Imagine that you’re the lead fire medic assigned to Rescue 15. You make a call with Engine 24 to an elderly patient who is being disruptive at a nursing home. The patient is 82 years old and uses a wheelchair. The nursing home staff tells you that he has been violent and noncompliant with his medication. The nursing home has durable power of attorney over the patient’s medical decisions, and the staff demands that the patient be transported to the ED for evaluation.
Captain Smith on Engine 24, also a paramedic, instructs you to give the patient 4mg/kg of ketamine IM in accordance with current protocol. You suggest that the patient might not need that much ketamine because of his age and other medical history, which includes renal failure and liver disease. Captain Smith insists. That’s when you give him that look. You know the one – the look that says, “If you weren’t a captain, I’d expose your lack of current medical knowledge.”
Captain Smith replies with his own glance. His body language says, “Don’t look at me in that tone of voice. I am a fire officer.” He is a captain. So you give the dose in accordance with protocol.
By the time you get to the ED, the patient is unresponsive and can no longer protect his airway. Now the ED physician and the nursing staff want to know why you gave this patient so much ketamine. “I followed protocol” doesn’t seem to lessen their critical body language. All you can think is, “Damn, I wish Captain Smith wouldn’t tell me how to take care of my patients!”
Authority-responsibility mismatches
Scenarios like this play out across America multiple times a day. Captain Smith created an authority-responsibility mismatch that caused a significant amount of unnecessary stress.
For tasks to be accomplished in an orderly, timely way by a group of people, someone must be in charge. And that person must be given the authority to compel others to accomplish the necessary tasks. This authority can be delegated to others, but the overall responsibility for completing the tasks cannot be delegated.
For example, if an inept company officer disregards standard operating guidelines (SOGs) at a hazmat incident and causes multiple civilian and firefighter casualties, then that officer has not fulfilled their responsibility. However, the fire chief has also not fulfilled their responsibility, even if they were not on the scene. If you want to know who has responsibility for any particular situation, ask yourself who is going to be blamed for a bad outcome. You can delegate authority, but your responsibility is your responsibility.
But Captain Smith was operating the way he was trained. Fire departments have hierarchal organizational and rank structures, and for good reason. At a structure fire, somebody must have the authority to make timely decisions and give orders. Ideally, those decisions are based on well-established best practices and the talents and experiences of the officer. We train our members to respect position and rank because there is no time for debate on the fireground. If Captain Smith orders his crew to begin evacuating an apartment building and the crew refuses, there will be dire consequences. Captain Smith has the authority to meet his responsibilities on the fireground.
When we apply this structure to EMS calls, the dynamics change because the transporting EMS providers are responsible for patient care. They are also the ones present to take the blame for poor outcomes. Of course, it’s a complicated issue. In our previous example, Captain Smith has the authority and the responsibility to intervene and direct patient care if his subordinates on Rescue 15 are mismanaging the patient. Captain Smith will also be blamed for a bad patient outcome, but only if it’s bad enough to warrant an investigation. These authority-responsibility mismatches cause fire medics great frustration. They cause poor patient care. They cause fire medics to quit the fire service. So what’s the solution?
Part of the solution is being aware of the problem. When patient care is mandated by a higher-ranking person on the scene, that individual should accompany the patient to the hospital. If nothing else, the officer should take the opportunity to provide subordinates with insight into their decisions and conduct meaningful coaching. Leaders should always stand up between their subordinates and external stakeholders who have issues with organizational performance. In other words, part of accepting leadership responsibility is taking the lumps for your crew.
One in the same
The landscape of the fire service has dramatically changed in the last 40 years. EMS calls now account for the vast majority of U.S. fire service responses, according to the NFPA (2021). One thing is clear: The U.S. public demands more responses than ever from the fire service, and that trend shows no signs of slowing down. The overwhelming majority of those calls are for EMS. However, most fire department organizational structures are still set up for fire suppression.
EMS was originally inserted into the fire service out of convenience. The stations were already there, and the people were willing. The organizations were already set up. But at the time of the integration, it was impossible to envision the massive shift toward EMS in the fire service. Our culture still seems to retain an underpinning of animosity toward EMS. But the fire service is EMS, with more U.S. EMS workers employed by the fire service than in any other sector (Rivard et al., 2020). But nevertheless, fire service culture seems to reflect a sort of self-loathing of who we have become.
Time to adapt
The fire service still has the same basic mission: Protect life and preserve property from all perils. The same public service motivation that prompted principled citizens to be firefighters in the early days still exists today. That motivation is to help people. Now more than ever, the fire service must find and recruit those principled citizens, and we must find ways to make the job bearable and rewarding. We can’t continue to drive off motivated newcomers with continuous frustrations.
It may be time for us to rethink the organizational structure for fire-based EMS. Could we implement a flatter organizational structure that encourages shared leadership and/or the development of high-performance, self-directed teams? Could the same personnel also revert to the traditional organizational structure for fire suppression, rescue, hazmat and other types of calls that require a more defined command?
The fire service cannot continue the schizophrenic practice of pitting fire suppression against EMS. We must acknowledge that the fire service is EMS and EMS is the fire service. Whatever direction we end up taking, one thing is certain. We must find ways to give our EMS workers the authority required to meet the responsibilities that they have accepted.
If you’re a seasoned fire service officer, you’re probably giving me that look right about now. Face reality, adapt to the changing times, and don’t look at me in that tone of voice. I am a fire officer.
