For Better or Worse: The Complicated Marriage of EMS and the Fire Service

Editor’s Note: Tracey Loscar, BA, NRP, FP-C, a member of the EMS World Editorial Advisory Board, wrote the opposing opinion to this article. Read it here.

A 35-year-old woman is riding in the passenger seat of a sedan on U.S. 1 just north of St. Augustine, Florida. The last thing she will remember is the impact. The call goes out as an MVC with entrapment.

A heavy engine, rescue, and medic supervisor arrive to find two cars in the ditch — one of them on its roof — and a sheriff's deputy inside the overturned vehicle, trying to reach the people still strapped in their seats. The patient is barely breathing with a faint radial pulse. Crews cut her seatbelt and lift her out. Within seconds she is unresponsive.

What happens over the next 15 minutes is everything modern prehospital medicine can do for a person suffering severe blunt trauma. A bag-valve mask goes over her face. A rapid trauma assessment reveals bruising across the chest and diminished breath sounds. The cardiac monitor shows sinus bradycardia with a BP of 70/42. An IO is drilled into the left femur as the medic supervisor performs bilateral finger thoracostomies. As blood seeps from her pleural cavity, respirations improve.

The patient is moved to the rescue where she receives TXA, calcium chloride and, crucially, a transfusion of two units packed red blood cells and plasma. The patient is intubated via rapid sequence induction prior to handoff to the helicopter for transport to the trauma center.

That outcome is the kind of save that used to be impossible. We saved this woman because our medical director wrote protocols that include these progressive procedures. We saved her because nothing about our governance structure required us to wait. That is the quiet miracle of fire-based EMS at its best — and it’s a story that is often mistaken for the whole picture.

A Model With Flaws

The truth is that the same model that produced this save continues to mask an industry-wide failure. Fire-based EMS performs extraordinarily well in agencies that combine strong leadership, sustained funding, an engaged medical director, and an institutional appetite for clinical innovation. It performs poorly almost everywhere else.

Unfortunately, when an agency lacks one or more of these key attributes, both the providers and their patients suffer. And to make things worse, there is nowhere for them to turn for help.

Fire-based EMS lives between two worlds that handle their jobs differently. The fire service is guided by a national consensus standards body, the National Fire Protection Association (NFPA), that has spent more than a century building protections for firefighters. Our partners in the hospital emergency department are governed by state and federal patient-protection laws and an independent accreditation body. EMS is governed by neither. While professionals study and take the National Registry exam and state licensure exams, federal protections don't currently exist. (The National EMS Advisory Council can only make recommendations, not enforce them.) The high-performing EMS systems carry the reputation of the profession; the underperforming ones quietly bury its consequences.

A Marriage of Convenience

EMS, as we practice it, wasn’t engineered. It was assembled. It evolved through war, neglect, and tragedy — from Major Jonathan Letterman’s battlefield triage in 1862, through the country’s first civilian ambulance in Cincinnati three years later, through a 100-year stretch where hospitals, funeral homes, and volunteers operated ambulances with no training standard at all.

When EMS finally professionalized in the 1970s, the question of who would house it had to be answered quickly. The fire service was the natural answer — not because anyone concluded that fire departments were the right home for clinical care, but because fire stations were already distributed throughout every community, structure-fire volume was declining, medical calls were surging as the population aged, and most of the first paramedics were career firefighters. Today, 97% of the 200 largest U.S. cities deliver EMS through their fire department.¹

It was a marriage of fiscal pragmatism, not a clinical design. We have been working out the consequences ever since. First, the credit. The marriage gave us a great deal.

Co-locating paramedics in fire stations placed advanced life support at the first point of contact in nearly every community in the country. Firefighter-paramedics deliver advanced medical care inside fires, extrications, hazmat scenes, and technical rescues — environments where a standalone EMS service cannot operate.

The model also created something less visible but more important: institutional stability, a comfort with calculated risk, an appetite for decisive action under uncertainty, and a willingness to push protocols when the evidence demands it. EMS medical directors operating inside fire-rescue agencies — particularly in states like Florida, where they carry broad statutory authority — can change the standard of care faster than any hospital committee cycle. That is not a defect of fire-based EMS. It is one of its most underappreciated assets.

And yet in 2026, the strain is unmistakable: a workforce leaving faster than we can replace it, a clinical scope the training pipeline never anticipated, and a reimbursement system that still funds transportation rather than medicine. We tend to talk about EMS’s problems in terms of resource allocation — we need more apparatus, better pay, and more staffing. While those are true, they are symptoms of a larger disease — the absence of meaningful, effective oversight.

Consider the two worlds EMS lives between. The fire service is guided by the NFPA, which has researched and published more than 300 standards covering training, fitness, fatigue, infection control, apparatus, protective gear, breathing apparatus, incident command, deployment — guidelines written and updated by people whose only job is to protect the men and women who do this work. When NFPA changes a standard, the entire fire service moves with it.

The hospital emergency department is governed by an independent accreditation body, federal patient-protection laws, state licensure, professional society guidelines, and quality measures tied directly to reimbursement. CMS Conditions of Participation. EMTALA. Joint Commission accreditation. Tort liability that converts those guidelines into the standard of care a jury will apply. When the Joint Commission moves, every accredited hospital in the country quickly falls in line.

EMS is governed by voluntary federal guidance, 50 different state agencies acting independently, and a patchwork of professional opinion. There is no NFPA. There is no Joint Commission.

Florida: EMS at its Best and Worst

Florida has a well-earned reputation as one of the top EMS systems in the nation. It is also a case study of fire-rescue-based EMS at both ends of its range.

The good is written into the law. Florida Statute and Administrative Code grant county EMS medical directors extraordinary clinical latitude. The medical director defines the agency's clinical scope of practice and introduces new interventions without prior state approval, without legislative action, and without sign-off from any outside accreditation body. That is the legal mechanism that allowed our system to introduce field blood transfusions, finger thoracostomy, prehospital antibiotics, and neuro-protective CPR (to name just a few recent additions to our standing protocols). In a high-functioning agency, that latitude is a clinical superpower.

The bad lives in what the framework omits. Florida imposes no specialty qualification on the EMS medical director beyond a state physician's license. There’s no requirement to be board-certified in emergency medicine. There’s no required EMS subspecialty certification. There’s no minimum prehospital experience and, aside from a required10 hours per year of “direct contact time” with their EMS providers, no demonstrated familiarity with the operational realities of an ambulance. Any licensed Florida physician can hold the role. The rest of the regulatory architecture is similarly thin — a small body of statutes and a single administrative chapter, most of which have not been meaningfully updated in decades. There is no equivalent of the Joint Commission, no enforceable accreditation, no triennial survey. Instead of capable governance, the state gives the medical director carte blanche.

The result is exactly what one would expect. Across Florida, the quality of EMS clinical care varies wildly from one county to the next — not because the providers are different, but because the medical directors are, and because nothing in the legal architecture catches the difference.

And then there is the most revealing detail in the statute. Section 401.265 explicitly excludes administrative and managerial functions from the medical director's role.² The medical director has total authority over how emergency medicine is practiced, but no formal authority over how that care is organized or delivered — over staffing levels, shift length, fleet condition, equipment selection, fatigue management, or any of the operational variables that determine whether a clinical protocol can be effectively executed in the field. Those decisions sit with fire administrators who, by training and selection, are typically not clinicians.

Clinical quality lives with the physician. Operational quality — including most of the variables that govern patient and provider safety — lives with the fire chief. And occupying the gap between the two are the patient on the stretcher and the medic running the call.

Who Is Looking Out for the People in the Truck?

Everything I have argued so far has been structural — standards bodies, federal agencies, regulatory architecture. EMS suffers from this gap, but EMS is not an abstraction. EMS is the men and women who do the work.

In our system, those are the same firefighter-paramedics we trust to run into burning buildings. When they take off the bunker gear and head to their next EMS call, the standards architecture that was built to protect them quietly disappears.

Picture the reality in a typical fire-rescue agency. Two providers — often less experienced than we would like to admit — climb into a cramped mobile emergency room. There is no NFPA-equivalent list of approved equipment that has been independently vetted for what they carry. They will work a 24-hour shift, during which they may handle two dozen patients. Some of those patients will present with the same acuity that would prompt an accredited emergency department to flood the room with a physician, two nurses, a patient care technician, a respiratory therapist, and a charge nurse. Our two providers will handle it with each other.

Who is looking after these providers? Who sets the floor for their training? Who vets their equipment? Who governs their fitness, their fatigue limits, their exposure surveillance, their behavioral health support, their cancer screening?

This is what the governance gap looks like at the level of a single human being. It is why the EMS attrition rates are high. It is why behavioral health issues keep climbing. It is why EMS loses some of its best people to nursing programs, PA school, and anywhere that offers compensation, structure, and academic recognition that match the work.

It is also why the state and federal regulators who set our reimbursement rates do not see clinicians when they look at us. They see first responders with a scope of practice they don’t fully understand, operating under a medical model they have never been briefed on. They see a profession with a high-school-diploma entry requirement, embedded inside fire departments and led by fire chiefs, categorized under public safety rather than healthcare — and they reimburse accordingly.

That is not a sustainable model. It is not a model that respects the medics who deliver the care. And it is the model the absence of governance has produced.

What Bold Leadership Looks Like

The EMS we have built over the last 50 years is a fragile inheritance. It depends on the right medical director, the right fire chief, the right grant cycle, and the right ZIP code. Individuals retire, get reassigned, get outvoted. Funding ends. Leadership turns over. The next breakthrough will come the same way the last one did — from fire-based agencies willing to act on imperfect consensus — and the patient saved by it will, again, be lucky to have had her MVC in that agency's catchment.

The patients who suffer their major trauma in someone else's catchment should not have to depend on luck.

What we owe the next patient is not the courage of an individual or the foresight of a single agency. It is a structure: A floor every EMS system must meet, a body that recognizes a proven intervention when one of our own services proves it, and an end to the unwritten rule that says outcomes in EMS are decided by where you live. That structure is not going to be built by hospitals. It is not going to be built by federal regulators who do not yet see us as clinicians. It will be built by fire-rescue leaders, or it will not be built at all.

We have the courage. We do not yet have the structure.

That is the work that comes next.

About the Author

Robert "Bob" Snell is the Deputy Chief of Operations (EMS) at St. Johns County Fire Rescue in Northeast Florida.

Sources

1. International Association of Fire Chiefs. (n.d.). Fire-based emergency medical services [Position statement]. https://www.iafc.org/about-iafc/positions/position/iafc-position-fire-based-emergency-medical-services

2. Medical directors, Fla. Stat. § 401.265 (2024). https://www.flsenate.gov/Laws/Statutes/2024/401.265