Rafal: The ACC Fire Dept is poorly equipped to save lives in medical emergencies

Sam Rafal is public safety advocate who has been working for years with Bob Gadd, a recently retired local paramedic, to shine a light on Athens’ private ambulance service which he believes is performing inadequately and putting people at risk.

Fire Department response: The ACC Fire Department often boasts of having an ISO rating of 1, and for good reason. This means that they provide truly excellent protection from property damage and loss of life from fires, putting them in the top 1% of fire departments in the entire country. However, their ability to respond to medical emergencies is a different situation. During his tenure, ACC Fire Chief Jeff Scarbrough has overseen his department’s improvement in this area. He has responded to some of the concerns Rafal has expressed in this letter to the editor (see below). -APN

The Sub-Standard State of Our Emergency Medical Response in Athens-Clarke County and Solutions to Fix It

If you, or a family member are experiencing a time sensitive, life-threatening emergency, seconds count, minutes matter, and receiving the appropriate pre-hospital medical care can mean the difference between life and death. TWENTY-ONE YEARS INTO THE 21ST CENTURY, we have uncovered the unsettling news that the Athens-Clarke County Fire Department (ACCFD) is not equipped to perform at their level of medical training, and have stopped training to a higher level.

Overwhelmingly, the number of calls run by ACCFD are medical calls [In 2020, 4,326 of the ACCFD’s 7,540 total calls, or 57.4%, were for EMS. -APN]. ACCFD has 120 medical personnel trained to the level of Basic EMT or higher. Currently, not a single one has the equipment, e.g., IV fluids for shock, breathing treatments for asthma, IV dextrose for diabetics, baby aspirin/nitroglycerin for heart attacks, IM epinephrine for severe allergic reaction etc., to respond at anywhere near their level of training.

This represents a tremendous loss of opportunity to save lives and reverse negative outcomes for the citizens of Athens-Clarke County at their time of greatest need.

According to Deputy Chief Mark Melvin, “We operate at the First Responder level.” That is a stunning admission, since that was a state of the art first fire response in the 1960s. It’s a long way from the modern fire department we need in 2021. “First Responder” has a very specific meaning in this context and refers to a level of medical training in Georgia that can be obtained in 5 days. It is BY FAR the lowest level of pre-hospital care available. Contrast that with the 6-9 months it takes to become a Basic EMT, the 9-12 months it takes to become an Advanced EMT, or the 2 years it takes to become a Paramedic.

When Chief Scarbrough came to us eight years ago from Sandy Springs, where he oversaw a Paramedic-based fire response, we had great hope that he would modernize our fire department. At that time, our first fire medical response was performing at about Day 2-3 of the First Responder course. Today we are not much better, performing in their words, as about a Day 5 graduate of that course. 

Twenty-six months ago, Mr. Gadd and I met with Chief Scarbrough for the precise purpose of talking about raising our first fire response from EMT-Advanced to Paramedic. We were told, “We need to walk, before we run.” Now we are being told that, “I believe in the crawl, walk, run approach.” What in the heck is going on! And why wouldn’t we want our fire department to carry the equipment to match their level of training, and to increase their training? Don’t we already have a for-profit, private equity ambulance company working in the community? [Rafal is referring to National EMS, which is indeed owned by a private equity fund. -APN] The answer is obvious. The Athens-Clarke County Fire Department often gets there well before the private ambulance service and could save the life of a citizen who is dying. It’s really that simple.

Why would you not want to do that?

Virtually every person I’ve ever met who went to EMT or Paramedic school wants to use their skills to assist people in need. I suspect it is frustrating for them to watch someone die whose life might have been saved by interventions they are trained for, but not equipped, to perform. We’ve had a record number of our citizens die this year from auto accidents and shootings. I would be negligent if I didn’t consider that there might be a relationship between a rising trauma death rate and a substandard pre-hospital emergency medical response.

In fact, a family in Anderson, South Carolina has just brought a civil lawsuit against Emergency Manager Van Taylor Jones for failing to provide tourniquets to Townville Elementary School that could have saved 6-year-old Jacob Hall’s life. He was shot at Townville Elementary School on September 28, 2016. The lawsuit claims that “negligent actions” resulted in Jacob Hall not receiving proper medical care in the field, which led to “the wrongful death of Jacob.” Here’s a copy of the “negligent action” lawsuit against Van Jones.

Here’s one of the last pictures of Jacob Hall with his mother:

Solution – Equip our ACCFD to perform to their level of training

I’ve created a list of 17 items that the Athens-Clarke County Fire Department is trained to use, but doesn’t carry, as well as the cost of each item. The cost of initially stocking 15 of those 17 items, at all nine of our state-of-the-art fire stations, is well under $10,000. Please see some critical examples below:

Breathing Treatments ($2.63 per treatment) – These are essential in opening lung passages in asthma and emphysema patients. These treatments can keep patients from dying due to suffocation. I use the word “suffocation” because that’s how it’s described by patients. The cost for Albuterol is $10.19 per case of 25, or $0.41 per treatment. The cost of Atrovent is $22.29 per case of 25, or $0.89 per treatment. The cost of the nebulizer kit is $1.33 per kit and that includes the tubing, mask, and connector. The total cost for the nebulized breathing treatment consisting of Albuterol and Atrovent is $2.63.

Heart Attacks ($0.07 per treatment) – Chewable baby aspirin cost $1.98 for 3 bottles of 36 count (81 mg), or $0.67 per bottle. According to Harvard Medical School, “It’s modern cardiology at its best, and it has improved considerably the outlook for heart attack victims. Aspirin helps by inhibiting platelets. But since the clot grows minute by minute, TIME IS OF THE ESSENCE. Chewed aspirin works the fastest (2 ½ times faster than swallowed aspirin)”.

Heart Attacks (up to $$4.53 per treatment) – Nitroglycerin costs $28.29 per bottle of 25 sublingual (under the tongue) 0.4 mg tablets. This oral medication needs to be given early onset to a citizen having a heart attack. It can mitigate the impact of the heart attack, saving a life, or saving valuable heart muscle improving a heart attack survivor’s quality of life.

Hemorrhagic Shock from Blood Loss (up to $14.95 per treatment) – Early IV access and fluid replacement before vascular collapse is known as “damage control resuscitation” and can save the lives of trauma patients who are victims of auto accidents, gunshot wounds, falls, or other severe trauma. The cost of an IV set is $1.68, the cost of an IV catheter is $3.38, and the cost of a 1000 mL bag of sodium chloride is $9.89.

If the Athens-Clarke County Government cannot afford the items listed above to better serve our citizens, I will personally contribute the money to put all of these things at all 9 fire stations.

Our ACCFD must be equipped to perform to their level of training, whether they’re responding to a double shooting in 5-Points, a 6-story fall from The Mark, a pedestrian hit by a car downtown, a heart attack in Forest Heights, severe difficulty breathing at a day care center, severe allergic reaction at one of our elementary schools, or some other time sensitive, life-threatening emergency. Would you rather be able to tell a grieving parent that everything was done for their child, or that we were NOT able to provide potential life-saving procedures in a timely manner, because we do not have the equipment to perform at our level of training? To me, the answer is obvious.

Sam Rafal

Read part two of Rafal’s letter to the editor here.

Chief Scarbrough responds

Chief Scarbrough has addressed some of Rafal’s concerns in a comment to APN you can read by clicking below. – APN

I believe in the crawl, walk, run, approach when increasing service delivery, especially when you are talking about medical treatment. We are still new at medical emergency response and Athens Clarke County Fire & Emergency Services (ACCFES) has made significant progress over the past few years.

First, let’s remember where we were with respect to medical emergency responses:

· 16% (27) of ACCFES Operations personnel EMT or higher certification (2013/2014)

· No ACCFES Medical Director

· First Responder a requirement in ACCFES Firefighter job description

· ACCFES not represented on EMS Oversight Committee

·  Very basic medical supplies on ACCFES apparatus due to lack of training/certification level

· First responder was medical training level in ACCFES FF recruit school

· On-going EMT medical training not provided by ACCFES

·  485 Medical emergency responses by ACCFES (2013)

Where we are now is the result of a lot of work, training, expense, and effort to get us to this point:

·  ACCFES Medical Emergency response model widened to respond to more medical emergencies (2014)

·  Medical Director Dr. Kurt Horst hired by ACCFES (2016)

·  ACCFES adopts medical protocols (2016)

·  ACCFES Fire Chief appointed to EMS Oversight Committee (2017)

· EMT part of ACCFES FF recruit school (2017)

·  Rescue trucks equipped with medical first responder supplies (2017)

·  ACCFES Radio communications initiatives with National EMS (2017)

·  EMT a requirement in ACCFES FF job description (2018)

·  Continual EMS training provided by ACCFES (2018)

·  ACCFES Naloxone grant funded initial Naloxone supply (2018)

·  New AEDs donated by National EMS put in service by ACCFES (2018)

·  Medical First Responder supplies placed on all ACCFES apparatus (2019)

·  69% (120) ACCFES Operations personnel EMT or higher certified (Oct 21)

·  3,987 EMS responses in 2021 by ACCFES (thru 11/9/21)

It is our desire to continue to grow and improve our service delivery with respect to medical emergency responses. We are not performing every skill allowed under the EMT certification because we do not have quality control/improvement components in place yet. I would say we are performing skills higher than a first responder but not all of the skills an EMT can perform. Because you can perform a skill or treatment does not mean you should. We have two primary goals with medical emergency responses: first we want to do no harm, and secondly we want to contribute to the best outcome for the patient.

The Athens Clarke-County EMS system is tiered and for the best patient outcome it takes all tiers working together. First, the public knowing CPR and having skills like stop the Bleed provides important initial care. Next our 911 Center has to be contacted by the public so Athens Clarke-County Fire & Emergency Services gets notified and responds to provide care. The next tier is the ambulance provider for our community which is National EMS, who responds in parallel with us and provides more advanced care and can transport the patient to a hospital if needed. The last tier is the hospitals who provide the most advanced care for best patient outcome.

ACC Fire Chief Jeff Scarbrough

Further reading

APN has written a number of times on this topic:

For-Profit EMS: Putting Georgia at Risk? [Video with transcript, July 2019]

National EMS Misled Officials About School 911 Call [Flagpole article, December 2019]

ACC Attorney to EMS Oversight Committee: Open your meetings to the public [May 11, 2020] (The EMS Oversight Committee has still not met; it may never meet again.)

National EMS definition of “response time” ignores patient perspective [February 15, 2021]

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