This concept is used when discussing risk management, healthcare, and engineering. It is also a component in designing better systems under the Just Culture model. Reason points out that failure is an inevitable result of human systems—we are all fallible. Countermeasures are based on the idea that “we cannot change the human condition, but we can change the conditions under which humans work.” So, failure is seen as a system issue, not a person issue.

High-reliability organizations take this approach to failure awareness:

• Analyze every event, no matter how small, to implement system-wide changes
• Encourage and reward error reporting
• View near-misses as opportunities for improvement rather than proof of success
• Continuously learn from defects and develop failure-free processes

Two years before wildfires incineratedswaths of Los Angeles, the city’s fire chief, Kristin M. Crowley, identified “one significant area of weakness” in her department’s ability to contain wildfires. L.A. had no specialized wildland unit to respond to daily brush fires and scrape vegetation, dig ditches and do the other labor to ensure blazes did not spread or rekindle, she wrote on Jan. 5, 2023, asking for $7 million to assemble its own squad.

In a memo that has not been previously reported, she told city fire commissioners that L.A. relied almost entirely on overburdened “hand crews” from other jurisdictions to bring such muscle to its brush fire emergencies. Hand crews, the most elite of which are sometimes called “hotshots,” fight wildfires with chain saws, axes and shovels, setting containment lines and then sticking around to meticulously monitor smoldering fires, feeling by hand for heat and digging out live spots to make sure fires don’t relight.

High-reliability organizations resist oversimplification of explanations for successes and failures:

• Constantly question “why” and invite diverse opinions
• Avoid simplistic explanations for failures
• Recognize the complexity of their work and its potential to fail in unexpected ways

Forget “wildland-urban interface”

When catastrophic fires occur, experts often blame the so-called wildland-urban interface, the vulnerable region on the perimeter of cities and suburbs where an abundance of vegetation in rugged terrain is susceptible to burning.

Yet the fire disasters that we’re seeing today are less wildland fires than urban fires, wildfire expert Jack Cohen said. Shifting this understanding could lead to more effective prevention strategies.

“The assumption is continually made that it’s the big flames” that cause widespread community destruction, he said, “and yet the wildfire actually only initiates community ignitions largely with lofted burning embers.”

The belief was that urban fires no longer exist, but they’ve come back. “It’s like watching polio return,” he said. “It’s happening repeatedly.”

While the Bel-Air fire in 1961, which destroyed 484 homes, and the Mandeville Canyon fire in 1978, which destroyed 230 homes, are often cited for the scale of their destruction, the 1991 Tunnel fire in the Oakland and Berkeley Hills marked the start of the modern era of urban fires, destroying 2,843 homes.

More recently, fires devastated Gatlinburg, Tenn., in 2016, the towns of Superior and Louisville in Colorado in 2021 and Lahaina, Hawaii, two years ago.(Curwen)

High-reliability organizations maintain high awareness of the state of their systems and processes:

• Focus on preserving constant awareness by leaders and staff of factors affecting the mission
• Proactively identify and prevent defects and harm
• Use real-time data and insights to prompt action, learning, and outcomes

Officials said that the Santa Ynez Reservoir had been closed since about February for repairs to its cover, leaving a 117-million-gallon water storage complex empty in the heart of the Palisades for nearly a year. (Hamilton)

High-reliability organizations cultivate resilience by:

• Prioritizing safety over other performance pressures
• Developing the ability to assess and respond to unexpected situations quickly
• Continuously learning from both successes and failures
• Investing in emergency training for unlikely but possible system failures

Thirteen years ago, Los Angeles Fire Department officials were bracing for the kind of dangerous winds that could drive flames across hillsides and canyons and tear through neighborhoods from Malibu to the Pacific Palisades to the San Fernando Valley.

The National Weather Service had issued red flag warnings of doomsday gusts as fierce as 90 mph.  LAFD commanders ordered up at least 40 extra fire engines for stations closest to the areas where the fire hazards were greatest, including the Palisades, The Times has learned through interviews and internal department records.

Among the additional rigs were more than 20 that were pre-deployed to those stations and 18 “ready reserve” engines that supplement the regular firefighting force in such emergencies, the records and interviews show.

“We could not take any chances on this, because the risk was too great,” said former LAFD Assistant Chief Patrick Butler, now chief of the Redondo Beach Fire Department, who led the agency’s preparations in 2011. (Tchekemedyian & Pringle) (Image is from staging for a 2010 brush fire – Mike Meadows)

High-reliability organizations value insights from those with the most pertinent knowledge, regardless of hierarchy:

• Empower frontline staff to make critical decisions
• Recognize that those closest to the work often have the greatest situational knowledge
• Ensure leaders know who possesses specialized expertise within the organization

Davis, Aaron C.; Boburg, Shawn; Sacks, Brianna; Hennessey-Fiske, Molly: & Lee, Joyce Sohyun. (2025 January 18) A key ‘weakness’ in L.A.’s wildfire strategy went unaddressed for years, Post probe shows. The Washington Post. https://www.washingtonpost.com/weather/2025/01/18/2023-memo-la-fire-chief-warned-significant-gap-wildfire-defense/

Curwen, Thomas (2025 Jan 11) Inconvenient truths about the fires burning in Los Angeles from two fire experts. Los Angeles Times. https://www.latimes.com/california/story/2025-01-11/fire-experts-asses-los-angeles-blazes-amid-changing-times

Hamilton, Mark. (2025 January 10) State to probe why Pacific Palisades reservoir was offline, empty when firestorm exploded. Los Angeles Times. https://www.latimes.com/california/story/2025-01-10/as-flames-raged-in-palisades-a-key-reservoir-nearby-was-offline

Tchekemedyian, Alene & Pringle, Paul. (2025 January 18) Amid dangerous winds in 2011, LAFD engines stood ready. That didn’t happen this time. Los Angeles Times. https://www.latimes.com/california/story/2025-01-18/amid-dangerous-winds-in-2011-lafd-engines-stood-ready-in-the-palisades-that-didnt-happen-this-time

Catastrophic reform drive changes to the fire prevention code: public assembly exits and interior finishes after the 1942 Cocoanut Grove nightclub fire in Boston, smoke/heat control through compartmentalization/fire doors and automatic detection in schools after the 1958 Our Lady of the Angels school fire in Chicago, sprinklers required in highrise buildings after the 1980 MGM Grand fire in Las Vegas, and pyrotechnics restrictions, interior finishes and exit signage after the 2003 Station Nightclub fire in Providence, Rhode Island.

The window of opportunity for reform is influenced by:

• Discrediting existing institutions and elites
• Weakening opposition to change
• Creating urgent pressure for solutions
• Shifting public expectations and demands
• Making previously “impossible” options seem necessary

Los Angeles fire operations are no strangers to catastrophic reform. Fire Chief Keith Klinger went to the Los Angeles County Board of Supervisors to report during the 1961 Bel Air-Brentwood wildfire. When the supervisors asked what should be done in the future, Chief Klinger immediately provided a comprehensive plan. Most plan elements had been proposed before and rejected by the board. Approvals were made at the height of the Bel Air incident.

In the early 2000s, residents and business owners in the San Fernando Valley felt that their city taxes were going downtown and not providing service to the valley. ValleyVOTE was an effort to secede from Los Angeles City. Inadequate rescue ambulance service was one of the issues, and some high-profile bad outcomes occurred.

Mayor James Hahn directed Fire Chief William Bamattre to “fix it.” This multi-year response increased the rescue ambulance fleet by 40% and put a paramedic asset (single-role paramedic or paramedic/firefighter) in every fire station.

… MAY BE A FIRE EQUIVALENT TO A CATEGORY 5 HURRICANE

That’s Stephen Pyne’s assessment. In 2019, fire historian Stephen Pyne and wildfire expert Jack Cohen spent three days touring Pacific Palisades and participating in the NFPA’s “Assessing Structure Ignition Potential from Wildfire” training with LAFD’s Defensible Space Program members and homeowners.  

Cohen makes these observations of the 2025 fire:

When you study the destruction in Pacific Palisades and Altadena, note what didn’t burn — unconsumed tree canopies adjacent to totally destroyed homes. The sequence of destruction is commonly assumed to occur in some kind of organized spreading flame front — a tsunami of super-heated gases — but it doesn’t happen that way.

In high-density development, scattered burning homes spread to their neighbors and so on. Ignitions downwind and across streets are typically from showers of burning embers from burning structures.

This fundamental misunderstanding has likewise led to a misunderstanding of prevention. No longer is it a matter of preventing wildfires but instead preventing points of ignition within communities by employing “home-hardening” strategies — proper landscaping, fire-resistant siding — and enjoining neighbors in collective efforts such as brush clearing. (Curwen 2025)

Will the replacement homes look like this house that used wildfire home hardening techniques and survived the Palisades fire?

HOW LARGE OF A FIREFIGHTER STANDING ARMY CAN THE COMMUNITY AFFORD?

When the National Weather Service issued its “Life-Threatening & Destructive Windstorm” alert on Monday, LAFD called in 90 additional firefighters to staff units and predeployed nine fire companies to vulnerable areas. Los Angeles County moved 30 extra engine companies into the area with 100 overtime firefighters. The U.S. Forest Service moved resources closer. It is the pre-planned response for a “Red Flag” alert. (Fuller, et al. 2025)

The Tuesday Santa Ana wind gusts of 85 to 100 miles an hour grounded firefighting airplanes and helicopters. The Palisades fire started at 10:35 am. Strike teams from Ventura and Orange Counties were mobilized. The high winds accelerated the fire spread in the high-density community described by Cohen as “… scattered burning homes spread to their neighbors and so on. Ignitions downwind and across streets are typically from showers of burning embers from burning structures.”

Many residents were forced to flee their homes. The fire was spreading faster than the traffic, resulting in cars abandoned on gridlocked roads – most without keys. The fire department used a dozer to clear the road for responding fire companies.

While all hands were engaged at the Palisades fire, a second major fire started in Eaton Canyon in the Altadena community at 6:18 pm.

Around 9 pm Los Angeles County Fire Chief Anthony Marrone called the California Office of Emergency Services and requested 50 strike teams: 250 engine companies staffed with 1,000 firefighters

At 9:26 pm. LAFD was calling back all available staff to fire stations and the maintenance shop.

By midnight, crews were losing water pressure from the hydrants. The water system was not designed to deliver 400% of its rated capacity. The power shutdown also affected the water pumps supplying Altadena.

By Sunday night, there were over 15,000 personnel, 2.500 California National Guard troops, 1,390 fire engines, 80 aircraft, 160 water tenders, and 170 dozers.

THE COST OF PREPARATiON

Redondo Beach Fire Chief Patrick Butler, a retired LAFD assistant chief, explained the issue of red-flag alert predeployments. It is expensive to call back staff and put additional units in service. Chief Butler points out that he was in 30 large-scale predeployments, with just three of those deployments handling significant work. From Chief Butler’s perspective, it is worth the cost.

What levels of firefighter staffing does the community want to pay for?

In July 2023, the National Institute of Standards and Technology released a case study of the 2018 Camp Fire in Butte County. At that time, the Camp Fire was the most deadly and destructive California wildland fire, killing 85, destroying 18,00 structures, and triggering the evacuation of 40,000 people.

As Los Angeles rebuilds, what type of community engineering (roads, building codes, landscaping, and fire breaks) and brush fire abatement will they implement to reduce the fire spread risk and the cost of fire department preparation?

_____________________________________________________

Curwen, Thomas (2025 January 11) Inconvenient truths about the fires burning in Los Angeles from two fire experts. Los Angeles Times. Accessed Jan 12, 2025 https://www.latimes.com/california/story/2025-01-11/fire-experts-asses-los-angeles-blazes-amid-changing-times

Fuller, Thomas; Berzon, Alexandra; Browning, Kellen; and Hubler, Shawn (2025 Jan 11) L.A. Was Prepared for Serious Fires. But It Wasn’t Ready for Four. The New York Times. Accessed Jan 12, 2025. https://www.nytimes.com/2025/01/11/us/los-angeles-calfire-firefighters.html

Maranghides, Alexander; Link, Eric D.; Mell. William “Ruddy,”; Hawks, Steven, Brown, Chrisopher; and Walton, William D, (2023 July) NIST Technical Note 2252: A Case Study of the Camp Fire: Notification, Evacuation, Traffic, and Temporary Refuge Areas. Gaithersburg, MD: National Institutes of Standards and Technology. https://doi.org/10.6028/NIST.TN.2252

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

(34) Advocacy Resource Center (2022 December 22) Issue Brief: Nation’s drug-related overdose and death epidemic continues to worsen. American Medical Association

(35) Thomas, L. & Biantoro, C. (2021 March) A Review of Fire First Responder Responses to Lift Assist and Traumatic Fall Incidents: Analysis on City of Surrey Medical Incident Response. Surrey, British Columbia: City of Surrey Fire Services

(36) Ward, M. (2020 January 20) Looking at Fire-EMS Lift-Assists: Aging Community, Troubling Health Trends and Healthcare Cost Shifting. Reston, VA: CompanyCommander.com Accessed April 11, 2023 https://companycommander.com/2020/01/20/looking-at-fire-ems-lift-assists-aging-community-troubling-health-trends-and-healthcare-cost-shifting/

(37) Sanko, S., & Eckstein, M. (2021). Mobile Integrated Health Care in Los Angeles: Upstream Solutions to Mitigate the Covid-19Pandemic. NEJM Catalyst: Innovations in Care Delivery 2021, 2(2). https://doi.org/https://doi.org/10.1056/CAT.20.0383 

(38) Thadani, T., & Cassidy, M (21 May 2022) S.F. finally has a new mental health team to respond to homeless people in distress. Is it helping? San Francisco Chronicle. Accessed 10 April 2023 https://www.sfchronicle.com/local/article/s-f-s-new-street-crisis-team-is-helping-people-16180437.php

(39) Office of the Mayor (2021 November 30) San Francisco Celebrates One-Year Anniversary of Street Crisis Response Team. Accessed April 10, 2023 https://sfmayor.org/article/san-francisco-celebrates-one-year-anniversary-street-crisis-response-team

“IT IS CHEAPER TO PAY OVERTIME THAN CREATE MORE POSITIONS”

There has been a long dance over what staffing a fire department needs to meet its operational requirements. Jurisdictions are resistant to creating new full-time positions, as they require 137% funding to cover salary, worker compensation, annual/sick leave, training, personal protective gear, and other human resource expenditures.

From my professional experience, the jurisdictional administrators and elected leaders struggle with the concept of having a workforce where there are more full-time equivalents (FTEs) on duty than the minimum required seats to fill.

As Steven Knight points out:

Using my old department as an example, the staffing was determined on a legacy basis and that legacy pre-dated most, if not all, of the institutional knowledge. For example, the department staffed five personnel for every seat on an engine, four for every seat on a truck company, and two for every seat on a rescue. While the daily minimum staffing was consistently applied, it had to overcome the inconsistency in staffing for each position. In fairness, these legacy-staffing strategies may have been compromises over the years and budget cycles, but to clearly articulate the strategy at a future moment in time proves difficult.

Knight, S. (2019 March 12) Full time, part time, overtime: How to fill fire department vacancies. firerescue1.com

LOOKING AT LOS ANGELES

In 1987 a Los Angeles County firefighter/paramedic made more money than the fire chief. That firefighter/paramedic got $59,673 in overtime pay along with his $38,811 annual salary. Firefighter/paramedic Wilson worked five consecutive 24-hour shifts a week, every week. That made the Los Angeles Times.

In the late 1990s, a single-role Los Angeles City Fire Department paramedic made significantly more money than the fire chief, working five to seven consecutive 24-hour shifts a week. At that time, Los Angeles City was losing paramedics quicker than they could hire them.

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, representing a 14% vacancy rate in the paramedic workforce. If you wanted to make sure that you could get off to take a vacation, enjoy a holiday, or attend a family event, you needed to work 96 hours of voluntary “assigned hire” overtime the previous month.

When I was looking at other fire departments pre-pandemic, the number of firefighters and paramedics willing to work overtime decreases when the number of authorized but unfilled positions exceeds 12%. This is usually when forced, or mandatory, overtime starts in earnest. After a few months of forced overtime, some departments see an increase in injuries, sick leave, retirements/resignations, and a decrease in the number of employees voluntarily signing up for overtime.

A 2015 audit of overtime resulted in the Los Angeles City Council approving the hiring of 48 additional firefighters. At that time, “420 LAFD employees earned more than $100,000 in overtime, and 19 earned more than $200,000. One Fire Captain made $311,316 in overtime on top of a $120,829 salary, for a staggering total of $448,594 in overtime pay. … a Commander at the LAFD informed the Controller’s office that the employee with $311,316 in overtime did obey all policies and procedures regarding overtime.”

Those 48 additional firefighter positions in 2015 did not end the overtime issue.

An audit of the Fiscal Year 2019 expenditures (July 2018 – June 2019) showed that “Eighteen employees of the Los Angeles Fire Department earned more than $200,000 in overtime pay last fiscal year, with one firefighter making $360,010 in overtime.”

The 2019 audit also observed that “More than 90% of sworn police and fire employees last fiscal year received overtime, earning an average of $27,737, while 40% of the city’s general employees, defined as other sworn and civilian workers, received such pay. That group earned an average of $7,528.”

Last week Company Commander posted an article that reported “A captain in the department made $434,394 in overtime in 2021, pushing their gross pay to $598,532 to become the highest-paid employee in the city that year. Another fire captain made $420,055 in overtime, pushing that person’s gross pay to $593,314 in 2021. That person was the second-highest paid employee in the city, according to city payroll records. A firefighter with a base salary of $129,638 made $411,606 in overtime, making that firefighter’s total compensation $554,056.

There were 86 employees in the fire department who made $400,000 or more in 2021. However, the highest ranking employee was not among those. The fire chief made $338,624, or nearly $250,000 less than the fire captain.”

AN ANNUAL DANCE OF MEDIA FUELED OUTRAGE

In many jurisdictions, this dance of overtime outrage occurs every year. Most of the media articles blame or shame the individuals that worked overtime, ignoring the elected officials and public safety leadership that developed and implemented policies that generate overtime. 

Company Commander posts these articles not to pile on blame or shame, but to share examples of the staffing and budgeting issues that every jurisdiction faces. The ICMA and Center for Public Safety Excellence white paper on 21st Century Fire and Emergency Services identified two themes:

• First, the past strategies of deferring conclusive action on critical issues with short-term solutions and leaving them for the next set of leadership is not a sustainable strategy for the future. To continue to do so will worsen the eventual correction(s) that will have to be made.
• Second, we must begin recruiting talent with the mindset, skill sets, and resolve to help build a core organizational culture that can adapt and respond to rapid changes and that are not vested in a 20th century fire service paradigm or antiquated local government bureaucracy.

This white paper may serve as a starting point to change the conversation with jurisdictional leaders and elected officials. We need to develop a new narrative promoting appropriate organizational staffing to meet the expanded and complex role that a fire/rescue department performs in 2022.

AN OBSERVATION ABOUT THE FREQUENCY OF OVERTIME POSTS

Company Commander also posts articles that describe closed fire companies and reduced staffing that some jurisdictions are forced to do to stay within their authorized overtime budget. In terms of number of posts, there are about four times as many posts about closed fire companies, reduced staffing, or “browned-out” fire companies as there are about overtime earnings.

Featured picture: “Firefighters Defend Neighborhood Structures as Hollywood Theater Goes Up in Flames.” LAFD.org. 7/13/2022

These situations provide opportunities and challenges for the front-line emergency service officer.

FIRE DEPARTMENT AS A SOCIAL SERVICES PARTNER

The San Francisco Fire Department Street Crisis Response Team (SCRT) is staffed with a community paramedic from SFFD, a behavioral health clinician from HealthRIGHT360, and a peer specialist with lived experience from RAMS, Inc. (Richmond Area Multi-Services) who together have a range of specialty skills to engage on the scene with a person in crisis.

In the first year of operation, November 2020 – November 2021, SCRT took more than 5,000 calls and engaged with nearly 3,000 people in crisis. In early 2022, the seventh team with six additional staff will launch.

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. (source)

Demonstrating the program’s success as an alternative to law enforcement, SCRT diverted more than one-third of all 911 calls (38%) for “mentally disturbed persons” from law enforcement cumulatively during its first year of operation. With six teams launched, SCRT is now diverting over half (58%) of calls monthly for “mentally disturbed persons” from law enforcement. Once fully operational, SCRT seeks to divert 100% of calls.

City of San Francisco (2021 November 30) San Francisco Celebrates One-Year Anniversary of Street Crisis Response Team Press Release

RISING PROBLEM OF HOMELESS ENCAMPMENTS: FIRES, INFECTIOUS DISEASE, VIOLENCE AGAINST CAREGIVERS, AND EMS WORKLOAD

Lexipol provided a 2019 webinar on “Crisis in the Streets: Fire Department Response to Homeless Individuals” that was eye-opening. Click on this link to see the on-demand webinar.

Homeless encampments experienced a 1,000% increase from 2007 to 2017 and are occurring throughout the United States. Half of the encampments have 11-50 residents, 17% of the encampments have more than 100 residences. (NLCHP 2017) Fire departments are responding to calls for violence, fires and infectious diseases like typhus and tuberculosis (Gorman 2018)

Due to violence against first responders, some fire departments are sending two crews to any EMS event at an encampment, to have one company commander function as the scene safety officer while the others work at the task-level. (Goldfeder, Long & Schaeffer 2019)

Seattle Fire Chief Harold Scoggins reports that from Jan. 1 to April 10 of 2022 the department responded to 478 encampment fires – three to five encampment fires a day. In 2021 during the same time period, it was 327. The year before that, they responded to 168 encampment fires. They are also responding to 30 to 35 medical calls to homeless encampments every day. (source)

Los Angeles Fire Department, a city 6 times larger than Seattle, responded to 24 encampment fires a day in May 2021, many spreading to adjacent businesses and residences creating millions of dollars of property damage. (source) In downtown Los Angeles, fires from homeless encampments account for 80% of the blazes in the summer of 2021. (source)

WE ARE NOT TELLING OUR STORY: FIREFIGHTERS RESCUE A LOT OF CIVILIANS

Stunning results from the Firefighter Rescue Survey. They have been collecting information on rescues made by firefighters as reported in the media or by fire departments. In 2021 they found that 2,173 civilians were rescued by firefighters. They received 757 completed rescue surveys. 

As of April 5, 2022, Firefighter Rescue Survey has received reports of 300 incidents where civilians have been rescued by firefighters in 2022. Statistically, that equates to nearly 3.3 incidents per day where firefighters are making grabs. (source) You can get Chief Brian Brush’s “2021 Rescue Survey & The Culture Shift for 2022: People Before Water“ through this (source).

The goal of the Firefighter Rescue Survey initiative is to reduce civilian home fire deaths to under 2,000 per year. U.S. news media reported 2,264 civilian home fire fatalities for the calendar year 2021. Please visit their website http://www.firefighterrescuesurvey.com/

REFERENCES

Thadani, T. & Cassidy, M. (2021 May 17) S.F. finally has a new mental health team to respond to homeless people in distress. Is it helping. San Francisco Chronicle. accessed April 14, 2022. https://www.sfchronicle.com/local/article/S-F-s-new-street-crisis-team-is-helping-people-16180437.php

NLCHP (2017). Tent City, USA: The Growth of America’s Homeless Encampments and How Communities are Responding. Washington, DC, National Law Center on Homelessness and Poverty. http://nlchp.org/wp-content/uploads/2018/10/Tent_City_USA_2017.pdf

Gorman, A. and Kaiser Health News (2019 March 8). Medieval Diseases Are Infecting California’s Homeless: Typhus, tuberculosis, and other illnesses are spreading quickly through camps and shelters. The Atlantic. New York, Atlantic Media, Inc.  https://www.theatlantic.com/health/archive/2019/03/typhus-tuberculosis-medieval-diseases-spreading-homeless/584380/

Goldfeder, B., A. Long and B. Schaeffer (2019 July 9). Crisis In The Streets: Fire Department Response to Homeless Individuals. Webinar. Irvine, CA, Lexipol.  https://info.lexipol.com/webinar-fire-department-response-to-homeless

Markovich, M. (2020 April 15) Seattle Fire Chief: Responses to daily encampment fires taxing already short staffed fire dept. Fox 13 Seattle. Accessed April 15, 2022. https://www.q13fox.com/news/seattle-fire-chief-reponses-to-daily-encampment-fires-taxing-already-short-staffed-fire-dept

Smith, D., Queally, J., & Molina, G. (2021 May 12) 24 fires a day: Surge in flames at L.A. homeless encampments a growing crisis. Los Angeles Times Accessed April 17, 2022. https://www.latimes.com/california/story/2021-05-12/surge-in-fires-at-la-homeless-encampments-growing-crisis

(2021 June 14) Homeless Encampment Fires Account For 80% Of Blazes Plaguing DTLA In Recent Weeks: ‘It’s So Sad.’ CBS Los Angeles. Accessed April 17, 2022. https://www.cbsnews.com/losangeles/news/rash-of-homeless-encampment-fires-continues-across-southland/

Feature image: Winthrop, C. (05 March 2021) One Dead Following Palms Homeless Encampment Fire in Possible Homicide. westsidetoday.com Accessed April 17, 2022 https://westsidetoday.com/2021/03/05/one-dead-after-palms-homeless-encampment-fire/

(2022 April 6) Year of the Rescue, FIREFIGHTER GRAB VIDEO, Reducing Civilian Fatalities Below 2000. County Fire Tactics. Accessed April 17, 2022. https://countyfiretactics.com/2022/04/06/year-of-the-rescue-firefighter-grab-video-reducing-civilian-fatalities-below-2000/

Brush, B. (2022 February) “2021 Rescue Survey & The Cultural Shift for 2022: People Before Water.” CountyFireTactics.com. Accessed April 17, 2022. https://countyfiretactics.com/2022/02/06/2021-rescue-survey-chief-brush-the-cultural-shift-for-2022-chief-isakson/

Out-of-Hospital Cardiac Arrest Research

Dr. Peter Safar conducted a number of experiments at John Hopkins University using expired-air ventilation with closed chest massage on human volunteers in the late 1950’s. “Closed-chest massage should be preceded and accompanied by pulmonary ventilation,” noting that the Baltimore City Hospital’s technique involved one operator inflating the lungs every five seconds, followed by a second operator providing four sternal compressions at one second intervals.

Closed chest massage was endorsed as in the United States as a:

• medical procedure in 1962
• reclassified as an emergency procedure in 1965
• Committee of Cardiopulmonary Resuscitation emphasized the A-B-C-D formula for resuscitation in 1966.

Baltimore City Fire Department Battalion Chief Martin McMahon encouraged his “ambulance men” to volunteer to be sedated so lung air exchange volumes could be determined when looking at different artificial ventilation techniques at John Hopkins University – including expired-air ventilation.

Out-of-hospital cardiac arrest research + The Great Society + federal response to traffic trauma = United States Emergency Medical Services

City “emergency” hospitals often included ambulance service at the start of the 20th century. (Burgess) Public safety organizations – police/fire/ambulance – got more involved in ambulance service after World War II. There was uneven coverage and levels of service.

Vince Robbins writes in Management of Ambulance Services that Miami was the first “nonphysician, mobile, advanced medical treatment service in America.” This determination is based, in part, on articles published in medical scientific journals describing out-of-hospital cardiac arrest research results.

Doctor Eugene Nagel developed a 54-pound defibrillator in Miami that was as effective as John Hopkin’s original 1959, 200-pound, portable defibrillator. The first out-of-hospital resuscitation from ventricular fibrillation occurred in Miami in June 1969.

United States EMS is a child of the Great Society

The Great Society was an ambitious series of policy initiatives, legislation and programs spearheaded by President Lyndon B. Johnson (D) with the main goals of ending poverty, reducing crime, abolishing inequality and improving the environment.

The first federal funding for EMS was $16M from the newly formed Division of Emergency Medical Services within the Department of Health Education and Welfare (DHEW) in 1972 to create demonstration projects in five states.

Congress passes the 1973 EMS Systems Act that provided a 5-year $454M Great Society grant program that funded the creation of more than 300 regional EMS systems. Funding was also provided for EMS feasibility studies, planning, operations, expansion and improvement, and research. In 1974 there was also a $15M Robert Wood Johnson Foundation grant that supported development of 44 EMS systems. (Shah)

Traffic Trauma

The 1966 National Academy of Sciences report on “Accidental Death and Disability” results in federal funding to establish Emergency Medical Services (EMS) as a component of the National Highway Safety Act of 1966.

A component of the National Highway Safety Act of 1966 was the improvement of emergency ambulance and rescue service to traffic collisions. This was assigned to the mission of the National Highway Traffic Safety Administration (NHTSA) within the Department of Transportation. This component included the development of a national EMS education curriculum. (Institute of Medicine)

Pittsburgh’s Hill District

The Hill District is a Pittsburgh neighborhood that often would not get the police ambulance to respond to emergency calls.

• Freedom House Enterprises was a community non-profit using grants to create African-American owned businesses
• Reached out to create a commercial ambulance service to cover the Hill and Oakland Districts
• Partnered with Presbyterian-University Hospital

Dr. Peter Safar, now working at Presbyterian-University Hospital in Pittsburgh, accepted 44 residents of the Hill district through Freedom House Enterprises in 1967. They took a 9-month training program at Presbyterian-University Hospital that included classroom and clinical rotations.

Twenty six students completed the paramedic-level training (EMT II). Paramedic ambulance service started June 16, 1968. Miami and Los Angeles County Fire Department paramedics started responding to emergencies one year later. Seattle two years later

There is a different focus between the Freedom House paramedics and the Seattle, Miami and Los Angeles programs. As a grant-funded community development project, the Freedom House paramedics started running calls as the primary caregiver from the very first day. The paramedics in Seattle, Miami and Los Angeles, because they were in a clinical research project, responded to emergencies with a nurse or physician on the unit during the first year or so. All of the paramedic programs included physician review of calls, with feedback on their clinical performance and case management.

Freedom House is the source of the National Standard Curriculum for Paramedics

The National Highway Transportation Safety Administration (NHTSA) developed the National Standard Curricula outline using University of Pittsburgh/Freedom House 300 hour “EMT II” training program as template. I recall pages of concept and practice bullet-point lists for each of the 15 modules.

University of Pittsburgh Presbyterian-University Hospital contracted with the National Highway Traffic Safety Administration in 1975 to write a paramedic textbook based on the outline. Nancy Caroline, M.D., was the primary author and Walt Stoy, Ph.D./paramedic, was the principal investigator.

NHTSA projected that a textbook to be available by late August 1977. Something happened. Instead of getting 25 textbooks I was buying a “blue line” pre-publication manuscript from the Government Printing Office. I needed the manuscript to develop study guides for a paramedic course. Emergency Care In The Streets was eventually published in 1979 by Little Brown.

Freedom House Ambulance 1967-1975

Freedom House Ambulance staffed five ambulances to serve the Hill and Oakland Districts, averaging 6,000 responses a year. A 1971 University Hospital study compared “inappropriate care” delivered by the two ambulance services. The police ambulances, staffed with Advanced First Aid credentialed caregivers, delivered inappropriate care 62% of the time, Freedom House ambulances, staffed with University Hospital trained EMT and EMT II’s, delivered inappropriate care 11% of the time. (Edwards)

Matthew Edwards is a physician who researches the intersection of medical history, ethics and public policy. His look into the history of Freedom House includes identifying the situations that lead to its demise:

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In 1975 the Freedom House caregivers were paid at a much lower rate than the police, firefighters and “superambulance” personnel. Few of the Freedom House caregivers were able to thrive as employees in the city-operated EMS system. They were required to be “retrained” as city ambulance attendants.

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Safar P, Brown TC, Holtey WJ, Wilder RJ. (1961) Ventilation and circulation with closed-chest cardiac massage in man. Journal of the American Medical Association. 176:574-576.

Safar P, Escarraga LA, Elam JO. (1958) A comparison of the mouth-to-mouth and mouth-to-airway methods of artificial respiration with the chest pressure arm-lift methods. New England Journal of Medicine. 258:671–7

Rasmussen, FN. (2005 February 13) Chief Martin McMahon, 94, first-aid pioneer. The Baltimore Sun. Accessed September 8, 2020: https://www.baltimoresun.com/news/bs-xpm-2005-02-13-0502130054-story.html

Burgess, G. (2018, April 30) Early Days of the San Francisco Emergency Service: From the Police Infirmary to Mission Emergency. Brought to Light, UCSF Archives and Special Collections. Accessed January 30, 2021: https://blogs.library.ucsf.edu/broughttolight/2018/04/30/early-days-of-the-san-francisco-emergency-service/

Robbins, V. (2015) “The History of Ambulance Services and Medical Transportation Systems in the United States” in Kirkwood, S., ed. Management of Ambulance Services. Boston: Pearson/Brady. ISBN 978-0-13-503829-2

Zeitz, J. (2018) Building the Great Society: Inside Lyndon Johnson’s White House. New York: Penguin Books. ISBN 9780698191594

Committee on Trauma and Committee on Shock (1966) Accidental Death and Disability: The Neglected Disease of Modern Society. Washington DC: National Academy of Sciences/National Research Council.

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

Committee of the Future of Emergency Care in the United States Health System, Board on Health Care Services (2007) Emergency Medical Services at the Crossroads. Washington DC: Institute of Medicine of the National Academies Press. ISBN 978-0-309-10174-5

Staresinic, C. (2004 February) Send Freedom House! Nobody has seen ambulance attendants like these before. PITTMED Vol 6, No 1. pp 32-34 Accessed September 14, 2020: https://www.pittmed.health.pitt.edu/Feb_2004/PittMed.pdf

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) pp. 440-466. doe: 10.1093jhmas/jrz041

I have posed a similar question to hundreds of emergency service providers attending a university course, a fire officer credential program or Just Culture presentation. Very few of them elected to continue to wait for the ambulance. Neither did Major Corey Britt, the Senior Company Officer at Oklahoma City Fire Station 34, when they responded to this Christmas Eve burn incident. (Meyer)

The students are shocked when the correct response from the formal organization’s perspective is to continue to wait for the ambulance. Major Britt was in a disciplinary hearing last Friday for his decision to transport the child and mother to the hospital on fire apparatus. (Yager)

The Just Culture Approach

The “Just Culture” approach can assist high consequence organizations (airlines, healthcare, and 24/7 industries) in holding its system and staff accountable within a supportive environment that provides a non-punitive means of reporting errors, while demonstrating zero tolerance for risky behavior. (Woods and Dekker)

It is a system of justice – using investigatory and disciplinary actions – that reflects what we know of socio-technical system design, human free will, and our inescapable human fallibility. (Nance)

After A Bad Outcome Event Occurs

Professor Sidney Dekker, founder of the Safety Science Innovation Lab, describes two approaches to just culture. Retribution imposes a deserved and proportional punishment while Restoration repairs the trust and relationships that were damaged.

The investigation of the bad outcome event looks at:

• What happened?
• What normally happens?
• What does the procedure require?
• Why did it happen?
• How are we managing it?

During this inquiry, we check to see if there is alignment of the department’s mission and value. Is there a clear understanding of the duty, what is defined as a breach of that duty and what are the consequences of breaching that duty.

The inquiry conducts an analysis to identify failed or absent defenses that takes a hazard or risk and makes it a loss, using the human error concepts developed by Professor James Reason.

Designing A Better System

Analysis of earlier bad outcome events result in four areas where we can design a better system. Emergency services have made such changes based on experience.

Controlling Contributing Factors

Changing the pre-cursors to human error at at-risk behavior. Two examples are requiring responders stop at every red light intersection and wear seat belts.

Adding Barriers

Preventing individual errors. Requiring a spotter when backing up vehicles.

Adding Recovery

Catching errors downstream. An example is checking your colleagues personal protective clothing before entering a hazardous environment.

Adding Redundancy

Establishing parallel elements to ensure safe activity. Using more than one method to confirm proper endotracheal intubation.

Just culture is set up to learn from incidents and identify changes in design, procedure and reward systems to promote better behavioral choices.

Understanding Risk

After understanding “what happened?” and comparing it to “What does the procedure require?” we look at the behavorial choice made and the individual’s understanding of the risk involved. Just culture focuses on three behaviors:

• Human Error is an inadvertent action, slip, lapse or mistake.
• At-Risk Behavior is a choice where the individual did not recognize the risk or believed the choice is justified
• Reckless Behavior is a conscious disregard of a substantial and unjustifiable risk

Evaluating the behavior includes the impact of Imposers. Imposers are persons or organizations who set the standards and rules, determines the risk threshold and renders judgement. EMS operations are regulated by a state agency, usually the Health Department. They issue a permit to jurisdictions to provide out-of-hospital care. They issue a license to individual caregivers.

Failure to follow state EMS regulations could endanger the jurisdictional permit to perform out-of-hospital care. In jurisdictions that charge for transport services, losing the jurisdictional permit could result in losing the ability to bill for services. Transporting patients on fire trucks endangers the jurisdictional EMS permit. From the organization’s viewpoint, losing the state EMS permit is a high risk.

Meanwhile, In Oklahoma City

The Emergency Medical Services Authority (EMSA) is struggling with increased call volume, a workforce thinned by the pandemic, long waits to unload patients at the hospital and more time to disinfect ambulances after transport. This results in fewer ambulances on the road and more late arrivals to Priority 1 and 2 calls.

EMSA Chief of Operations John Graham states that with fewer ambulances on the street, more of the responses are coming from the hospitals instead of community posts. This may place the ambulance 15 to 20 miles further away from the incident scene. In December 2020 there were 40 ambulance responses that took longer than one hour for the ambulance to arrive. (Meyer)

An Area With No Pre-planned Guidance

It is not clear if Engine 34 received an accurate estimated time of arrival for the ambulance assigned to the burn incident. (Yager) They had been on the scene for 16 minutes and were told the ambulance was at least 10 minutes away. The Oklahoma City Fire Department regulations may not include guidance on this type of situation.

Dana Libby, a former firefighter/paramedic, police officer and executive with a faith-based international charity organization, observed that the Doctrine of Necessity, along with necessary safeguards, has long been recognized in civil and criminal law. (Christie)

Libby further states:

Every Standard Operating Procedure should start with a statement of policy, principle, or purpose. The enumerated procedures should provide guidance on fulfilling the policy, principle or purpose, under a set of circumstances.

If the circumstances and conditions differ, there is at least guidance concerning what you are supposed to be accomplishing . . . good training, creativity, experience and wisdom will then get you as close as possible to the goal.

Take-Away for All

Many jurisdictions and state medical agencies have made changes in clinical and operational guidelines in response to the COVID-19 pandemic. The transport of critical patients when no ambulance is available is no longer an obscure “what-if” but now a “what-when” scenario. What is a just procedure for the patient, family, emergency responders, and healthcare staff?

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Christie, George C. (1999 March) The Defense of Necessity Considered From The Legal and Moral Points of View. Duke Law Journal 48 (5), Accessed January 25, 2021 https://scholarship.law.duke.edu/cgi/viewcontent.cgi?article=1052&context=dlj&fbclid=IwAR10x3HC831W5BqI2pNo1pFzsWz17e48gzjw2qYBBt5uGa2kpKY59mI1Zug

Dekker, Sidney (2017) Just Culture: Restoring Trust and Accountability in Your Organization. 3rd edition. Boca Raton, FL: CRC Press, Taylor & Francis Group. ISBN 978-1-4724-7578-7

Meyer, Ali (2021 Jan 19) EXCLUSIVE: ‘The system failed us’ – Family disappointed in EMSA ambulance delay. Oklahoma News 4. Accessed January 23, 2021 https://kfor.com/news/local/exclusive-the-system-failed-us-family-disappointed-in-emsa-ambulance-delay/

Nance, John J. (2008) Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care. Bozeman, MT: Second River Healthcare, ISBN 978-1-93640-604-3

Reason, James (1990) Human Error. New York: Cambridge University Press. ISBN 978-0-521-31419-0

Woods, David D., et al (2010) Behind Human Error, Second edition. Burlington, VT: Ashgate Publishing Company. ISBN 978-0-7546-7834-2

Yager, Peyton (2021 Jan 22) Oklahoma City Fire Major faces punishment within the department after driving burn patient to the hospital after ambulance delay. Oklahoma News 4. Accessed January 23, 2021 https://kfor.com/news/local/oklahoma-city-fire-major-faces-punishment-within-the-department-after-driving-burn-patient-to-the-hospital-due-to-ambulance-delay/

Like many, my plans and expectations continue to be rocked by the pandemic and the associated economic disruption. So, what will 2021 bring?

Research: Pandemic Impact on EMS Caregivers and Firefighters

One of the reasons to get a Ph.D. is to think about the “big questions.” That starts while honing skills and performing research as a student. I am part of a group looking at the pandemic’s impact on EMS caregivers in terms of PPE and worker compensation.

The first wave of the pandemic was an unscheduled major event that overwhelmed first responders. Like the 9/11 attack in New York City, there were assumptions and promises that crumbled months later as the magnitude of the World Trade Center illnesses were determined by state and federal authorities.

Worker compensation for COVID-19 is inconsistent. We are seeing the same pushback for COVID-19 infected EMS caregivers similar to last year’s Company Commander documentation of the Texas approach to firefighter occupational cancer claims.

There is a tremendous disparity in the protection of EMS caregivers based on their job classification and type of employer. Within the Fire Department of New York, firefighters get unlimited sick leave while single role EMS providers get 12 days a year.

Paul Cary, a retired Aurora, Colorado firefighter/paramedic, was working on a FEMA-deployed commercial ambulance in New York City. He gets infected on-the-job and dies of the coronavirus. Since he is not an employee of a jurisdictional emergency service organization when he was infected, his family will not get the same line-of-duty death benefits that a family of a volunteer rescue squad caregiver receives after a LODD coronavirus death.

Follow: Delivering Emergency Service During Austere Times

Last May the International Association of Fire Chiefs warned that the impact of the pandemic shutdown and quarantines could result in the loss of 30,000 fire department jobs because lost tax revenues will significantly reduce local government budgets.

These job losses come at a time when emergency service workload has increased, from both the pandemic as well as the increased number of residential cooking fires and fires in unoccupied businesses and office buildings.

EMS workload has skyrocketed, with many systems recording their “busiest days ever” that includes day-to-day workloads 50% higher than normal. This is driven by more patients and the fallout of overwhelmed hospitals during a COVID surge generating more interfaculty transports.

Some emergency service agencies have stepped up to help overloaded health care and public health colleagues by assuming additional roles and responsibilities.

Develop: Company Commander Supervision and Management During Times of High-Stress, Hyper-Partisanship, and Poor Quality Information

We are working in extraordinary times where we often encounter tsunamis of conflicting or confusing information that call for a response by a supervisor or manager. Beyond the arena of national politics, this affects our ability to command, supervise and train our team as these controversies can “… suck all of the oxygen (and energy) out of a room” and skew our decision-making process.

How can you maintain a non-hostile work environment when television, print and social media work every day to increase readership by promoting conflict, anger and angst?

Share: New and Recurring Voices

Opinion leaders, innovators and recognized experts drive emergency service practices. I continue to seek out the next opinion leader or subject matter expert that is working to make us better, safer and righteous. If there is someone or a team I need to know about, please send me an email.

This Week’s Take Home: Vincent Dunn’s Fire Battlespace Trilogy

On January 7, Chief Dunn posted an essay on his FaceBook page “Why I Wrote 7 Books.” https://www.facebook.com/VincentDunnFireBattlespace

I recall being a rookie engine company commander and reading the first edition of Collapse of Burning Buildings. It remains one of the most impactful experiences in my professional development.

As communities transition from lock-down to a phased opening, fire and ems commanders are facing unique and challenging situations as we continue to be on the front line of public safety, public health and medicine.

Revisiting the Hammer and the Dance

Tomas Pueyo created a great visualization, “The Hammer and the Dance,” to look at lockdown and reopening. “The dance” is the period we’re entering now. The period where we need to think about our movements like the ebb and flow of a complicated dance.

Pueyo says that “It’s called ‘the dance’ because it is a much more fluid phase. You might have outbreaks, so you need to react to that. It’s much more technical, too.” More testing, more contact tracing, masks and social distancing are elements of the dance.

“What I will say is life will never go back to what people have in mind as normal,” Pueyo said. “Once you change your habits as a society for months, it is likely that many of these habits will remain afterwards, so the world we knew until February 2020 is gone.”

KGO-TV (2020)

How Long Will We Dance?

Michael Osterholm, Ph.D., MPH, is the Director of the Center for Infectious Disease Research and Policy at the University of Minnesota. He advises both Republican and Democratic presidents and was the interim Director of the Centers for Disease Control (CDC). His 2017 book Deadliest Enemy, foretold a global pandemic.

Blue Zones founder Dan Buetner interviewed Osterholm and calls him “… one of the most dependable, non-political sources for straight answers for COVID-19.” Here are some of the bullet points, you should read the entire interview. (click here)

• If you’re under age 55, obesity is the #1 risk factor.
• Wearing a cloth mask does not protect you much if you’re in close contact with someone who is COVID-19 contagious. It may give you 20 minutes, instead of 10, to avoid contracting the disease.
• We can expect COVID-19 to infect 60% – 70% of Americans. That’s around 200 million Americans.
• We can expect between 800,000 and 1.6 million Americans to die in the next 18 months if we don’t have a successful vaccine.
• There is no guarantee of an effective vaccination and even if we find one, it may only give short term protection.

We have to learn not only how to die with this virus, which tragically we’ve had to do, but we also have to learn how to live with it. If we’re not going to lock up and we’re not going to open up willy-nilly, then what is the approach? What are the things that we can do to change society that will help us maintain society to the best we know but at the same time also reduce transmission? That’s a key activity right now that public health needs to be playing a very important role in. (Osterholm)

The 1918 Influenza had a second wave in the fall that was made more severe by a mutated virus spread by wartime troop movements. (Roos 2020) There were three waves of infections in the two years that the 1918 Influenza was active.

In Chapter 19 “Pandemic: From Unspeakable to Inevitable” Osterholm describes a tabletop pandemic scenario that starts in April, gets hammered down by late July, second wave begins in late September and continues through June.

I speculate that the current spike of new cases in western and southern states are from the first wave perking up after lockdown ended. The second wave comes with the fall flu season and COVID-19 will continue well into 2021.

COVID Clusters

With each subsequent week of patient data we get a clearer pattern of who is getting sick. (Lu) This includes work places where there is no ability to socially isolate and conditions that facilitate the transmission of the coronavirus through aerosol transmission.

Nursing homes and assisted living facilities are COVID clusters, representing 42% of U. S. deaths. (Roy)

New data from CDC shows that the death rates among Black and Hispanic/Latino people are much higher than for white people, in all age categories. (Brookings)

Not long after the virus started spreading, counties with relatively larger black populations faced higher case counts, higher COVID-19-related mortality, and a faster pace of progression compared to counties with a lower share of black people. The 681 high-concentration black counties account for only about a third of the U.S. population but 53 percent of the cases and 63 percent of the deaths nationally. (Zephyrin)

More than 28% of people diagnosed with COVID-19 are Hispanic. (Zarefsky)

In New York City communities with large Hasidic populations experienced some of the highest infection rates in the city. (Stack) This situation also infected most of the firefighters working Brooklyn Park’s FDNY Engine 282/Ladder 148 that were responding to crowded “places of worship, schools and mikvahs,” or ritual baths, in the ultra-Orthodox enclave, an FDNY employee said. (Balsamini)

The reasons for these racial differences are driven by essential workers in high-risk medical and service jobs, inadequate infectious disease resources, poverty, and community practices.

Emergency Service Exposures From Community Infection

The first COVID-19 San Jose firefighter was infected off the job and asymptomatic. He infected 15 of his colleagues, 10% of the fire department, by March 6.

He covered a shift for a buddy at another firehouse, exposing colleagues there. He attended a career development course at the department’s training center — and the disease spread further. … From March 6 to March 12 the number of infected San Jose firefighters increased to over 50.

Kelliher 2020

The first FDNY EMT diagnosed with the coronavirus was infected off-the job from a person who recently travelled overseas (Maisel 2020).

Both of those examples occurred at the beginning, when the Hammer was coming down. With communities opening up again, we are looking at the Dance and the continuing challenge of off-the-job infections.

Last week provides a great example of our current situation, with 8 Greensboro, North Carolina, firefighters getting infected after a four-fire station golf outing. (Fox 8 WGHP)

Battalion Chief Tom Bouthillet, Hilton Head Island Fire Rescue, points out “This is the new challenge. Previously, we were worried about exposure on medical calls. Post-shutdown, off-duty exposures are more likely. Kids are getting exposed in daycare, spouses are getting exposed in their jobs, and then there’s daily life, whether a golf outing, wedding, or some other thing. Test, trace, isolate.“

Face Masks As A Political Issue

Prior to some governors requiring face masks as part of the phased opening up of states, less than half of the population were voluntarily wearing masks.

“Attitudes about masks have become politicized,” said Robert Kahn, a University of St. Thomas Law School professor who has been following the mask debate. “I don’t think they were always that way, like in, say, March, early on in this.” (Vetterkind 2020)

Surveys in May showed that 75% of Democrats and 53% of the Republicans are wearing facemarks (Pepinsky 2020)

The conflict and confusion of mask usage comes from the mixed messages, as pointed out in this June 2 Washington Post 4-minute video, showing Dr. Anthony Fauci saying on March 8 that citizens should not be wearing masks – in part to keep the too-small inventory of masks available for medical staff – and then saying that citizens should be wearing cloth face masks on April 2:

https://www.washingtonpost.com/video/politics/as-states-reopen-coronavirus-masks-symbolize-a-cultural-divide/2020/06/02/60900f1d-3f37-4241-b218-c3f905ab30ad_video.html

A long article in the June 19th Washington Post looks at the face mask battle:

Mask-wearing for some people is an identifier of broader beliefs and political leanings. Like so many issues rooted in science and medicine, the pandemic is now fully entangled with ideological tribalism. This has played out before: helmets for motorcyclists, seat belts in cars, smoking bans in restaurants.

To many people, masks represent adherence to civic duty and a willingness to make individual sacrifices for the greater good of public health. To others, masks symbolize government overreach and a violation of personal liberty.

Within the work environment, company commanders have the employer directives for use of personal protective equipment. Delivering clinical care best practices provides infection control directives. Caregivers may encounter patients that fight them when deploying a facemask.

COVID Conspiracies and the Infodemic

Along with the pandemic there has been an infodemic – an overabundance of information – including false or misleading stories. Nature provides an example of a false story:

On 19 March, the website Biohackinfo.com falsely claimed that Gates planned to use a coronavirus vaccine as a ploy to monitor people through an injected microchip or quantum-dot spy software. Two days later, traffic started flowing to a YouTube video on the idea. It’s been viewed nearly two million times.

The idea reached Roger Stone … who in April discussed the theory on a radio show … The interview was covered by the New York Post, which didn’t debunk the notion. Then that article was liked, shared or commented on by nearly one million people on Facebook. “That’s better performance than most mainstream media news stories,” says Joan Donovan, a sociologist at Harvard University in Cambridge, Massachusetts.

Nearly 8 in 10 surveyed by Gallop/Knight between April 14-20 say misinformation about the virus is a major problem. Asked to identify the common sources of mis-information, 68% said social media and 54% say the Trump administration. (Jones 2020)

In addition, 36% of the respondents saying that they feel overwhelmed by all of the COVID-19 information.

23,000 Non-Peer Reviewed Articles

Kim Tingley, writing for The New York Times Magazine, describes two actions taken by peer-reviewed publishers to make potentially life-or-death research available as quickly as possible:

1. Dropping the paywalls of Science, The Lancet, Journal of the American Medical Association (JAMA) and The New England Journal of Medicine to make coronavirus content free online.
2. Encouraging researchers to post their submissions on pre-print servers, where anyone can access them before they undergo a peer-review process.

This means that an article submitted to Science was available in days instead of months. Posting initial research findings on pre-print servers allows researchers to quickly share preliminary work and may help the scientific community to collaborate more effectively and efficiently.

The Atlantic science writer Ed Yong describes how peer-review and scientific knowledge works:

It’s less the parade of decisive blockbuster discoveries that the press often portrays, and more a slow, erratic stumble toward ever less uncertainty. “Our understanding oscillates at first, but converges on an answer,” says Natalie Dean, a statistician at the University of Florida. “That’s the normal scientific process, but it looks jarring to people who aren’t used to it.”

With over 23,000 non-peer reviewed scientific papers about the disease and the novel coronavirus that causes it flooding the scientific community (Brainard), factoids and tidbits are grasped as “the solution” without follow-up studies. This creates contradictory comments and erodes the public’s confidence in scientific information,

The Dunning-Kruger effect

There is a phenomena known as the Dunning-Kruger Effect. Coined in 1999 by then-Cornell psychologists David Dunning and Justin Kruger, the Dunning-Kruger Effect is a cognitive bias whereby people are unable to recognize their own incompetence. And not only do they fail to recognize their incompetence, they’re also likely to feel confident that they actually are competent. (Murphy)

ZDoggMD – Doctor Zubin Damania – provides a 7 minute video explaining this: “From antivaxxers to moon landing deniers to poorly-trained medical folks, our idiocracy is often fueled by the so-called Dunning-Kruger effect.”

A person can counteract this effect by questioning what you know and pay attention to those who have different viewpoints. Seek feedback from people you trust who are knowledgeable in your area of interest. Be open to constructive criticism. Keep learning.

Some people will cherry-picking factoids from non-peer reviewed research to justify an ideological tribalism that supports a conspiracy theory. It is not the company commander’s role to dissuade a person’s belief. We are there to provide a service.

Unfortunately, as the pandemic continues to disrupt normal life, it builds frustration, anger and rage in some people. Fire and ems providers may find themselves in harm’s way.

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Pueyo, T. (2020 March 19) Coronavirus: The Hammer and the Dance.  What the Next 18 Months Can Look Like, if Leaders Buy Us Time. Medium.com Accessed June 18, 2020 https://medium.com/@tomaspueyo/coronavirus-the-hammer-and-the-dance-be9337092b56

Kreutz, L. (2020 May 20) SF author’s viral ‘Hammer and the dance’ gives new perspective amid COVID-19 pandemic. ABC 7News KGO-TV. San Francisco. Accessed June 18, 2020 https://abc7news.com/hammer-and-the-dance-update-tomas-pueyo-coronavirus-article/6199923/

Buettner, D. (2020 June 6) COVID-19: Straight Answers from Top Epidemiologist Who Predicted the Pandemic. Bluezones.com. Minneapolis, Minnesota Blue Zones LLC. Accessed June 18 https://www.bluezones.com/2020/06/covid-19-straight-answers-from-top-epidemiologist-who-predicted-the-pandemic/

Roos, D. (2020 April 29) Why the Second Wave of the 1918 Spanish Flu Was So Deadly: The first strain of the Spanish flu wasn’t particularly deadly. Then if came back in the fall with a vengeance. History.com. New York: A+E Television Networks. Accessed June 19 https://www.history.com/news/spanish-flu-second-wave-resurgence

Lu, M. (2020 April 15) The Front Line: Visualizing the Occupations with the Highest COVID-19 Risk. Visual Capitalist. Vancouver, CA: Visual Capitalist Accessed June 18, 2020: https://www.visualcapitalist.com/the-front-line-visualizing-the-occupations-with-the-highest-covid-19-risk/

Roy, A (2020 May 26) The Most Important Coronavirus Statistic: 42% Of U.S. Deaths Are From 0.6% Of The Population. Forbes.com. Accessed June 20, 2020 https://www.forbes.com/sites/theapothecary/2020/05/26/nursing-homes-assisted-living-facilities-0-6-of-the-u-s-population-43-of-u-s-covid-19-deaths/#16bfbb3b74cd

(2020 June 7) COVID-19 Nursing Home Data. data.CMS.gov. Baltimore, MD. Centers for Medicare & Medicaid Services. Accessed June 20, 2020 https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg/

Ford, T., Reber, S. & Reeves, RV. (2020 June 16) Race gaps in COVIS-19 deaths are even bigger than they appear. Brookings.edu. Washington, DC: The Brookings Institute. Accessed June 20, 2020 https://www.brookings.edu/blog/up-front/2020/06/16/race-gaps-in-covid-19-deaths-are-even-bigger-than-they-appear/

Zephyrin, L., Radley, D.C., Getachew, Y., Bumgartner, J.C., & Schneider, E.C. (2020 April 23) COVID-19 More Prevalent, Deadlier in U.S. Counties with Higher Black Populations. To the Point (blog), Commonwealth Fund, Apr. 23, 2020. https://doi.org/10.26099/y3xs-qr19 Accessed June 20, 2020 https://www.commonwealthfund.org/blog/2020/covid-19-more-prevalent-deadlier-us-counties-higher-black-populations

Zarefsky, M. (2020 May 21) Physicians detail COVID-19’s impact on Latinx communities. AMA. Chicago, IL: American Medical Association. Accessed April 20, 2020 https://www.ama-assn.org/delivering-care/population-care/physicians-detail-covid-19-s-impact-latinx-communities

Stack, Liam (2020 April 21) “Plague on a Biblical Scale “: Hasidic Families Hit Hard by Virus. In the New York area, the epidemic has killed influential religious leaders and torn through large, tight-knit families. The New York Times. Accessed June 20, 2020 https://www.nytimes.com/2020/04/21/nyregion/coronavirus-jews-hasidic-ny.html

Balsamini, D., & Edelmann, S.(2020 April 11) NYC firehouse crippled by coronavirus as 11 firefighters test positive. New York Post. Accessed June 20, 2020 https://nypost.com/2020/04/11/brooklyn-firehouse-crippled-by-covid-19-as-11-test-positive/

Kelliher, F. & Debolt, D. (2020 April 6) ‘The threat from within’ : How the coronavirus spread through San Jose’s fire department. As the pandemic reached the Bay Area, first responders quickly realized that they were facing a threat on multiple fronts. The Mercury News. Accessed June 17, 2020 https://www.mercurynews.com/2020/04/05/first-coronavirus-cluster-san-jose-fire-department/

Maisel, T. (2020 March 9) FDNY confirms that first EMT has been diagnosed with coronavirus. AMNY. Accessed June 17, 2020 https://www.amny.com/coronavirus/fdny-confirms-that-first-emt-has-been-diagnosed-with-coronavirus/

Digital Desk (2020 June 17) 8 Greensboro firefighters test positive for coronavirus after 4-station golf outing, Fox8 WGHP. High Point, NC. Accessed June 17, 2020 https://myfox8.com/news/8-greensboro-firefighters-test-positive-for-coronavirus/

McCarthy, N. (2020 May 12) The States Most & Least Likely to Wear Face Masks. Statista.com. New York: Statista. Accessed June 19 https://www.statista.com/chart/21687/share-of-the-public-who-have-worn-a-face-mask-in-public/

Pepinsky, T. (2020 May 13) Yes, Wearing a Mask is Partisan Now. tompepinsky.com. Ithica, NY: tompepinsky.com Accessed June 19 https://tompepinsky.com/2020/05/13/yes-wearing-a-mask-is-partisan-now/

Vetterkind, R. (2020 May 20) Face masks becoming a political symbol of the COVID-19 era. Wisconsin State Journal. Accessed June 19 https://madison.com/wsj/news/local/govt-and-politics/face-masks-becoming-a-political-symbol-of-the-covid-19-era/article_0f3b0379-23c6-54da-a424-c2fd7360fe28.html

Rozsa, L., Janes, C., Weiner, R., & Achenbach. J. (2020 June 19) The battle over masks in a pandemic: An all-American Story. The Washington Post. Accessed June 20, 2020 https://www.washingtonpost.com/health/the-battle-over-masks-in-a-pandemic-an-all-american-story/2020/06/19/3ad25564-b245-11ea-8f56-63f38c990077_story.html

Ball, P. & Maxmen, A. (2020 May 27) The epic battle against coronavirus misinformation and conspiracy theories. Analysts are tracking false rumours about COVID-19 in hopes of curbing their spread. Nature 581, 371-374. doi: 10.1038/d41586-020-01452-z Accessed June 18, 2020 https://www.nature.com/articles/d41586-020-01452-z

Jones, J F. (2020 May 11) Americans Struggle to Navigate COVID-19 “Infodemic”. Gallup. Washington DC: Gallup. Accessed June 19, 2020 https://news.gallup.com/poll/310409/americans-struggle-navigate-covid-infodemic.aspx

Tingley, K. (2020 April 21) Coronavirus Is Forcing Medical Research to Speed Up. The New Your Times Magazine. Accessed April 24, 2020: https://www.nytimes.com/2020/04/21/magazine/coronavirus-scientific-journals-research.html 

Yong, Ed (2020 April 29) Why the Coronavirus Is So Confusing: A guide to making sense of a problem that is now too big for any one person to fully comprehend. The Atlantic. Accessed April 29, 2020: https://www.theatlantic.com/health/archive/2020/04/pandemic-confusing-uncertainty/610819/  

Brainard, J. (2020 May 13) Scientists are drowning in COVID-19 papers. Can new tools keep them afloat? Science. doi:10.1126/science.abc7839 Accessed June 21, 2020 https://www.sciencemag.org/news/2020/05/scientists-are-drowning-covid-19-papers-can-new-tools-keep-them-afloat

Murphy, Mark (2017 Jan 24) The Dunning-Kruger Effect Shows Why Some People Think They’re Great Even When Their Work Is Terrible. Forbes.com Accessed June 20, 2020 https://www.forbes.com/sites/markmurphy/2017/01/24/the-dunning-kruger-effect-shows-why-some-people-think-theyre-great-even-when-their-work-is-terrible/#5ae2c84a5d7c

Dunning, D. (2011) Chapter five – The Dunning-Kruger Effect: On Being Ignorant of One’s Own Ignorance. Advances in Experimental Social Psychology. 44, 247-296 https://doi.org/10.1016/B978-0-12-385522-0.00005-6

Feature Image: New Jersey Turnpike: Exit 15. Photo credit: Rob L. via  Henry Cortacans et al #NJEMSTASKFORCE1

1. Compliance with Rules and Regulations

The company commander represents the formal fire department within the fire station when transmitting the rules and regulations as well as assuring firefighter compliance. In large or bureaucratic jurisdictions it may not be possible to assure 100% compliance.

Let’s look at a fictional example. General Order 2020-039 was issued last week that describes complex changes in infection control practices due to shortages in personal protective clothing. It is in conflict with Standard Operating Procedure 2.3.1 that is built upon a federal regulation that carries a penalty for non-compliance.

If this was a question on a promotional exam, the candidate may (1) Describe how to comply with both GO 2020-039 and SOP 231 to the best of the crew’s ability – with emphasis on firefighter health and safety and delivering the maximum possible level of community service, (2) Notify the battalion chief of the conflict in directives, (3) If this is a resource issue, describe an innovative resolution, and (4) Prepare a document for the chief’s review describing the conflict with a recommended solution.

Is the new fire officer “by the book” and believes every single sentence that comes from headquarters as accurate gospel? That officer will believe the downgrading of the quality and level of infectious disease personal protective equipment below the federal minimum is just fine.

If this was real-life, the experienced Lieutenant will have a brief discussion with the battalion chief to look at options. The Lieutenant will then do the tasks that protect the firefighters/public and keep the supervisor out of federal court.

2. Firefighter Satisfaction

When new fire officer is tested by the crew, many stumble at the REQUEST stage. They will be asked to allow or do something that is clearly not allowed in the rules and regulations.

Rookie officers often want the crew members to like them. It is difficult to improve fire company performance once you have given away your formal authority so you can be like “… one of the guys.”

Respect is based on being trustworthy and authentic. Likeability is subjective, people often like people who are similar to themselves, or have a certain charisma. Being likable or popular does not always earn you the respect.

Being a respected supervisor is different than being their buddy. Many of the officers Hugh Caulfield assisted struggled with this.

You cannot manufacture respect. You cannot become something you weren’t or aren’t. Firemen will see through it in a second.

Don’t try to gain respect by doing the things you think will make you look ‘salty’ or bad ass. Gain it by doing your job. Gain it by having strong core values and instilling them in your organization.

Bastinelli, Brian (2017 Winter) #RESPECT. The Art of Firemanship. 02(1) https://static1.squarespace.com/static/5668c7042399a34df12fe70b/t/58c0a0cebf629ab8bacd5a81/1489019112067/AOF+Journal+Winter+2017+Single.pdf

How important is for you to be Beloved … or Respected?

3. Productivity

Fire company productivity includes performance at emergency incidents as well as completion of routine assignments such as hydrant inspections or fire station maintenance.

One of the features of the Blue Card Incident Management certification program is the use of “sets and reps” to hone muscle memory and mental cues when commanding an incident. It is a term used in physical training:

A Rep (repetition) is one complete motion of an exercise. A Set is a group of consecutive repetitions. For example, you can say, “I did two sets of ten reps on the chest press.” This means that you did ten consecutive chest presses, rested, and then did another ten chest presses.

Our goal is to be highly skilled to the point that the evolution (throwing a ground ladder, advancing a 2.5″ smooth bore) appears natural and easy. Firefighters are Unconsciously Competent.

Becoming unconsciously competent requires a lot of sets and reps. Officers will get resistance when increasing the training tasks. In doing Caulfield’s assessment, how important is company productivity to you?

4. Risk

Taking care of your crew is a sacred trust. We are in an environment that requires the company-level supervisor to be a vigilant and consistent advocate for the team.

This becomes a challenge when a chief officer or administrator asks “… how well do you like working here?” The officer may be warned that continuing to advocate for an issue – even those affecting the safety of the crew – may hurt the fire officer’s career.

Some of you may recall the “Career Dissipation Light” phrase from Backdraft

You may be planning to move upon the career ladder to become a command officer or senior administrator. That may be hard to do if you get formal discipline designed to stop or discourage your advocacy. What level of professional risk are you comfortable with?

5. Leader Satisfaction

What is a great work day for you? Is this the rank and assignment you plan to retire at? Where do you see yourself when you retire?

I have a long-gone fellow firefighter/paramedic that said “I do not want to be staring through the windshield of an ambulance when I am 40.” At 40 he was running the EMS side of the Academy.

Winning The Leadership Game

Caulfield said that the company officer wins the leadership game when the fire station runs on the company officer’s terms. The officer is satisfied with

• Firefighter Productivity
• Their Own Feelings About Being a Leader
• How They Are Meeting the Formal Organization’s Expectations of the Company Officer as a Leader

Caulfield provided leadership tools and different point of reference to help FDNY lieutenants and captains get through the War Years and significant economic crisis during a time of great cultural upheaval.

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Caulfield, Hugh J. (1985). Winning the Fire Service Leadership Game. Saddlebrook, NJ: Fire Engineering. ISBN 0-912212-09-8

Blue Card Command Training and Certification: http://www.bshifter.com/about_01.aspx

Curtiss, PR and Warren PW (1973) The Dynamics of Life Skills Coaching: Life Skills Series. Prince Albert, Saskatchewan: Training and Development Station, Department of Manpower and Immigration.

Adams, L. (no date) “Learning a New Skill is Easier Said Than Done“ Gordon Training International. Accessed February 16, 2019, from http://www.gordontraining.com/free-workplace-articles/learning-a-new-skill-is-easier-said-than-done/ 

Ericsson KA, Roring, RW and Nandagopal K. (2007 June) “Giftedness and evidence for reproducibly superior performance: an account based on the expert performance framework.” High Ability Studies. Vol. 18, No. 1, pp. 3–56.

Featured image: U Street Firefighters, Washington DC (2018) Facebook

Pictures are to illustrate concepts and DO NOT imply that the personal or organizations pictured are doing improper or unsafe activities