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December 12, 2011

Fire-EMS rivalry plays out in Fla. system

By Aaron Hale
Naples Daily News

NAPLES, Fla. — Collier's EMS system is supposed to work like a NASCAR pit crew, with everyone working in coordination to win the race.

At times, though, the relationship between the fire departments and EMS seems more like rival drivers trading paint on the track.

Agency leaders - most notably those in the North Naples Fire Control and Rescue District and Collier EMS - have long clashed over the role of firefighters in medical emergencies.

Though officials insist the rivalry rarely plays out on the front line when patients' lives are at stake, there have been recent episodes of poor communication from frontline personnel that have ended with embarrassment and tragedy.

Two medical calls in Naples earlier this year were met with long ambulance response times, in part because fire and EMS agencies weren't communicating over the radio. One of those calls turned fatal after EMS arrived.

In October, a mishandled emergency call on Marco Island was the result of failed communication between NCH Healthcare staff, dispatch officers and Collier EMS.

To be fair, Collier is above the national average in cardiac arrest saves - a benchmark for EMS success. But those numbers have been dropping in recent years, and the poor coordination is signaling a decline in public safety.

If Collier's EMS system is going to move forward, it needs to shift its culture toward one of cooperation, said Geoffrey Moebius, chairman of a blue ribbon panel that recommended ways to overhaul the current EMS system. Otherwise, some fear the system will fragment, causing quality of care to suffer even further.

Moebius pointed to systems in Broward County and King County, Wash., as examples of emergency medical leaders building cooperation and consensus.

If Collier is going to live up to the goal of a unified system - the county's first-response stakeholders have to overcome years of agency disputes.

Problem with growth
The rivalry that threatens to fragment public safety actually stems from efforts to expand it.

That's according to Ed Morton, ex-CEO of NCH hospitals and co-chair of the blue ribbon panel that studied Collier's dysfunctional system a year ago.

As recently as a decade ago, Collier County EMS, which largely acted as the sole pre-hospital medical service, was considered one of the best providers in the state, Morton recalled.

Around the same time, a few of Collier's fire districts wanted to grow emergency medical capabilities. It's become a national trend for fire departments to handle emergency medical response as the number of structure fires have dropped with better building codes.

What could have been a good opportunity for concerted growth was spoiled by turf guarding, Morton said, adding, "Things started to fray because there started to be competition."

As fire districts became more involved in EMS services, both sides became territorial - wanting to dictate the standards for care and protocol, Morton said, not blaming either side.

Talks of merging the fire districts with Collier EMS into a single consolidated agency only stoked the flames.

"What we're talking about is organizational survival," he said. "I think everyone thinks standardization and consolidation makes sense. The question they're asking themselves is 'where am I going to fit into that?'"

Integration troubles
The feuding has turned, Collier's nationally recognized emergency medical director, into a polarizing figure locally.

He's been outspoken against fire district expansion into EMS. Tober's supporters praise his steadfast fight to maintain high medical standards; detractors accuse him of stubbornness, which has alienated firefighters and stunted cooperation.

Compared to Collier, medical directors in Broward and King counties, where doctors are seen as unifying figures, have been far less controversial.

Tober, or Bob as he's known by many of his colleagues, is thin and well-groomed. His thick, hair-sprayed mane looks practically the same now as it does in a photo taken in 1986, with some streaks of gray.

Now in his mid-'60s, Tober came to Collier County after cutting his teeth in emergency medicine at the Cleveland Clinic. He is the only medical director Collier EMS has had since it was established in 1981.

"His training and sophistication was uncommon in a small community like Naples," Morton said. "He was able to leverage that and begin to train personnel with clinical protocols that were atypical for this type of community."

When relaxed, Tober is charming with an old-fashioned, distinguished air. When challenged on the direction of Collier's EMS, that bedside manner melts into a feistier side, quick to go battle over his medical beliefs.

Tober's problem with the fire districts, he said, is they have been unwilling to integrate into his system and maintain his medical standards.

"I'm either going to drive the boat in the right and prudent direction, or I'm not going to drive it," Tober told the Daily News.

For better or worse, Tober said, he isn't a politician and he doesn't compromise when it comes to medicine.

Tober paints the feud as a fight between responsible medicine and a power grab by fire districts and firefighters. The doctor's distrust of the fire districts runs deep. He accuses the firefighters' unions of holding too much political sway in the districts and not looking out for the interest of patients.

North Naples Fire Chief Orly Stolts said the district is only trying to improve public safety for its residents.

But fire officials think Tober and EMS personnel have felt threatened by that expanded level of fire department service.

Best practices
There are eight framed pictures showing outdated methods of resuscitation on the wall of a 12th-story Seattle office.

Compared to modern medicine, the methods shown are almost comical. One is of a practitioner pulling a patient feet-first up a tree with a rope; another shows a doctor pushing air into a patient with a fire bellow.

Sitting at his desk, Dr. Mickey Eisenberg, King County's regional emergency medical director, muses that when these "life-saving" methods were used, it only took one successful try every few decades to institutionalize the practice.

In contrast, Eisenberg and others in the King County medical system test and track the theories of their operation over and over to ensure they work. King County officials say that amount of diligence leaves no room for controversy over medical direction.

Cooperation between firefighters and doctors - and an appreciation for emergency medical research - were built into the fabric of the EMS system from the beginning there.

In 1968, University of Washington cardiologist Leonard Cobb approached Seattle Fire Chief Gordon Vickery about training firefighters to treat cardiac arrest in the field.

With the latest available CPR techniques and the development of portable cardiology equipment, Cobb said it made sense to use firefighters as medical practitioners because their departments already respond to calls quickly.

Fifteen firefighters were trained as Seattle's first paramedics. The University of Washington converted an RV into a portable emergency room, nicknamed "Moby Pig," and the Seattle Fire Department began responding to emergency medical calls with physician supervision.

In 1979, University of Washington professor Eisenberg helped develop King's tiered approach, which aims at getting basic first responders on scene quickly, followed by more sophisticated responders. He trained firefighter-EMTs to use cardiac defibrillators. He would later work with dispatchers in developing CPR instructions over the phone.

Doctors, particularly the county's top medical director, tend to garner respect from firefighters because of that history.

Openly questioning medical direction just isn't done in King County, said Aaron Tyreman, a paramedic for King County Medic One.

"Dr. Eisenberg doesn't flex his muscle very often," Tyreman said, "but when he says something, you're going to do it."

It's not just medical direction, either. King County has avoided disruptive interagency disputes while the system has evolved.

When asked directly about the quality of relationships between agencies, officials and firefighters don't hesitate to praise the system.

"I think in some ways, we just don't know any better. Part of it is culture," Seattle Fire Capt. Jonathan Larsen said.

The medical director
An asphalt truck overturned on a man in Fort Lauderdale last year, pinning him underneath.

It was a difficult scene for paramedics to work, not only because the truck was crushing the man's limbs, but the heat and smell under the truck were overwhelming, recalled Robert Hoecherl, assistant chief of the Fort Lauderdale Fire-Rescue Department.

Despite the conditions, the fire department's medical director, Dr. Nabil El Sanadi, crawled to the patient and paramedics to consult, the assistant chief said. They eventually saved the man's life, though three limbs were amputated.

What's earned El Sanadi the respect of his medics, Hoecherl said, is that he leads by example: "He's very hands-on and interactive with our crews, but he's not obtrusive."

What impresses Tim Heiser, deputy EMS chief for Fort Lauderdale, is the doctor's ability to bring people together.

El Sanadi, director of emergency medicine at Broward County's largest hospital system, is also medical director for the county's two largest fire-rescue agencies, Fort Lauderdale fire department and the Broward County Sheriff's Fire-Rescue.

He sits on or chairs a half-dozen committees related to hospital or pre-hospital medical care.

El Sanadi said each committee puts him in a place to communicate with Broward County leaders in an EMS system that has nearly two dozen providers: "It takes a lot of diplomacy and energy to make it work."

To be sure, there is a rivalry among 22 existing municipal fire departments and the Sheriff's Office, which oversees EMS. Currently, officials debate whether service is more effective through a single countywide agency or by smaller local fire departments.

However, these grievances typically don't lead to poor coordination among agencies.

El Sanadi said disagreements occur, but typically in private. He said it's important not to take criticism personally.

"I try to leave politics, finance and personal issues out of it," he said. "When we're operating as professionals on the job, everything else disappears, other than that one patient."

Providing equal service
Patients lose when agencies don't cooperate, former NCH executive Morton said.

He sees Collier at a crossroads that could lead to either further fragmentation or greater consensus.

Fragmentation, he said, would lead to lower standards in some parts of the county.

The challenge, according to Morton, is maintaining a pre-hospital medical service that's "as fair to the family in Immokalee as it is to the family in Port Royal."

He posed a scenario where the three wealthiest Collier regions, North Naples, and the cities of Naples and Marco Island, broke from Collier EMS to provide their ambulance service.

There's some truth to his fear. Naples Councilman Doug Finlay complained earlier this year that wealthier areas of Collier are having to pay more in fees to EMS without getting better services. Finlay even proposed exploring establishing an ambulance cooperative with North Naples or Marco.

In August, North Naples signaled interest in launching its own ambulance service. In recent weeks, Marco Island city staff began exploring the idea, too.

If those fire agencies were allowed to provide their own ambulance services, it would mean a loss of dollars for the rest of the county, Morton said.

He paints Collier County EMS as the agency that at least maintains public safety equality in Collier County. That won't remain the case, he said, if the wealthier urban fire districts operate independent of Collier EMS.

"Who's going to take care of Immokalee?" Morton asked. "They don't have the money. They certainly don't have the tax base. How about Golden Gate Estates?

"There's a standard of service that should remain independent regardless of their postal address."

Copyright 2011 Collier County Publishing Company

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