Resuscitation 51 (2001) 33–38

Acceptance of a medical first-responder role by fire fighters

Karen Smith a,*, Denis Rich b, John Pastoriza Pinol a, Judy Hankin a, John McNeil a

a Department of Epidemiology and Pre�enti�e Medicine, Monash Uni�ersity, Monash Medical School, Alfred Hospital, Commercial Road,Prahran, Vic. 3181, Australia

b Emergency Medical Ser�ices, Metropolitan Fire and Emergency Ser�ices Board, 619 Victoria Street, Abbotsford, Vic. 3067, Australia

Received 5 March 2001

Abstract

Study Objecti�e: In July 1998, a pilot trial which used fire fighters as medical first-responders for the first time in Australia, wasimplemented in Melbourne. We aimed to assess the impact of the introduction of a medical first-responder role to the fire service,on the fire fighters both professionally and personally. Methods: Focus groups were conducted at the fire stations located in thestudy area. Data from the focus groups was collated and examined for themes. The issues identified as important through thefocus groups were then incorporated into a questionnaire. Results: The fire fighters located at the pilot stations involved in thefirst-responder programme appear to view their new role as first-responders as a positive addition to their emergency profession.Some areas of the programme were identified by this study as in need of improvement. Some aspects of the communicationstrategies utilised by the Fire Brigade were highly criticised. Some aspects of the support system offered by the Fire Brigade alsoappear to be regarded as unfavourable. Conclusion: Results from this study provide useful information on professional fire fighterfirst-responder programmes and their impact on participating personnel. These results can be used to improve training modules,communication strategies and support services. © 2001 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Emergency medical services; Emergency medical technician; Cardiac arrest

Resumo

Objecti�o do estudo: Em Julho de 1998, foi implementado em Melbourne pela primeira vez na Australia, um ensaio piloto emque eram usados os bombeiros como primeiros elementos de resposta medica. Pretendemos avaliar o impacto desta nova funcaonos bombeiros, em termos profissionais e pessoais. Metodos: Grupos piloto foram conduzidos aos quarteis de bombeiroslocalizados na area do estudo. Os dados dos grupos foram reunidos e analisados por temas. Os assuntos identificados pelos gruposcomo importantes foram entao incorporados num questionario. Resultados: Os bombeiros dos quarteis piloto envolvidos noprograma parece verem a sua nova funcao de forma positiva. O programa identificou algumas areas que necessitam de melhorias.Alguns aspectos das estrategias de comunicacao utilizadas pelo Corpo de Bombeiros foram muito criticados. Alguns aspectos dosistema de apoio do Corpo de Bombeiros tambem foi visto de forma desfavoravel. Conclusao: Os resultados deste estudo forneceminformacao util para programas de socorrismo primario para bombeiros profissionais e do seu impacto nos intervenientes. Estesresultados podem ser usados para melhorar modulos de treino, estrategias de comunicacoes e servicos de apoio. © 2001 ElsevierScience Ireland Ltd. All rights reserved.

Pala�ras cha�e: Servicos de emergencia medica; Tecnicos de emergencia medica; Paragem cardıaca

www.elsevier.com/locate/resuscitation

1. Introduction

In order to achieve early defibrillation, many emer-gency medical service systems (EMS) have utilised first-

responders equipped with automatic externaldefibrillators (AEDs) [1,2]. In the United Sates most ofthe first-responder programmes use level 1 responders,such as fire or police fire fighters, who are routinelydispatched to medical emergencies [3–5]. World-wide,flight attendants, security personnel, police, fire fightersand other trained laypersons in the community have

* Corresponding author.E-mail address: karen.smith@med.monash.edu.au (K. Smith).

0300-9572/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved.PII: S 0 3 0 0 -9572 (01 )00385 -9

K. Smith et al. / Resuscitation 51 (2001) 33–3834

been trained as first-responders and used AEDs suc-cessfully in public access defibrillation (PAD) schemes[4,6–8].

In July 1998, a trial which used fire fighters asmedical first-responders for the first time in Australia,was implemented in Melbourne. This trial, the emer-gency medical response (EMR) pilot, was a conjointprogramme with the metropolitan ambulance service(MAS) and involved simultaneous dispatch of fire first-responders and ambulance personnel to life threateningevents, known as priority 0, as determined by theCentral Communications Agency (Intergraph) [9].

While it is recognised that during the late 1800s andearly 1900s the Melbourne fire service responded tomedical emergencies, this is the first time in moderntimes that the Metropolitan Fire and Emergency Ser-vices Board (MFESB) has responded to medical emer-gencies in a formal co-operative programme. Theintroduction of the first-responder programme to theFire Brigade has widened the role and activities re-quired of the fire fighters. The role has meant increasedtraining, turnouts and response to life threatening med-ical emergencies involving cardiac arrests. Both theadditional training and the change in their role withinthe community, have the potential to impact on the firefighters both professionally and personally. As yet theimpact of the introduction of a medical first-responderrole to a fire service, on the fire fighters, has not beenexamined in any published study.

2. Materials and methods

The MFESB is an urban fire service staffed by pro-fessional fire fighters. The service is provided from 47stations (�1500 fire fighters) strategically placedthroughout the fire district which covers an area of�1300 km2. This provides services for the mainmetropolitan area of Melbourne, Victoria, which has apopulation of �2 million over 1096 km2 (1754 pop/km2).

The EMR pilot trial area comprised a portion of theMFESB district (�1/6). A total of 21 fire stations,incorporating seven within the pilot trial area and 14support stations were involved in an initial trainingprogramme and were equipped with AEDs and oxygenequipment.

Training for the EMR pilot programme commencedin 1998 with 240 fire fighting personnel receiving initialtraining. Training fire fighters for EMR was based onthe first-responder concept, in which personnel who arefirst on scene provide initial response to an incident.Thus, it was directed towards basic life support, revers-ing sudden death or sustaining survival during the firstfew minutes of a medical emergency. Training com-prised an eight-day course with the qualification having

a 3-year certification, subject to routine ongoing in-fieldaudit and continuing education of critical skill areas.

In order to investigate the impact of EMR and itsassociated training, focus groups were conducted at theseven fire stations located in the EMR pilot area. Datafrom the focus groups was collated and examined forthemes. The issues identified in the focus groups werethen incorporated into a questionnaire, which was ad-ministered to all of the fire fighters at the seven EMRstations located within the pilot area.

2.1. Focus groups

Nine focus groups incorporating 3–10 individualswere conducted involving fire fighters located at theseven EMR pilot stations. The Fire Brigade operatesfour different working shifts (A–D). Shifts from eachstation were selected so that the focus groups could beconducted within a set time period (2 weeks) and eachshift would be represented at least once. A total of 70fire fighters were involved in the focus groups con-ducted during September and October 1999.

During the focus groups, which ran for �90 mineach, the researcher guided the conversation by askinga set of questions regarding EMR and its associatedtraining. The questions were designed to encouragediscussion. The fire fighters were also encouraged todiscuss issues beyond the set questions. Areas encom-passed by the questions included, general perceptions ofthe EMR programme, training and support.

Each focus group was audiotaped, which was ex-plained to the fire fighters at the beginning of eachsession. A researcher then transcribed the tapes. Con-tent coding was used to analyse the transcripts. Thiswas achieved by dividing the transcripts from eachgroup into text units, which were defined as a para-graph of text spoken by an individual. These wereanalysed for key points and issues. Summaries of eachtranscript were produced which identified key ideas foreach topic under discussion and allowed for responsesto be tallied.

2.2. Questionnaire

The aim was to validate issues identified as importantby the focus groups and to ascertain that they representthe views of the majority of fire-fire fighters involved inEMR. To achieve this, an anonymous quantitativequestionnaire using a Likert scale from 1–5 and someopen-ended questions, was distributed to all fire-firefighters located at the seven EMR pilot stations duringthe study. Issues and themes generated from the focusgroups were transposed into 43 multiple choice ques-tions which could be answered along a scale rangingfrom ‘strongly agree’ to ‘strongly disagree’ by choosingone of the five points on the given scale. The question-

K. Smith et al. / Resuscitation 51 (2001) 33–38 35

naire also contained two short answer questions associ-ated with information on EMR and a space for anyadditional comments. Topics covered in the question-naire included the EMR programme, training and sup-port. The time taken to complete the questionnaire was�15 min.

A researcher personally handed out and collected thequestionnaire from each fire fighter. Distribution of thequestionnaire occurred during November 1999. Thus,the study population for the questionnaire consisted ofall fire fighters located at the EMR pilot trial stationsduring this period, who had been EMR trained. Thisconsisted of 144 fire fighters.

Data from the questionnaires were entered into aMicrosoft Access database and analysed in the statisti-cal package Stata [10]. The responses from the ques-tionnaires were tallied and are presented as percentageof respondents who agreed (circled 4 or 5 on the Likertscale) and the median (middle) response (where applica-ble). A quality control check on the accuracy of thedata entered into the Access database was performed.A random sample of 13 (10%) questionnaires was se-lected and the responses entered into the database foreach questionnaire was re-checked. The accuracy forthe data entry of the random sample was found to be100%.

3. Results

Response to the focus groups and the discussionyielded valuable information regarding the first-respon-der programme and its associated training. While thecomments were diverse, only those which were iden-tified as recurring through a number of the groups,were regarded as key issues. As all of they key issuesand some secondary points were incorporated into thequestionnaire, only the results from the questionnaireare presented.

Of the 144 fire fighters who were EMR trained andplaced in one of the seven EMR pilot stations at thetime of data collection, 133 (92%) completed the ques-tionnaire. Of the non-respondents, two were away onsick leave, five changed stations during the data collec-tion period and four were away on a training course.This high response rate was achieved by the researchervisiting each station and working shift individually.

3.1. First-responder programme

Response to the first-responder programme as awhole was positive. Over 90% of the fire fighters sur-veyed felt that participation in the programme hadgiven them valuable extra skills. Only 9.8% felt that theBrigade’s participation in EMR was a misdirection offire resources. The EMR programme was viewed by

over two thirds of the fire fighters as an improvement tothe EMS services in the community and 64.7% felt thatit was improving the chances of survival for priority 0call patients (Table 1).

Most of the fire fighters surveyed had attended be-tween 1–5 first-responder calls over 12-months. Only15% of the fire fighters felt that they were attendingenough incidents to maintain their confidence/skills indealing with medical emergencies. Interestingly, thiswas not reflected in their belief in their capabilities. Thissuggests that while the lack of calls has an impact onthe fire fighter’s confidence, they still feel that they arecapable at performing their tasks as first-responders(Table 1).

When asked to identify concepts that they perceivedas negative impacts of working as a first-responder, themost common response was that the community wassurprised to see the Fire Brigade arrive at a medicalemergency. The next most common response was thefact that a lot of the patients are beyond help when thefirst-responders arrive. However, the type of EMR callsthat the fire fighters attend was not viewed as a negativefactor (Table 2).

The questionnaire also addressed the positive impactsof working as a first-responder in the field. Ninety-twopercent of fire fighters identified the fact that they hadincreased their skill base as a positive effect. The nextmost common response was the fact that the firefighters felt more confident to deal with medical emer-gencies. Interestingly, while the predominant feelingarising from the questionnaire appeared to be positive,only 51.5% of the fire fighters chose increased jobsatisfaction as an effect associated with the first-respon-der programme (Table 2).

3.2. Training

The training component of the first-responder pro-gramme appears to be regarded as one of it highlights.The fire fighter’s responses to the training were predom-inantly positive. Training provided the fire fighters withthe confidence and skills to use the first-responderequipment. Seventy-two percent of the fire fighters feltcompletely capable of performing the tasks required ofthem in the field. Areas of the training which wereconsidered to be highlights included the hands-on ses-sions, the skill maintenance and the type of skills taught(Table 1).

An area in training, which appeared deficient, was amechanism for reducing the stress associated with thefirst-responder role (Table 1). Sixty-one percent of firefighters would like additional time learning how to dealwith grieving friends and relatives. The majority (88%)would also like more practical experience during train-ing, such as a day spent working with an ambulancecrew (Table 2).

K. Smith et al. / Resuscitation 51 (2001) 33–3836

3.3. Communication

The major criticism by fire fighters was directedtowards the strategies employed by the Brigade todisseminate information regarding the first-responderprogramme and its associated training. Less than 50%of fire fighters felt well informed about the trainingcourse structure, the expected statistics/outcomes, theduration of the programme and the type of calls toexpect (Table 1).

While the fire fighters felt inadequately informed

about most of the first-responder programme, only47.4% stated that they read the Fire Brigade newsletterregularly and only 21.2% said that they watched the firevision EMS segments on a regular basis (an in-housetelevision programme used by the Fire Brigade). Thissuggests that although the fire fighters feel ill informed,and are critical of the Fire Brigades communicationstrategies, they do not appear to be availing themselvesof the two most common media used to communicateinformation concerning their role as first-responders(Table 1).

Table 1Fire fighter’s responses to questions regarding first-responder programmea

Number of fire fighters agree Median scoreTotal number of(score 4 or 5)respondents

First-responder programmeEMR is a misdirection of fire resources 132 13 (9.8%) 1

215 (11.4%)Sometimes feel incapable of performing the tasks required 132118 (90.1%) 5Participation has provided valuable extra skills 131

490 (68.2%)132Programme is making a difference and improving the EMS services tothe community

84 (63.2%) 4133The Brigade and the MAS work well together133Improving the chances of survival for priority 0 call victims 86 (64.7%) 4

Worried about the legal implications 226 (19.5%)13320 (15.0%) 2133Attending enough EMR jobs to maintain confidence/skills

Fire uniform is appropriate for first-responder activity 133 28 (21.1%) 2Patient care records are too complicated 133 63 (47.4%) 3

TrainingFire fighter skills relevant to skills taught in EMR training 132 67 (50.8%) 4Felt suitably trained to use the equipment 133 125 (94.0%) 5

133Taught to interact with other teams (e.g., MAS) 64 (48.1%) 34104 (78.2%)Complete understanding of EMR after training 133

133Previous first-aid skills were good preparation for the training 83 (62.4%) 4125 (94.0%)Principal instructors were effective 4133

Sessional ambulance instructors were effective 133 120 (90.2%) 4Covered methods to deal with stress 133 10 (7.5%) 2

132 4On completion felt capable of performing the tasks required 94 (72%)117 (88%) 4133Practical sessions most effective teaching method

133 496 (72.2%)Different delivery modes of course (theory, demonstrations andpractical sessions) related well to each other

133Do not feel properly trained to deal with grieving relatives/friends 361 (45.9%)

Highlights of the training:131 4114 (87%)The hands on sessions

91 (70%) 4The skill maintenance 130The variety of the lectures 130 68 (52.3%) 4The talk from CIS 2130 30 (23.1%)

100 (76.9%) 4130The type of skills learnt4Debriefs provided by ambulance fire fighters more useful than peer 132 82 (62.1%)

support and CIS support131 4Like support offered to become more proactive (rather than reactive) 72 (55.0%)

The support system for EMR isAvailable during working hours 482 (66.7%)123

77 (63.1%) 4122HelpfulEasy to access 122 77 (63.1%) 4

123Confidential 77 (62.6%) 475 (59.1%)127 4Available immediately after an event

Consistent 3.5121 66 (54.5%)123 23 (18.7%)Forced onto us 2

a Statements were scored from 1 (strongly disagree) to 5 (strongly agree).

K. Smith et al. / Resuscitation 51 (2001) 33–38 37

Table 2Fire fighters responses to options provided regarding the first-respon-der programme

Number of fire fighters whocircled this option

Some of the negati�e impacts from working as a first-responderCommunity are surprised to 97 (73.5%)

see first-responders84 (63.6%)Most of the patients are

already dead on arrivalDealing with friends and 75 (56.8%)

relatives of the patientsThe number of calls is less 69 (52.3%)

than expected36 (27.3%)Become anxious when the alert

tones go off (didn’texperience this prior toEMR)

12 (9.1%)The types of EMR callsattended

Some of the positi�e impacts of working as a first-responder in thefieldIncreased skill base 122 (92.4%)Fell more confident in dealing 104 (78.8%)

with other medicalemergencies (e.g., from fires)

Appliances are better equipped 94 (71.2%)89 (67.4%)Helping the community

Increased job satisfaction 68 (51.5%)Number of calls is less than 51 (36.8%)

expected14 (10.6%)Types of calls attended are

more diverse than expected

Impro�ements that fire fighters would like to see made to the EMRtrainingMore practical experience 117 (88.6%)Additional time teaching how 81 (61.4%)

to deal with grievingrelatives and friends

74 (56.1%)More time spent withambulance personnel andtheir equipment

Shorter days during training 73 (55.3%)Additional time teaching how 72 (54.5%)

to communicate withpatients

More information on the 39 (39.5%)support services available to

4. Discussion

The collaboration of the Fire Brigade and ambulanceservice in a medical first-responder programme is uniquewithin Australia. Thus, far this programme has beenaccepted with no major dislocation between the twoservices. However, it should be noted that this programmeoperated under the auspices of a pilot and there is nodoubt that further refinement is required.

The overall feeling that arose from the focus groupdiscussions and the questionnaire was that the fire fightersfelt positive about the first-responder programme. Theywere accepting of their role as first-responders within thecommunity and felt that they had been equipped withvaluable extra skills. Only 9.8% of respondents felt thatparticipation in the programme was a misdirection of fireresources. This is an encouraging response.

The fire fighters appear to have coped well with theirnew role and their required extra training and responsi-bilities. Generally, they have adapted well to the situationand appear to value their additional training and skills.This is probably due to the fact that they already possessthe experience required to act in an emergency situationand have a strong support network within their ownteams.

The skill acquisition-training programme was iden-tified as a major highlight of the first-responder pro-gramme. However, it appears that the fire fighters do notfeel as if they were taught coping mechanisms to deal withthe extra stress associated with working as a first-respon-der. The Fire Brigade allocated formal teaching towardscoping with stress. It is possible that the time allocatedwas insufficient or that the training delivery method wasinadequate. However this is a difficult area to address andeven after extensive training some fire fighters may notfeel adequately equipped with coping mechanisms. Whensomeone’s job description changes, it is important thatan organisation ensures that this change results in theminimal amount of personal stress to the individual.

The number of first-responder jobs attended by eachfire fighter varied, however the fire fighters predominantlyfelt that they were not attending enough calls to maintaintheir skills and confidence. This highlights that a first-re-sponder programme needs to have a very active skillmaintenance programme, with a variety of methodsaimed at maintaining both confidence and skills.

The fire fighters wanted more practical experienceduring training. A day spent riding on an ambulanceobserving medical emergencies was suggested. Theseride-alongs were a sensible suggestion, which would helpin a number of areas. Fire first-responders would acquiremore practical experience, they would be exposed togrieving friends and relatives and it would help them todevelop a working relationship with the ambulanceservice. This is the first time that the ambulance and fireservices have been dispatched together in a coordinated

3.4. Support

The fire fighters appeared to be comfortable with thecurrent support network offered by the Fire Brigade, asonly 31.8% felt that it could be improved. However, only34.6% felt comfortable using the peer support service andthe critical incident stress (CIS) support service. Peersupport is available from fire fighters trained in support,while CIS support includes access to a psychologist. Theinformal operational clinical debriefs provided by theambulance fire fighters after an event, were identified asthe most useful form of support (Table 1).

K. Smith et al. / Resuscitation 51 (2001) 33–3838

programme and developing a working relationship wasessential to the success of the pilot.

An important negative impact associated with first-re-sponder programmes that was highlighted by this study,is the fact that the majority of patients are beyond helpwhen the EMS arrives. Perhaps, this needs to be addressedin more detail during training. Survival from out-of-hos-pital cardiac arrest in Melbourne is as low as 3% [11,12].Thus, the fire fighters need to be educated about theprobability of survival, particularly for patients whosearrest is not witnessed.

Public awareness programmes are important additionsto first-responder programmes where emergency person-nel acting as first-responders have not typically respondedto medical emergencies. A public media launch followedby a mail drop of pamphlets explaining the first-responderprogramme did occur to houses located in the pilot area,prior to the programme commencing. However, accord-ing to anecdotal feedback from the fire fighters the publicawareness campaign appears to have had little influencein increasing public awareness about the first-responderprogramme. In February 2000, the pilot was expandedacross the entire metropolitan fire district. A publiclaunch, pamphlets and reports in the media (newspapersand radio) were used to publicise the expansion. In time,we will be able to ascertain the effectiveness of thesestrategies in informing the public of the role of first-re-sponders.

The existing support programme offered to fire fighterswas thought to be adequate. Thirty-five percent of firefighters suggested that they were comfortable accessingthe support systems offered. While this appears low, itis important to recognise that not everyone will utilise suchsystems regardless of their quality. Also anecdotal reportsfrom International Fire Services have suggested that 35%is a good achievement. The varied response from firefighters indicates that the level of support required is quiteindividual. This highlight the need for a range of supportoptions to be available to personnel involved in first-re-sponder programmes. Support needs to be readily avail-able, well publicised, easily accessible and confidential.

The support offered by the Brigade is multifaceted andincludes, CIS, peer, skills maintenance, re-training, con-tinuing education and departmental support (24 h contactnumber). While this study differentiated peer supportfrom CIS, it did not address all levels of the Brigadessupport programmes and tended to generalise it underthe word ‘support’. In order to elucidate fully the officer’sopinions on the support offered to the brigade, furtherstudy, which characterises the support system at all levels,is needed.

5. Conclusion

The fire fighters located at the pilot stations involved

in the first-responder programme appear to view their newrole as first-responders as a positive addition to theiremergency profession. Some areas of the programme wereidentified by this study as in need of improvement. Someaspects of the communication strategies utilised by theFire Brigade were highly criticised. Some aspects of thesupport system also appear to be regarded as unfa-vourable. Whilst training was generally considered fa-vourably it was identified as lacking an experientialcomponent and lacking in methods for dealing withadditional stress.

Results from this study provide useful information onprofessional fire fighter first-responder programmes andtheir impact on participating personnel. These results canbe used to improve training modules, communicationstrategies and support services. This study highlights someof the areas that need consideration when planning andimplementing first-responder programmes, which utiliseemergency personnel who do not typically respond tomedical emergencies. The areas highlighted in this studymight apply to other levels of emergency response, suchas work place emergency response teams and communityemergency response teams.

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