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Call to Action

Firefighters are working themselves out of a job. The ambulance authority is developing a world-class reputation. How a new partnership could change the face of emergency services.

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The shrill-toned electronic buzzer that ends lunch for the crew of Richmond Fire and Emergency Services Station 6 is a far cry from the clattering claxon bells that once drove firefighters racing toward unknown infernos.

The series of staccato bleeps sounds more like a TV quiz show buzzer than a portent of peril, but they're enough to send the station's crew sprinting for its blaze-red truck.

“It's a fire, I can smell it,” says an eager Charles Barkley, encapsulating a frustrating day spent rushing to false alarms: Finally there's a real fire to fight, a job to do.

The placid scene at the Berkshire Apartments, a multistory building near the Jefferson Hotel, belies all the pent-up giddy tension that just sped down West Franklin Street under full lights and siren.

Firefighters in full gear clamber from their “quint” — a truck so named because of its fivefold usefulness at emergency scenes — and trudge through the open lobby doors. They're followed close behind by two smiling Virginia Commonwealth University students, backpacks slung over their shoulders and seemingly oblivious to the tall men in full gear, wearing helmets and tanks of oxygen strapped to their backs.

In the end, the students have bet right; it's the fire sprinkler alarm company running a test on the pressurized system but failing to disable the alarm that summons Station 6. Another adrenalin rush ends in a puff of imaginary smoke.

Forty minutes later, the scene repeats itself, this time with the truck rushing deep into the heart of the Fan district. … to put out a cigarette. Someone has tossed the still-smoldering butt in a flower pot behind a house.

False alarms are a daily part of modern, professional firefighting, a happy but somewhat frustrating fact of life for the men and women who train for emergency even as they preach safety. Those false calls bear witness to the success of the city's Department of Fire and Emergency Services, creating an awkward irony: After years of pushing fire prevention and educational programs, firefighters — both locally and nationally — are edging closer and closer to putting themselves out of business.

For fire departments such as Richmond's, which receive state and federal funding based in part on calls for service, less demand has created a financial crunch. In the midst of this slow smothering of the once-epidemic danger of residential fires, Richmond Fire and Emergency Services is sitting down at the discussion table with the city's quasi-private medical transport and emergency medical services company, the Richmond Ambulance Authority. On the agenda is something unprecedented: cooperation.

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>“Our world is changing and we have to change with it,” Richmond Fire Chief Robert Creecy says. He initiated the conversation with the ambulance authority shortly after Mayor Dwight Jones took office and partly as an extension of the ongoing — but thus far unproductive — city conversation about consolidation of such services as the city's motor fleet or purchasing departments, which began under former Mayor L. Douglas Wilder.

Responding to Creecy's outreach, the Richmond Ambulance Authority's board of directors voted two weeks ago to allow its new chief executive officer, Chip Decker, to sign a sweeping memorandum of understanding with Richmond Fire that lays everything on the table.

The two city agencies in many ways compete for the same emergency calls to prove their worth. They now agree to cooperate, cede duties to one another or ultimately merge, should that prove to be the best course of action. Leaders of both agencies say it is logical, as long as the prime motivator is the best interest of the patient — not the taxpayer.

“What we have to do as an industry is look at how the paradigm is changing,” Creecy says, noting that even as fire frequency is down, the city is responsible for maintaining a force capable of fighting fires when they do break out. The key, he says, is in finding ways to maintain the value of those otherwise-underused resources: “How do we create value in lieu of responding to emergencies? Our role in EMS is one of those ways.”

Even as the city's fire department struggles to redefine itself, the ambulance authority faces its own challenges. The General Assembly created the quasi-governmental body from the ashes of competing systems in 1991. It operates primarily on customer payments and a fairly minimal city subsidy of about $4 million a year.

Increasingly, the authority's customers are indigent patients who call the ambulance not for transport but for basic medical care. With 40,000 transport calls each year, only 20,000 or so end up being paying customers. So calls for service are increasing along with costs, while the money to pay for those services is decreasing.

The authority essentially eats the cost by running the tightest ship possible through a complex algebra dependent on high-tech computer modeling and other innovations in patient care and time-saving measures. With a depressed economy and no assurance that the city's budget will always provide, officials realize that it's worth looking to the outside for ways to further cut costs without damaging service.

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>That service has a world-class reputation, according to administrators and such champions as Rob Lawrence, who came to Richmond to study the Richmond Ambulance Authority. Last year he parlayed what was essentially a work-study visit into a full-time job as the authority's chief operating officer.

Lawrence had been running a large EMS system in England when he took the Richmond job, and “it was a big deal in the English papers when he stayed here,” says his boss, Chip Decker.

“This is EMS' ‘Top Gun,’” Lawrence says. “Who wouldn't want to be here?”

He means it; despite the careful balance between expenses and services necessary to maintain high-level performance, the authority's average remains in the 94 percent range for arriving at calls for service within 8 minutes, 59 seconds. That tops the internationally accepted world-class response standard of 90 percent and eclipses the worldwide average of 75 percent.

Moving forward with a conversation with the fire department just makes sense, Lawrence says. “Just under half of our workload is common with fire,” he says, meaning that in nearly half of the calls they get — for advanced life support — specifically require the fire department to be on the scene as well. 

Depending on the nature of the emergency call, it's as likely that fire and an ambulance will arrive on the scene. Emergency 911 calls routed through the police dispatch center all pass through the fire department's computer system before being patched through to the ambulance authority, and in calls involving likely medical emergencies fire crews are also dispatched.

It's a necessary arrangement because ambulance authority crews are not allowed to enter the “hot zone” at accidents or fires in which they'd be exposed to greatest danger, and Richmond fire crews are not allowed — or prepared — to do patient transport. By having both sets of crews at a scene, the patient gets better and faster care.

The relationship is fraught with inefficiencies too, says Dr. Joseph P. Ornato, a Virginia Commonwealth University physician who also serves as medical director for both the fire department and the ambulance authority.

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>“If [fire crews are] going on calls where they offer little or nothing to the patient, then all we're doing is taking a unit out of service,” Ornato says. The logistics of running two vehicles at high speeds through downtown streets when just one might do is complicated as well, he says: “More vehicles moving through city streets, that really is a potential accident waiting to happen.”

Another potential flaw with this sort of overlap: What if that crew is needed in two places at once? Because fire and ambulance crews maintain separate call centers, with computer systems that don't interact, there's no way for dispatchers to know when calls require both fire and ambulance service.

“So if Richmond fire responds with a full fire crew and a full fire truck to a call here,” Lawrence says, gesturing with one hand in one direction, “what happens if there's a fire over here?” He holds up another hand pointing in the opposite direction. 

Such issues rarely arise; the city staffs 20 stations and 23 engine companies, but it used to staff far more (29) and its firefighter ranks have shrunk by a third over the years. Ensuring efficiencies between fire and EMS would further preserve fire's manpower should multiple fire emergencies — or one large fire disaster — break out.

Like Lawrence, Ornato says he's happy to see the conversation taking place between the two agencies.

“It's totally unprecedented,” he says, also calling it practical. “The reality is that fire has been so successful with prevention that their calls for service have gone way down. But you have to have that certain level of service that's out there.

“Now, for the very first time, we're really able to look around as a team: What could we do? Are we one agency or two? What could make our care of the patient faster or better?”

Many less urban communities combined fire and EMS services decades ago. Large urban communities, such as New York, that came late to the game have experienced painful and awkward processes of unification. In Richmond, there's no goal to unify, only to identify how to work better together.

Providing EMS is not part of most civil contracts and only became an assumed responsibility of localities in the 1970s, says Chief Creecy, who himself is somewhat incredulous when he describes the 1971 television show “Emergency” as the watershed moment. Before that, ambulances focused more on transport rather than on the advanced lifesaving techniques spotlighted in the show and often were run more as meat wagons that traveled from accident to morgue with just a courtesy stop at the E.R. to check a pulse. Many were even operated by local funeral homes — a darkly humorous conflict-of-interest relationship unlikely to have struck much confidence in the stricken.

Richmond's model followed a public utilities approach, similar to providing water or sewer services. Ambulances provided a paid service in a noncompetitive, customer-driven marketplace.

But like many communities that maintained the division between fire and EMS, Richmond is faced with a fire service that has less to do and an EMS service that's seeing more business as its urban clientele depend more on alternative means of receiving medical services.

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>Richmond's first area of discussion taking place is how to better prioritize 911 calls, to know when and if a fire crew also should be dispatched. With two separate call centers, neither organization can know whether the other has a crew en route or available. Linking those two systems will be a major step toward better service for patients, officials say.

Dr. Ornato knows about improving service. It's by his hand that many of the cutting-edge medical technologies in use here made their way into the ambulance authority's mobile emergency rooms.

Technologies, such as AutoPulse backboards that provide chest compression for cardiac patients or cool saline drips that cools heart attack patients' internal body temperatures to improve survivability, are leading efforts that are gaining traction internationally. They're already available on every Richmond Ambulance Authority ambulance.

Ornato also knows about the potential pitfalls to keeping the dialogue open and honest between the fire department and the ambulance authority. He was there when Creecy first proposed talks to the authority's board of directors. “They were very worried about, ‘Gee, is this a takeover attempt?’” Ornato says, recalling a tense meeting as Creecy laid out his proposal.

Creecy acknowledges that it looked like he might get the usual cold shoulder at first as he asked a competing agency to let its guard down — to even put on the table the possibility of putting itself out of business.

“I know there's a lot of talk on the street,” he says. “It's common knowledge that … there's always been this speculation that fire coulda' woulda' shoulda' been involved in the authority — maybe even when they created the service.”
Authority board member Terone Green broke the ice, Ornato says.

“When Creecy came to us to talk about a collaborative effort ... [I] basically cut to the chase,” Green recalls. “I said just look us in the eye and tell us what your intentions are, so we can help correct or defend any misperceptions that are out there.”

The response was enough to warm the other board members too, Green says: “He looked back and in a straightforward honest manner shared with us what his interest was. In this day and time you don't see that sincerity and honesty coming from officials.”

For years there'd been rumors that Richmond fire wanted to take over the ambulance authority. There were even rumors of a shadow fleet of ambulances under the Richmond Coliseum that would be rolled out late one night as the ambulance authority was disbanded.

None of the rumors proved true, but the distrust remained — until Creecy reached out.

“What's unprecedented, and what I think is really phenomenal is that this isn't happening because some political person has put a gun to somebody's head,” Ornato says.

But even if the two parties to the conversation are taking a friendly approach, there are other parties whose motives are more political — and who are interested in a potential merger of the two entities perhaps even in spite of what those talks might reveal about efficiencies in the system.

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>Though Creecy says his overtures are aimed purely at opening a dialogue, he also notes that Mayor Jones brought up the topic of combining the two agencies during a meeting shortly after he took office. The Jones administration is not shy about saying it would like to see the entire idea of authority boards — entities such as the ambulance authority, but also the Richmond Redevelopment and Housing Authority board — reconsidered en masse.

“The administration recognizes that boards and authorities are very powerful entities — entities with vast powers — and is of the opinion that their roles were not seriously discussed in the context of the change in the form of government,” says David Hicks, Jones' senior policy analyst. He says their continued existence should be “part of the examination.”

Hicks says Jones would like to see the city's Charter Review Commission, which is meeting to discuss possible additional changes to the city charter to account for the new elected-mayor system, consider the issue of authority boards. The matter, he says, is of central importance in defining the mayor's powers because the boards decentralize a broad range of day-to-day city functions.

“An argument can be made that the powers granted to these boards are not consistent or take away from some of the powers granted to elected bodies,” Hicks says. Any change would have to be initiated by the General Assembly, which created Richmond's various authority boards and is solely charged with dismantling or altering them. 

Decker with the ambulance authority board shrugs at the mayor's suggestion, adding that his board shouldn't simply be discarded in order to consolidate power.

“I'm not a part of any city department, but I'm certainly a partner in public safety,” he says. “Our job is to give people the best EMS that we can. It is working. Since we're working so well, it's one less thing city administration has to worry about.”

Ornato also urges caution in considering whether to do away with the ambulance authority board. Because the board's not beholden to City Council or to other elected bodies, Ornato says it's better able to react and change — even pioneer — advancements in medical transport and first-responder care.

“The notion that cost would go down or efficiencies would go up is not exactly true,” Ornato says, adding that “the devil is in the details.” Issues like the questions of equalizing pay and training between the two departments could create obvious land mines.

“I don't think anybody who's looking at this believes that if a merger occurs that it would necessarily save the city money,” he points out. Besides, he and others involved in the conversation say, saving money shouldn't even be part of the conversation.

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>Shaun Whiteley, a firefighter at Station 6, was an EMT with the ambulance authority before joining the city's fire department. Asked if he thinks combining the two agencies would be a good idea, he slowly shakes his head side to side.

Cooperation between the two is “phenomenal,” Whiteley says, but the very different missions of the two agencies should never be assigned to a single fire crew.

“There's a lot of older guys in other stations where they feel like we didn't get hired to do EMS,” says Whiteley, who along with other firefighters assigned to Station 6 has a uniquely sympathetic view toward ambulance authority employees. He's a step below holding his paramedic certification, and the station itself — centrally located near the Virginia Commonwealth University campus — operates as a de facto paramedic unit for the division, intentionally staffed at all times with someone who is paramedic certified.

But even when they're acting in their paramedic capacity, firefighters at Station 6 are not ambulance drivers, he says, and they shouldn't be if they're also going to be asked to potentially fight fires.

Whiteley and his colleagues are back at the station at 4:30 p.m. on a Friday. They're about halfway through their 24-hour shift. As much of their day is spent horsing around the station and napping as it is responding to emergencies. While that may seem like a waste, it's not, according to fire agency staffing experts.

Throughout the day, there are occasional references to the Carver Community fire that blackened Richmond's skies, burned structures over a half-dozen blocks, cost far in excess of $20 million in damages and that could easily have burned a larger chunk of the city without modern firefighting techniques and equipment.

Down time is necessary to maintaining a fit fire crew ready to enter a potentially deadly fire or emergency scenario, Whiteley says.

But it's not necessary in the same fashion to run an ambulance crew, says the ambulance authority's Decker.

“It really comes down to … what percentage of an hour can someone be working before they are overworked or become too inefficient?” he says. On any given day, the city has 23 fully staffed engine companies that are as likely to be watching television as running to fire calls. By comparison, at any given time there are 11 to 17 ambulances patrolling the streets, and none of them sits still for long. All are staffed with EMT or paramedic crews; all constantly shift position according to the algorithm used to assign the ambulances via the authority's computer deployment system.

That system, Decker says, plots according to daily and historical data the most likely areas of the city where an incident will take place — rush hour means the likelihood of accidents on major arterial roads, Thursdays and weekend nights are a sure bet for downtown calls related to nightlife.

He acknowledges the drain on the human element in his high-tech system, but notes a big difference in the type of staff he employs. These are not firefighters, and they're not required to do the same rigorous physical and technical fire training that Richmond Fire requires. They do have ongoing and intensive first-responder medical training, but many come with the intention of receiving this training and the experience of serving urban clients before moving on to other medical jobs at hospitals, in firefighting or in more sedate EMS jobs in smaller or less urban places.

It's perhaps one of the greatest ironies in the conversation about how to streamline and find efficiencies between the two departments: What may contribute most to the ambulance authority's success is its computer system for predicting emergencies. For all its technical brilliance, there's no reason to think the system could ever be applied as directly or as predictably to fire operations.

The inherently inefficient model necessary in fire requires maintaining multiple stations, expensive equipment and often-idle crews, all in case of an unknown emergency that inevitably will come where and when you least expect it.

There's a downside to the computer modeling technique too, when it comes to wear and tear on employees. EMS workers work shorter shifts by necessity. Pounding pavement to keep up with a high call volume means 12 hours is about all they're good for. Firefighters are like fighter pilots; more physical preparation, lots of downtime that looks like wasted time, longer shifts — 24 hours is typical — because calls are more scattered but often require greater expenditure of energy when they come.

“I can see the response time being a good model — but it just wears on your employees,” Whiteley says. He calls employment at the ambulance authority a “revolving door” because most ambulance employees leave after about two years. “All that stuff builds up and you get burned out,” he says.

This and other potential pitfalls to combining or sharing services is why there should be no preconceptions in moving forward with this conversation between the fire department and the ambulance authority, Creecy says.

“Many [other fire] agencies see EMS as the savior of their fire service,” Creecy says, disagreeing that this is necessarily the case. How the system should be configured “will be revealed as we go forward,” he says. “That may or may not include a change or merger of services.”

Decker agrees, downplaying the memo of understanding even as he hypes its transformative possibilities. It just says “we're sitting down talking,” he says. “The things you can't have are turf wars or sacred cows or what-have-you. Now, we have an opportunity to look at the system for efficiencies — and not just our part of the system. I think that's a very big thing.”

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