It was quarter to one a.m., and I was wide awake in the shift leader’s office. I was the boss of Engine 28 and responsible for the safety of my crew.

The fire suppression books I memorized for the promotion exam were authored by big city chiefs who worked with fire companies staffed with four to six firefighters and supported by a rapid arrival of command officers. There was no way a two-person truck company could perform the initial fireground tasks that a heavily staffed Fire Department of New York (FDNY) truck company could accomplish.

The county was evolving from a coalition of rural/suburban volunteer fire companies to an urban county fire department, which would be accomplished years later.

When I was sleepless in Seven Corners, we had daywork career battalion chiefs, three or two-person fire crews, rudimentary SOPs, and the beginnings of an incident management system. It was a very different environment than FDNY.

As a fire officer candidate, you would respond to an assessment center scenario with everything you remembered. The sequence of factoids was not as important as it was to get every item ticked-off in the assessor’s checklist to get the highest score.

I struggled as a paramedic student. The “nice to know” trivia factoids interfered with what I needed to know to get credentialed, and I was having the same problem now.

As the boss of Engine 28, I needed to do the right things first when arriving at a structure fire with our three-person engine company. Ironically, I recalled something from a retired FDNY Chief of Department that provided focus.

Edward P. McAniff’s book Leadership in the Fire Service, was on our promotional exam reading list. The IAFF local hired McAniff and Associates to deliver a preparation class, as this was our first exam to use an assessment center.

Chief McAniff said: “The goal of the first arriving engine is to advance an attack line and gain control of the interior stairs.”

That worked for me. A couple of weeks later, I applied this concept.

At 8 p.m., we were dispatched to an “Across from …” structure fire. We arrived at a single-level home four blocks south of the fire station. Fire was showing from the roof. A car was in the driveway, and lights were on in the house. After no response to our banging on the door, we forced the door open and advanced the 1.5” attack line.

There was no smoke or heat in the house. The second arriving engine company got to the rear and reported a fire coming from the natural gas regulator that spread to the soffit. When we opened the attic stairs, we found the fire.

The attic was finished with a hardwood floor and jammed with a lifetime of items from international travel. Overhauling the attic took a couple of hours using two engines and a truck company. The occupants were having dinner at a restaurant.

Returning at 1 a.m. for a fire watch check, we watered down the pile of steaming international debris in the front yard. I slept well that night.

Featured image: Shutterstock

Replaceable Semi-Skilled Carbon Based Productivity Components

A speaker at the Fitch and Associates Pinnacle EMS leadership conference was the chief executive officer of a commercial ambulance company that could be found in many regions of the United States. His presentation acknowledged that many of his younger caregivers were waiting to get a fire department job. He used the fast-food industry approach, expecting a high turnover of caregivers that perform services using standardized tasks and responsibilities in a regimented format. I thought Skip Kirkwood’s head would explode.

That CEO, as well as the corporation, is no longer in the medical transportation industry. But his approach may be based on workforce reality. We have two distinct ems caregiver workforces: private/jurisdictional and fire department. As well as two generations. Let’s look at the available data.

The 2019 AAA/Avesta Ambulance Industry Employee Turnover Study provides details concerning the private/jurisdictional/community EMS services. This is the second year this survey has been conducted. The overall annual turnover shows:

• Full-Time Paramedic: 19%
• Part-Time Paramedic: 37%
• Full-Time EMT: 28%
• Part-Time EMT: 47%

Part-timers, or per-diem caregivers, are the hardest to retain. Per-diems represent up to 50% of the ambulance service workforce in commercial and jurisdictional services. Only full-time paramedic positions have a slightly better annual turnover than the national rate of 20% for all occupations.

EMS Is A Professional Afterthought 

Michael Corman points out in his 2017 industrial ethnography of Alberta, Canada, paramedics that there has been little sociological attention paid to EMS providers. Donald Metz was a professor of sociology who produced a 1981 ethnography of ambulance work while he was a part-time Emergency Medical Technician (EMT) for a private ambulance service providing urban 911 services.

Metz pointed out the incongruity of an ems caregiver police-style uniform as found in the early 1980s – collared shirt, badge, shoulder patch, name tag and metal jewelry showing authority – and the requirement to use a clip-on tie. The clip-on tie is to protect the caregiver if the patient or a bystander grabs the tie. Metz also pointed out that EMTs in the private ambulance service as well as EMTs and paramedics in the fire department face no future advancement – “EMS work is at best a detour, and perhaps even a barrier, on the road to advancement” (page 185).

Sociologist Eddie Palmer (1989) looked at paramedic performances and “trauma junkies” indicating that the street performance of paramedics was similar to police officers. “Within an occupational milieu of excitement, danger, and public attention, paramedics perform a variety of roles constituting street work similar to that documented for police officers. Playing the roles of authority figure, lifesaver, information specialist, partner, grief manager, and counselor, paramedics are immersed in a work world replete with teamwork demands, conflicts with medical and nonmedical personnel, vaguely defined legal standards, and occupational uncertainty due to the newness of their medical niche.”

In a small qualitative study looking at recruitment and retention of ems caregivers in 2005, P. Daniel Patterson’s team identified three themes:

1. EMS Is a Professional Afterthought
2. EMS is an Emotional Paradox
3. EMS is an Educational Black Box

In Theme 1, many of those interviewed by Patterson did not originally plan to be an EMS caregiver. This job was chosen after completing their first career, often military or nursing. Or they chose this job after failing to complete training for another, more attractive job.

When I ran an online bachelor degree completion program at a private university many of the students were going back to school after suffering an academic or career crash 4 to 10 years earlier. Now, often with a spouse and children, they want to go back to their original plan. About 12% of the bachelor degree graduates went on to get a master’s or professional degree with 6 of them becoming physicians. All of them were credentialed as a paramedic before 2014.

University of New Mexico EMS Physician Scene Response Program – Albuquerque

Pay, Unionization and Education

The paramedic recredentialling exam as administered by the National Registry of EMTs (NREMT) includes industry research questions. Paramedics must take the recertification exam every two years. In 2013 NREMT asked those who identified that they worked for Zero EMS agencies the reasons they were not working as a caregiver and their intention to return to practice (Cash) . The most frequent reason they were not working as a paramedic was a desire for better pay and benefits.

Paramedics, especially the majority who do not have union labor representation, fall into the lower-middle class level of pay. The California 2017 study of ems caregivers identified that there was a 39% difference in pay from those working for commercial ambulances and those working for fire-department based ambulances. (Jacobs) The single-role, non-firefighter, paramedics working in California fire departments are members of IAFF, the local labor organization.

The second most frequent reason paramedics were not working was the desire for further education. It appears this further education is to move beyond the role of a paramedic and to become a nurse (18% of the respondents) or go to medical school (5%). This reinforces Patterson’s Theme 1 that “EMS is a Professional Afterthought.”

Despite the vigorous pushback by old school paramedic leaders at the proposal to require an Associate Degree before credentialling as a paramedic, a 2020 study of the demographics of National Registry credentialed caregivers show that 28.5% of paramedics possess an associate degree (Rivard).

This is due, in part, to the caregivers that received their initial training since 2014, when the new Educational Standard went into effect. A snapshot from the Committee on Accreditation of Allied Health Education Programs shows that there are 375 paramedic programs run by a two-year technical or community college where the student is required to complete the degree requirements before they are eligible to sit for the NREMT paramedic credential exam.

In addition, there are 171 accredited paramedic certification programs not directly affiliated with an academic institution or teaching medical center. An example would be a paramedic training program run by a fire department. To meet the new Educational Standard, they were required to have a consortium agreement to allow academic transfer credit for successful credentialed paramedics. For many of these students, they will need to complete about 15 semester hours of general education courses to get an associate or technical degree from the consortium educational partner.

The Next Generation of Caregivers, 2014 and onward

It appears we may be seeing a change in the demographics of paramedic caregivers with the 2014 implementation of the 2008 Educational Standard for initial paramedic training. With many paramedics having a “clinical caregiver career” of just 3-7 years, many single-role paramedics initially trained before 2014 will be aging out. On the other hand, fire department paramedics, both single role and firefighter/paramedic, tend to work an entire 20-to-30-year municipal career (Byron).

If You Were Credentialed as a Paramedic AFTER 2013 What Do You Need to Become an EMS Professional?

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ACEP (2020 May 16) “EMS Week” Irving, TX: American College of Emergency Physicians. Accessed May 16, 2020:  https://www.acep.org/administration/ems-resources/emsweek/

AAA/Avesta (2019 July) AAA/Avesta 2019 Ambulance Industry Employee Turnover Study. McLean, VA: American Ambulance Association.

Ethnography is a set of qualitative methods that are used in social sciences that focus on the observation of social practices and interactions. Its aim is to observe a situation without imposing any deductive structure or framework upon it and to view everything as strange or unique.

Corman, M (2017) Paramedics On and Off The Streets: Emergency Medical Services in the Age of Technological Governance  Toronto: University of Toronto Press

Metz, D. L. (1981) Running Hot: Structure and Stress in Ambulance Work. Cambridge, MA: Abt Books.

Palmer, C. E. (1989). Paramedic performances. Sociological Spectrum, 9 (2), 211-25. http://dx.doi.org/10.1080/02732173.1989.9981884.

Palmer, E. (1983) “Trauma junkies” and street work: Occupational behavior of paramedics and emergency medical technicians. Urban Life, 12 (2), 162-83. http://dx.doi.org/10.1177/0098303983012002003

Patterson, P.D., Probst, J. C., Leith, K. H., Corwin, S. J., Powell, M. Paige. (2005) Recruitment and Retention of Emergency Medical Technicians: A Qualitative Study. Journal of Allied Health 34 (1) 153-162.

https://emed.unm.edu/clinical/emergency-medical-service-consortium/physician-ems-field-response.html

Rebecca E. Cash, Remle P. Crowe, Riddhima Agarwal, Severo A. Rodriguez & Ashish R. Panchal (2018) Exiting the Emergency Medical Services Profession and Characteristics Associated with Intent to Return to Practice, Prehospital Emergency Care, 22:1,28-33, DOI: 10.1080/10903127.2017.133974

Jacobs, K.; Heller, H; Waheed, S & Appel, S. (2017 February 7) Emergency Medical Services in California: Wages, Working Conditions, and Industry Profile. Berkley, CA: UC Berkley Labor Center and UCLA Labor Center http://laborcenter.berkeley.edu/emergency-medical-services-in-california-wages-working-conditions-and-industry-profile/

Rivard, M.K., Cash, R.E., Mercer, C. B., Chrzan, K. & Panchal, A. R. (2020): Demography of the National Emergency Medical Services Workforce: A Description of Those Providing Patient Care in the Prehospital Setting. Prehospital Emergency Care. DOI: 10.1080/10903127.2020.1737282

CAAHEP (2019) Emergency Medical Services – Paramedic. Clearwater, FL: Commission on Accreditation of Allied Health Education Programs https://www.caahep.org/Students/Program-Info/Emergency-Medical-Technician-Paramedic.aspx Accessed November 15, 2019.

Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, EMTs and Paramedics. Accessed April 22, 2020: https://www.bls.gov/ooh/healthcare/emts-and-paramedics.htm.

Byron, J. (2018) Career Paramedic-Firefighter Staffing Problems: Is Recruiting Women Part of the solution? (master’s thesis) Naval Postgraduate School, Monterey, California. Retrieved from https://www.hsdl.org/?view&did=821413

George is dying of cancer and under hospice care. His wife wanted those that worked with George to sent a short positive and upbeat memory or message. One of her adult children would assemble the videos into a loop for George to see and hear when he was awake.

Kübler-Ross: The 5 Stages of Grief

Emergency service workers learn about the five stages of grief as defined by Elisabeth Kübler-Ross, MD. She identified these stages after spending two-and-a-half years working with dying patients, The stages are:

1. Denial and Isolation
2. Anger
3. Bargaining
4. Depression
5. Acceptance

A follow-up book took those five stages of loss to help the survivors find the meaning of grief.

We share grief – our story, our loss, our feelings.

Shared and witnessed grief is grief abated.

Our Emergency Service Family

Our emergency service family provides a unique structure when we are confronted with an unexpected death. For example, there was a rookie firefighter who suffered a line of duty death. His spouse, their parents, and their network of regular friends and work colleagues were not aware of how we take care of our own.

It starts with a fire department member staying with the body from the hospital to the cemetery. Continues with providing a single-individual as the fire department or union representative that worked with the family on all of the details. One of the parents said, “… they just came in and started doing things. They took care of our every need.”

The other factor with our tribe is a deep understanding of disease pathophysiology, recovery/rehabilitation, the mixed quality of medical care, human behavior under crisis, and end-of-life reality.

We know death on an intimate level.

Our Digital World

Every Sunday visit to my elderly parents used to start with the sick and dead report. They would tell me who in their wide circle of friends was sick or had died. A lot of that information came from a breakfast ritual of reading obituaries in The Washington Post. That reporting ended when the number of their friends could be counted on one hand.

Within a private social media retirement group, I know about two-dozen fire department colleagues who are dealing with serious medical issues. Some will not have a great resolution.

I have a lot of digital friends and work colleagues. Our face-to-face meetings often start with a comment or question about their latest Facebook status update or crisis.

Through programs like CaringBridge (https://www.caringbridge.org/) and GoFundMe (https://www.gofundme.com/), I am able to financially support friends and colleagues and get detailed updates.

Is Too Much Information Creating Compassion Fatigue?

I wonder if this constant information flow becomes too much. Compassion Fatigue is described as a condition that develops over time, but it is not PTSD. When we are consistently hearing vivid stories of traumatic occurrences it can spur feelings of empathy and suffering in us. Over time, those feelings can invade and result in many waking hours without sleep, and lessen our ability to feel “optimism, humor, and hope.” (Figley)

I was sobbing after recording the video because someone that I worked closely with is in pain and dying. I cry for his family and their loss.

I also cry for my loss. A chunk of my fire department history will fade when George is gone. I feel my mortality.

Update May 20, 2020: retired Captain II George L. Sisson has died. Godspeed ….

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Kübler-Ross, E. (1969, 2019) On Death & Dying: What the Dying Have To Teach Doctors, Nurses, Clergy & Their Own Families. New York: Scribner.

Kübler-Ross, E. and Kessler, D. (2005) On Grief & Grieving: Finding the Meaning of Grief Through the Five Stages of Loss. New York: Scribner

Kessler, D. (2019) Finding Meaning: The Sixth Stage of Grief. New York: Simon & Schuster.

Figley, C. R. (ed) (2002) Treating Compassion Fatigue. New York: Brunner-Routledge.

Featured Image: Engine 18 (1967 Seagrave 1000 gpm/300 gwt) photo probably by Clark Martin

This excerpt from “The Day After” in his memoir describes how Chief Dunne became absolutely sleep-deprived as rose through the ranks. Dunne’s did four things when operating under chronic sleep deprivation while on duty:

1. Used a routine to complete tasks and respond to emergencies
2. Stay caffeinated during the overnight stage
3. Maintain awareness of what is happening on the street by monitoring the radio
4. Do not deeply sleep while on-duty

EMS Fatigue Guidelines

Chief Dunne’s workload is a lot like an EMS crew working a 24-hour shift. The National Association of State EMS Officials (NASEMSO) partnered with the University of Pittsburgh School of Medicine to develop evidence-based guidelines. This graphic shows where they are in the process:

The evidence-based results included 5 recommendations:

Both fire commanders and ems caregivers have to make critical decisions with limited information and under severe time requirements. Exploring the documents available at NASEMSO’s page http://www.emsfatigue.com may provide some ideas to improve your performance.

When you hit the brick wall

Chief Dunne shared a problem that some of you will recognize:

The only time I would really hit the proverbial brick wall was when I had to produce some detailed administrative report after a particularly rough night. There were times when I actually nodded off at the keyboard of my office computer.

A great book

I have enjoyed reading Chief Dunne’s book. It provides a great panorama of the FDNY as described by someone who spent 33 years on the streets.

There is a lot of content that is valuable for the aspiring or rising company commander.

Like his fire conference presentations, the book is engaging and provides memorable stories and vivid details of big city firefighting.

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Dunne, Thomas (2020) Notes from the Fireground: Memoir of a New York Firefighter. Jefferson, NC: McFarland & Company.   ISBN (print) 978-1-4766-7988-4.  https://www.amazon.com/Notes-Fireground-Memoir-York-Firefighter/dp/1476679886/

P. Daniel Patterson, J. Stephen Higgins, Hans P. A. Van Dongen, Daniel J. Buysse, Ronald W. Thackery, Douglas F. Kupas, David S. Becker, Bradley E. Dean, George H. Lindbeck, Francis X. Guyette, Josef H. Penner, John M. Violanti, Eddy S. Lang & Christian Martin-Gill (2018) Evidence-Based Guidelines for Fatigue Risk Management in Emergency Medical Services, Prehospital Emergency Care, 22:sup1, 89-101, DOI: 10.1080/10903127.2017.1376137    Accessed March 8, 2020: https://www.tandfonline.com/doi/full/10.1080/10903127.2017.1376137