Interview with Richard Liebmann

Compte tenu de la durée de cet entretien, la version française de cet entretien sera publiée séparément.

(21-03-2024)

Richard Liebmann is the Director of the Montréal Fire Service with 2400 firefighters working out of 67 stations across the entire island of Montréal. The service provides fire, rescue, and emergency medical first response services to a territory of 500 square kilometres, with 400,000 residential, commercial, industrial and institutional buildings and a population of nearly 1.9 million. In 2022, the Montréal Fire Service responded to 118,916 calls.

In sitting down for a formal interview, Liebmann and I continued a conversation which has spanned decades at this point. It's quite challenging interviewing someone you've known since you were both in your teens and just starting out in your respective careers in emergency services. I had to consciously remember to introduce the Richard Liebmann I know – to each of you. As with all good interviews, I learned several things about Liebmann that I didn't know before this conversation.

Newman –

Did you start your career as a paramedic?

Liebmann –

Well, actually I started my career as a volunteer first responder at Cote-Saint-Luc EMS a long time ago. I started as a dispatcher and really caught the bug for emergency medical services when I was very young after taking a CPR course. I eventually decided that I wanted to become a paramedic and because advanced care paramedic training wasn’t really available here in Québec, I decided to go to the United States. I went to the Medical College of Ohio and got my advanced care paramedic certification. I ended up coming back to Montreal because I always wanted to be here.

Newman –

You also did a stint in Los Angeles?

Liebmann –

It was part of the training that I did as a prerequisite to my paramedic. I had to do my Emergency Medical Technician-EMT basic (EMT-B), and I did that with the Los Angeles (LA) County Fire Service. As part of the internship, rather than being on a private ambulance, I got a special dispensation to ride with LA County Fire. Because I was already accepted at the Medical College of Ohio to paramedic school and knowing that I wanted to go on to do advanced life support, they let me ride my practicums with LA County Fire paramedics.

Newman –

What was that like riding with LA County Fire EMS at the time?

Liebmann—

Well, it was super interesting. It was just before the 1984 Olympics. It was in Inglewood, California (population 107,000). It was a lot of gun violence and that kind of stuff that we saw. Our class was out of Daniel Freeman Memorial Hospital which was also the designated trauma center for that area at the time. So, I got to see a lot in a very short period of time. It was quite an intensive program, but it also gave me that exposure to fire-based emergency medical response, which really showed me another way of doing things with respect to how things were done here.

When I left Montréal, it was all private ambulance companies and I believe it was in 1982 that Urgences-santé (the EMS service for Montréal and Laval) was launched, but was only doing the dispatching. So it was a central number rather than calling the private ambulance companies. When I did my CPR course way back when, it was with Resuscicar ambulance and I'd done some ride-alongs. I wasn't even 18 yet. I'd done some ride-alongs with Resuscicar and Medic-One because I had a passion for it and got the opportunity to do so. But back then, you had to know the number of a private ambulance company or find it in the Yellow Pages, or you would call the police, which was also a seven digit number at the time. And they had police officers that had training anywhere from standard first aid up until some of the police officers that happened to have been paramedics that had gone through a pilot program at Dawson at the time. But they had no equipment. It was a van with a white metal first aid kit and a stretcher in the back. So, when Urgences-santé got started, it was responsible for the dispatch of all these private ambulance companies. And eventually it morphed into what it is today, which is the ambulance, the EMS service for Montreal and Laval.

Newman –

When you came back you worked at Côte-Saint-Luc EMS. We worked together. When did you go into the Fire side of the service?

Liebmann –

Côte-Saint-Luc EMS was a great outlet for me because it was a volunteer EMS service that had grown out of civil protection. It started running first response, as you know, a long, long time ago. So, it gave me the opportunity to have patient contact. When I came back from paramedic school as an advanced care paramedic, I did try and get a job with Urgences-santé, but it was very complicated at the time. I had to get my Quebec (Ministère de la Santé et des Services sociaux) MSSS card. I jumped through all the hoops. I went and did the equivalence exam. I actually got a part-time job teaching the ambulance technician course at one of the CEGEPs. But the the short story is Urgences-santé required a “Perfectionnement” course in order to get a card to work with them. And they weren't offering the course anymore. So, I was stuck in a bit of a Catch-22. After several months they re-approached me and asked if I wanted to be a supervisor. At the time, the supervisors were people with higher levels of training such as advanced care paramedics, nurses, etc. that were riding around alone in a Jeep full of advanced life support support equipment that they weren't allowed to use. They were just there to provide support to the doctors who were the Advanced Life Support (ALS) providers at the time. I thought that as a very young freshly trained ALS paramedic that was a recipe for disaster.

So, I declined, and I followed through on a promise that I'd made to my parents to get a university education. They agreed to support me when I ran off to paramedic school in Ohio but on the condition that I agreed to finish a university degree at some point. So, I went back to school and did an undergrad degree in psychology with a minor in psychophysiology. I came back and started teaching water rescue and ice rescue because I had worked for the Coast Guard during the summertime and worked as an instructor for the Coast Guard.

After I finished university, I tried to start a business and it was there that I discovered that there was a fundamental disconnect between the primary objective of a business which is to maximize profit and the primary objective of teaching life-saving procedures -- which is to maximize availability. And somebody said to me, ‘Why don't you look into the fire department? That way you can work 13 days a month and teach for fun without having to rely on it as a career path.’ So, I applied to the Côte-Saint-Luc Fire Department, and I got a job as a firefighter, and everything kind of just took off from there.

Newman –

What were your roles with the Côte Saint-Luc Fire Service?

Liebmann –

I continued working as a volunteer at Côte-Saint-Luc EMS. Every time I came back to Montreal. We worked together there, as you remember. Even when I was a firefighter, I continued working at the volunteer EMS service. When the fire chief at the time retired, the new fire chief that took over was much more open to the concept of fire-based medical response and to medical response in general. One of the first things that he did was asked me if I would come on board as a Chief with the Côte-Saint-Luc Fire Department, and at the same time re-involve the firefighters with medical response whenever the volunteer service was unavailable, whether it was a second call or whether it was a shift that couldn't get covered.

Eventually, the person in charge of Côte-Saint-Luc volunteer EMS, left for other jobs, as you know, and it was at that point that the decision was made by the city to integrate the management of the volunteer EMS into the fire department structure. So, I was a division chief in the Côte-Saint-Luc Fire Department. I was responsible for fire-based medical response in the fire department, as well as all my other duties and the management of the EMS service, which remained a volunteer service. The two services worked as complementary services. The primary responder was always the volunteer EMS service, but whenever they were unavailable, the firefighters were there to back them up for critical responses.

Newman –

You’re also a SWAT medic. A tactical medic. Can you tell me about that experience?

Liebmann –

That was an interesting tangent that I took in my career path. When I was going to paramedic school in Toledo, I became very good friends with a guy who was going through the police academy and got the opportunity to do some training with the Toledo police. Later in life, he worked his way up through the Toledo Police Department to become a SWAT officer. And there was a debate at the time of what was best to do for tactical medicine. Should we take a cop and train him as a medic, or should we take a medic and integrate them into the entry team? And so my buddy, at the time said, ‘Well, why don't you come down here and go through our basic SWAT class and we'll see if a paramedic who's not a cop can get through the SWAT training.' To help them make their decision as to whether they wanted to integrate medical professionals into the entry team or whether they wanted to take cops and train them as paramedics. So, I went through that training. I also got the opportunity to go to CONTOMS, which was the US Uniformed Services University's Counter-Narcotics and Tactical Operations Medical Support, which you also went through. So, that was a great opportunity. In Côte-Saint-Luc, we did as much work as we could do at the time with the local police department for special events and that kind of stuff. It was another eye opener to other aspects of emergency care.

Newman –

And then Côte Saint-Luc became part of the City of Montreal ?

Liebmann –

In 2002, there was a forced merger of all 27 municipalities on the island of Montreal into one big megacity which also as a consequence, merged the 22 fire departments that were on the territory into one big fire department. Côte-Saint-Luc was a part of that. So, their fire station became part of the new service, Service de sécurité incendie de Montréal (SSIM) as we know it today. The peculiarity is that Côte-Saint-Luc EMS stayed on as a volunteer service. What was then the borough of Côte-Saint-Luc Hampstead and Montreal West. With the de-mergers on the political horizon Côte-Saint-Luc kept the autonomy of their EMS service.

Because I was a chief officer in the fire department, I went over to the fire side with the merger and I became a battalion chief attached to the Office of the Fire Chief. I was in charge of media relations and public affairs – which was never exactly my dream when I became a firefighter. But looking back, in retrospect, it was probably one of the most critical things to help me get into the seat that I'm in today as fire chief, because it allowed me to see every aspect of the fire department – to be attached to the office of the chief and accompany him in developing a strategic plan. Which is an opportunity I probably never would have gotten had I become a battalion chief in one of the West Island communities where the new fire department was looking for bilingual people to serve those communities.

Newman –

You were responsible for implementing medical first response across the entire service. Can you talk to me about the particular challenges of bringing a large metropolitan fire service online as medical first responders?

Liebmann –

So just to be clear from the history standpoint, when we merged in 2002, there were several stations that were providing first responder services, which were the municipalities that provided it before. Montreal West, Hampstead, Dollard-des-Ormeaux, TMR, Kirkland, Pointe-Claire, Westmount and Outremont. Those cities continued to provide medical first response. In 2003, I believe, the new city of Montreal made the decision to extend the first responders service across the island of Montreal and the new megacity to all 67 stations of the new SSIM, which was about 2400 firefighters. It was done on a voluntary basis.

To backtrack, there was a division chief who was in charge of first response. After public affairs, I went to special operations. I was in charge of implementing our ice and water rescue programs. In 2005, I was approached by the senior management at the time – by the director – and asked to take over from the division chief overseeing first response and really move forward with the implementation of fire-based first response. So, in 2005, we really worked with Urgences-santé to look at the statistics. What would be the impact? In 2006, we were negotiating the agreement with the provincial government for the funding and the modalities to extend first response across the territory.

One of the first steps was that I harmonized the equipment and procedures and the eight stations that were doing it, because we had all different equipment in the different stations. That was the first step. And then when we finally signed the agreement with the province, we also signed an agreement with the firefighters’ union to implement fire-based medical response. It was done on a voluntary basis. We didn't force anybody to become a first responder who didn't want to do so. We had a participation rate of just over 75 percent. So more than three-quarters of firefighters said, ‘Well, yeah, I want to be a first responder.’

We implemented it over three years. We started in, I believe it was April of 2007, and we finished the implementation on the 9th of December of 2009, implementing all 67 stations as first responders, including the station in Côte-Saint-Luc, even though Côte-Saint-Luc retained the competence of first response using their volunteer EMS service on the territory of what eventually became the reconstituted city of Côte-Saint-Luc. But the firefighters in the fire station in Côte-Saint-Luc are still first responders and respond to medical calls because their station territory of what is now Station 78 covers more than just the City of Côte-Saint-Luc.

Newman –

Did firefighters receive a financial incentive to become first responders?

Liebmann –

Yes. The only way that we were able to come to an agreement with the firefighters is that we took the existing conditions in the eight cities that already provided the service. I wasn't a part of the negotiations, but in negotiating the first collective labour agreement, they came to an agreement on a compensation package for those firefighters who decided to go above and beyond the minimum and volunteer to be first responders. And that was done based on the conditions of the eight cities that that were providing the service at the time, and that compensation has been maintained throughout the successive collective labor agreements that have been implemented.

Newman –

What is the retention rate on first responder firefighters and are all new firefighters already trained as medical first responders when they are hired?

Liebmann –

One of the things we did over the course of time is we discovered that that there was some basic training and firefighter training for first responders, but not enough to qualify them to be a first responder in Montreal. So, during the implementation period or just post the implementation period around 2010-2011, we worked with the fire schools to upgrade their level of training so that when a firefighter graduates fire school, they are already qualified – instead of coming to us with three quarters of the training, and then we start from scratch and train them again.

In answer to the first part of your question, the retention rate is pretty high. We have very few firefighters that decide to opt out of being first responders, which they do have the option of doing, or they did have the option of doing up until the latest collective labor agreement and firefighters that come out of fire school now have the certification. So, we don't have to do their initial training anymore unless they've been out of school and haven't maintained that certification between the time they graduate and the time we hire them. We do provide continuing education, obviously, for everybody who's a first responder firefighter. And that's according to the Ministry standards. It's actually Urgences-santé that has been doing our training up until now. We're looking at transitioning, or the possibility of transitioning to taking that on ourselves at some point. But at this point, we still work closely with Urgences-santé for our training.

With respect to the latest collective agreement that was signed in December of 2020 and came into force in 2018, retroactively, now all new firefighters that come in do have to be first responders. So, they either come already certified or we train them as soon as they come in and they are recognized as first responders. One for one with the number of people that we're still training that that were already Montreal firefighters that were not trained as first responders. But with the goal that eventually every firefighter will become a first responder, because today medical first response represents roughly 60 to 65 percent of our call volume. That's pretty much standard across most North American cities. It's anywhere between 50 and 80 percent of the call volume of a fire department today.

There's a really important misconception that I'd like to clarify, because I know there's a lot of talk about the pertinence of having firefighters run as first responders. And really, it's super important to understand that the number of firefighters in a community is established based on response times required to have a sufficient firefighting force to put out a fire, according to the response time and what you need initially. If we stop doing first response tomorrow, it would not reduce the number of firefighters we still need on the territory, distributed strategically so that we have quick response times for fires.

The idea behind tiered response or using firefighter first responders is that we optimize the use of those resources that are already there, already on standby, ready to save lives and integrate them into the emergency pre-hospital care chain so that they can stabilize a patient until the paramedics arrive and continue along that continuum of care, provide a higher level of care and transport the patient. And what allows us to do that is the short call duration. We get there quickly because we're already strategically deployed. We stabilize the patient, and as soon as the ambulance arrives, we transfer care and we could theoretically become available for another call. Whether it's a fire or another medical call. We'll often stay on-scene and support the paramedics in their work. We can do so while we're available to respond to other emergencies. So, our average call duration is around 15 minutes or a little bit less.

Newman –

What’s your volume of calls?

Liebmann –

At one point we were a little over 80,000 medical calls a year. We've managed to reduce that a bit because we only respond to priority zero, which are immediate, life-threatening calls, and priority one, which are a high threat to life calls. We have, over the last several years, been able to modulate those calls based on the estimated time of arrival of the ambulance. If it's one of the calls, which according to the Ministry's system are determined to be 'modulable' – so the less urgent of the priority one calls. If there's an ambulance that has an estimated response time that's below a certain threshold, that means that we're likely to get there at roughly the same time. They can opt to not dispatch firefighters. So that's brought our call volume down to somewhere around 70,000 calls a year.

Newman –

What is your target response time?

Liebmann –

So, it depends on the context in which that question is phrased. For emergency medical calls, our target response time is based on the Health Ministry's target response time for pre-hospital care, for urgent priority one and zero calls. So, that's a system response time of seven minutes and 59 seconds. And that is from the time the call is received at Urgences-santé from 9-1-1 until the time the first unit arrives on-scene. We have no control over how much time it takes to process the call (at Urgences-santé).

Once we receive the call, on average, we're able to respond within roughly five minutes from the time we receive the call at our dispatch center until the time a fire truck arrives in front of the address. And that's an average. That's roughly the same for fire calls as it is for medical calls. In the case of fire calls, it's not a target, per se.

The target that we have established by the Ministry of Public Safety is ten firefighters in ten minutes for low-risk occupancies. But we're well within that target because that's a provincial standard that applies no matter where you are and considering the level of risk, the population density, etc., we're well within that target response time.

Newman –

Can you define medical first responder – is that the equivalent of an Emergency Medical Technician-Basic?

Liebmann –

Not quite. First responder is about 62 hours of training that we do here. The minimum standard is 60 hours. And that's decided by the provincial health ministry. So, when we started this in 2007, there was only one level of first responder. It was 60 hours. We can provide defibrillation. We can provide epinephrine injection for anaphylaxis using an EpiPen Auto-injector. We provide oxygen and basic stabilization care. I believe the EMT basic standard is roughly double that number of hours, depending on state to state. But we can provide good basic stabilization care with defibrillation, CPR, oxygen. We carry naloxone as well through a nasal applicator. And that's again established by the province.

In 2012, I believe, the provincial health ministry came out with four different levels of first responder. We are what's considered a first responder level three. We respond to all priority one and priority zero calls. There is level two which has a lower number of hours of initial training and the lower number of required hours of continuing education that respond basically to a subset of priority zero and priority one. They'll respond to all priority zero calls, but they respond to a smaller subset of priority one calls. That pretty much excludes a lot of medical emergencies but includes trauma. Then there's first responder level one, which is once again a lower level. And that provides care basically for cardiac arrests, anaphylaxis, and major immediate life-threatening emergencies. And then there's first responder AED, which is essentially intended for police departments that want to just respond to cardiac arrests with a defibrillator and CPR training.

So far, we've maintained level three first response. I believe that is an appropriate level for an urban center like us, especially an urban agglomeration, where we have some areas where the wait times for ambulances are quite a bit longer. Once again, we're already there, for fast fire response and can provide that stabilization for even medical emergencies. The advantage of having the different levels of first responders is it allows different communities, especially some suburban and some rural communities, to implement a first responder program without paralyzing their ability to continue responding to fires. If it's a fire-based system or with a call volume that that makes sense for a rural community.

Newman –

You’ve got some interesting additional resources you bring to the job. You earned an executive certificate in Public Leadership from the Harvard Kennedy School and you’re also a member of the Metro Chiefs which allows you to network with the chiefs of the largest fire services in North America. What are your takeaways about the future of the fire service and providing emergency medical services (EMS)?

Liebmann –

I think the fire service is an absolutely indispensable partner and link in the chain of survival. We're not there to replace ambulance services. We're there to stabilize a patient until the paramedics get there. They can deliver a higher level of care and can transport to the hospital for definitive care. The reason being, and the reason I truly believe that fire departments are the key to tiered response is because, like I said before, we already have to be strategically deployed across any territory to provide an initial attack force and a firefighting force for fire protection within a rapid response time.

Most North American departments strive for the NFPA standard. The NFPA is the National Fire Protection Association. They establish standards of service and the standard for the organization and deployment of a fire service, which is NFPA 1710 and 1720. It's being morphed into one single standard in the future. But the basic standard is to essentially have a firefighting force – that if I take it from the time the call is received to have an initial fire truck there within six minutes and 24 seconds from the time we received the call. And that applies to any urban territory. So, for fire departments, that's 90% of the time. That's something that most fire departments strive for. Not all of them accomplish it, but most are pretty close when we're talking about metro departments. And that requirement to have that presence there to respond quickly to fires and be able to rescue people and contain fires at the same time, gives us the ability to respond quickly, to save lives by stabilizing a patient until the ambulance can arrive.

The difference between a first responder and an ambulance is that once the paramedics gets there, they have to stabilize the patient, load them on board, transport them to the hospital, and as you well know, the time to discharge a patient at the hospital can be very long because of a multitude of complex issues at hospitals in terms of their ability to take patients. And then the ambulance has to be decontaminated, restocked and put back into service before it can become available again. Whereas a firefighter first responder unit, we respond with our fire trucks.

That's a very frequent question that we get. Why do we respond with big trucks? Simply put, we're using the resources that are already there, already in place. If we had to add resources for the medical mission, then it wouldn't make sense. Then it makes more sense to put more ambulances on the road. But the idea of tiered response and fire based medical response is that the resources are already there, already strategically deployed, and already with the mindset of saving lives. And we can stabilize those patients until the paramedics get there and the ambulance will always take a little bit longer because their mission is different. It's a different mission. They're there to really pursue a higher level of care and transport the patient to another level of care. For us, we don't load the patient on board our trucks, so our return to service happens much, much quicker.

Newman –

Sometimes I worry that we ask the wrong questions when we're when we're talking about EMS, and so hence we get the wrong answers. I wonder what you look at in terms of key performance indicators that you've developed, not ones that have been imposed. What do you look for in terms of strategic outcome for first response? What's a meaningful outcome? Is it tied to patient care?

Liebmann –

I'm really glad you asked because we always talk about response time. But just because we get there quickly doesn't prove that we've made a difference.

Before we implemented fire-based medical response, we commissioned a study by a university research group to evaluate the economic impact of implementing first response in Montreal. Their conclusion was that it made sense for all the reasons that I explained before. When we finished implementation in 2017, I asked them to do another study to measure the outcome. Did we achieve our objective and was their hypothesis correct? And so they did this study in 2017. That's because that's when our agreement with the province expired for funding, and we had to renegotiate it.

We tried to get them to measure the reduction in morbidity and mortality that's basically attributable to fire-based first response. And unfortunately, it was very difficult for them to calculate the reduction in morbidity because it's very hard to measure without being able to follow patient outcome all the way through to the hospital and through discharge. But the simplest thing that they were able to do is measure the reduction in mortality. So, look at out of out of hospital discharge survival rates for cardiac arrest. So, they were looking at the mortality rate only for cardiac arrest events, and only for those events that had not just a return of spontaneous circulation, but survived to hospital discharge. And based on the most conservative hypothesis that we only made a difference in x percent of calls.

So using the most conservative hypotheses, both for the percentage of calls in which we make a difference, the percentage of calls in which we arrive before the ambulance does, etc., they calculated that our reduction in mortality, could be calculated at anywhere between $36- and $78-million per year, which translates to 100 and some odd lives per year that are that are directly saved by first responders being present on the territory just through rapid defibrillation and early intervention.

We were never able to prove it to, to calculate it, to quantify it but I can tell you anecdotally, having worked in this field for a long time, I am absolutely certain that first responders make a difference in a reduction in morbidity as well. I've seen it firsthand just by reducing the patient's stress level and reducing the cardiac load due to that stress level and waiting for somebody to show up, even if we're not providing clinical interventions that are determined to be crucial to positive patient outcome, we definitely make a difference by having that presence there.

And if nothing else, we make the community feel a lot safer by having that rapid response to medical emergencies. We’re used to it. We've been in this business for a long time. To us, 9-1-1 is a daily thing. But most people, you know, God willing, they're only going to have to call 9-1-1 once or twice in their lifetime. And so, for them, when they're experiencing a medical emergency, it's a life-changing event for a lot of people. And just to have somebody show up quickly makes a big difference.

Newman –

Do you have any inkling as to why we're unable to prioritize EMS as a service and that applies not only in Quebec? This is a problem and a challenge across North America where we embrace the fire service but EMS has always kind of been the orphan service.

Liebmann –

This is just my personal opinion, but I think it's kind of similar to the under-investment I see in fire prevention as well. How do you prove what you prevented from happening? And it's a bit of the conundrum that we have with quantifying the reduction in morbidity. At least in the case of first response, it's very difficult to prove that you prevented a patient from getting worse.

Whereas with fires, a building is on fire, you've got to go. You've got to put it out. If you don't show up, that fire is going to spread and spread and spread. You see it, you feel it. And when the firefighters get there and put it out, well, it's an immediate, measurable response to the intervention.

Whereas showing up for medical calls, a lot of the time it's like, well, had you gotten there a half an hour later do we know what the outcome would have really been? It's very difficult to quantify that in scientifically valid terms.

That's what I think is at the root of a lot of this under-investment there because I mean, personally and once again, I'm going off onto a tangent that is really not my area of responsibility, but I think a key component is also investing in community paramedicine. Having people respond to avoid hospital transports. I don't think that is necessarily the role of the fire department, because then we tie ourselves up in the event that we get somewhere and we determine that, okay, well, this person is not stable and they need to be transported. Then there's a long wait time until somebody arrives for care and transport and we tie up those resources for fire response.

I think there's a really important role there for the EMS service to engage in that and thereby free up ambulances from unnecessary transports. But right now, the way the system is built – it's a one call, one ambulance response, one call, one ambulance response. And once you get there, you can't really walk out easily without being able to transfer them (the patient) to another type of service that will then take care of them.

So, I think there tends to be an under-investment in prevention – to the benefit of an investment in response. Just because when there's an incident that we respond to, we immediately see the outcome of our response in prevention. It's much more difficult to get that direct feedback that your investment in that active prevention saved lives.

Just just the other day, we had fire inspectors go into a bar and have them remove some flammable curtains that were installed in different places. And several days later there was a fire. And the fire ended up being a minor fire because we had removed all of that combustible material. I can't say with absolute certainty that 50 people would have died had those flammable curtains still been there, because the fire would have accelerated much quicker. Nobody really knows what could have happened and what would have happened. But I can tell you with absolute certainty that we made a difference in saving lives that day with an act of prevention. But it's very difficult to measure what that impact was.

Having had a fire immediately after we removed that stuff and saying, well, look, you see, the outcome would have been much worse. But a lot of times, we've removed tiki torches and all kinds of stuff from bars and clubs and restaurants and never had a fire subsequent to that. So how do I prove what we prevented from happening? And that's the touchy part about prevention.

And that's I think EMS is slightly stuck in that – it's really, really difficult to quantify. How much degradation of a patient do you prevent from happening other than the obvious outcomes. In cardiac arrest we know exactly what it is – the chances of survival diminish 10 percent for every minute you delay treatment. But there are other cases that are much more difficult to quantify.

One of the examples that I use often in the argument, because we've we're in the midst of discussion right now with the Ministry as to whether or not it makes sense to continue to respond at a first responder level three to all of the priority one medical calls. And my argument is, what if you don't respond with a first responder to those chest pain difficulty breathing calls. Granted, it's a small percentage of those that degrade to a cardiac arrest. But when they do, had you had a first responder there providing oxygen and reassurance and comfort to the patient and the patient codes (suffers cardiorespiratory arrest) in front of a first responder with a defibrillator, your chances of resuscitating them are exponentially higher than if you don't send a first responder to that chest pain call. And then the patient goes into cardiac arrest. The family calls back 9-1-1. They upgrade the call to a priority zero, then the firefighters are dispatched. Well, then there's that – on average – five minute delay until we get there and defibrillate and you've just decreased that patient's chances of survival by 50 percent versus a witnessed cardiac arrest.

That's all speculation. That's all anecdotal. It's all hypothetical. And that's one of the difficulties we have in this argument. But in this discussion about the benefits of first response for things that are not limited to just the cold and clinical impact of an action that a first responder can pose. So, it's very easy. Defibrillation. Yes. Makes a difference. Seconds count. Applying oxygen to a patient having chest pain, difficulty breathing.

Newman –

Are we asking the wrong questions about how we evaluate the contribution of our paramedics in that we're hyper-focused on response times, stopping the clock. We don't do things like look at, STEMIs (ST-elevation myocardial infarction) identified in the field using a 12-lead ECG and realizing this patient's actually having a heart attack with a greater risk of serious complications. We need to get rolling, get him to a definitive care facility. And if we had advanced care paramedics, they could actually stabilize en route. And instead, we keep looking at cardiac arrest events where we've already maxed the threshold and we're into life or death. It’s my hope that eventually we’ll start asking the right questions.

Liebmann –

Again, this is a little outside of the scope. But, as a metro chief, I go to these conferences and I see what some places are doing. This goes back years. I don't remember how many years ago. It was in Toledo, Ohio, where I went to paramedic school. They have a mobile stroke unit. They have a mobile CT scanner that gets dispatched to suspected stroke calls where the technicians can transmit imagery in real time and start thrombolytic therapy in the field for a stroke victim. The big difference, of course, is financing. In the United States, you have hospitals that are for-profit organizations, and most of those mobile stroke units and those kind of high-value, high-ticket items are based out of these hospitals that that have sources of revenue to be able to generate them versus, all the public funds that are used here in Quebec and throughout a lot of Canada.

Coming back to the whole question of first response and level of first responder care. One of the best parallels that I can draw is a number of years ago, we decided to increase the number of trucks we send to calls that come in for report of a fire. One of the ideas is we wanted to move up that initial attack force so that we have more firefighters there to knock down that fire quickly and prevent it from spreading into a multiple-alarm fire. That has to be balanced with the risk of sending a lot of big, heavy trucks with lights and sirens through a community.

We've determined that we only send that stronger initial attack force when there are multiple calls. When you know, as they say, ‘it smells like fire on the telephone’. When there are a number of indicators that lead us to believe that it's an actual fire. We've increased that initial attack force and moved it up from the first alarm assignment, so that we can have better success. And we've seen a reduction in the number of multiple alarm fires we have, because that early intervention allows us to control the fire a lot quicker.

The same principle applies in first response, I believe. In some communities they really have no choice. I applaud the move towards different levels of first responders, because some communities just would not have the resources to be able to respond to all of the priority one medical calls because the dispatch system will always err on the side of caution. But in communities that have the depth of resources to be able to do that, I think it's well worth the investment to continue responding to all those priority one medical calls and have that early intervention available on those times that the need comes up.

Newman –

Do you feel that that your early career as a paramedic has had an impact on you now and your role as a fire chief? And if so, what are the tangible impacts and how has it helped you in your career?

Liebmann –

Well, the short answer is absolutely yes, it has, because I believe, like I said, you know, all throughout this discussion that a firefighter's job is to respond within the community to any emergency where life is in jeopardy. Obviously excluding the police aspect of it, because that's a completely different thing. But, when there's someone that's in immediate distress and it's a time-dependent emergency, I believe that the resources that are already there with the mindset of saving lives should be used, and that a lot of that comes from having seen the EMS side of things and how long it can take for an ambulance to get there – because we'll never have enough ambulances to have the kind of response times the fire department has, because it's not the same mission.

I think, you know, that's helping me see, that ultimately, and this is this is something I learned from you, a long, long time ago. That's a philosophical statement that I've always applied in. Everything that I do in emergency services is the grandmother rule. How would I want my grandmother treated if she was having an issue? I find it unconscionable to have a bunch of firefighters trained and equipped sitting in a fire station for several minutes and have an ambulance pass by that fire station en route to try and stabilize somebody who could have been helped by those resources that were already there.

Never to the detriment of our primary mission. You know, I'll never forget that when there's a building on fire, no one else is coming. When there's a medical emergency, the ambulance is still coming. So, our primary mission will always be to fight fires and to rescue people, in technical rescues and hazardous material calls where no one else is there to do that job. But we do have an important role to play in emergency medical care as one link in that chain of survival.

And I think that's just fundamental. I saw it watching the TV show emergency in the 1970s, and I lived it when I was doing my training in Los Angeles and in Ohio. In Toledo, it's a fire-based ambulance service for emergencies and a private-ambulance-based system for inter-hospital and other non-emergency transports.

I believe there's a synergy there between the emergency services that needs to be strengthened – that partnership between all the emergency services, because we all work together for the same ultimate objective – but each of us with our particular roles.