A change in approach
Ambulances aren’t meeting response-time goals; can training firefighters to be paramedics help?
In a nearly empty fast-food restaurant on Federal Boulevard, Denver firefighters started oxygen for a man who was having trouble breathing while they waited for a Denver Health ambulance.
The man answered a paramedic supervisor’s questions until the ambulance wailed into the parking lot two minutes later, and then the two crews worked together to load the patient into the ambulance, bringing along his walker, which was piled high with his belongings.
The call was one of many times that day that Denver firefighters and Denver Health’s paramedics and emergency medical technicians worked hand in hand on the city’s streets, sometimes waving each other off from scenes — the man reported as a downed party was just asleep on the sidewalk, a firefighter told the Denver Health supervisor — and other times working together to provide patient care.
“Even though there are 200 of us, and however many on the fire (department) side, it’s still a small crew at the end of the day,” said Denver Health Lt. Alex Wilkinson.
“We’re all doing the same job; there are just different intricacies of it.”
The sometimes-fraught relationship between Denver Health, which provides emergency medical services in the city, and the Denver Fire Department has improved in the year since changes to Denver Health’s contract with the city gave more leeway to firefighters, officials from both agencies say, even as Denver Health still fails to meet response-time goals and the fire department considers adding paramedics to its crews in the outlying areas to fill in the gaps.
“It’s been night and day in terms of the cooperation,” said Denver Fire Department Assistant Chief Jeff Linville.
“Before, we did our thing, (and) they did their thing. We never got patient follow-up; we never sat down as agencies together and looked at cases from a quality improvement lens. And now we sit down monthly. We look at cases together. … We look for ways to improve the system. That has never happened before.”
The city changed its contract with Denver Health for 2023 after firefighters complained to Denver Post news partner Denver7 about paramedics’ slow response times, policies that limited firefighters’ ability to provide care to patients and what they described as the strained relationship between the two agencies.
Before 2023, firefighters received EMT training from Denver Health and were not allowed to place patient IVS, even though that is an Emt-level skill. Under the new operating agreement, firefighter EMT training now happens in-house at the fire department, and firefighters can place IVS. The two agencies also agreed to hire a new medical director for the fire department, instead of having a sole Denver Health medical director on the paramedic side.
That new position in particular has increased collaboration between the two agencies in the year since the changes, Linville said. Denver has one of the longest-running hospital-based EMS systems in the
“If you see a Denver Health ambulance driving by your office, the natural reaction is, ‘Oh, gosh, they must be going to something important. They’re not, most of the time.”
country, a relatively rare arrangement across the U.S.
Brent Stevenson, deputy chief of operations at Denver Health Paramedics, suggested the firefighters’ concerns were overblown but acknowledged the relationship between the two agencies has been a “hot button” topic for the past couple of years.
“I think, personally, a lot of it has been blown out of proportion, pre-2022,” he said. “We’ve always had a strong relationship with our public safety partners; we’ve always worked well together. We’d never claim that it was perfect. But I think everyone is in alignment that we want to make it better.”
Response times below goal
Despite the improved collaboration, Denver Health paramedic response times still fall short of the goal set out in the hospital’s contract with the city: that paramedics will make it to calls within nine minutes at least 90% of the time.
Ambulances made it to the scene within nine minutes 85% of the time in 2023, according to Denver Health. That’s up from 81% in 2022 and 84% in 2021, but down from 2020, when Denver Health met its goal 90% of the time.
“It’s where we are, and that’s the reality,” Stevenson said. “We would like to do better, but there are a lot of factors that play into what the response times are currently.”
He cited higher call volumes, 911 calls for non-emergency needs, heavy city traffic and an ongoing struggle to hire and retain paramedics as reasons for the slower response times. Denver Health acts as the city’s safetynet hospital and is struggling financially: state lawmakers have approved $10 million in emergency payments to the hospital in the past year to try to stabilize the system as it provides an increasing amount of uncompensated health care.
Denver Health has about 245 field workers now — about 91% of its full staffing level of 269 field staff, a count that includes paramedics and EMTS but excludes administrators and support workers, Stevenson said. On a given day, there are likely 23 to 28 ambulances on the street, he said, with a handful fewer overnight.
The nine-minute response time is a goal in the city’s contract with Denver Health, not a requirement, Stevenson said.
There’s also growing recognition in the field that the nineminute mark is an arbitrary goal that doesn’t impact patients’ outcomes, said David M. Williams, a former paramedic and national expert on ambulance system design.
“That number is based on one study in 1979, and it has been replicated across the country and the world for years,” he said. “Communities live and die by that number … and there is no medical evidence that it makes any difference.”
Generally, most emergency medical calls are for situations that are not immediately life-threatening, like general illness or mild trouble breathing, so an ambulance arriving in nine or 15 minutes doesn’t have a major impact, Williams said.
“If you see a Denver Health ambulance driving by your office, the natural reaction is, ‘Oh, gosh, they must be going to something important,’” he said. “They’re not, most of the time.”
In truly life-threatening situations — like a cut artery or a person choking — nine minutes is way too long of a response time, Williams said. In those situations, the people involved need to take immediate action by calling 911 and following dispatchers’ instructions for care.
“And then the next-fastest person — and this is where the fire service can make an amazing difference — is having EMTS on a fire engine or EMTS on a police car come, because they tend to have shorter response times,” Williams said.
“They are the ones who could make a life-saving difference.”
Firefighters’ role in emergency medical services
The sometimes-fraught relationship between Denver Health, which provides emergency medical services in the city, and the Denver Fire Department has improved in the year since changes to Denver Health’s contract with the city gave more leeway to firefighters, officials from both agencies say, even as Denver Health still fails to meet response-time goals and the fire department considers adding paramedics to its crews in the outlying areas to fill in the gaps.
The department was not able to provide The Post with its response time compliance rates before this story’s publication.
The majority of calls the Denver Fire Department responds to are medical calls — 68% of the calls firefighters responded to from 2018 to 2022 were for medical treatment, according to the agency’s annual report. Only 3.5% of the fire department’s calls were for fires.
All firefighters are also basic EMTS — the lowest level of emergency medical technicians — and provide basic life support care until an ambulance crew arrives to provide advanced care.
The fire department is considering training some firefighters as paramedics and putting those paramedics on firetrucks, particularly in the outlying areas of the city, where Denver Health’s response times tend to be slower. While EMTS go through as much as 200 hours of training and can do basic skills such as splinting or giving oxygen, paramedics complete as much as 2,000 hours of training and can administer medications, perform intubations and perform other advanced tasks.
The idea is in the early stages, and Linville wasn’t able to share details on the cost or scope of the potential change. But he emphasized that Denver Health will remain the primary paramedic provider in the city.
“The vast majority of the time, a Denver firetruck is on scene first, but you are only getting an EMT basic,” he said.
“Putting a paramedic on a Denver firetruck is going to get that higher level of care, that higher level of critical thinking on scene quicker. And again, there is this underlying fear with the line paramedics of Denver Health that Denver Fire wants to take them over. That is not the case. We don’t want to take anybody’s jobs; we just want to make the system better.”
Generally, placing paramedics on fire trucks tends to be expensive, is rarely truly needed and can make it tougher to maintain a high quality of care, Williams said. There is a higher salary cost, and fire departments must also buy equipment and figure out how to keep firefighter-paramedics’ skills sharp even when they’re seeing only a handful of patients who need advanced life support.
“It’s really tough to maintain their skills,” Williams said. “While it seems like a great idea to get the highest-trained EMS person to a patient’s side, the number of times you need that and the amount of expense and effort that go into training that person to do well in that moment is too much.”
Several agencies across the Front Range have firefighter-paramedics, said Eric Hurst, a spokesman for South Metro Fire Rescue, which provides EMS and fire services in Littleton, Centennial, Parker and other southern suburbs.
The agency staffs its ambulances and firetrucks with firefighter-paramedics, Hurst said. About 19 ambulances are staffed with paramedics who are also firefighters, and such firefighterparamedics also work on a handful of fire engines, he said.
“The difference with our ambulances is they are equipped with all the firefighting equipment they would need,” he said. “So when we have a house fire, the firstarriving ambulance, those first two personnel are participating in firefighting unless there’s an immediate patient, and then we send another ambulance to do the medical standby. So they’re very hybrid, where they could be doing firefighting or EMS throughout the day.”
Denver Health’s Stevenson said paramedics on firetrucks might make sense in the outlying areas of the city, but that is just one of several ways the system could be improved.
“I think everyone looks for that silver bullet,” he said. “What’s the silver bullet to fix everything? And it doesn’t exist. It’s a mythical silver bullet. I think we have to look at it a little more organically and look at all the components of the system and figure out where we can make improvements.”
Changes to a misfit system
Denver’s hospital-based EMS system — with ambulances run by Denver Health under contract with the city — is relatively rare across the United States.
Across the country, about 40% of EMS systems are operated by fire departments. Another 40% are run by private companies such as American Medical Response, and the remaining 20% of ambulance services are a mix of different systems, like a hospital-based system or having EMS as a separate city department, Williams said.
Ambulance service in the United States wasn’t widely formalized until the 1960s, when new federal funding led cities to create such systems and experiment with different approaches, he said.
“It was a hodgepodge,” Williams said.
“In the early ’80s, the funding got switched off, and almost everyone was locked in with what they had. … The only communities that have shifted from that are ones in which there was some kind of economic or performance problem that was significant enough that people said, ‘We think we should go in a different direction.’”
There’s no evidence that one type of system is better, although each system has strengths and weaknesses, said Guillermo Fuentes, a partner at emergency services consulting firm Fitch and Associates. Continuity of care often is cited as an advantage of a hospital-based system, because paramedics work within the health center’s systems.
“The benefit of being with Denver Health and having the ambulances respond and transport is we’re integrated into the overall health care of the patient,” Stevenson said. “We’re running the calls. It’s what we focus on. It’s what we do. We have a very highly trained, highly competent group of people who are able to interface on the hospital side for the definitive care.”
A larger issue facing EMS providers, across all systems, is that ambulance service has fundamentally changed since it was formalized 60 years ago, Williams said. Today, more people rely on ambulances to fill holes in their health care, calling for ambulances even for non-emergent care, he said.
“If you were to wipe your slate clean and start from scratch, you wouldn’t build your EMS system the way you have it,” Williams said. “If you were to go back and say, ‘Here are the patient needs, types of patients, the severity and here’s where they are,’ you would create a completely different system, and it would be a lot of EMTS and a lot of ways to take people out other than an ambulance.”
In Denver, the fire department and Denver Health have made changes aimed at addressing the high level of non-emergency calls to 911. The fire department staffs a pickup truck with EMTS — solely EMTS, not firefighters — to respond to lower-acuity calls in the downtown area, Linville said, so that a full firetruck and crew don’t have to take on those calls as frequently.
In Denver, about 30% of calls require only Emt-level care, Stevenson said. The hospital runs up to two basic-life support ambulances staffed with EMTS only to go to those lower-level calls, Stevenson said. The hospital also runs Denver’s Support Team Assisted Response program, which sends mental health professionals in vans to 911 calls and operates a nurse line for 911 callers who have basic medical questions.
“Back in the day, it was just: send an ambulance to fix everything,” Stevenson said. “We can’t do that anymore.”