Posted with permission of Dr. MacNamara.
June 26, 2010
Dr. Martin McNamara,
Dear Mr. Smitherman;
I was somewhat surprised as I read your recent comments with regards to a “Fire/ems” model of prehospital care. I must say that, in your previous role as Minister of Health, you won my respect. I admired the manner in which you arrived at difficult decisions using evidence and facts from a variety of sources. To read that you have based this service altering decision on an opinion piece developed by a special interest group such as the IAFC ( International Association of Fire Chiefs ), without input from all participants, was disheartening, to say the least.
I would respectfully offer the following facts for you to consider:.
The EMS average response time to high priority calls is 7 minutes and 32 seconds, not 12 minutes as you stated. More than half of all cardiac arrest have the EMS team apply their defibrillator first, before other first responders. In 50% of high priority calls, EMS arrives before or at the same time as Fire. 5.6% of all cardiac arrests in Toronto survive to discharge not 2.5% as you were quoted.
In 26.7% of arrests in Toronto, the paramedics are able to restore a heartbeat before arrival at the hospital.
One of the difficulties in determining response times is that various agencies record their times in a variety of ways, making comparisons difficult. Fire starts the clock when the pumper leaves the station; EMS starts the clock when the call is received.
If you are truly concerned with improving outcomes, there are other avenues. In some European countries, ALL licensed drivers are legislated to be current in CPR, effectively making their entire population First Responders, not being wholly dependent on allied agencies such as Fire and Police.
If the purpose of the exercise is truly to get an Advanced Care Paramedic to the patient in a minimum of time, there are much faster and safer methods than on the back of a pumper with four Fire fighters.
Less than 5% of emergency calls require Advanced Life Support. The most effective method of providing this service is to place the ALS medics in rapid, small, first response vehicles. Some jurisdictions use motorcycles, others, small, agile cars. In this manner, an ALS medic can arrive within the shortest time frame and begin care while assessing the scene and determining the type of support needed.
Research has shown that brain death occurs in 4-6 minutes. We know that we must get a responder to the scene within this time frame to be effective. We also know that the fire department strives for a 4 minute response time and have their halls conveniently placed appropriate distances to achieve this. The question is why? Insurance actuaries have calculated that a 4 minute response time is as effective as a 7 minute response time and does not result in more property loss. This is reflected in the premiums calculated for both homes and businesses. Accordingly, one can conservatively estimate that 1/3 of fire halls could be decommissioned with no resultant loss of property. Imagine the savings here.
Consider further, if you will, the fact that Fire Departments run at a staff to:management ratio of 4:1 whereas EMS averages 9:1. Which system is more cost effective?
Consider that Fire deployment is based on a static model simply because businesses and property don’t move. EMS is based on a dynamic model, vehicles and staff moving hourly with the population they serve as commuters flow into and out of the city.
Consider that Fire has effectively bargained that each fire truck MUST have four Fire fighters around the clock, regardless of call volume. EMS upstaffs for peak hours and downstaffs during slower times, again presenting a savings to the tax payer.
Fire fighters in Toronto are allowed to work 7 twenty four hour shifts per 28 days, with a built in 8 hour “rest” period and get the rest of the month off.
I have attempted to highlight for you some of the more obvious problems with a U.S. styled, Fire/EMS system. An entire tome could be written describing the differences between the two cultures, the differences in training, education, liasing with Base Hospitals, differences in their respective approaches to patient confidentiality, approaches to treatment of patients, medical directives, continuing medical education, etc.
I would be pleased to meet with you and discuss some of these at your convenience.
Once again, know that I have long admired your approach to medical problems in your previous role as Minister of Health and certainly appreciate the fine work you completed in that role. I find these latest comments poorly researched and certainly out of character for you. I must express my disappointment in your presentation.
Respectfully,
Dr. Martin McNamara. CCFP/EM
