Fire and EMS 1

Running header: Fire and EMS

The Development of Fire and EMS

William W Nelson
Glen Allen High School

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Introduction
Emergency Services have made a great transformation since the times of
Benjamin Franklin and his local fire brigade in the 1750s, Emergency Services in todays
modern society use some of the most state of the art technology and based off the most up-todate research. However, the same cannot be said in every agency across the United States. While
todays modern urban cities have made the transition to the cutting edge of emergency services,
while rural agencies have been left in the dust. Urban fire and EMS departments today have
extremely small response times to when they can get water on a fire to care to a patient, while
rural systems can have response times closer to an hour, that is if water does even make it on the
fire or if the patient is still alive. Todays Emergency Medical Services have moved from strictly
direct pressure in bleeding control protocols, where you hold pressure on a wound until it stops,
to using tourniquets and hemostatic agents as well as Advanced Life Support and advanced
pharmacology. Fire Services have moved to foam instead of water and extremely technologically
advanced apparatuses. Not all people across the United States receive the same quality of
Emergency Services. Advances in Emergency services have greatly increased the quality of
patient services and differences across demographics have greatly varied the quality of services.
EMERGENCY MEDICAL SERVICES
History
Emergency Medical Services (EMS) according to John Page in his History of Emergency
Medical Services goes into depth about how Napoleon and his army were the first to implement a
protocols and triage system for the transportation of patients, which laid the ground work and
allowed for the birth of EMS. The first non-military ambulances were placed on the streets in

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1895, as well as the establishment of the first volunteer rescue squad in 1922 in Roanoke, VA. In
1960, Cardiopulmonary resuscitation (CPR) was shown to be efficacious (Page 1997). After
proven studies in European countries such England and France, CPR eventually made its way to
the United States in major cities such as Miami and Los Angeles. Following the 1960s and the
implementation of CPR in the United States, survives rate of witnessed cardiac arrest increased
by a total of fifty-six percent (Page 1997).
Apparatus
In todays EMS many different types of ambulances are used to get the lifesaving
treatment and resources to the people that need it. Ambulances are spilt into four different types
and all the different types have different abilities and purposes. Types I ambulances have their
boxes mounted to medium-duty truck chassis and normally host an array of advance life support
supplies. Type Is are used by volunteer and professional emergency response systems in the
same and are especially prevalent in airports and other industrial settings. Type II ambulances are
long wheel based vans with raised roofs allowing for enough room for patient care. Most type
IIs only carry basic life support supplies because of their purpose as private and long-distance
transport vehicles. Type III ambulances play the same purpose as type Is except type IIIs boxes
are mounted to cut-away van chassis and most have the option of being gasoline or diesel fueled.
Lastly, Type IVs are mini-ambulances built of ATV style chassis and its compact design enables
[operators] to maneuver in areas that conventional emergency vehicles cant access and therefore
greatly reduces your overall response times (Metronix 2012). Type IV ambulances can be used
in events with large crowds or in situations with difficult terrain.
EMS also using an array of special service vehicles in order to accommodate for special
populations such as the critically ill and the obese populations. Bariatric (obese) ambulances are

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modified with extra-wide interiors and specialized lifting gear; including large mats, winches,
and specialized bariatric stretchers in order to make for the safe moving and transport of obese
patients weighing over 300 lbs. (Triggle 2011). Critical care ambulances are also becoming
increasingly more popular because of the increased need to transport critically ill patients from
small emergency rooms to larger better equipped facilities. Critical care ambulances can carry a
wide variety of personnel including doctors, Registered Nurses (RNs), Respiratory Therapist
(RTs), as well as paramedics and EMTs. EMS also utilizes Quick Response Vehicles (QRVs) that
are non-transport vehicles that can get highly trained personnel to the scene of emergencies and
treat acutely ill patients in a times typically faster than an ambulance can. QRVs can be cars,
SUVs, motorcycles, ATVs, or even bicycles.
Levels of Certifications
There are two different types of certifications that individuals can hold in EMS:
individual state certifications, that are only valid in the tested states, and National Registry
certifications, that are national across most states and hold reciprocity across states lines. States
certifications are the minimum qualifications that a provider must hold in order to practice in a
certain state and before the inclusion of National Registry, each of the fifty states had their own
testing process and course curriculums. The National Registry system and the integration of it
has allowed for the nationalization of training and course curriculum allowing for nationwide
improvements in the quality of care. The transition to national registry is due to great differences
in the levels of training and care between states. The standardization of training allows for the
ease of transition when providers move from state to state. While most states have adopted the
National Registry and their guidelines some have not including New York, Montana, and
Wyoming.

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The National Registry system consist of four different levels of certification and all the
different levels have different amounts of training. All levels of training consist of two different
types of testing: psychomotor (skill based) and knowledge based. Once both sections are passed,
candidates receive a certifications; NOT a licensure. The four levels of certification are spilt into
2 different sub-categories: Advanced Life Support (ALS) and Basic Life Support (BLS). Basic
Life Support providers have the ability to provide initial stabilization of a patient and have
abilities [that] are essential to a positive medical outcome (Hicks 2011). ALS providers have
the ability to provide the initial stabilization like BLS providers; along with administer more
than 30 advanced medications and medical procedures (Hicks 2011). The first level of training,
Emergency Medical Responders (EMRs), have the ability to perform non-invasive interventions
to reduce the morbidity and mortality associated with acute out-of-hospital medical and
traumatic emergencies (NHTSA 2007). EMRs are the only level of certification that hold a
duty to act clause in their scope. This means that if an EMR can be identify by another
individual while in the presence of a medical or traumatic emergency, legally and ethnically they
must act and render care. EMR are not designed to be the highest level of care a patient receive
and that is why they are unable to claim sole patient care and transport patients (NHTSA 2007).
The next level of certification is the Emergency Medical Technicians (EMT), EMTs are
responsible for the acute management and transportation of critical and emergent patients
(NHTSA 2007). In rural areas, EMTs provide the highest of out-of-hospital care available. EMTs
have the ability to perform all of the skills of an EMR, plus the ability to transport and immunize
the risk of secondary injury; this allows EMTs to be considered BLS. EMTs are trained to make
decisions on the disposition of patient with limited medical oversight and training.

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After EMTs are Advanced Emergency Medical Technicians (AEMT) which can provide
basic and limited advanced skills focused on the acute management and transportation of
critical and emergent patients (NHTSA 2007). AEMTs are expect to be proficient in all BLS
skills of EMTs, along the knowledge of basic and some advanced skills and pharmacology.
AEMTs are amazing for low risk and rural EMS systems because they can perform lower risk,
high benefit advanced skills that can ultimate reduce the risk of death and morbidity (NHTSA
2007). With AEMTs ability to perform invasive skills such as establishing Intravenous access,
they are to be considered ALS providers. The highest level of pre-hospital care available in the
United States is the Paramedic (NRP), they provide a broad range of BLS and ALS skills
including all those of EMTs and AEMTs, but as well as invasive and pharmacological
interventions to reduce the morbidity and mortality associated with acute out-of-hospital medical
and traumatic emergencies (NHTSA 2007). The skills that paramedics perform are considered
to be high risk and if perform incorrectly or inappropriately have to ability to contribute to the
likelihood of mortality and morbidity instead of help it. With Paramedics ability to perform a
broad range of ALS skills and ability to make pre-hospital medical decisions with extremely
limited medical oversight, they are to be considered top tier ALS providers.
While most states recognize the National Registry, they also have individual levels of
states certification that hold reciprocity to the National Registry levels. In the state of Virginia,
the level of EMR, EMT-B and EMT-P hold complete reciprocity to their national Registry
counterparts: EMR, EMT and NRP. Virginia also includes levels such as the EMT-E which is
similar to the AEMT, but with a more limited set of advanced pharmacology. Another level of
certification available in Virginia the EMT-Intermediate, they can do most of the skill a

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paramedic can excluding nasal and pediatric intubation, cricothyrotomy and also have a more
limited set of pharmacology.
Techniques
There is a broad range of BLS skills that can be applied during emergent patient care that
can greatly improve patient outcome. EMRs and EMTs have the ability to provide oxygen for
patients, manually stabilize fracture, and use automated external defibrillators (AEDs) and much
more. These are all basic skill that can be provided in order to stabilize a patient, until they can
reach a higher and more definitive level of care. EMTs, AEMTs, and Paramedics have the ability
to use hemostatic agents, which are clot forming agents that when in contacts with blood, a
reaction occurs that coagulates blood causing it to clot and bleeding to become controlled. ALS
providers such as AEMTs and Paramedics are able to gain intravenous access and administer
drugs in order to correct certain conditions and emergencies. Paramedics are able to provide
advanced invasive procedures such intubation and cricothyrotomy. Endotracheal (ET) intubation
is placing an ET tube down the throat past the epiglottis in order to protect a patents airway and
gives providers the ability to breathe for the patient when needed. In order to perform this
procedure the patient must not be able to protect their own airway and be unable to breathe on
their own. There is a procedure known as Rapid Sequence Intubation (RSI) that with the
anticipation of a breathing and airway compromise, a RSI qualified Paramedic may administer a
series of drugs temporarily paralyzing all voluntary muscles of the body, which can stall any
further damage to the patient, but as a result stops the patients breathing which requires
intubation and attaching a Bag-Valve-Mask in order to breathe for the patient. When Paramedics
are unable to intubation a patient, they must rely on a procedure known as cricothyrotomy. A
cricothyrotomy is the most invasive rescue airway skill [a paramedic processes] and is indicated

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only when all other means for ensuring effective and safe ventilations are impossible or have
failed (Collopy et al., 2014). There are three different methods of cricothyrotomies: needle,
Seldinger, and open. The Seldinger is the most commonly used method in EMS; this is because it
is more effective than the needle method, but less risky and time consuming than the open
method. The Seldinger method consists of cutting the skin and circothyroid membrane and
dilating the incision, followed by inserting a tracheal tube and retracting the dilator and securing
the tube (Collopy et al., 2014). Once the tube is in place provider then attach a bag-valve mask
and begin to breathe for the patient.
FIRE
History
The National Association of Emergency Dispatch (NAED) in The History of Fire
Fighting talks about how fire departments were originally formed by insurance companies as a
way to protect investments and it wasnt until 1865 when local government began to fund fire
departments as a means of protecting their citizens. They talks about how in New York in 1848
fire wardens were appointed, thereby establishing the beginnings of the first public department
in North America (NAED 1984). As well as how these first public agencies lead up the
development of emergency dispatch systems. They also included a section talking about
debatably one of the most revelatory inventions in fire suppression which is leather stitched hose
that enabled fire fighters to work closer to the fire without endangering their engines and to
increase the accuracy of water placement (NAED 1984). The National Fire Protection Agency
in Fire through the Ages: A Timeline lays out a detailed timeline of events in fore suppression.
For example, in 1800 the first automated sprinkler system was invented and in 1803 the first fire
hydrants were established.

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Training
There are two different main levels of firefighter certifications: Firefighter I and
Firefighter II. Firefighter Is have to know the organization and command systems of fire
departments, along with how to wear protective equipment properly, tie knots, and talk on radios.
They must be proficient in using Self-contained Breathing Apparatuses (SCBAs). Firefighter Is
must also know about how water flows and the different types of hoses and nozzles, as well as
forcible entire techniques, how to place water on a fire, and conduct search and rescue inside of
buildings (White 2002). On the other hand, Firefighter IIs must be able to assume and transfer
command at a fire scene using the [individual] department's incident management system
(White 2002). They must be able to follow standard operating procedures and complete incident
reports on calls. Firefighter IIs must be able to extinguish fires using foam and know different
types of fire and the different strategies to attack them. Also, they must be able to select tools to
force entry into a building and how to provide proper ventilation in a building based on the
structure and nature of the fire (White 2002). Finally, Firefighter IIs must be proficient in
inspecting and correctly documenting hazardous materials.
There are also different kinds of technical rescue certification that firefighters can obtain
in order to further expand their sets of skills. Any Firefighter can take initial classes on basic
extrication followed by courses such as swift water rescue, cave rescue, farm machinery
extrication, vertical rescue, and terrorism response.
Apparatus
When people see fire trucks coming down the street, what they are most likely not
seeing a fire truck at all, they most likely seeing a fire engine, so when referring to firefighting

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emergency vehicles, the general term apparatus is used and when an apparatus is staffed with
trained personnel, it is referred to as a company. Most fire departments utilize four main types of
fire apparatus: Engines, Trucks, Squads, and special services. Engines have the job of pump[ing
water], transport[ing] personnel, and carry[ing] hose (Calfee 2011). Engines have extremely
large pumps with the ability to pump up to 2500 gallons per minute. Engines can carry a small
amounts of hand tools and shorter ladders. Trucks as well as engines have pump, but are smaller.
Truck also have ladders, but each individual ladder spans fifty feet or longer. The most
recognizable feature of truck companies are their large hydraulic aerial ladders or snorkels; it
is optional whether or not they have platforms on the end; these large ladder normally span
eighty to one hundred feet (Calfee 2011). Squad trucks unlike normal fire apparatus are not
designed to put out fire, but to perform specialized task and rescues. This is why squads can be
referred to as rescue squads or heavy rescue companies. Squad trucks carry, if any, small
pumps and few, if any, ladders. Squad trucks carry equipment such as generators, structure
braces, repelling equipment, as well as an assortment of hydraulic tools such as spreaders or the
jaws-of-life. Special services units include thing such as Battalion Chiefs, Hazardous Material
units, Light and Air Units, Tankers, Brush trucks and EMS supervisors.
Foam vs. Water
When fighting a fire, firefighters have the option of using two different substances when
trying to suppress it: Compressed Air Foam (CAF) and water. There are obvious upsides to water
in that it has been used since the beginning of time and there is an almost endless supply of it,
but it notably less effective than CAF. CAF is a fire retardant-water mixture that when placed
under pressure creates a foam like substance. CAF has many benefits including faster

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knockdown time, rapid heat reduction, lowered potential for flare-ups, and reduced water use
(Dicus et al. 2013). CAF is though very expensive and there are not large supplies of it available.
Joint Response Systems
Joint response systems are fire-EMS departments that when in response to a medical or
fire call dispatch both ambulances and fire apparatus. In joint response systems, fire apparatus
have the same qualified EMTs and Paramedics on-board as well as some of the same ALS and
BLS equipment as an ambulance does (Rosenbaum 2014). The purpose of joint response systems
is that there are more fire apparatus than ambulances in certain departments, allowing trained
EMTs and Paramedic, on medical calls, to reach a patient and initiate care before an ambulance
can arrive. This ultimately improves patient care and also improves cardiac arrest survivals rates
and the effectiveness of early on-set CPR and rapid defibrillation (Rosenbaum 2014). In most
joint response systems, all firefighters are trained EMTs/Paramedics and all EMTs/Paramedic are
trained firefighters creating a full service system.
Volunteer vs. Paid
There are two different types of staff in fire and EMS systems in the United States: paid
and volunteer. The United States in the urban areas has moved away from volunteer fire
departments and towards professional fire fighters. Early in American history firefighting was
100% volunteer, starting with Benjamin Franklin and moving through the 18th century and since
the 1980's firefighting in the United States has begun a great shift toward professional
firefighting in urban areas (Hensler 2015). A main focus in fire-fighting is professionalism and
contrary to popular belief in most situations volunteers have the tendency to be more dedicated

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and professional then there paid counterparts. Though, the benefits of paid systems is their
reliable 24/7 staffing.
Difference in Demographics
The differences across demographics change the quality of services that can be provided
in emergency situations. In an Analysis of Emergency Medical Systems Across the World by
Christopher Page, Majd Sbat, Keila Vazquez, and Zeynep Yalcin, it talks about how EMS differs
not only across the United States, but the entire world. It goes through multiple countries
including South Africa, Taiwan, Germany, and the Unites Kingdom and explains their individual
dispatch systems, levels of certifications and there different types of ambulances. When explain
the different cities in the United States such as New York, Boston, and Seattle, they explained
their responses times, tiered response systems, as well as things such as their individual budgets
and training. At the end of the article, there is a comparison of all fifteen cities and countries that
they outlined and how successful each of them are. This allows for the readers to see the
differences in major cities in the United States. In Firefighting history: How did we get
professional? by Bruce Hensler, it talks about urban fire services and their transition from
volunteer to professional. It talks about the differences between the two and how some are more
effective in different situations. It also debunked a lot of myth of volunteer systems, which have
been detrimental to them in the past. In The Rural EMS Crisis by Raphael Barishansky, he talks
about the challenges that rural EMS agencies have to deal with such as geography, low
population, and low call volume and density. He places a large emphasize on the detriments of
long transports, remote facilities, and poor infrastructure. It talks about the possible solutions of
the lack of specialty recourse and how to solve to the issues of long transport times in acute
cases.

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Conclusion
EMS and Fire have made a lot of changes in the past to get where it is now and todays
systems are very effective in their execution. With such high levels of training and ever
improving patient care and fire suppression techniques, fire and EMS will become even more
effective than they are now. The gap between rural and urban EMS has left poor outcomes on
patient and there are constant attempts to improve the gap between the two types of systems.
EMS and Fire departments play integral roles in the communities in which they serve and always
answering the calls of those in need.
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http://www.emsworld.com/article/10321567/rural-ems
Calfee, M. L. (2011). Fire Service Apparatus. Retrieved from
http://www.fireserviceinfo.com/apparatus.html
Collopy, K. T. & Kivlehan, S. M. & Snyder, S. R. (December 31, 2014). Surgical
Cricothyrotomies in Prehospital Care. Retrieved from
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Dicus, C. A. & Korman, T. & Grant, C. & Lohr, S. & Madrzykowski, D. & Mowrer, F. &
Pascual, C. & Turner, D. (July 1, 2013). COMPRESSED AIR FOAM AND
STRUCTURAL FIREFIGHTING RESEARCH. Retrieved from
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Hensler, B. (April 7, 2105). Firefighting history: How did we get professional?. Retrieved from
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Hicks, J. (August 23, 2011). ALS vs. BLS: What's The Difference?. Retrieved from
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Jakescomic. (March 12, 2014). Evolution of the Ambulance FINAL. Retrieved form
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Metronix. (2012). Ambulances. Retrieved from http://metronixinc.com/site/ambulances.html
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