Should patient-transport capabilities be designed into future fire apparatus?

It’s important to consider the implications before assuming transport-capable apparatus is the simple solution to ambulance delays


There is one call that still haunts me.

A man was on his way into work when he noticed an argument between two women. As he stepped between the two to break up the fight, one of the women pulled a gun and shot him in the chest.

I can still see his eyes when I slipped the non-rebreather over his face. He told me, “I’m going to die, I’m going to die.”

As EMS services struggle to keep up with staffing needs, firefighters all over the country are finding themselves stuck on the scene waiting for ambulances responding from farther and farther away.
As EMS services struggle to keep up with staffing needs, firefighters all over the country are finding themselves stuck on the scene waiting for ambulances responding from farther and farther away. (Getty Images)

In paramedic school, I was taught to never lie to a patient. So I told him the only truth that might bring him some comfort: “Just hang on, the ambulance is coming.”

I could hear the ambulance’s siren and I tried to judge the distance. The emergency room was 1 mile down the road. Would he have a better chance if I took him in the engine? Or should I wait?

I chose to wait. When the man lost a pulse, I started chest compressions. By the time the ambulance arrived, I knew his chances of survival were nearly hopeless. Did I make the right choice?

Patient transport in the engine: It's already happening

Back in 2020, firefighters in Oklahoma City responded to a 3-year-old who had been burned with cooking oil. After waiting on scene for an ambulance for nearly half an hour, Maj. Corey Britt of Oklahoma City Fire chose to do what I didn’t. He decided to use the fire engine to transport the patient to the hospital.

For his actions, the child’s parents publicly praised Britt, feeling he made the best decision when the EMS system failed. However, their gratitude didn’t change the fact that Britt had violated state law. He was later disciplined by his fire department.

The case caught the attention of Oklahoma lawmakers, and in 2021, a law was passed allowing firefighters in that state to transport patients on fire engines during certain situations.

Now in 2022, multiple cities have moved to allow firefighters to transport patients on fire engines. But this isn’t a result of a public outcry, but rather a tactic being utilized to combat the COVID pandemic.

From “Should we do it?” to “How should we do it?”

Based on my own experience, the situations in OKC and the ongoing battle with COVID-19, designing fire apparatus with the capability to transport patients seems like a no-brainer. There are only so many ambulances on the road. As EMS services struggle to keep up with staffing needs, firefighters all over the country are finding themselves stuck on the scene waiting for ambulances responding from farther and farther away. We see the problem, so why wouldn’t we adapt to fix it? Isn’t that what we’ve always done?

Further, if transporting patients on fire engines is the answer, then shouldn’t we be designing our apparatus to do this in the safest possible manner?

Propping up a bad system

Lt. Stephen Cook is a good friend of mine. He travels the country instructing firefighters how to operate pumpers, aerials and tankers. Cook has also served on our department’s specification committees weighing in on the design of our new apparatus. Given his experience, I assumed he could provide some insight on the matter.

He was kind enough to put his thoughts in an email:

I think, as firefighters, we are often our own worst enemy when it comes to staffing, mission and, in this case, equipment. We have always interjected ourselves in an emergency with the feeling that we can figure out how to make things better. We've expanded the scope of our trade from fire safety and fire suppression to hazmat, EMS, technical rescue, community healthcare workers, social workers, and prehospital transport. As we expand our primary tasks, we have continually agreed to take on more and more responsibility, while simultaneously solving budgetary shortfalls of politicians.”

Lt. Cook raises some valid points, in particular, the fact that by taking on the responsibility of transport, we would allow those creating the budgets a way out of providing some much-needed funding to our struggling EMS system. And isn’t that the root of the problem?

Where do we draw the line?

The problems in Oklahoma – understaffed, overworked and struggling to get ambulances to patients quickly – could be used to describe EMS transport systems everywhere. The biggest reason: money, for the agencies and the employees.

EMTs and paramedics have long been underpaid. And reimbursement models for ambulance services are still treating EMS as a service that does nothing more than move patients from point A to point B. Instead of absorbing more responsibility by changing the way we design fire apparatus, we should be looking to attack the problems at their root.

We can start by using a tool that is already in our toolbox: public education.

In Oklahoma City, the parents of the young girl who was burned said they felt the EMS system had “failed” after waiting for an ambulance for 20 minutes. I can’t help but think that if those parents had been informed of the state of EMS prior to that awful day, maybe their expectations would have been more in line with reality. I agree that 20 minutes is a long time to wait, but when compared to places where patients are waiting hours, and sometimes not having an ambulance arrive at all, 20 minutes doesn’t sound so bad.

I understand that, though rare, transport-capable fire pumpers already exist. So before we begin making transport-capable fire apparatus the norm, we need to consider the unintended consequences.

Had I had a transport-capable fire pumper the night I made the choice to wait for the ambulance, could I have been held liable for the man’s death? Could I have convinced a jury that by administering oxygen, bleeding control and eventually CPR that I did my best to save the man’s life? Would they be able to differentiate providing on-scene treatment with simply waiting for an ambulance? If they can’t, then whose fault is it if the patient dies?

I believe the best action we can take as fire-based EMS providers is to do a better job of informing the public of what is really happening when they call 911.

Who knows, if they see what we see, maybe they will come to our rescue.

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