Topeka Considers Fire Department ALS

Topeka city and fire leaders are looking into different means of providing emergency medicine to city residents – specifically, letting their already-certified paramedics work in that capacity from firetrucks.

Fire officials laud the effort as an attempt to provide better services to the community. Equipping first responders already trained as paramedics would mean delivering higher-level care faster to those in medical emergencies.

“We would like to untie their hands and afford them opportunities to practice at the scope of their training and acknowledge their skillset,” said Fire Chief Greg Bailey.

Bailey and Deputy Chief Greg Moody didn’t know how many calls that would open up for the fire department, or the costs involved in making the transition, but, Moody said, ideally, the move would be budget-neutral.

Others in the industry question the cost-benefit of equipping fire trucks with $30,000-plus worth of equipment per vehicle – not to mention insurance and wage bumps – with no proven benefit to patient outcomes.

“It sounds great on the surface, but you run into larger logistical issues and operational issues,” said fire/emergency medical expert Art Hsieh.

Current Practice

Current practice prohibits firefighters certified as paramedics – some of whom are employed by the county’s private ambulance provider, American Medical Response – to act as such while on duty with the fire department.

Making the transition would require the Topeka Fire Department become certified and equipped to provide advanced life support, or ALS.

Currently, Topeka fire employees can offer basic life support, or BLS. That basically limits them to bandaging wounds, splinting broken bones, administering oxygen, giving aspirin and using automated external defibrillators during cardiac emergencies. Nationally, first responders and emergency medical technicians can provide BLS after 80 and 160 hours of training, respectively.

Advanced life support, however, is invasive medicine, Hsieh said. Paramedics can start IVs, inject medicine using needles, insert breathing tubes – all of which require life-saving, or potentially life-ending, skills.

“It’s really difficult to kill someone as an EMT, whereas almost everything a paramedic can do, if done incorrectly, can result in a catastrophic mistake,” he said. “The liability goes way up for a paramedic practitioner.”

First-responder advanced life support has an appeal. For one, the fire department isn’t putting out many fires anymore.

Last month, 54 of its 1,661 calls related to fire, but four out of five of the calls in August required emergency medical services.

Shawnee County medical protocols, which were updated in May 2012, allow fire department staff to perform ALS if supervised by a practicing paramedic – a transport paramedic with AMR, for example.

Further down the line, Bailey and city officials envision a fire department that can provide ALS without supervision from a private ambulance service. That effectively would limit AMR service only to transports, and that is fine with the fire department. The fire department doesn’t have an interest in providing transports and would require a private contractor to continue to do so, even if the transition is made, Bailey said.

The fire department so far has had preliminary discussions with a consultant and Arizona-based Rural/Metro, a private fire and ambulance service provider, for insight into transition.

“We still don’t know if this is going to be something that’s good for us,” Bailey said. “If we don’t ask, if we don’t explore, then we would be remiss.”

Cost-Benefit

Neither Moody nor Bailey were able to say how many ALS transports AMR provides in a year, and records kept with Shawnee County emergency management didn’t provide insight, either. For 2013, records show, AMR responded to 13,135 calls inside the city limits and 2,071 outside. Records don’t include whether ALS was needed.

Neither could they speak to what costs the city could incur with the change. Bailey also didn’t know what potential revenues there could be, but said the city isn’t interested in billing.

“Ideally, we are only looking at something that would be budget-neutral,” Moody said. “We’re not looking at something that’s going to cost more to provide that service.”

A budget-neutral solution doesn’t seem likely, Hsieh said.

He teaches at a paramedic education program at a California community college, and since 1982 has worked both as a medic and a chief officer in private and fire-based emergency medical services.

Providing ALS includes a host of capital costs, he said.

Equipping one fire engine with advanced life support supplies can run anywhere from $25,000 to $35,000, Hsieh said. Other equipment and prescriptions tack on another few thousand dollars to that cost.

Also, becoming a paramedic requires an average of 1,500 hours of training – 10 times the amount for the average EMT – not to mention at least another 48 hours every two years in continuing education. As a result, firefighters in other parts of the country who become ALS-certified have received between 5 percent to 15 percent wage increases in addition to continuing education funding, Hsieh said.

Other costs range from the higher liability assumed by the city to a likely jump in workers compensation.

In short, Hsieh said, giving firefighters advanced life support capabilities is a costly venture – one that usually falls to taxpayers.

County Effect

If it is ALS they want, AMR can help Topeka fire employees become certified, and, in fact, has offered to do just that a number of times, said Ken Keller, who runs the county’s AMR system.

The fire department hasn’t yet reached out to AMR about the transition, Moody said.

Shawnee County paid a subsidy of $837,000 to the AMR service last year. That was cut by $100,000 for next year, after commissioners contended the for-profit AMR was making enough of a “fair profit,” according to the contract.

The county’s contract with AMR ends Dec. 31, 2016, at which point, the county likely will put the services up for bid. In counselor Rich Eckert’s time with the county, any time it looked at ambulance services, the county considered response time within the city, response time outside the city and the overall county subsidy. Likely, he said, those three factors would come into play with any new contracts with the county.

“I’d never have a problem with shopping to see if there’s something better,” Eckert said. “I support what the city’s doing, as long as we can continue to provide at least the same level of services we do now. We don’t want to get into a situation where we’re paying more for the same or decreased level of service.”

If the city finds a separate service for its transports, the rest of the county would be at risk of losing ambulance services, Keller said.

Ambulance transports within Topeka make up more than 90 percent of AMR’s business. If the city was carved out, AMR likely wouldn’t stick around.

“If we had no opportunity to transport at all within the city limits, I think it would be very hard for us to continue to exist in Shawnee County,” Keller said. “It would spread us out so far, we couldn’t have good response times.”

It also could jeopardize the company’s services to Wabaunsee County, he said, though Linn and Johnson counties probably could be maintained.