Imagine you worked in an EMS system where only firefighters—and no paramedics—had been hired in five years. In the meantime, the paramedic ranks continue to decrease through firings, resignations or promotions. Also, imagine if most of your paramedics were looking for any way out because of how bad things were.
Imagine you worked in an EMS system where no training occurs. You’re required to get all training on your own, including continuing education, ACLS, pediatric ALS (PALS) and Department of Transportation (DOT) refreshers.
Imagine you worked in an EMS system and you have no paramedics in any management positions. Instead, fire battalion chiefs with no EMS background try to manage EMS issues, including disciplining employees for medical mistakes.
Imagine you worked in this system and the EMS quality improvement program is nothing but a tool to catch responders doing something wrong so they can be disciplined. Imagine you worked where the equipment was poor at best and ambulances were designed by mechanics who wrote the specifications based on their knowledge of engines. Imagine at least four complaints are received from the citizens on a weekly basis and there are seven major malpractice lawsuits against the department.
This hypothetical EMS system used to be the real-world Memphis Fire Department (MFD) eight years ago—and the Memphis Fire Department is no small system. It has more than 1,899 employees, 57 fire stations and responds to more than 110,000 EMS calls a year. All responders are firefighters and are cross-trained as an EMT or a paramedic.
Back then, patient care delivery from some firefighters was so inadequate that nurses and doctors in the local EDs would shudder when they saw firefighters coming through the door. Something definitely had to change.
Firefighters committed to improving things petitioned and pleaded with then-new Fire Director Richard Arwood that many things weren’t right and the department needed a transformation. Arwood commissioned a consulting study, which verified problems in the EMS system and made 38 recommendations for improvement.
Key to changing the system was an attitude adjustment. Contained within the 138-page study was telling language: “In order to address the challenges and the opportunities that will be brought forth in this document, a top-to-bottom cultural attitude change toward EMS needs to take place within the fire department. This top-to-bottom cultural attitude change begins with the Director. The Director of the fire department will set the tone for how EMS is viewed now and into the future. Breaking down a culture that has existed for decades requires strong leadership from the Director. This new attitude should be reflected through the ranks, all the way down to the firefighter position.”
The MFD Ambulance Committee designed this ambulance to effectively treat and transport bariatric patients. Photos courtesy Memphis Fire Department
A New EMS Leader
Prior to the study, Arwood had already budgeted for a deputy fire chief—a member of the senior command staff who would manage the EMS system—since there was currently no one in a senior management position addressing EMS issues directly. This was an important position, since 76% of calls were EMS-related.
Arwood would eventually ask Gary Ludwig to join the MFD as the deputy fire chief overseeing the EMS system. Ludwig already had 25 years of EMS experience working in St. Louis, where he retired as the chief paramedic for the St. Louis Fire Department. Ludwig has since become a nationally recognized EMS author and speaker, recently served six years as chair of the EMS Section of the International Association of Fire Chiefs and was named the 2014 James O. Page EMS Leadership Award recipient.
According to Ludwig, things were so bad in Memphis that he initially thought it wasn’t worth it and almost quit. He said, “I was driving across the Mississippi River Bridge heading into downtown Memphis and a little voice kept telling me that this just doesn’t feel right. I should just turn around and head back to St. Louis and let Chief Arwood know this isn’t for me.”
“But,” Ludwig added, “I made a commitment to Chief Arwood and the employees in the Memphis Fire Department and I needed to deliver on my promise.”
Now Ludwig says it’s the best decision he ever made. “The opportunity to turn an EMS system around and work with true professionals of all ranks within Memphis to build it from the ground up is an opportunity that doesn’t come around too often.”
A key element to rebuilding the EMS system was developing a strategy. Ludwig wrote a three-year plan that added 42 new EMS positions, including 36 lieutenants, five battalion chiefs and one division chief dedicated to EMS. The new positions would be assigned to field operations, training and administration. The positions would be filled through a competitive process and only firefighters who held a paramedic certification would be eligible.
One of Ludwig’s first orders of business was to get a new medical director. Ludwig said, “I got tired of arguing with the existing medical director about training issues. He told me he viewed ACLS, PALS and other education as merit badges and not needed.”
Ludwig added, “I needed a medical director who saw my point of view about being progressive and changing the system for the better.” He tapped Joseph Holley, MD, who already served as medical director for Tennessee and several other fire departments throughout the Memphis area.
“Joe was just the ticket we needed,” said Ludwig. “He’s smart, progressive, and easily approachable by the medics and crews, and likes to stay cutting-edge like me. He has truly been an asset to the rebuilding process.”
Ludwig felt the best way to manage these necessary radical changes was to get as many firefighter/paramedics involved in the process. Before the three-year plan promotions occurred, Ludwig sought input from firefighters to help him write a strategic plan that addressed many areas including: operations, training, management, logistics, medical direction, recruitment, consequence management, quality improvement, 9-1-1 alternative programs and recognition programs.
Where there was no involvement of paramedics in any activities in the past, they would eventually find themselves on internal committees for ambulance design, disposable supplies, education, quality improvement and EMS Week, as well as regional and national committees like a steering committee and representatives appointed to the Regional Medical Communication Center Committee, Paramedic Program Advisory Board, Medical Dispatch Review Committee, Tennessee Emergency Medical Service Association—Education and Research Committee, Western Tennessee Ambulance Strike Team Committee, Memphis STEMI and Stroke Committee, Tennessee Ambulance Service Association, Tennessee Emergency Medical Service Association, Cardiac Arrest Registry to Enhance Survival (CARES) and Pediatric Emergency Care Committee.
Improvements in many areas stemmed from the various committees while the MFD prepared for the promotional testing process to determine who would be promoted in the first year, which eventually saw paramedics promoted to division chief, four battalion chiefs and 19 lieutenants.
With the assistance of cadaveric donors, the MFD EMTs and paramedics are routinely educated on new tools and technology, and are able to practice their skill sets. Here they observe the location of the carotid artery and proper placement of chest decompression needles. Photos A.J. Heightman
A top priority was recruiting paramedics—the MFD was tremendously short of the number needed. The short-term plan was to hire from the outside and the long-term plan was for Memphis to train its own paramedics. Ludwig had to work with Tennessee state representatives, who eventually changed state legislation to allow the MFD to be the first paramedic training program in Tennessee not affiliated with a college or university. After that occurred, all firefighters hired after September 2007 were required to become paramedics within 3.5 years.
While at a conference, Ludwig learned from an Ohio educator that there were a bunch of paramedics in that state looking for jobs. To attract them, the City of Memphis offered a $10,000 recruitment incentive, plus moving expenses. The city bought a list of all the registered paramedics in Ohio from the National Registry of EMTs (NREMT) and sent each one a letter offering the $10,000 bonus. It was so imperative to immediately fill the ranks with paramedics that Ludwig said he even had the letter folded in such a way that the bonus would be the first thing the paramedic saw.
Ludwig assigned Memphis firefighter/paramedic Steve Fort as the point of contact if any Ohio paramedic had questions. Fort said the phone rang off the hook. Eventually, the MFD would hire more than 150 paramedics from Ohio, and many others from throughout the U.S.
To assist out-of-state medics moving to Memphis, Ludwig developed an innovative Ambassador Program: Under the direction of Lieutenant Don Mosby, each new medic was assigned to a Memphis firefighter who would call them prior to moving and let them know they were there to assist them with the move, including where to find housing, schools if they had children, how to get a driver’s license, how to set up utilities, and any other challenges that one could experience when moving from another state.
After training as a firefighter in the Academy, the new paramedics underwent 30 24-hour shifts of field training. This process, developed by Batalian Chief Pam Kiestler, included evaluating recruits using a behaviorally anchored rating scale as well as objective measurements.
Kiestler also transformed the selection of field training officers (FTOs). FTOs were carefully selected by an interview and clinical evalution. Only the best firefighters and clinicians, with the best attitudes, made the cut. This program was highlighted in a 2008 JEMS article called “Mentors in Memphis.”
Besides changing the legislation at the state level to allow the MFD to educate its own paramedics, Ludwig worked with State Representative Ulysses Jones to allow Memphis to change the color of its ambulances to red. Tennessee law previously mandated all ambulances had to be orange and white.
“We needed to change the color of the ambulances to the same color and striping as the fire trucks,” Ludwig said. “We’re trying to merge EMS and fire and here we got two vehicles that look totally different. Psychologically, it just smacked of division.”
During this early rebuilding period, Ludwig also faced the daunting task of moving the patient data collection system from paper to electronic. But as he describes it, “Our Philips monitors capture blood pressure readings, pulse, SpO2s and capnography readings. Along with the ECG, the paramedic can now Bluetooth all the data from the monitor to the Toughbook with no double entry.”
At the end of three years everything was clicking. Under the direction of Division Chief Joseph P. Rike, each shift now had five EMS lieutenants and one battalion chief who not only provided supervision, but provided coaching and mentoring.
Ludwig said, “As my right hand, Joe was the perfect fit in such a pivotal and important role. He had institutional knowledge of where things went wrong in the past and he was well respected by the paramedics and the fire officers because he had previously been a truck lieutenant. When changes had to be made, Joe was a great sounding board to bounce ideas off of. Many times he came up with other ways of doing things I hadn’t considered—but it was the right way.”
Holley also made significant improvements in the medical protocols and added more advanced treatment practices that would eventually lead to Memphis paramedics performing advanced procedures such as intraosseous infusions, 12-lead ECG recognition for ST segment elevated myocardial infarctions (STEMIs), continuous positive airway pressure (CPAP), induced hypothermia, mechanical LUCAS CPR and capnography.
Eight years later, the MFD EMS asystem has been totally transformed into a model fire-based EMS system. Today there are almost 500 firefighter/paramedics and over 1,100 firefighter/EMTs. All 56 engine companies and all 36 front-line ambulances are ALS capable every day. When you add the five lieutenants and the one battalion chief, each day there are 98 ALS-capable vehicles in Memphis. This allows the MFD to deliver ALS care with an average response time of four minutes anywhere in the city.
The EMS training division now has 13 instructors and one battalion chief. The MFD paramedic education program has a 98% pass rate on the NREMT exams, has graduated over 170 firefighters as paramedics, and recently became accredited by the Committee on Accreditation of Educational Programs for the EMS Professions. In addition, the MFD also trains EMTs, is a certified American Heart Association education center, and is the only fire department in the U.S. authorized by the Continuing Education Coordinating Board for EMS to issue its own continuing education units.
The EMS training division also teaches DOT refreshers and other continuing education classes including “Paramedic Centric” classes that consist of four to six firefighter/paramedics and one instructor providing individual instruction on enhanced programs such as 12-lead ECG recognition for STEMIs. Other classes focus outside the classroom and are conducted in cadaver labs and other institutions of learning.
Today, the MFD exceeds high clinical standards with an aggressive STEMI program that boasts at one hospital a 43- minute first-medic-contact-to-balloon time and under 56 minutes for the other chest pain centers for STEMIs.
The return of spontaneous circulation (ROSC) for cardiac arrest victims is 26%. This includes all initial rhythms including systole, v fib and pulseless electrical activity (PEA), and applies to medical and trauma victims. Ludwig led the charge to get LUCAS II devices on all 36 ambulances this past year either through city funding or private foundation funding. According to LUCAS manufacturer Physio-Control, the MFD is the first major EMS system to have mechanical CPR devices on all frontline ambulances.
The MFD’s quality improvement (QI) process is now viewed by employees as adding value instead of the previous watchful eye of “big brother” and has adopted the FedEx QI model where the leadership takes responsibility for the success or failure of the QI program.
The MFD has also added specialized vehicles with a bariatric unit, a MedStat ambulance, and multi-causuality trailers and multi-patient buses purchased with Metropolitan Medical Response System funding.
If you build it, they will come. That doesn’t only apply to a corn field in Iowa. Today, it’s not uncommon for other EMS systems to travel to Memphis and spend several days learning the system and taking ideas back to their own communities. Last year, the MFD even hosted EMS professionals from Norway. The U.S. Army uses the MFD as a clinical training ground for new EMTs and paramedics, and paramedic schools from as far away as Alaska regularly send students to Memphis to do their clinical ridealongs.
Ludwig credits many people for the success in Memphis, including the current fire director, Alvin Benson. “Director Benson is a fire chief who truly and without question embraces the EMS mission of the department,” explains Ludwig. “He’s consistently been an advocate and champion for the EMS system. He’s been the fire director for over five years now and many of the changes have occurred under his watch, with his approval, and many times were his suggestion.”
Ludwig also credits the firefighter/paramedics and the dedicated EMS staff in Memphis for making such a dramatic change in an EMS system. According to Ludwig, “I have never seen a more dedicated group of professionals who were hungry for change, embraced that change, took ownership, and are now very proud of what they’ve built.”
As a measure of its success, the MFD was awarded the Tennessee EMS Service of the Year in 2012.