Saved by the bell - Macleans.ca

Saved by the bell

The firefighter’s job is changing as ever more medical calls come in

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Every pump truck in Winnipeg has a cross-trained firefighter-paramedic

“Maisie,” an elderly Toronto woman whose chain smoking often leaves her gasping for air, is so well-known to the firefighters at the nearby station that when her address is announced on the loudspeaker, they all bellow her name. They lumber up the dark stairwell to her squalid apartment as often as three or four times a night. On this particular occasion, they listen to her breathing and give her oxygen. After the paramedics arrive, her colour improves. She signs a waiver, refusing to allow EMS to take her to hospital. On his way out, the fire hall captain empties an ashtray, and places a few dirty dishes in the sink.

While firefighters may be known more for their courage than caregiving, the reality, says Susan Braedley, a post-doctoral fellow at York University’s Institute for Health Research, is “they’re doing more emergency medical care than anything else.” In 2006, 52 per cent of calls to the Toronto Fire Service were medical in nature—a statistic that prompted Braedley to spend 10 months observing the city’s firefighters. Her research, which includes the visit to Maisie’s home, is slated for publication by the McGill Queens University Press next spring in a book entitled Neoliberalism and Everyday Life. According to Braedley, the “accidental assignment of some health care provision” to firefighters has been brought on by several factors: better fire prevention, which has freed up firefighters for other tasks; aging baby boomers; a dearth of family doctors, which has forced marginalized populations to use 911 as a way into the system. It’s a shift that has been subtle and the source of conflict. The result, however, is clear: in municipalities across Canada, what it means to be a firefighter is changing significantly.

Firefighters have long played an informal role in health care delivery. Until the ’70s, when formalized paramedicine became an integral component of emergency health care, they were often called upon to administer oxygen and deliver CPR. Though paramedics eventually assumed, and dramatically improved upon, pre-hospital care, firefighters continued to assist, particularly on calls where lives are at risk. (In some smaller centres, like Brandon, Man., and Lethbridge, Alta., the paramedic service grew out of the fire departments; today, members are cross-trained to perform all emergency rescue tasks.) With the push to improve survival rates for cardiac arrests—brain function begins to deteriorate after just six minutes—firefighters were called upon more often, in large part due to the speed at which they can arrive on scene. Due to pressure from home insurers, in urban areas, a pump truck is rarely more than five minutes away.

Today, the Toronto experience is hardly unique. In Prince George, B.C., where, according to fire captain and union president John Iverson, two-thirds of calls to fire departments are medical, “Everybody that gets into this business now fully understands it’s a huge part of their job.” To Iverson, increasing their medical capabilities just makes sense. So, last year, the Prince George fire service became the first in the province to increase the medical training of most of its members to Emergency Medical Responder (EMR) level. But because of provincial regulations limiting the degree of medical attention firefighters can provide, they’ve not been able to put their new skills to use. “We didn’t anticipate there would be such a bottleneck trying to get through the system,” he says. “From my members’ point of view, it’s extremely frustrating.”

According to Jim Lee, a former firefighter and the Ottawa-based assistant to the general president of the International Association of Fire Fighters (IAFF), “We’ve been trying, on an ongoing basis, to educate the politicians that we’re a resource that they should be using.” In 2002, the IAFF made a presentation to the Romanow commission, arguing that “the true potential [of firefighters] in the realm of EMS remains largely untapped.” But despite emergency room delays, which, in some municipalities, tie up ambulances to the point where not a single EMS vehicle is available for hours at a time, Lee says that, since 2002, not much has changed. “The political will is still not there.”

Though the specific guidelines that regulate the provision of emergency medical care vary, in both Ontario and B.C. firefighters are limited to basic assistance in life-threatening situations, such as providing oxygen to an asthmatic or applying a defibrillator to someone in cardiac arrest. But in B.C., change could be on the horizon: the province is reviewing regulations that govern what firefighters can and can’t do in emergencies, and, as a pilot project, Prince George firefighters will soon be allowed to practice some EMR-level skills under the supervision of a medical director.

But as they inch further into the realm of emergency medicine, firefighters also find themselves at odds with those whose reason for existence is pre-hospital care: paramedics. Darryl Wilton, president of Ottawa’s Professional Paramedic Association, decries the push by fire departments to take on more medical responsibility as partly “hard-core unionism” in the face of a “diminished primary function.” Some paramedics express concerns about medical oversight and training of firefighters: would-be paramedics must beat out fierce competition to gain acceptance into difficult college programs, which take years to complete. But beyond that, Ottawa paramedic chief Anthony Di Monte says he worries that summoning firefighters to a wider range of medical calls would detract from what they were trained to do. “I would be diminishing the suppression capacity in my city. What if there was a major fire?” Cardiac arrests, he says, make up a mere one per cent of the total EMS call volume.

Though the turf war does not play out on the ground, where, by all accounts, the interaction between emergency responders is good, it has caused some animosity behind the scenes. Dispatch times are a major sticking point for firefighters: in life-threatening situations, they say they are sometimes alerted after EMS, despite the fact that they can often arrive faster. EMS, meanwhile, says that fire is alerted the moment it is determined that lives are at risk. (The process varies, but generally a 911 call is answered by an attendant in a central location, who transfers it to fire, police or ambulance. In life-threatening situations, such as a heart attack, the ambulance dispatch forwards the call to police and fire. Likewise, in the case of a burning building, fire summons police and ambulance.)

Still, in pleading their case for a more formal medical role, firefighters often cite Winnipeg as an example of their services being maximized. There, after a decade-long attempt to amalgamate EMS and fire, the services reached an agreement in 2007. Though two separate streams, they are headed by a single chief, and dispatch is coordinated from one centre. Significantly, there is a cross-trained firefighter-paramedic on every pump truck: if firefighters find that EMS is not needed, they can tell ambulances, which are often in short supply, to turn back.

The new arrangement seems to be working. Last year, the fire trucks handled some 10,000 medical calls on their own. But the partnership didn’t come easy. The attempted merger saw relations between the firefighters and paramedics degrade to the point where, by the time a deal was reached, three unions had become embroiled in formal labour disputes with the city. According to Fire and Paramedic Chief Jim Brennan, the difficulty came from trying to homogenize two distinct workplace cultures, with different seniority structures, uniforms and senses of identity. Brennan, who in the 1960s worked for Frank Pantridge, the Belfast cardiologist who pioneered paramedicine, says he has a unique understanding of changing something as simple as a rank insignia: “When you do that, someone appears to have lost, and that causes conflict.”

But even informally, the cultural divide between fighting fires and tending to the sick runs deep. Of the 37 firefighters Braedley interviewed, “all but four expressed sentiments ranging from discomfort to outright rejection of their work in the health care provision,” which, she says, has “shaken the hyper-masculine core of fire services and firefighting culture.” As a firefighter in her study explains: “The things they’re asking us to do are so far outside the realm of what we anticipated, that you almost feel like ‘I’m losing some of what I was really meant to be.’ ”

But regardless of any apprehension they may have, firefighters understand that, for better or worse, their role evolves according to the public need. This need, it seems, is the reason Toronto firefighters continue to bound up Maisie’s stairs. As one member told Braedley, “Some people would say she’s a nuisance, but she needs help. There is no one else. So we do it.”