emergency. The firefighters were doing CPR for 14-15 minutes before the nearest available ambulances arrived. (13a)

Evaluating Issues Impacting the Wicked Problem of Fire-Based EMS Staffing, Ambulance Workload and Response Times

Dover Professional Firefighters Local 1312 (2023 Feb 12) “Ambulances 1, 2, and 3 stacked up at Wentworth-Douglass Hospital. Just another Sunday evening.” New Hampshire. Ambulance 3 was added on September 18, 2022.

In considering this wicked problem, lets look at three areas impacting any solution today: best clinical outcome for patient, best situation for the EMS caregivers, and best result for the fire department.

What Provides the Best Clinical Outcome for the Patient?

This question is more focused and nuanced than the old-school “What is Best For the Patient?” In the first 18 months of the Seattle Medic One program (March 1970 – August 1971) firefighter/paramedics resuscitated 111 clinically dead patients. (14) Today, success is measured by the number of resuscitated out-of-hospital cardiac arrests (OOHCA) discharged from the hospital without neurological deficiencies.

Establishing an 7 minute, 59 second response time for paramedic ambulances

Preliminary results from “Project Restart,” a three-year Robert Wood Johnson funded study looking at community cardiac mortality identified two OOHCA survival metrics and established the 7:59 minute paramedic response time.

Mickey Eisenberg’s group analyzed 604 CPR incidents in Seattle and King County from April 1976 to August 1977. At that time, there were four paramedic ambulances in the community. Two Seattle Fire Department ambulances at Harborview Medical Center, one at Bellview Fire Headquarters, and one at Evergreen Fire Department. In 1976 only paramedics could use defibrillators, administer IV medications, record a heart rhythm, and use an advanced airway.

Eisenberg’s group identified two OOHCA survival metrics: If CPR was initiated within four minutes and if definitive care was provided within ten minutes, 43% of patients survived. If either time was exceeded, the changes of survival fell dramatically. (15)

Refining the Clinical Outcome Question

As research continued into out-of-hospital cardiac arrest survival, a subset of patients were identified as most impacted by these efforts. Focus was on patients who suffered a cardiac arrest that was witnessed by someone else and showed ventricular fibrillation as the cardiac rhythm. Adoption of the 1991 Utstein Style guidelines on uniform reporting of cardiac arrest, updated in 2004, 2015, and 2019 are an effort to provide “apples to apples” comparison for out-of-hospital and in-hospital cardiac arrest final outcomes.

The Resuscitation Outcomes Consortium is a massive research effort started in 2004 that conducted experimental and observational studies of out-of-hospital cardiac arrest and trauma treatments at eleven regional centers. (16) The most significant clinical change is the impact of two minutes of continuous closed chest compression (CCCC) applied at 100-120 compressions a minute to a witnessed cardiac arrest patient in ventricular fibrillation. The number of patients experiencing a restoration of spontaneous circulation (ROSC) almost doubled when first responders provided CCCC as the first treatment, followed by defibrillation as the second treatment. (17 & 18)

In 2007 the U.S. Metropolitan Municipalities EMS Medical Directors, known as the “Eagles,” developed evidence-based performance measures to benchmark urban EMS systems. They used the Number Needed to Treat (NNT) metric. NNT is the number of patients you must treat to prevent another bad outcome (death, stroke, etc.).

The clinical situations benchmarked included:

• ST-elevation myocardial infarction (STEMI)
• Pulmonary edema
• Asthma
• Seizure
• Trauma
• Cardiac arrest

Four of the situations required out-of-hospital paramedic-level medical intervention. Trauma situations focused on minimal on-scene time with transport to a trauma center. Cardiac arrest focused on the arrival of CPR-trained providers and a defibrillator within five minutes. (19)

For cardiac arrest the Eagles proposed that EMS systems not focus response time measurement on ALS ambulances, but rather pay greater attention to first response/BLS response time to measure what it called the “… most important predictive elements for optimal outcome: time elapsed until initiation of basic chest compressions and time elapsed until defibrillation attempts.”

At the same time, I analyzed the out-of-hospital clinical tasks delivered by firefighter/paramedics in a large urban county. Using a year of patient care reports, I counted the number of times caregivers documented:

• Inserting an advanced airway, like an endotracheal tube or King LT
• Performing a chest decompression
• Administering a medication though an intravenous line, intermuscular injection, nebulized breathing treatment, or by mouth
• Infusing 500 or more milliliters of Lactated Ringer’s (the protocol for fluid resuscitation)
• Delivering a defibrillation or cardioversion

Six percent of the patients transported to an emergency department received one of those treatments. Within this group, one-fourth of the patients received two to more treatments, representing 1.5 percent of the patients transported. (20)

The majority of the patients transported did not receive paramedic-level care to improve clinical outcomes of serious medical conditions.

An updated survey of delivered out-of-hospital tasks will probably show a higher percentage of patients receiving paramedic-level care due to COVID complications, opioid overdoses, an aging population, and increased focus on stroke/ST-segment elevation myocardial infarction (STEMI) care. Using the percentage of transported patients getting paramedic-level care is a difficult metric to use when considering paramedic staffing, dispatch, and deployment.

Many fire departments identify critical EMS calls based on how the telecommunicator coded the incoming 9-1-1 call. Critical EMS calls are the “Echo” and “Delta” responses under the Medical Priority Dispatch System (MPDS). (21) This Pitt County video provides a reenactment of a “Delta” call,

The number of EMS calls coded as Echo or Delta is significantly higher than that of transported patients receiving paramedic-level care. The MPDS dispatches documents the fire department resource commitment to the incident before the first patient contact.

What care does the other 94% of transported patients receive?

Within the reports I reviewed, almost all patients had documented vital signs; some were splinted, some received wound care, some received a 12-lead EKG, and others had an intravenous line started without medication or fluid resuscitation. Many of the 94% transported needed to go to an emergency department, clinic, or physician’s office for further treatment.

What is the Best Situation for the EMS Caregivers?

Let’s look at three factors impacting EMS caregivers.

Excessive and exhausting work hours

Just before 5:20 a.m. Sunday, April 2, as BLS 16 responded to a call, it slammed into a power pole, a crosswalk sign, and a wall. The crew suffered minor injuries.

“Right now, we still have employees who are still dealing with sleep deprivation and knowing that this has been going on for over a year and didn’t come up with concrete solutions to solve it,” said Pritchard.

President Rex Pritchard, Long Beach Firefighters Association Local 372, said he and leaders of the International Association of Machinists Local 1930 have been urging the department to address what they say are extreme call volume and fatigue issues for over a year but haven’t seen any changes.

“What is very common in this department is to work 72-hour shifts,” said Pritchard. “You’re lucky if you get, in that 72 hours, four to six hours of rest. (22)

Phoenix firefighters interviewed by AZ Family discussed working “Stand Up 24’s” – a 24 hour shift with no rest periods. An increase in mandatory overtime means many firefighters and firefighter/paramedics are working “Stand Up 48’s”. (23)

Single-role paramedics treated like second-class fire department members

There is not much peer-review research on how fire service leaders influence the attitudes of firefighters as motivational predeterminate of performance and organizational outcomes. Perceived Organizational Support (POS) is a social exchange variable in which justice perceptions affect organizational commitment and job satisfaction. Huntsman’s group surveyed two metro-sized Western fire departments. The fire department members perceive justice in both procedures – such as promotions – and outcomes – such as pay rates. (24) I often hear EMS single-role caregivers complain that they are treated as second-class members within their fire department.

The pandemic identified unequal pay and working conditions for the single role EMS providers employed by the Fire Department of New York when compared to firefighters. Mayor De Blasio’s response “… EMS work is different.” was not well received.

Twenty five single role EMS caregivers filed a federal class-action lawsuit against the city and FDNY. The Equal Employment Opportunity Commission determined that:

… any difference in duties between the EMS first responders and firefighters fails to explain the pronounced gap in wages and benefits, and [the city has] failed to adjust the pay scales of EMS first responders to keep pace with the changes to their duties since the City merged EMS with the Fire Department in 1996. (25) We may learn a lot about “occupational separation.”

Moral injury and compassion fatigue

Moral injury was first used in 2009 to describe soldiers’ response to their actions in war. It represents “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” (26) Physicians adopted the concept when describing the frustration of being unable to provide high-quality care and healing in the context of front-line health care. (27)

Moral injury occurs for paramedics and firefighters when there is a gap between what they want to do and the conditions they are confronting. An example is the opioid epidemic, where caregivers resuscitate the same person a couple of times a year with no change in addictive behavior. Or the person with a behavioral health situation who will not benefit from transport to an emergency department but that is your only option.

In some communities, the number of on-duty firefighters has shrunk while the workload has increased. There are incidents where paramedics and firefighters face devastating human conditions that they cannot reverse or mitigate, creating a situation described by Litz as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”

Compassion fatigue (CF) is a secondary traumatic stress syndrome defined as a sudden or gradual loss of compassion from exposure to stress or stressful events. Colloquially, CF is referred to as the “cost of caring,” which describes the process by which compassion and empathy felt by a caregiver for their patient can devolve into a lack of compassion by the continuous exposure to traumatic situations that is both unhealthy for the caregiver and distorts reality, despite its protective notion. (28)

Examples of compassion fatigue include:

• Lack of compassion
• Frustration with the patient
• Rage response
• Gallows humor
• Somatization: “suppression of emotions and distancing strategies after exposure to intense emotional material, which can ultimately lower empathy and result in additional traumatization”

These are some factors that contribute to the suicide rate of caregivers (29) and the 26% voluntary turnover of active paramedics in 2022. (30)

What is Best Result For the Fire Department?

Fire departments have significant economies of scale when establishing a new emergency ambulance service. Existing fire stations, a two-way communication system that includes dispatch/deployment, vehicle maintenance capability, tiered command structure, and logistics. With all of those advantages, adding an emergency ambulance service is not revenue neutral. The insurance reimbursement system does not cover the actual cost of services. (31)

Changing community needs

Modern United States Emergency Medical Services started in 1966 with a combination of federal funding that was focused on reducing highway accident deaths and disabilities, medical research to improve the survival rate of out-of-hospital cardiac arrest, and President Johnson’s “Great Society” initiative that included the creation of the Freedom House Ambulance paramedics in Pittsburgh. (32 & 33)

Up to 80% of fire company responses are for EMS incidents. The opioid overdose crisis was overshadowed by the pandemic, but continues to outpace other accident-related morbidity and mortality situations, with more than 107,000 deaths in calendar year 2021. (34)

There has been a continuing increase in lift-assist calls from individuals and assisted living/nursing homes. It appears that some healthcare facilities are cost-shifting lift assistance from facility staff to EMS caregivers. They are calling 9-1-1 because the labor organizations representing security and maintenance workers removed patient handling as one of their job-related responsibilities. This was due to worker compensation claim denials and liability concerns. (35 & 36)

Advanced Practice Provider (APP)

The COVID 19 pandemic accelerated the expansion of emergency ambulance into other services. Los Angeles has added Advanced Provider Response Units (ARPU), staffed with a nurse practitioner or physician assistant teamed with a firefighter paramedic. The ARPU is capable of treating patients in place or navigating them to select alternate destinations, such as a mental health urgent care or a sobering center.

The initial APRU was deployed in South Los Angeles in 2016. It was able to safely treat or navigate 50% of patients away from the ED by performing on-scene, simple procedures that lie just beyond the traditional paramedic’s scope of practice, including applying clinical decision rules, performing uncomplicated laceration repair, providing culturally sensitive health teaching and promotion, connecting patients with social workers, and helping patients and their families navigate to ongoing in-network care. (37)

Street Crisis Response Team

An alternative to police or EMS response to behavioral health issues is the San Francisco Street Crisis Response Team (SCRT). SCRT is staffed with a fire department community paramedic, a behavioral health clinician from HealthRIGHT360, and a peer specialist with lived experience from RAMS, Inc. (Richmond Area Multi-Services) who have a range of specialist skills to engage on the scene with a person in crisis.

The first six months of the program showed that 9% of the SCRT encounters have ended in a 5150, an involuntary mental health hold for those who are a danger to themselves or others. 18% were transported to a hospital and 18% to a program such as residential care or drug treatment. (38)

With six teams launched, SCRT is now diverting over half (58%) of calls monthly for “mentally disturbed persons” from law enforcement. In the first year the SCRT responded to over 5,000 calls related to people suffering mental health and substance abuse issues on city streets. (39)

Los Angeles Skid Row – a Challenging Community of Addiction and Unsheltered Homeless

The out-of-hospital emergency medical services environment in 2023 is tremendously more complex than Baltimore and Los Angeles handled in 1999. A dramatic example is what LAFD encounters in the Skid Row community. Public Broadcasting Service (PBS) spent a day with the firefighters at Los Angeles Fire Station 9 in 2019. This 27-minute documentary was shown on SoCal Connected on February 18, 2020. https://www.pbs.org/video/fire-station-9-9syxup/

Footnotes

(1) staff (2000 May 24) The debate: city fire coverage. The Baltimore Sun. Accessed March 5, 2023 https://www.baltimoresun.com/news/bs-xpm-2000-05-24-0005240127-story.html

(2) Operational & Management Assessment: Baltimore City Fire Department – Final Report. (2021 November). FACETS Consulting LLP. https://fire.baltimorecity.gov/baltimore-city-fire-department-facets-report

(3) Fox, S. (1999 Dec 26). Proposal Targets Paramedic Shortage. Los Angeles Times. Los Angeles, CA. Accessed March 5, 2023 https://www.latimes.com/archives/la-xpm-1999-dec-26-me-47674-story.html

(4) Williams, E. (2007 Aug 29) Paramedic Coded Assign Hire to End Sept 9. Battalion 14 News & Information (dormant rss feed).

(5) Ditzel, P. (1965) Dial 0 for Rescue. The Firemen’s Grapevine.

(5a) Hisserich, J. C. (2020 July 1) How the Los Angeles Fire Department Became the City’s Ambulance Provider. Los Angeles Fire Department Historical Society

(6) Faught, J. (2006). “Breaking Up is Hard to Do: Explaining the 2002 San Fernando Secession Vote.” Journal of Urban Affairs 28(4): 375 – 398.

(7) Wells, W (2004 February 1) “Los Angeles Fire Department Implements EMS Resource Plan.” Firehouse.com Accessed Mar 5, 2023 https://www.firehouse.com/home/news/10526932/los-angeles-fire-department-implements-ems-resource-plan

(8) Bamattre, W. R. (2006 June 12). EMS Resource Deployment Plan Update, Los Angeles Fire Department.

(9) Silva, G. (2023 February 12) ” ‘It happens every day’: LAFD paramedics say 911 response times continue to rise. Fox 11 News, Accessed March 5, 2023 https://www.foxla.com/news/lafd-paramedics-say-911-response-times-continue-to-rise.

(10) “What’s a Wicked Problem?” Stony Brook University. accessed February 25, 2023 https://www.stonybrook.edu/commcms/wicked-problem/about/What-is-a-wicked-problem

(11) Baltimore Fire Officers IAFF Local 964 (2023 April 19) “On this date in 1986, Aerial Tower 111 was placed in service. Engine Co No 1 and Truck Co No 11 were disbanded and combined to place the tower in service, at their station at 401 W. North Avenue. The unit ran as both an engine and a truck company on fire boxes, and was staffed with 6 personnel. The tower lasted a little over 10 years, being disbanded on 4/9/1997, and the firehouse closed.” FaceBook https://www.facebook.com/BFO964/posts/693953376068826

(12) LAFD (2008). Five-Year Emergency Medical Services (EMS) Plan 2007-2012, Los Angeles Fire Department.

(13) ABC 7 (2023 March 7) Fire Chief Crowley and Mayor Bass Discuss State of the LAFD. https://youtu.be/NOvvSgigols

(13a) Silva, G. (2023 May 1) LA’s ambulance shortage impacting city’s public safety, paramedic says. Fox 11 News. Accessed May 6, 2023 https://www.foxla.com/news/las-ambulance-shortage-impacting-citys-public-safety-paramedic-says

(14) “50th Anniversary” in Seattle Fire Department 2020 Annual Report. City of Seattle. p. 26.

(15) Eisenberg, M., Bergner, L., & Hallstrom, A. (1979). Paramedic Programs and Out-of-Hospital Cardiac Arrest: I. Factors Associated with Successful Resuscitation. American Journal of Public Health, 69(1), 30 – 38. 

(16) Zive, D.M.; Schmicker, R.; et al. (2018) Survival and variability over time from out of hospital cardiac arrest across large geographically diverse communities participating in the Resuscitation Outcomes Consortium, Resuscitation. 131:74-82

(17) Brown SP, Wang H, et al. (2015) A randomized trial of continuous versus interrupted chest compressions in out-of-hospital cardiac arrest: rationale for and design of the Resuscitation Outcomes Consortium Continuous Chest Compressions Trial. Am Heart J;169:334-341.e5

(18) Nichol, G., Leroux, B., et al. (2015) Trial of continuous or interrupted chest compressions during CPR N Engl J Med, 373 (23), pp. 2203-2214

(19) Myers, J. B., Eckstein, M. et al. (2008). “Evidence-Based Performance Measures for Emergency Medical Services Systems: A Model for Expanded EMS Benchmarking.” Prehospital Emergency Care 12(2): 141-151.

(20) Unpublished 2006 data from an internal study.

(21) Pennino, J. A., III. (2021). The expanded implementation of the medical priority dispatch system (MPDS) in Pinellas County: A public value perspective [Doctoral dissertation, Valdosta State University]. In Dissertation Abstracts International: Section B: The Sciences and Engineering (Vol. 82, Issue 1–B).

(22) staff (4 April 2023) Long Beach unions say ambulance crash highlights staffing shortage. KCAL CBS. Accessed April 6, 2023 https://www.cbsnews.com/losangeles/news/long-beach-unions-say-ambulance-crash-highlights-staffing-shortage/

(23) staff (31 January 2023) Phoenix Fire Department in Staffing Crisis. AZ Family. Accessed 8 April 2023 https://youtu.be/qulxrnOtNO8

(24) Huntsman, D., Greer, A., & Murphy, H. (2020) Leveraging Justice: How Leaders Influence Performance Determinants in the Fire Service. Risk, Hazards & Crisis in Public Policy. 11(3) 270 – 295. doi: 10.1002/rhc3.12188

(25) Freeman, D. (2023 January 10) EMS unions sue city, FDNY alleging pay discrimination: Suit concerns effects of ‘occupational separation’. The Chief Leader. Accessed January 22, 2023 https://www.thechiefleader.com/stories/ems-unions-sue-city-fdny-alleging-pay-discrimination,49591

(26) Litz, B. T., Stein, N. et. al (2009). “Moral injury and moral repair in war veterans: A preliminary model and intervention strategy.” Clinical Psychology Review 29(8): 695-706.

(27) Talbot, S. G. and Dean,W. (2018) “Physicians aren’t ‘burning out.’ They’re suffering from moral injury.” STAT.

(28) Renkiewicz, G. K., & Hubble, M. W. (2021). Secondary Traumatic Stress in Emergency Services Systems (STRESS) Project: Quantifying and Predicting Compassion Fatigue in Emergency Medical Services Personnel. Prehospital Emergency Care. https://doi.org/10.1080/10903127.2021.1943578 

(29) Vigil, N. H., Grant, A. R., et. al (2018). Death by Suicide—The EMS Profession Compared to the General Public. PreHospital Emergency Care, 23(3), 340-345. https://doi.org/10.1080/10903127.2018.1514090 

(30) Doverspike, D. (2023) 2022 EMS Employee Turnover Study. American Ambulance Association and OnShift Inc-Avesta Systems Inc.

(31) Finance Committee. (2016 ). EMS Funding and Reimbursement: FINAL. National EMS Advisory Council. Washington, DC: U.S. Department of Transportation 

(32) Shah M. N. (2006). The formation of the emergency medical services system. American Journal of Public Health, 96(3), 414-23

(33) Edwards, M.L. (2019) Pittsburgh’s Freedom House Ambulance Service: The Origins of Emergency Medical Services and the Politics of Race and Health. Journal of the History of Medicine and Allied Sciences 74 (4) 440-466. dot: 10.1093/jhas/jrz041

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