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Supply + Demand = Crisis

September 4, 2009

Today’s New York Times features a front page article on the effect of the nation’s health care crisis on Washington, D.C. firefighters.  The article examines the plight of the crew of Engine 10.  Eighty percent of all the calls attended by this crew, like many others across the country, involve medical treatment.  Many of the citizens who require their care have no private health insurance, and no other options for accessing primary or preventive health care.

That this situation has become so common, and indeed so troubling, is not just a question of growing demand.  For sure, the health care crisis, which has left some 16 percent of Americans without health insurance and many more dependent upon aid programs that only provide for urgent treatment, has had an effect.  But so too has firefighters’ need to be needed.

Until the 1970s, few fire departments handled medical emergencies.  Firefighters had training in first aid, and often administered basic treatment to those they rescued from fires, motor vehicle crashes, and other situations, but no one considered them health care professionals.  When people got sick or injured themselves, they had to find another way to get help.

Until that time, in many communities, the local undertaker might carry you to the hospital in a hearse if your condition was dire enough and you had no other means of making the trip.  But few people found this option attractive due to what it suggested about the trip leaving the hospital.

In the 1970s, as persistent poverty became an entrenched feature of the urban landscape, city services struggled to keep up.  At the same time, public administrators faced frequent boom-bust cycles, which encouraged a preoccupation with the productivity of public servants.

Even back then, when firefighters attend nearly twice the number of serious fires they do today, they had plenty of downtime.  Rather than filling this with administrative duties, training, and fire prevention programs, many departments succumbed to public pressure to find new ways of delivering service to their communities.  Emergency medicine was an obvious choice.

The popularity of the television program Emergency! which featured Los Angeles County’s paramedic program added impetus to these efforts.  Every week a national television audience witnessed compelling stories illustrating the benefits of training firefighters to deliver advanced medical treatment to the seriously ill and injured in the field.

Firefighters then as now echoed the complaints of D.C. Fire & EMS Engine 10’s T. J. Myleart who told the Times, “I joined the force to battle blazes, not to be an emergency room doctor.”  Neither these complaints nor the fact that few cities or states had established the authority of firefighters to deliver these services deterred demand.  As cities moved to supply these services they often did so with no clear aim besides improving productivity and meeting growing public expectations.

Firefighters have benefited from engaging in emergency medical services.  Without this demand, few departments could justify the large standing armies they maintain for firefighting and other emergencies.  The skills required to deliver competent emergency medical services have also raised the bar for prospective firefighters, making it all the more important they possess intellectual and social skills required to engage diverse populations.

But as it stands today, with demand increasing at rates of 2-5 percent per year, city leaders should be asking whether the situation is sustainable.  When will it become clear that we no longer have firefighters providing emergency medical service, but rather emergency medical technicians and paramedics fighting fires?

Firefighters and city officials should support health insurance reform for moral as well as practical reasons but many don’t.  Working in a system that’s become so badly broken, they have become intensely cynical about human nature and deeply skeptical of public leaders’ motives.  As such, many of them have become fierce opponents of a public option, and some even wonder aloud whether universal access bestows benefits on unworthy recipients at theirs and others’ expense.

When and if health care reform arrives, we would all do well to consider carefully what role the fire and emergency services should play.  As it stands now, this looks like it will be an afterthought.  Demand will not disappear overnight, and as it stands now much of the care provided by firefighters does not involve critical care.

Fire service EMTs and paramedics may be better positioned than most to deliver primary and preventive care efficiently and effectively to many of our nation’s most vulnerable citizens.  If we decide this is true, then systems and processes must be put in place to manage both the supply and demand for these services.

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