As Boise firefighters pursue a new ambulance service for part of the city, both major hospitals are pushing back, the state bureau that regulates Emergency Medical Services has cited several concerns and the Ada County Paramedics Department doesn't want the competition.
"To have two governmental agencies in a competing role is not going to lead to an effective, efficient and smooth system of care," said Ada County Paramedics Director Troy Hagen.
Boise firefighters say they want more control over medical response in city limits to give firefighter-paramedics more experience and to improve response times. And they are looking to buy their first ambulance with or without the support of Ada County.
"I put my resources where they can get to fires and medicals the quickest and the best," Boise Fire Chief Dennis Doan said. "He [Troy Hagen] does the same thing, without looking where I put mine."
In May, Boise Weekly reported that Ada County has located several ambulances adjacent to Boise's paramedic fire stations. Doan called that duplication of services. The article and a recent story on the Boise Guardian blog set off a fury of comments from anonymous firefighters and paramedics, revealing an underlying hostility that has been brewing for years, if not decades.
Allegations of sexism, suggestions that firefighters are bad medics and paramedics are slow and fierce debate over the best model for emergency medicine emerged.
But on a recent Friday night, none of that hostility was evident as the ambulance stationed on Ridenbaugh Street in the North End ferried people to the hospitals.
En route to St. Al's, Boise Fire Captain Bill Sipple rode in the ambulance, along with county paramedic Anna Chavez, a 9-year-old boy who was strapped to the gurney and the boy's mother.
It took three city firefighters, two county paramedics and two cops to figure out why the boy had been lying face down on the pavement for an hour and a half, restrain him as he kicked, bit, spit and cussed, get him into the ambulance and deliver him to the hospital for a psychological evaluation.
Ada County paramedics responded to 21,104 medical incidents in Ada County last year--more than 13,000 in Boise alone--assessing and stabilizing patients in the field and transporting them to the hospital. Boise Fire, which also has 24 trained paramedics on staff, responded to 10,666 medical calls last year--nearly 68 percent of its calls. Since there are more fire stations than ambulance stations in the city, firefighters often get to the scene first, provide basic life support or higher levels of care, depending on their certification, and then turn the patient over to the county crew.
While both fire and ambulance have medical directors and work under specific medical protocols, Ada County, as the transport agency, has strong ties to both of Boise's major hospitals and many of the emergency room doctors who work there.
"It's not an issue of who provides that pre-hospital care, but we want to make sure that it continues to be of the highest quality," said Neeraj Soni, chairman of emergency medicine at St. Luke's.
Soni said that Ada County paramedics have been trained in certain cardiac procedures that enhance the transition between ambulance and hospital. He agreed with the chairman of Idaho Emergency Physicians, a group of emergency docs at St. Al's, that consolidation of fire and EMS is a good goal, but, that Boise Fire's plan to put up its own ambulance is not collaborative or efficient.
In 2003, a county-led Blue Ribbon Task Force recommended more consolidation of fire and EMS services across the county. Po Huang of IEP, who wrote to Boise Mayor Dave Bieter recently opposing the fire department's move agrees.
"I wouldn't mind working toward that but not in this crazy haphazard way," he said.
Bieter, who campaigned on consolidation, said that the city and county are exploring ways of emergency services delivery, though county commissioners denied that any substantive discussions have occurred.
"No decisions have been made regarding transport services," Bieter said.
City Councilman Vern Bisterfeldt, a former county commissioner, requested that the Boise City Council discuss the fire department's plans for EMS.
"I feel that transport is a money loser," Bisterfeldt said. "I have no problem with the fire department being trained as EMS ... to give our citizens the quickest and best medical attention possible, but as a county commissioner, it was a money loser."
In December 2008, Boise Fire applied to the state Bureau of EMS for a transport license. The bureau denied the application because the call volume was too great for one ambulance.
The fire department resubmitted an application in February, asserting that its ambulance was only meant to enhance services provided by Ada County, not to replace them. It was again denied. In June, they submitted another application with a map showing a smaller coverage area.
"The state made us pick an area," Doan said. "We didn't want to."
The ambulance is slotted for Paramedic Station 57, which is the old Fire Station 2 on Ridenbaugh Street in the North End. The EMS Bureau declared the application "complete, with concerns," the first step in getting a transport license.
"There are however aspects of your proposed deployment model that may affect public safety if not addressed as you proceed in your plan to deploy a single ALS [Advanced Life Support] ambulance within the Boise City limits," wrote Wayne Denny, standards and compliance manager for the bureau. Denny cited the lack of agreement with Ada County and the still large coverage area as possible impediments, but said he would inspect the city's ambulance once it is acquired.
Boise Fire Capt. Aaron Hummel, vice president of the Boise Firefighter's Local 149, has prepared a detailed history of EMS in Ada County, arguing for an expanded role for firefighters in medical emergencies. Hummel said he has been frustrated for some 15 years that firefighters can only take their medic skills so far.
"We try to progress and Ada County goes on the defensive and fights," Hummel said.
Meanwhile, the county denies that Boise has made any concrete proposal for consolidation.
"We haven't quite identified where the system is broken," said Commissioner Sharon Ullman, who is a liaison to the paramedics. "I believe that it has to do with control--they want to be in charge."
The county offered to take firefighter-paramedics along on ambulances for extra shifts to provide training and experience, but Fire said it will still pursue its own car.
Paramedic Chavez asks a question that neither the city nor the county has asked of the public for many years: "Who do you want to take care of you?"