Todd Stroger has served as an Illinois state representative, Chicago alderman and Cook County Board President. But that doesn’t mean he understands everything about local government.  

In fact, he’s been wondering about something for a long time, something that caught his eye more than 20 years ago, when his future and current wife lived near a senior living facility on Chicago’s North Side.

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“It seemed that whenever I’d drive up there to visit her, there would be a fire truck outside the senior facility,” he recalls. “And I was always wondering why there’s a fire truck there when I know there’s no fire going on. And if someone’s sick, why do they need a fire truck?”

So Stroger asked Curious City: Why do fire trucks often show up before an ambulance for medical emergency calls?

It’s a question people are asking across the country, and one we’ve gotten from a few curious citizens over the years. They want to know why it makes sense to send a fire truck with ladders, hoses and a full crew of firefighters when someone is having a medical emergency.

In reporting the question out, we got a very logical official explanation from the fire department. But when we dug deeper, we found something murkier, and even distressing — especially given soaring numbers of medical calls and plummeting numbers of fire calls to the the city.

Let’s start with the fire department’s easy answer.

The Fire Department’s version

The Chicago Fire Department is in charge of both firefighters and paramedics, who work in 98 firehouses spread across the city. In each of the stations, the department keeps a combination of fire engines, fire trucks and sometimes ambulances. So when you call 911 in Chicago, dispatchers have to decide which vehicle to send.

Fire department spokesman Larry Langford says that decision is largely determined by the number of available vehicles — 158 fire vehicles but only 75 ambulances. (This does not include private ambulances, which are mostly used for hospital-to-hospital transports.)

He says that that the department’s ambulances can get so busy that some may leave the station in the morning and not return until the next day.  Meanwhile, fire vehicles are often waiting in one of those 98 firehouses — generally no more than two miles away from a given residence — ready for a call.

So, Langford says, dispatchers “save valuable time by sending the closest vehicle, which is usually a fire truck or a fire engine.” These days, that engine will likely have a firefighter who is also a state-licensed paramedic on the crew. If the fire crew needs more help or patient transport, they can be joined by an ambulance with two full-time paramedics when one becomes available.

This all sounds pretty logical until you ask why the fire department has twice as many fire vehicles as ambulances to begin with. This is especially strange at a time when fire calls made up only 3.7 percent of Chicago Fire Department calls. But medical calls made up 73.3 percent. That’s 20 times more medical calls than fire calls. (Others call categories include false alarms and health check calls.)

Still, Langford says people shouldn’t get so hung up on what kind of vehicle brings the first paramedic to the scene. He’s even developed with a catch phrase to drive the point home: “Don’t look at the conveyance, look at the care.”

Why ambulances matter

So if you go by the logic of Langford’s catch phrase, the vehicle shouldn’t matter as long as you get the medic, right?

Well, actually, it can. That’s because fire engines and trucks aren’t allowed to take patients to the hospital — they’re not equipped to secure and transport them.  Ambulances, on the other hand, can transport a patient and provide medical care en route. This key difference can prove crucial in cases like stroke, heart attack and severe gunshot wounds.

“When you get a stroke or trauma patient, the most important thing is that they get transported to the hospital as quickly as possible,” says veteran Chicago paramedic field chief Richard Raney. “As they say with stroke patients, ‘time is brain.’ And with a trauma patient, it’s even more important.”

This is because many trauma patients need care that only a hospital can offer. These include shooting victims whose internal bleeding can only be located and stopped during surgery in an emergency room.

Indeed, several studies show the significant benefits to survival and patient outcomes when trauma patients are taken to hospitals quickly — as only ambulances can do — rather than being treating on the scene.

Raney acknowledged  some benefits to the fire truck-first model, including extra manpower and securing the scene with traffic control. And he thinks the city’s doing its best with limited resources. But objectively, he says, “if people have to wait for that kind of care [and transport], there are going to be people who die.”

Chicago mirrors national trends

In Chicago, fires have dropped to one fourth of what they were 38 years ago, and that’s not unique, according to national fire and emergency medical service data. Over the last few decades, fires have dropped across the nation due to improved construction materials, better public education, sprinklers and smoke alarms.

Meanwhile, emergency calls have risen due to an aging population, legislation that guarantees ambulance service regardless of a patient’s ability to pay and the rising use of emergency services  to treat basic medical needs.

Consequently, many fire departments are finding that medical calls make up the bulk of their work. But they’re still staffed primarily to fight fires.

Public policy researcher Phil Keisling wrote an article in 2015 looking at the issue, provocatively titled “Why We Need to Take the ‘Fire’ Out of ‘Fire Department.” It asks why departments across the country have been so slow to adapt to the new landscape. Keisling says he didn’t get a lot of good answers.

“I [kept] getting answers that, at least in my book, are ‘that’s the way we’ve always done’ it,’ ” he says. “And that’s not a very good answer when you are living in a world with limited resources and you want to optimize the resources you’ve already got.”

The need for more ambulances

Most agree with Keisling that the best way to optimize limited resources in this situation is to buy more ambulances. But Langford at the Chicago Fire Department is not so sure.

“If the mayor wanted to give us more [ambulances], I’m sure we could use them,” he says, But, he adds, Chicago is “pretty good” at getting a medic to a scene quickly, and has “better response times than many other big cities.”

Still, the strength of department’s medical response times is disputed. According to reports by city Inspector General Joe Ferguson, they actually fall short of national standards. The IG further charges that the fire department uses unreliable data collection methods to gauge response times.

Paramedics further say that the real response time metric should be how long it took for a trauma victim to get an ambulance — not a firetruck.

But response times aside, paramedics say there are two more big signs we need both more ambulances and paramedics.

The first sign is the millions in overtime the city pays paramedics each year to cover the unmanned shifts. In 2016 it paid paramedics more than $14.9 million in overtime — one paramedic earned almost $90,000 in overtime alone.

But this doesn’t just exhaust city coffers. Firefighter turned 38th Ward Alderman Nick Sposato says it can exhaust paramedics, who work jobs where it’s crucial to stay sharp.  

“To be working 24-on, 24-off — that’s just too much for somebody to do,” he says. “Certainly if they work a busy ambulance and they’re doing those 25 runs a day and they’re up all night.”

The other sign that there are not enough ambulances in the city can be heard by listening to dispatch calls on EMS/Fire radio. Paramedics say dispatchers regularly make desperate calls for any available ambulance because they’re busy at the same time.

Paramedics and dispatchers say such calls are so common that a supervisor at the Chicago Office for Emergency Management issued a memo telling dispatchers to “avoid terminology like, ‘We have no ALS ambulances available,’” according to a report by Pam Zekman at CBS Ch-2, who obtained a copy of the memo.

WBEZ recorded two such “shout outs” from the EMS scanner on a recent winter day on a tip from a city worker.

Reasons for slow change

When I asked more than a half a dozen sources — all in the field of emergency services — why fire departments have been so slow to adapt to a more EMS-centric model, I heard a few different theories.

Theories included complicated explanations of how these decisions affect homeowner insurance rates, and the low economic status and clout of those who use 911 most.  

But the most common theory for the slow change was inertia in a deeply entrenched fire-centric fire department. Sources claim that, for cultural and infrastructural reasons, paramedics just don’t command the respect and power that firefighters do. And so as long as paramedics work under fire departments, and as part of firefighter unions (as they do in Chicago), their needs may never take precedence over the needs of the fire side.

I got a hint of this while talking to outgoing Firefighters Union Local 2 president Tom Ryan recently. He said he supports the idea of adding more ambulances to the department. But when I asked how he’d feel if the ambulances came at the expense of some firefighting funds, his enthusiasm waned.

“We still have fires,” Ryan says. “We still have a very large city and fires. Even though fires are down in numbers, you have a higher incidence of collapse, and they burn harder because of what is burning, so the intensity and danger of them has actually increased.”

“You need to find funds to fund both sides of the equation properly,” Ryan says.

Change may be coming

Ryan represents a pretty traditional view. But new blood is coming later this year with incoming union  president Jim Tracy. He ran on a promise to finally get and staff five more ambulances for the department.

This promise has given some paramedics hope. But those paramedics say they will remain skeptical until the city buys the ambulances and hires enough paramedics to staff them — along with existing ambulances — properly. They estimate this will require more than 150 new paramedics.

Some wonder whether these hires will really be approved and paid for, but not Sposato.

“I’m not the least bit concerned that they’ll figure out a way,” says Sposato, who has championed the “more ambulances” argument for years. “The budget director will work this all out. We’ll have the extra five ambulances and we’ll get our manning up to snuff at what it should be.”

Raney further points out that adding paramedics may actually save the city money in some areas. With more paramedics on staff, he notes, it won’t have to spend millions in overtime. And, perhaps less obvious, revenue can be generated through ambulance transport services, which are billable through private and public health insurance.

“Paramedics and ambulances generate money for the city, and that money can be used for the expense of hiring paramedics,” he says. “We shouldn’t let money get in the way of public safety. If we need more ambulances…they should be added because it helps protect the public, and that’s what everyone says is the most important thing.”

Paramedics are hopeful the new ambulances will become a reality by the end of summer. But in terms of reorganizing the fire department, some of that may be determined by the Firefighter Local 2 Union contract negotiations later this year.

Until then, folks shouldn’t be surprised when they call for an ambulance and a fire truck arrives. Because, chances are, it’s the closest help available.

More about our questioner

Todd Stroger is the son of John Stroger, one of the most power African-American politicians in Cook County history. The younger Stroger followed in his father’s political footsteps and served as an Illinois State Representative, and later as alderman for Chicago’s 8th Ward. He succeeded his father as the President of the Cook County Board of Commissioners, a position he held from 2006 to 2010.

But before all that, Stroger grew up on the South Side around 87th Street and Blackstone Avenue in the Avalon neighborhood. “About 40 years ago we had a fire there,” Stroger recalls. “Some crazy kid did something crazy and the fireman came and saved our home.”

But that wasn’t his family’s only encounter with emergency services. “My brother had asthma and another time he overdosed on medicine,” Stroger says. “The paramedics came and saved him a couple of times.”

So he has a history with both firefighters and paramedics and wants to say, “Thank you, [Engine] 72!”

When I explained to Stroger what I’d learned about the fire and EMS issues at the Fire Department, he said he was surprised that private ambulances — which typically do hospital-to-hospital transport in Chicago — don’t play a role. But, as a veteran of local government, he wasn’t at all surprised by the politics involved in the situation.

Monica Eng is a WBEZ reporter. Follow her at @monicaeng or write to her at meng@wbez.org