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Have Times Really Changed?

Kurt Lewin, recognized as a pioneer of social, organizational and applied psychology said, “If you want to truly understand something, try to change it.”

In the fire service, change and tradition can conflict, creating complicated challenges.

Fueled by an expanding mission that includes everything from prevention to active-shooter incidents (let’s call it what it is—domestic terrorism), the traditional need of the fire service has been questioned because actual fire calls have declined.

With growing responsibilities, our guiding principle of saving lives and property remains. We do it while acknowledging that we will risk a lot to save a lot and risk nothing to save nothing.

The most basic lesson of fire attack is to “put the wet stuff on the red stuff.” The simplicity of that lesson can be lost when we start factoring in offensive vs. defensive, two-in/two-out, or vent/enter and search.

In a continuing effort to reduce injuries and deaths, the science of fire ignition, spread and attack is continually studied. Recent research and live fire burns conducted by Underwriters Laboratories, the FDNY, the National Institute of Standards and Technology (NIST), the International Society of Fire Service Instructors and the South Carolina Fire Academy studied the effects of firefighting techniques and impact on vertical ventilation on fire behavior.

According to NIST, in the 1970s people had on average 17 minutes to escape a fire in the home. Today, escape time has been reduced to just three minutes, making prevention efforts and the need for smoke detectors and residential sprinklers more important than ever.

We know that modern building construction and furnishings result in higher interior temperatures, a faster probability of flashover and an increased possibility of collapse requiring us to rethink strategies.

Relearning What We Thought We Knew Was True

As a result of those experiments, we’ve learned that things ingrained into us as probationary firefighters, or used when scoring promotional fire simulations, are no longer true.

Applying a hose stream from the outside will not push the fire. Fire attack from the unburned to the burned side is no longer relevant.

There still needs to be coordinated fire attack/ventilation efforts but with emphasis placed on putting water on the fire first.

How We’ve Done It Keeps Changing

Putting the "wet stuff on the red stuff" is a basic firefighting philosophy that extends back as far as 6 C.E., when the Romans fought fires using bucket brigades. Get water on the fire is a simple attack principle we base the need for residential sprinklers on—the sooner the better.

From early history, when a member of a household was stricken ill or injured, we depended on the doctor to come to the home, to the bedside, to render a diagnosis and treatment. Evolution of medicine brought new tests, new technologies and equipment requiring the patient be brought to a hospital for advanced care.

Ambulances were used by the Spanish as early as 1487. Wars advanced their use, bringing the injured to receive treatment. Evolution of the ambulance resulted in the emergence of the rescue squad, initially often a group of volunteers called to your home with the single purpose of getting a patient to a hospital and a doctor. In many places, a hearse doubled as an ambulance.

Over time, that concept evolved; rescue squad personnel began to learn first aid, often taught by local physicians, and start treating patients. In many communities, the rescue squad became an expanded function of the fire department, introducing the world of EMS.

In Baltimore, Dr. R. Adams Crowley discovered rapid treatment and transport of multiple trauma patients; defining the "golden hour" resulted in increased patient survivability rates. Because of his work, Maryland developed the first statewide EMS system, using state police helicopters to transport patients. The first medevac transport took place in 1969.

In 1972, the TV show Emergency! showcased the fire-based paramedic program developed by Los Angeles County, setting a new, and later expected, standard of care. On Cape Cod, emergency room physicians Lloyd Bremer and Robert Riggen developed Massachusetts' first paramedic program with fire-based paramedics in 1974.

Today, as paramedics administer life-saving procedures and medications minutes after the initial 9-1-1 call is made, using helicopters in medevac is a recognized norm. Yet there are still many areas that don’t have access to advanced life support.

Why the history lesson? The proverb “the more things change, the more they stay the same” applies to the latest chapter in patient care.

Fire and EMS Redefined Once Again

Escalating healthcare costs, access to medical care and the Affordable Care Act are redefining the industry. One goal of the program is to reduce costs by eliminating waste and with that, abusers of the healthcare system who use the ambulance as a taxi or use emergency transport as a mechanism to bypass triage and be seen quicker in the emergency room.

Some states and other jurisdictions have already passed legislation and protocols defining parameters when patients no longer have to be transported by ambulance and can be treated on site or transported by other means—getting back to basics by utilizing emergency transport only when it's an emergency.

Defining Community Paramedicine

Though firefighters proudly boast that they still make house calls, with these changes comes a new concept EMS providers must prepare for: community paramedics.

At the 25th Congressional Fire Service Institute/National Fire and Emergency Services dinner, veteran actor Randolph Mantooth, known for his role on Emergency! and an advocate for emergency medical providers, speaking informally said, “We don’t even know what community paramedics are yet!”

He’s right; it’s still evolving and being defined. But community paramedics will be an extension of the healthcare system, and fire-based EMS, already making house calls, is ideally positioned to answer this new call. In April 2011, Minnesota was the first state to sign a bill establishing a statewide community paramedicine program; Wisconsin, Idaho, Colorado and Maine have followed with their own programs.

Defined by the American Nurses Association, the community paramedic is viewed as an extension to the primary care provider by delivering such services in the home as case management and nursing care, including immunizations, medication administration, wound care and patient education.

The concept is evolving, but it's coming. Why should we care? We should care because the fire service should help define what community paramedics are, what role they’ll play, how they’ll be dispatched and how we’re going to be reimbursed. It’s better to be a part of the planning process then to have this new mission thrust upon us with no additional resources or revenue.

Water on the fire and house calls—it doesn’t get any more basic.

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