Administration and Leadership, Columns

How Fire & EMS Make an Unlikely Union

Issue 40 and Volume 41.

Several months ago, while preparing a commencement address for a class of graduating firefighter-EMTs, I got to thinking about their future roles and responsibilities.

As firefighters, they’d use Halligan tools and flathead axes to make forcible entries, and suppress fires using thousands of gallons of water. As EMTs, they’d use stethoscopes and pulse oximeters, and treat patients with nitro, aspirin and oxygen.

There aren’t many fields that encompass two entirely different disciplines and skill sets with such divergent and disparate cultures.

Even more challenging, most of the graduates didn’t come to their chosen professions having completed degrees in biology, physiology or even fire science. Some had been on battlefields in Iraq and Afghanistan, while others had worked on construction sites, ranches, in retail or the food service industry.

Graduation day meant that all of them had demonstrated their dedication, commitment and ability to successfully navigate the classroom and training environment. But I wondered: How many would embrace these two skillsets throughout the course of their careers? And so, I began to think deeply about the (red) elephant in the room, and why the unlikely marriage of Fire and EMS has had such a complicated past.


In reality, many firefighters go into this field for suppression and technical work. Most of their leadership came up through the ranks during a time when emergency medical calls didn’t make up 80% or more of the 9-1-1 call volume. That being said, it’s probably not too surprising that the integration of Fire and EMS hasn’t been a seamless one. It’s not just the cultural, political and economic bleeding or burning edge that separates us.

Both firefighters and dedicated EMS professionals are often uncomfortable with patient interactions. We often find ourselves managing complicated cases—maybe someone dying of cancer or heart failure, or perhaps a child who gets run over in the street. At first, we may not have a lot of our own experience to draw from, but I suspect the skills needed to handle a fire scene aren’t all that different from those needed to manage a dying patient.


Both Fire and EMS must be able to anticipate and manage what may be about to happen by employing common skill sets on-scene.

First, is communication. Containing a three-alarm blaze from inside of a burning building or treating a patient with a ruptured spleen requires effective communication with the crew, patient and family. You’ve got to figure out what’s going on, while providing them with the sense they’re in good hands.

Next, is courage—going into a multi-threat hazmat environment or helping a spouse who’s been beaten or abused by family members requires discipline and nerve.

Finally, both critical thinking and decision-making: How do you prioritize and manage multiple patients pinned in an unstable collapsed structure? What should you consider in an elderly hypertensive, diabetic patient whose only complaint is that he just doesn’t want to eat?

You can open any EMS textbook and find differential diagnoses for things like chest pain or shortness of breath, but there’s no chapter on “I just don’t want to eat.”

So that’s the problem in front of you, and it’s your responsibility to figure it out before, perhaps, you take a refusal and leave the patient on-scene. Maybe that patient has profound renal insufficiency from years of poorly controlled diabetes and hypertension. Now he’s in renal failure—a good reason to lose his appetite—because he has the flu and hasn’t been able to drink anything for a few days. By the time a second call comes in, you get there just in time to put an AED on and shock him, once his potassium has reached a high enough level.


The bottom line is that the skill sets and missions that seem so different on the surface may end up with common denominators. We have the same awesome responsibility in front of a burning building that we do in front of a patient who’s weak and dizzy.

We have to hone these skills with the same devotion and dedication, but with a slightly different edge. Once that happens, the guy who doesn’t want to eat may be as interesting to us as the four exposure size-up that’s about to come down. Who knows—the sense of gratification may even be the same, giving a little hope for where this field of ours is going.