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The Ontario Professional Fire Fighters Association (OPFFA) has made proposals

to expand the role of firefighters into emergency medical care. In the latter
part of 2016, the Ontario Ministry of Health and Long Term Care (MOHLTC)
responded to the OPFFA demands by holding consultations on a more modest
proposal to expand the role of fire trucks and firefighters in emergency medical
services.

CUPE, as the representative of the majority of paramedics in Ontario, has


consistently opposed these proposals. The proposals raise serious issues of
the quality of care and costs.

The History: have significant negative consequences when


The first proposal in recent years on this used by those with almost no training.
issue from the OPFFA called for fire-medic
This first proposal drew significant criticism
instructors to undergo 16 hours of training.
and, perhaps, the OPFFA has recognized that
Upon successful completion of this training, they
it is not viable. In any case, in November 2015,
would train and certify a quarter of the current
the OPFFA developed a different tack. Noting
firefighters through a 20-hour course.
legislation which (for good reason) prohibits
While this proposal would increase OPFFA work, the practice of paramedicine outside of the
it obviously courted danger and death. It would highly regulated ambulance EMS system, they
amount to a dramatic reduction in expertise. proposed amending existing legislation to allow
Symptom relief skills should only be provided firefighters trained as paramedics that respond
by a fully certified paramedic, not by those who to medical emergencies to be able to use all
are focused on a completely different profession their training and skills at emergency medical
with almost no training or qualifications in incidents. The unifying point between these two
emergency medical care. Paramedics treat proposals from fire is that both would increase
patients in emergencies where lives are in peril. the work in OPFFA bargaining units.
The drugs the OPFFA proposed to administer

March 2017
In 2016, the MOHLTC responded by holding an Investigation, Complaint and Regulatory
consultations on a modified version of this Compliance program. The Ambulance Act
proposal firefighters who are trained and who contains standards for Ambulance Service
also work as paramedics at an ambulance service Certification, Ambulances and Communicable
could provide paramedic services when working Diseases, Ambulance Service Documentation,
as a firefighter. While this is a more modest Patient Care, Transportation, as well as Basic and
proposal it would open the door for more steps Advanced Life Support Standards. The provincial
later. The OPFFA has continued to call for a government requires public reporting of land
more aggressive intervention even after the ambulance response times.
government made this concession.
In sum, there are multiple levels of oversight
CUPE has raised with the government a wide and quality assurance of paramedic Emergency
variety of quality and cost concerns. Medical Services (EMS) in Ontario. Put simply,
this broad range of oversight and quality
control are missing for fire departments,
[A] Quality of Care firetrucks and firefighters doing emergency
medical calls. To have any possibility of
maintaining even somewhat similar quality
The necessary oversight of paramedic control, the provincial government would have
services is completely missing in fire to duplicate every bit of this oversight and
departments: intervene extensively into fire departments, a
With increasing demands from the public, part of municipal government which has, until
paramedic services have rapidly evolved over now, been largely free of provincial government
the last several decades. Both paramedic scope control. Even if this could be done (which is far
of practice and training has greatly expanded. from certain) this will mean, in most cases, that
Primary Care Paramedics must undergo two- a level of government (lower tier municipalities)
years college education and complete annual will have to develop tremendous expertise in an
on-the-job training to maintain certification. area that they have absolutely no experience in.
Paramedics now perform more controlled All of this is fraught with uncertainty, problems
medical acts than any other health care and expense.
professional except physicians. Paramedics
face oversight from their ambulance employers, Twenty-four hour shifts:
the provincial government, and base hospitals. Many firefighters work 24 hour shifts. Research
Extensive provincial legislation, regulation, and indicates however that such work hours can have
policy controls almost all aspects of paramedic serious consequences on judgement hardly
service. The MOHLTC oversees paramedics and making them appropriate candidates to make
may take steps up to and including removal of life or death medical decisions. The Ontario
a paramedics ability to practice. The province Association of Fire Chiefs and Ontario Municipal
also appoints base hospital physicians to oversee Human Resources Association released a paper
paramedics. These physicians may also limit or on 24 hours shifts noting that cognitive and
remove the ability of a paramedic to practice, physical performance declines after 16 hours and
or require additional training. The MOHLTC also gets worse after that, risk of accidents increases,
sets and enforces detailed ambulance, equipment and that workers who are fatigued cannot
and patient care standards. The ministry certifies estimate their own sleepiness. In addition, they
and reviews land ambulance operators under note firefighters who are awoken to respond
legislated regulations and requires peer reviews to a call may take 30 minutes to become alert
every three years. Paramedic call reports are and 2-4 hours to reach peak efficiency due to
audited by base hospitals for compliance with sleep inertia. Clearly, 24 hours shifts are not
legislated patient care standards and delegated appropriate for those making life and death
medical acts. The ministry also operates medical judgements in emergency situations.

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Problems of transfer of responsibility Interruptions:
from fire to EMS and the likelihood With great respect to our firefighting colleagues,
of tragic miscommunication in an the feeling among paramedics is that firefighters
emergency: are sometimes a distraction or sometimes
Designing an emergency medical system so even an impediment on emergency medical
that it requires a transfer of care (or handoff) calls. When paramedics are treating a patient,
from fire to EMS builds in significant risk that will firefighters are more and more often ignoring
lead in some cases to tragic miscommunication our direction that they absent themselves from
and error. Transfers of care are a key point the immediate scene so we can get on with our
of trouble in our medical system, even in the work. These interruptions disrupt our emergency
relatively sedate world of hospital acute care. medical care to critically ill patients. We do not
But tragic and life threatening miscommunication understand how this disruption and this attitude
is particularly likely in chaotic emergency can benefit the patient.
situations the core business of paramedicine.
Review Tiered Response:
Medical errors already account for thousands
Fire response should be narrowed to only those
of deaths in the Canadian health system, so
areas where there is some scientific evidence
designing the system in a way that increases
that a fire response will make a difference.
the risk of error is a serious problem.
Fire responds more slowly to many emergency
The requirement to pursue two medical calls and it is not beneficial to the patient
separate and very different to have firefighters disrupting our care to a
critically ill patient.
professions will inevitably increase
the off the job training time for Fire chiefs and other fire managers are
firefighters while also decreasing not qualified to oversee paramedics.
expertise: Competent management is a bare minimum for
Firefighter paramedics will require more time the adequate provision of paramedic services,
off the job for training as paramedics require but, unless they have spent years working as
significant ongoing training simply to maintain a paramedic, fire chiefs and their subordinate
their certification as paramedics. Yet, because managers cannot possibly meet even this
they will be required to perform two very minimum competency. In many cases fire
different professions, firefighter paramedics will chiefs will not even have the foggiest idea of
inevitably have less experience and therefore what a paramedic should do at a given time.
less expertise. The overwhelming trend has been They will not be able to appropriately direct,
to increase the skills, training, and qualifications instruct, engage, mentor, or discipline firefighter
of paramedics, so the proposal to have one paramedics and they will not be able to oversee
person do two very different professions is appropriate quality assurance programs. More
likely to become increasingly problematic. over, under privacy laws a fire chief would not
even have the right to access a patients record
Sending fire trucks on unnecessary so there is no possibility for that fire chief to
calls on overcrowded roads is going evaluate a paramedics work.
to lead to some accidents.
In the United States, it is reported that motor The OPFFA does not appear to be
vehicle crashes are the second leading cause satisfied with this proposal and so
of death for on-duty firefighters. Firetruck more conflict seems likely:
crashes, occurring at a rate of approximately We note that in our review of the public media
30,000 crashes per year, have potentially dire comment from the OPFFA on this issue, we
consequences for the vehicle occupants and have not seen strong public support for the
for the community if the firetruck was traveling governments proposal. On our review of their
to provide emergency services. comments to the media, the OPFFA has instead

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focused on more aggressive take overs. Even Provincial funding:
as this proposal is being considered they have For municipalities, however, the extra cost is
talked of firefighters who merely have some larger, as half of municipal costs for ambulance
paramedic training (and so who are not certified, paramedic services are funded by the province.
working paramedics) providing emergency Fire costs are not funded by the province.
medical care. We can only conclude that far As a result, one hour of fire service costs a
from resolving the problem, this proposal is municipality $224.50 more than one hour of
only a stepping stone into emergency medical ambulance paramedic service ($331 - [$2132]).
care. Encouraging this step likely will only That is nearly $2,000,000 more per year at the
encourage years (and probably decades) of municipal level to use a fire vehicle rather than
conflict between paramedics and firefighters. an ambulance.
Firefighters and paramedics work together
every day in emergency situations. Such ongoing Fire truck and fire staffing costs:
conflict cannot be good for the quality of care. Fire trucks are extremely expensive to own and
operate and this is no doubt a significant part
of the extra costs associated with fire service
[B] Extra Costs delivery. But it also has to do with the large
number of firefighters that attend medical calls
on a single fire truck and the relatively large
Cost per hour of service: number of fire managers.
As is made clear in the ministrys own discussion
paper, service by fire departments is much more Cost savings through rational
expensive per hour than service by EMS. The planning for services:
ministry shows that the average cost for fire The ministrys discussion paper also raises
department service is $118 more per hour than another point: the long-term decline in the
ambulance service, a 54% cost increase. If a fire number of fires and fire related calls and the
vehicle replaces an ambulance for one year increasing number of emergency medical
(24 hours x 365 days) the extra costs will be calls. Several municipalities have responded
over $1 million. to this by reducing the number of firefighter
positions. There has also been a marked move by
municipalities to reduce the number of medical
calls that fire responds to based on

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a lack of scientific evidence of medical benefit. More capital equipment costs for
We strongly oppose the layoff of firefighters and fire departments:
as far as we know there have been none recently. Paramedics need the equipment in their trucks
But municipalities have an obligation to rationally to respond this costs many thousands of
plan their spending. The province should not dollars per paramedic. Significant retrofitting
encourage obstacles to that rational process. of the fire trucks will be necessary to secure
narcotics and carry the necessary equipment in
Extra time wasted on the scene: a safe fashion. The time required by paramedics
Typically fire trucks respond to medical calls
for checks at the beginning and end of each
with four firefighters on each truck (EMS
shift (e.g. counting narcotics) will reduce the
response is typically two paramedics, and
ability of that fire truck to respond to fires. Fire
in some cases only one). So fire response is
departments will need computer hardware and
inherently inefficient, but this will be made
software to document and share information
worse by having a firefighter paramedic as one
with EMS. Fire will also need access to secure
of the four. Unlike a firefighter first responder,
servers to keep patient information confidential.
the firefighter paramedic could be consumed
by the call for some time and cannot abandon As of March 13, we are still awaiting a
their patient. This will hobble the ability of their response from the government on their
fire truck to respond to actual fires. consultations.

March2017:cope491:djk