Megan O’Toole Jul 16, 2011 – 11:46 AM ET
( by Megan O’Toole, the National Post)
The man has fallen about 30 feet downhill, a young woman explains in a rush, and his right arm is bleeding.
Emergency medical dispatcher John Lynas has been answering these calls for close to three decades. On the other end of the line, inside the Dufferin Street 911 call centre, he calmly instructs the woman to keep pressure on the wound, to watch for signs of worsening, to wait for help.
Moments later, it arrives: “Flag that fire truck!” the young woman exclaims.
While paramedics may be more fully equipped to handle medical incidents, Toronto Fire Services often beats ambulances to the scene, reflecting the department’s greater resources and a dramatic shift in its caseload over the years, away from fighting fires and toward rushing to medical emergencies.
Rather than dispatching massive, expensive fire trucks to such calls, critics say, the city would be better served to put more ambulances on the road. Citing the shifting emergency burden, a recent report by city-commissioned consulting firm KPMG points out response times for Toronto Emergency Medical Services have been deteriorating while the fire service has remained consistent.
A half-century ago, nearly 50% of the calls coming into Toronto’s fire department were fires. That figure has dropped steadily: Last year, just 1% of about 150,000 recorded incidents were fires. Mirroring a countrywide trend, the bulk of calls were medical, with the remainder including false alarms, vehicle accidents, rescues and a host of other situations.
“Fire’s main role in the [emergency medical] system is to stop the clock,” argues Toronto Paramedic Association president Geoff MacBride, alluding to provincial response-time standards. While the arrival of a fire engine may indeed “stop the clock” that starts running when someone dials 911, that does not mean its response is genuinely useful.
“Anecdotally, [a majority] of the time, we’ve shown up and fire has literally done nothing except perhaps acquired a name, tried to determine what’s going on and they provide that report to us,” Mr. MacBride says.
The increasingly fire-free mandate of Toronto Fire Services came under renewed scrutiny this week after KPMG suggested merging fire and ambulance services, as has been done in other Canadian and U.S. municipalities with varying levels of success. The potential cost-saving measure is politically fraught, particularly within the emergency response sector itself, dredging up old rivalries stemming from a common paramedics’ complaint that the city’s budget is skewed in fire’s favour.
“Fire has twice the budget, but the largest majority of calls for service are for EMS,” notes the KPMG report, which contains a series of potential cost-saving measures to help fill Toronto’s $774-million budget hole. A merger, it suggests, could save up to 20% on the city’s budget for fire and EMS.
The report also recommends reducing the range of medical calls to which the fire department responds. Currently, firefighters are dispatched for all serious medical calls as well as some less serious incidents.
The consultants acknowledge the political difficulties inherent in a merger or shift of responsibilities: “Cultural issues, the history of the services, the pride of service and the high esteem with which the services are held are all major barriers to change.”
Toronto’s population has risen by more than one million people in the past half-century. Yet the number of fires has fallen, from 3,700 in 1960 to just 2,239 last year — a drop experts attribute to better building materials and fire-prevention measures.
Over that same time period, the number of employees at Toronto Fire Services has nearly tripled, in large part because of the 1998 amalgamation of six municipalities into one city of Toronto. Accompanying that rise was a massive upsurge in the number of total incident responses: from fewer than 8,000 in 1960 to more than 150,000 last year, according to data provided by the fire service.
More than half of the fire department’s calls are medical, fuelling grumbling among paramedics that fire’s funding — $374-million in 2010, more than double that of Toronto EMS — is inequitably high considering the realities on the ground. The fire department has almost triple the staff of Toronto Emergency Medical Services, and the city has 82 fire stations but 45 ambulance stations.
A paramedic speaking on condition of anonymity says the fire service is “almost invariably” first on scene at medical calls, thanks its superior resources. He compares the fire department’s role in medical calls to that of a lifeguard: “They do first aid, they do CPR and they put oxygen on somebody. And the lifeguards get paid a hell of a lot less than firefighters do.”
Mark Ferguson, president of the union representing Toronto paramedics, says internal studies by Toronto EMS show firefighters are only needed at a tiny fraction of the medical calls they attend. Rather than merging the two services as the KPMG report recommended, Mr. Ferguson believes the city should eliminate firefighter first response to medical calls.
“It doesn’t make sense to send four firefighters and a million-dollar pumper to a call that can be serviced by a single, highly trained paramedic,” Mr. Ferguson says.
Toronto Fire Chief William Stewart disagrees, arguing the fire department plays an integral role in the medical system. Because of the large network of fire stations in the city, designed to ensure a four-minute road response time to fires, the department is inherently better positioned to respond first to medical calls. Once there, firefighters can begin life-saving treatment.
“What people don’t recognize is the wide range of expertise and emergency skills that come from firefighting. We do firefighting operations, provide a variety of rescues, vehicle extrication, hazardous materials mitigation, search and rescue, ice and water rescue, medical response and intervention -and we’re just naming a few,” Chief Stewart says.
Vehicle accidents, meanwhile, have been another bone of contention between firefighters and other emergency workers.
A veteran Ontario Provincial Police officer glances in the rearview mirror of his parked cruiser as he jots down a few notes on an accident reporting form. Across the top, he writes: “Fire was told not to attend.”
He complains to the two strangers whose cars collided minutes ago on Highway 401 of his frustrations with Toronto Fire, who are also on scene.
He accuses the department of rushing to highway accidents unnecessarily, clogging the roads with massive fire trucks while offering little concrete assistance.
“We’re in a war with the fire department,” he says.
Officially, a spokesperson for the OPP denies the system is fundamentally flawed. Kimberly Wood of the Toronto Police Service says it is important to “err on the side of caution.” In some cases, firefighters are required at accident scenes to assist with victim extrication or to clean up hazardous spills.
But the unprompted remarks from the veteran OPP officer suggest other emergency workers in the city, beyond paramedics, are seeking change.
Alan Hills, acting co-ordinator of the pre-service firefighting program at Seneca College, says the clear “duplication of service” must be addressed swiftly.
“[We] need to be able to streamline the services to be able to give the best value for the taxpayer,” Mr. Hills says. “I think all three services — police, fire and ambulance — would agree that we could use our resources a lot better than we are now.”
The city’s recent KPMG report says the current dispatch process is designed to err on the side of “over-response” and could benefit from a more “risk-based approach.”
Mayor Rob Ford did not respond to questions on whether he supported some form of restructuring, but his government has already asked the fire service, along with all other government departments, to find ways to trim 10% off their budgets as part of a deficit-reduction strategy.
Ed Kennedy, president of the Toronto Professional Firefighters Association, says his group opposes any reductions in fire staff, but agrees there could be merit to a discussion on restructuring.
“I have no problem with the stakeholders talking about fire and EMS sitting together to see if we can deliver our services better,” Mr. Kennedy says. “Whether or not it means actually merging them, I don’t know.”
At the Dufferin Street 911 call centre, Mr. Lynas, in his 29th year as a dispatcher, watches a monitor showing the number of available ambulances in the city. With each passing moment, it drops: 26, 25, 24. It regularly falls below 10, he says, and several times a week, it hits zero.
“It’s always a concern,” Mr. Lynas says. “It could have serious consequences to someone who needs an ambulance right away.”
Toronto EMS Chief Paul Raftis says the need for ambulance services will rise exponentially in the coming years as the city’s population ages, placing a heightened burden on the already overtaxed health-care system.
“Looking at EMS into the future, we’re going to need to deal with the rising call demand. There’s no question about that,” he says. Many among the rank-and-file believe they know where the extra resources could be found.
Mr. MacBride readily acknowledges all emergency workers in the city play a vital role. However, paramedics in his association have grown weary, even resentful, of the funding gap between the fire and emergency medical services.
“Could some of that funding be refocused to reflect the realities of what’s required in today’s world, meaning not too many things burn but a heck of a lot of people get sick and injured?” he asks. “I think that’s something that’s very, very relevant.”
As part of Toronto’s tiered response system, fire and ambulance are both automatically dispatched to Delta and Echo calls, the two most serious classes of injury. Police also attend Echos, and all three services attend highway accidents. For less serious calls — Alpha, Bravo or Charlie — dispatchers can make a judgment call. The system is designed to ensure speedy responses to potentially lifethreatening situations.
Proponents of the system call it world class, and say it leads to better patient survival. All that matters, they argue, is that someone gets to the scene fast to begin basic life support.
A key difficulty in the debate is the dearth of reliable data to indicate how often firefighters’ response to a call turns out to be unnecessary.
Brian Schwartz, senior advisor to the Sunnybrook Osler Centre for Prehospital Care and a member of the city’s tiered response committee, says the body has no figures to show how many fire service responses are unnecessary. It is gathering data, however, with results expected in the fall.
Dr. Schwartz points out that even when firefighters cannot perform the necessary medical intervention, they can assist in other ways, from gaining entry to buildings to holding elevators for paramedics.
The idea of a full-fledged merger of Toronto’s fire and ambulance services is controversial but not new. During the mayoral campaign last summer, candidate and former health minister George Smitherman proposed a friendly takeover of Toronto EMS by Toronto Fire, suggesting it could save both lives and money.
He still favours such a move, citing the possibility of paramedics riding on fire vehicles, or firefighters acquiring more advanced lifesaving skills. While each service has a “territorial interest” in staying independent, Mr. Smitherman says, the question of which service should respond when “needs to be resolved in the public interest.”
In some respects, the services have already started working more closely together. Police stopped attending medical calls that were not imminently life-threatening years ago, scaling back Delta calls to a dual fire and EMS response.
Because of fire’s extensive coverage area — stations were historically situated close enough together that a horse and carriage could dash to any scene without running out of breath — ambulance services have increasingly housed their services out of local fire stations. In addition to possibly boosting response times, the measure saves operational costs. In Toronto, 11 EMS stations are colocated with fire stations, and two in police stations; in Mississauga, four of 20 fire stations are co-located or being considered for co-location.
“It’s an opportunity to save costs on real estate and servicing,” says Mississauga Deputy Fire Chief Kevin Duffy.
In other major cities, such as New York and Winnipeg, fire and EMS have undergone full mergers, with differing levels of success. In Edmonton, EMS was brought under fire’s umbrella in the early 1980s, only to be separated months later in an experiment Mr. MacBride terms an “absolute failure.”
In Winnipeg, however, the merged model appears to be working. Jim Brennan, chief of the Winnipeg Fire Paramedic Service, explains that dispatchers are trained to take both fire and EMS calls, ensuring “the right resource mix” for each emergency.
“All of our trucks carry one licensed firefighter paramedic, so they can arrive very quickly and they can assess the situation and render care right away,” Mr. Brennan says. Ambulances are then dispatched as required. The streamlined system cuts costs by close to $1-million each year.
The Winnipeg transition was not without its hitches, Mr. Brennan acknowledges. Tribal rivalries between the services festered; there were disputes over matters as simple as which service should be listed first in the merged name.
“There’s a lot less tension than there used to be,” Mr. Brennan says, “but it takes a long time to overcome those kinds of identity problems.”