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Fire Dept. defends using trucks for medical calls

Some doubt need if EMS responds

By Keith O'Brien
Globe Staff / January 23, 2009
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The massive 42-foot ladder truck, with its 110-foot rear-mounted ladder and 500-gallon water tank, was designed for fighting raging fires and plucking people from burning buildings. But on its recent fatal run, Ladder 26 was on a more pedestrian duty: a medical call for a man having difficulty breathing.

In recent years, such calls have become commonplace for fire departments across the Commonwealth. And firefighters, who receive far fewer calls for fires than they did a generation ago, have welcomed the work. With a declining number of fires to fight nationwide, the medical runs have helped to keep fire departments busy and boost sagging call numbers. Last year, medical calls accounted for 37 percent of the 70,176 runs made by Boston firefighters.

But this month's crash, in which Lieutenant Kevin M. Kelley was killed, indicated the dangers that firefighters face anytime they leave the firehouse and rekindled a long-smoldering debate about why Boston firetrucks, staffed by firefighters, and ambulances, operated by a separate agency, Boston EMS, both need to be responding to the same medical calls.

"We need to discuss new ideas and new approaches to managing our resources and our city," said Councilor at Large Sam Yoon, chairman of the City Council's Postaudit and Oversight Committee, which examines the efficiency of city agencies and operations. "Sending a ladder truck, as well as two sets of first responders, to answer routine medical calls seems like an inefficiency we can't afford."

Fire departments nationwide responded to 1.64 million fire calls in 2006, compared with 2.98 million in 1980, a 44 percent decline, according to the Quincy-based National Fire Protection Association. But at the same time, the association said, they went on more medical calls: from 5 million in 1980 to 15 million in 2006, a 200 percent increase.

In the 1990s, a Boston Finance Commission report found a similar trend here. In 1993, the report found, the Boston Fire Department responded to 47,670 calls, roughly the same as a decade before. But there were about 50 percent fewer fires, the report went on to say, meaning an increase in medical runs, not fires, was keeping Fire Department numbers steady.

Fire Department and EMS officials say that you never know what you might find at a scene, justifying the need for both agencies to race out on calls.

But some have long questioned whether it is necessary to have both respond. Task forces have studied the issue, and there have been calls over the years to merge the two agencies, including one made last week by Edward A. Kelly, president of the firefighters union. Kelly said he believed that the two agencies could be more productive if they were run together.

Richard Serino, the city's EMS chief, replied by saying that the current arrangement works fine and that, in any case, it is too soon after the tragedy for such discussions.

"A number of people have looked at the system, and we provide the very highest level of medical care," Serino said. "We have some of the best-trained EMTs and paramedics in the country, and we've been recognized for that many times."

And so it goes. The two sides have been at odds for years, with each looking to protect what they see as their turf. Firefighter unions asserted in the 1990s that merging was the best way to go. After all, in most major cities EMS and fire departments operate as one.

But over the years, others, including some doctors and paramedics, have spoken out against merging. Some have said the firefighters' position was motivated by a need to justify their jobs by going out on more calls.

"There is a major issue brewing over the response to medical calls for emergency services," concluded the Boston Finance Commission, a city watchdog group, in a 1994 report that analyzed the troubled relationship between the two agencies. "It is about jobs and clout and has to be addressed."

Officials at both agencies say the relationship is more cordial than it was years ago; the two sides meet regularly to discuss how the city's protocols are working and are generally more cooperative.

But even small attempts at changing the practice of sending firefighters to medical calls have sparked outcry in recent years. When the Romney administration, at the urging of Lieutenant Governor Kerry Healey, approved new regulations in 2004 allowing nursing homes to circumvent 911 and call private ambulance companies directly, the state firefighters union and fire chiefs association sued the governor, alleging that political donations from ambulance companies had greased the wheels of change.

The firefighters lost the suit. But much about the way the two agencies operate has stayed the same, and at times in recent years, it seemed as if the two agencies were competing to get to the same scene, said Samuel Tyler, president of the Boston Municipal Research Bureau.

"Sometimes the ambulance is on the way and will be there in a minute, and the fire engine really isn't needed. And the ambulance radios that it's going to be there," Tyler said. "But the fire engine continues on and meets the call."

Kelly, the Boston firefighters union president, defended the practice. Firefighters, at least half of whom are trained as emergency medical technicians, are only doing their jobs, he said.

The practice of sending both an ambulance and a firetruck, equipped with defibrillators, oxygen, and other first aid essentials, to a medical call is widespread nationwide. And the reason, fire chiefs say, is simple: With fire stations located strategically throughout a city and paramedics often tied up for an hour on a single call, firefighters, even firefighters driving a bulky ladder truck, can often get to an emergency faster than an ambulance.

"People are alive today because the Fire Department responded to their medical emergency," Kelly said. "And if my mother, my daughter, or my wife had a medical emergency, I'd want the closest available public safety officers to immediately respond."

New details obtained by the Globe about the 911 call that led to Kelley's death on Jan. 9 show that firefighters arrived first. Dispatchers received word at 2:05 p.m. that a man was having difficulty breathing on Parker Hill Avenue in Mission Hill, said Jennifer Mehigan, a spokeswoman for EMS. The dispatcher treated the report as a "priority one call," said Mehigan, a code that indicates that both the Fire Department and EMS were responding. Ladder 26, housed nearby, arrived five minutes later, Mehigan said, four minutes ahead of the first city ambulance and six minutes ahead of a second ambulance.

A short time later, at about 2:34 p.m., the firefighters were given the go-ahead to leave, Mehigan said. The EMTs would ferry the man to the hospital, and Ladder 26 would depart, heading down a steep hill and apparently suffering catastrophic brake failure. The subsequent crash killed Kelley instantly and injured several others.

But even knowing the outcome, firefighters say it was still worth going on the medical run.

"We work in a situation where people need comfort," said Richard Paris, vice president of the Boston Firefighters Union. "They are out there waiting on the front porch for us to come down the street. And until you're waiting there, you don't know how important it is to have the first responders show up to help."

Steve MacDonald, a Fire Department spokesman, said the process works this way: 911 calls taken by a dispatcher are coded according to priority, and firetrucks are automatically sent on the most severe cases, such as car accidents with injuries, cardiac arrests, and people reporting shortness of breath. The Fire Department is typically not alerted to calls reporting minor ailments.

Each firehouse alternates the vehicles it sends on medical calls, MacDonald said. One month, the fire engine will answer medical calls. The next month, the ladder truck will respond. The goal, he explained, is making sure firefighters assigned to each truck use the EMT training they have received.

He dismissed the suggestion that a ladder truck should not go out on medical calls. As Ladder 26's fatal run proved, a ladder truck can get to a scene before a smaller, more nimble ambulance. For starters, there are more of them. At any one time, the city has 57 firetrucks on duty, compared with the 24 ambulances EMS has on average.

The idea is that "seconds count," MacDonald said, and doctors agree. Dr. Alasdair Conn, who as chief of emergency services oversees the emergency department at Massachusetts General Hospital, said he has never heard of a fire engine or ladder truck transporting a patient to the hospital. But he does not care whether help arrives on a motorcycle, he said, as long as its gets there quickly, especially in cases where someone's heart has stopped.

"After three minutes, every minute delayed in initiating CPR leads to an increase in mortality," Conn said, "so the quicker you can get them there, the better."

That is why many communities have adopted the approach of sending both firetrucks and ambulances on medical calls. Lori Moore-Merrell, assistant to the general president in charge of research at the International Association of Firefighters, said the practice is standard operating procedure, even in fire departments that operate their own ambulances.

In St. Louis, for example, EMS and the Fire Department merged in 1997, in an effort to save money and cut down on duplicated service. But Fire Chief Dennis M. Jenkerson said his department still sends firetrucks on most medical calls, believing they will get there first.

"People call and say, 'I'm having trouble breathing.' Can they afford to wait 5 1/2, 6 minutes, for an ambulance? No," Jenkerson said. "So we get there first, stabilize, and wait for the ambulance."

But as long as both firefighters and paramedics are arriving separately for medical calls, there will be some who question the policy. It just does not seem necessary, say some nursing home administrators, who often prefer to call a private ambulance company directly in an emergency instead of 911. It is not that the Fire Department and EMS cannot do the job, they say. It is that a single ambulance is often less traumatic and just as effective.

"Why do you need a firetruck unless there's a fire?" said Margaret Leoni, vice president of regulatory affairs for the Massachusetts Senior Care Association, a trade group representing the state's nursing homes and assisted living centers. "I guess I can't appreciate, from the Fire Department's perspective, why they would send a truck unless someone calls and says, 'I have a fire.' "

Maria Cramer and Donovan Slack of the Globe staff contributed to this report. Keith O'Brien can be reached at kobrien@globe.com.</p>

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