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Why Timing Matters for Prehospital Interventions

Article by Faizan Noorani, NRP and James Li, MD FAEMS
Edited by Michael DeFilippo, DO, FAAEM, Editor-in-Chief, NAEMSP Blog. March 23, 2026

0200 hours. The station finally goes quiet. Boots are off. Radios are turned down. Just seven hours into the shift, you’ve already encountered your district’s favorite frequent flyer, activated a trauma alert, and helped lift a grandmother from her commode. The last chart is signed. You settle into the bunk.

Then the tones drop.

“MEDIC 3… DELTA MEDICAL… TROUBLE BREATHING.”

Four minutes later, you are standing in a living room with a patient sitting upright, elbows on knees, working hard to breathe. You hear inspiratory and expiratory wheezing. A bronchodilator is started. Air movement improves slightly. The monitor looks reassuring. The hospital is only a few minutes away. The thought comes easily and feels reasonable: they’ll get steroids in the ED. Except, they don’t. Not quickly. By the time the medication is ordered, prepared, and administered, more than 45 minutes have passed since first patient contact. What could have been started in the field within minutes is delayed by crowding, boarding, and throughput strain. This scenario illustrates a common but underappreciated gap in acute care delivery.

The clock on patient care does not reset when we arrive at the hospital.

The “Close-to-the-Hospital” Bias in EMS
In urban EMS systems especially, proximity to definitive care can subtly influence decision-making. When transport times are short, some interventions begin to feel optional. Treatments that are not immediately lifesaving are often deferred under the assumption that the emergency department will deliver them shortly.

The most commonly deferred therapies share a key characteristic; their benefit is physiologic and delayed, not immediately visible to the crew or the patient. Common examples include:

Systemic corticosteroids
Magnesium sulfate
Early fluid resuscitation
Other protocolized, time-dependent therapies

The logic is familiar. Why start something now if it will be done in ten or fifteen minutes anyway? The problem is that this assumption is frequently wrong.

Emergency Departments Are Not Time-Neutral Environments
Emergency department crowding is no longer episodic. It is a defining feature of modern emergency care. Delays in triage, bed placement, order ex*****on, and medication administration are routine. National analyses of ED crowding describe measurable delays in time-sensitive therapies, even after patients arrive and orders are placed [3]. EMS clinicians experience this reality every day while holding the wall with patients who are physiologically ill but operationally delayed.

In practice, a “short transport” often becomes:
Prolonged EMS offload delays
Hallway or waiting room boarding
Deferred medication administration while higher-acuity patients are prioritized

From a physiologic standpoint, the patient does not stop deteriorating because they crossed the threshold of the ED.
Evidence for Earlier Prehospital Treatment and Downstream Outcomes

Acute asthma exacerbations provide a well-studied model for examining how prehospital treatment timing affects patient outcomes.

Adult Asthma and Prehospital Steroids
A retrospective study comparing adults with moderate-to-severe asthma who received intravenous methylprednisolone in the prehospital setting versus after ED arrival demonstrated a clear difference in outcomes [1]. Key findings included:

Average time to steroid administration:
Prehospital: approximately 15 minutes
Emergency department: approximately 40 minutes

Hospital admission rates:
Prehospital steroids: 12.9%
ED-only steroids: 33.3%

Patients who received steroids only after ED arrival were more than three times as likely to be admitted. The medication and dose were the same. The difference was timing.
Pediatric Asthma and Protocol-Driven Care

Similar patterns have been observed in pediatric populations. After implementation of a pediatric EMS asthma protocol requiring prehospital glucocorticoid administration – primarily oral dexamethasone – investigators observed measurable improvements across several outcomes [2].

Following protocol implementation, children experienced:

Shorter total hospital length of stay
Shorter total care time from ambulance arrival to discharge
Lower hospital admission rates
Reduced need for ICU admission among hospitalized patients

Importantly, these improvements occurred without an increase in adverse events. This was not escalation of care. It was earlier initiation of evidence-based therapy.

Taken together, these two studies reflect a consistent and reproducible pattern; earlier prehospital treatment changes what happens downstream.

Outcome-Shaping Does Not Mean Optional
Many prehospital interventions do not produce immediate, dramatic improvement. That does not make them discretionary. Systemic corticosteroids do not instantly relieve bronchospasm, but they reduce airway inflammation, shorten exacerbations, and decrease admissions. Magnesium does not immediately normalize airflow, but it improves outcomes in severe respiratory distress. These therapies work on time, not spectacle. Delaying them rarely causes sudden visible deterioration in the ambulance. Instead, it quietly worsens downstream outcomes – longer ED stays, higher admission rates, and prolonged patient suffering.

Protocols Exist to Prevent Delay
Prehospital protocols that authorize medications such as systemic steroids or magnesium are not written for convenience. They exist because evidence consistently shows that earlier initiation improves outcomes. Deferring treatment because transport time is short shifts decision-making from physiology to geography. Geography is a poor surrogate for patient need. Protocols are designed to protect patients from delay. They also support and authorize clinicians to act early, even when the benefit is not immediately visible.

The wrong question is: Will the patient survive the next ten minutes without this medication?

A better question is: Does delaying this intervention meaningfully worsen the patient’s trajectory?

In many cases, the answer is yes.
Conclusion – A Call to Act Earlier

Not every prehospital intervention is immediately lifesaving. Many are outcome-shaping. They quietly determine disease progression, resource utilization, and patient experience. In crowded systems, deferring these therapies to the emergency department often means deferring them far longer than intended. Short transport times do not guarantee timely care.

As EMS clinicians, we are often the first – and sometimes the only – opportunity to start evidence-based treatment early. When protocols allow us to act, we should use them. When we recognize a therapy is indicated, we should not wait for geography to make the decision for us.

The clock does not start at triage. It does not reset at hospital doors. It starts with first contact. What we choose to do in those early minutes matters.

References
Knapp B, Wood C. The prehospital administration of intravenous methylprednisolone lowers hospital admission rates for moderate to severe asthma. Prehosp Emerg Care. 2003;7(4):423-426. doi:10.1080/312703002119

Nassif A, Ostermayer DG, Hoang KB, Claiborne MK, Camp EA, Shah MI. Implementation of a prehospital protocol change for asthmatic children. Prehosp Emerg Care. 2018;22(4):457-465. doi:10.1080/10903127.2017.1408727

Kelen GD, Wolfe R, D’Onofrio G, et al. Emergency department crowding: the canary in the health care system. NEJM Catal Innov Care Deliv. 2021;2(5):CAT.21.0217. doi:10.1056/CAT.21.0217

About the Authors

Faizan Noorani is a nationally registered paramedic practicing in the St. Louis region and an undergraduate student at Washington University in St. Louis. Following graduation, he plans to gain additional clinical experience and serve in a fire-rescue role before applying to medical school.

James Li, MD FAEMS is an EMS physician, Assistant Professor of Emergency Medicine and Public Health, and Program Director of the EMS Fellowship at Washington University School of Medicine in St. Louis. Dr. Li also serves as the Chair of the NAEMSP Education Committee.

When 'They'll Get It at the Hospital' Becomes a Delay - NAEMSP EMS medicine is medicine; just because patient's are in the hospital parking lot does not mean medically necessary treatment DOESN'T need to happen.

BOSTON — A two-alarm fire forced the evacuation of some patients in the intensive care unit at Boston Medical Center — Brighton in Boston early Wednesday.

The fire in an electrical room knocked out a generator at 1:30 a.m. at the facility on Cambridge Street, which is the former St. Elizabeth's Hospital.

Twenty-four patients have been moved out of the facility and transported to other facilities.

Officials said the evacuation was "labor intensive," and firefighters, accompanied by hospital staff, used Stokes baskets to carry patients down the stairs.

"All patients are safe here at the hospital," Boston Medical Center - Brighton President Paul Smith said. "We are transferring a subset of patients from the hospital. We have had great collaboration from other hospitals, as well as Boston Medical Center main campus."

The emergency department at Boston Medical Center Brighton is not accepting ambulance patients at this time, the hospital said.

Some planned elective procedures and outpatient appointments will be rescheduled.

"We currently have stable power through our generators across the hospital," Smith said.

All patients and staff are safe, the hospital said, and no injuries have been reported.

The cause of the fire remains under investigation.

24 patients evacuated after fire at Boston Medical Center in Brighton The fire knocked out a generator at 2 a.m. the facility on Cambridge Street, which is the former St. Elizabeth's Hospital.

On Friday morning, April 10, Alameda Fire Department (AFD) responded to a reported fire in the Alameda Hotel Apartments at 1415 Broadway. AFD initially sent three engine companies, two truck companies, one ambulance, one battalion chief, and the Alameda Care Team, according to AFD reports on Facebook and Instagram.

The first units on the scene reported smoke coming from the windows of a second floor apartment and heavy black smoke inside the second floor hallway, with multiple people who needed to be rescued on the roof and fire escape on the Santa Clara Avenue side of the historic building, which once was the Alameda Hotel.

Firefighters immediately accessed the apartment where the fire started and were able to extinguish the fire there, protecting adjoining units and saving the remainder of the three-story apartment building, AFD reported. They also successfully rescued residents from the roof and fire escape.

Due to quick actions of the firefighters, the fire was contained to the single unit on fire. Building management assisted other residents who needed relief from remnant smoke odor in the building. The fire was contained and extinguished in approximately 20 minutes.

A total of 22 firefighters responded to the fire scene. There were no reported firefighter injuries. Three patients were treated and released at the scene.

The cause of the fire is currently under investigation.

Alameda Municipal Power, PG&E, the Alameda Police Department and the Alameda Building Department all provided assistance. Additionally, the Oakland Fire Department provided mutual aid fire station coverage and one mutual aid Falck ambulance was requested to the scene for standby, according to the AFD report.

Built in 1926, the Spanish Colonial Revival-style complex contains a total of 93 apartments. Many comments on the AFD social media reports thanked firefighters for putting the fire out so quickly, rescuing those who needed help, and saving the beautiful old building.

Alameda Firefighters Extinguish Blaze at Historic Apartment Building, Rescue Tenants AFD responded to a call at Alameda Hotel Apartments at 1415 Broadway on Friday. Firefighters immediately accessed the apartment where the fire started and were able to extinguish the fire there, saving the remainder of the building. They also successfully rescued residents from the roof and fire esc...

KISSIMMEE, Fla. — Kissimmee firefighters are starting a new work schedule on April 25 that will prioritize giving them time to recover after responding to emergencies and stressful situations, following a previous fire assessment study.

The new schedule is known as a 24-72 schedule. Firefighters work a 24-hour shift and have 72 hours off. On the former schedule, the first responders worked 24 and were then off 48.

To support this change, 42 firefighters have been hired to work for Kissimmee Fire over the past seven months. Thirty-three people will be sworn in on Thursday ahead of the schedule change into their new roles, including 15 new hires, 10 promoted engineers and eight promoted lieutenants.

Chief Jim Walls said he thinks they’re setting an example for other fire departments to adopt the 24-72 schedule.

“We're the first Central Florida fire department to implement that schedule. So, I've shared our studies with a lot of chiefs around here," Walls said. "So, everybody's looking at it. It's a very competitive market right now.”

Last year, Gov. Ron DeSantis signed House Bill 929, which amends the Florida Firefighters Occupational Safety and Health Act to include more safety precautions and protections for firefighters. Those include “encouraging firefighter employers to implement work schedules with normally scheduled shifts” of 42 hours per week.

Walls said this will also prepare the Kissimmee Fire Department to handle future predicted population growth and demand.

“The city, Kissimmee, we're growing rapidly. I think we did an impact assessment, and we'll be over 100,000 residents here in the next 10 years. So we have to plan for that now,” Walls said.

Kissimmee Fire Department logistics technician Ronnie Lagana has worked with KFD since 2021. He handled ordering required personal protective equipment, gear, bunks, desks, refrigerators and more for the Kissimmee fire stations to accommodate the new hires.

“The demand for fire service is increasing every year, more and more and more, which taxes not only the members, but the apparatus," Lagana said. "The hospital plays are impacted by patients needing to be transported and cared for. So that additional day off, it gives them another day to basically reset themselves to get ready to come back to work again.”

Brithany Carrington is a new hire that will be promoted Thursday. She said time off is precious because it allows first responders time to recover for the next shift.

“The stuff we’re exposed, sometimes you take this with you," Carrington said. "So, I believe just that little extra time when you get to spend (with) your family and kind of like it decreases the chances of burnout.”

Armando Rodriguez, also a new hire, said he’s grateful for the 24-72 schedule, which played a role in many new firefighters’ decisions to apply for the job.

“When we consider the next 30 years of my career, having one extra day off after we work, it's going to be huge. It's going to allow us to recuperate better and be ready for the next shift because we never know what might come up on those shifts,” Rodriguez said. “We're thankful that the city and the people that are behind it are able to make it happen because, like I said, it's going to be huge for us.”

Local 4208 Kissimmee Firefighters Union President Joshua Clark called the transition to the 24-72 schedule “a significant and positive step forward” for both firefighters and the community.

“By moving to a 24-hours on, 72-hours off schedule, our firefighters will see a meaningful reduction in total hours worked, nearly 700 fewer hours annually," Clark said. "That added recovery time is critical in helping reduce fatigue, improving mental and physical health, and allows our members to spend more quality time with their families, which is often limited in this profession."

“Ultimately, better-rested firefighters who have strong support at home are better-prepared to respond and serve our residents," Clark added. "This is about taking care of our people so they can continue taking care of the community.”

Chief Walls said the new schedule announcement has already helped retention. This was made possible by a city-wide tax increase and Kissimmee commissioners approving their $310.3 million budget last fall to hire new staff members.

“We have not lost any firefighter since we've made the announcement. Normally, we would probably lose two or three to local departments,” Walls said. “So, recruitment retention, mental health, physical well-being it's all coming the way we thought it would be.”

Two years ago, the Federal Emergency Management Agency completed a study on the Impact of shift work on firefighters. It found that sampled firefighters experienced fatigue, stress, and difficulty balancing life outside of work because of long shifts and irregular sleep. It called the 24-72 shift the “most beneficial to firefighters” for their long-term well-being.

New schedule for Kissimmee firefighters reduces annual workload by 700 hours The goal of the switch to a 24-hours on, 72-hours off work schedule starting April 25 is to prioritize mental health and safety.

An ongoing dispute between the City of Atlanta and the firefighters' union is raising questions about emergency fire coverage across the city.

"When one out of every five fire engines are out of service, that is not normal. For a department such as Atlanta Fire Rescue, that is a state of emergency," said Nate Bailey, president of Atlanta Professional Firefighters.

The debate comes as several fire stations are closed for renovations and some fire trucks remain out of service, while city leaders insist coverage is still being maintained.

According to the Mayor's Office, Atlanta Fire Rescue operates under a system that sends the closest available units to emergencies across the city, even if they are outside of a specific area. The city said that the model allows coverage to continue even when stations are temporarily closed or equipment is being repaired.

But the firefighters' union argues that what is happening on the ground does not match that message.

Bailey said an engine has been out of service for weeks in Midtown, one of Atlanta's busiest parts, and warned that the situation could impact response times.

The city has pushed back on those concerns, calling claims about reduced coverage misleading and emphasizing continued investment in equipment, staffing, and fire stations.

The firefighters' union is now calling on people living in the area to make their voices heard at an upcoming Atlanta City Council meeting. They said they plan to gather at City Hall on April 20.

Atlanta firefighters warn of "state of emergency" over engine shortages amid ongoing dispute As Atlanta faces fire station closures and equipment outages, the city's firefighters' union claims public safety is at risk and urges residents to speak out.

In 2015, construction workers plowed through an abandoned gas station in southeastern San Diego to make way for a new, temporary fire station.

The site, which would house a fire engine and an ambulance, was opening to improve emergency response times in the area after our reporting revealed people died of gunshot wounds and overdoses because emergency responders came too late.

Then-Mayor Kevin Faulconer applauded the city’s efforts at a press conference outside the soon-to-be station in 2015. He made a bold promise: “In two to three years, we will begin building a permanent fire station right here on this very spot.”

That never happened. Instead, Fire Station 51 is still a temporary fire station. The fire truck sits under a large tent and firefighters’ living quarters are a mobile trailer.

George Duardo, president of the San Diego City Firefighters IAFF Local 145, has worked more than 100 shifts as a firefighter at Fire Station 51. He said it does not meet the standards of a “modern fire station.”

Duardo said the station’s vinyl structure has slowly degraded, the station lacks enough bathrooms and needs an additional engine to fight brush fires. And Councilmember Henry Foster, who represents the area, says city officials prioritized other areas to build stations.

Officials from the city’s Fire-Rescue Department said funding challenges have prevented the city from building a fire station, but that the current station provides the same level of service as other fire stations.

“Though we keep hearing the word ‘temporary,’ I can assure you that Station 51 provides the same level of service as any of our other fire stations,” said Assistant Chief Theodore Moran in an interview with Voice. “The facility itself does not at all play into the service that we’re providing.”

They also say emergency response times improved in the area after the station opened, but Fire-Rescue data shared with Voice of San Diego reveals response times and incident calls, in general, are higher today.

Fire Station 51 is in the southeastern San Diego neighborhood of Skyline, a residential area surrounded by canyons. The neighborhood’s population is a majority of Black and Latino middle-class families.

In 2011, a study identified Skyline as one of the top five neighborhoods with the highest risk of delayed emergency response times in the city.

In response to the report, the San Diego City Council passed a plan to build five fire stations over the next five years in areas they considered to be a priority. Two years later, Voice reported that officials didn’t build the stations. Our reporting showed residents died when paramedics didn’t arrive in time to save them.

City officials promised to do better and put funding toward two new fire stations, including one in Skyline. The estimated cost to build a permanent station in 2013 was approximately $13 million. Two years later, city officials opened the temporary Fire Station 51.

Foster was former Councilmember Myrtle Cole’s chief of staff when the station opened.

“I haven’t received any clear information as to the why,” said Foster in an interview with Voice about building a permanent fire station. “What I’m seeing instead is an indication that this is an equity issue and it appears decisions have simply been made to prioritize other areas, which needs to change.”

The city built other fire stations in that time. This includes Fire Station 2, opened in 2018 in Little Italy for $15 million. Fire station 50 also cost $15 million and opened in 2020 in University City. City Heights also got a new and improved fire station in 2018.

In 2024, city officials opened the city’s “most environmentally friendly” fire station in La Jolla. UC San Diego covered most of the $22 million project and the city paid for a $2.1 million electric fire engine.

Duardo said the station’s vinyl structure has degraded over time with the sun and elements. He said in the summer, the temperature in the tent that houses the fire engine and equipment can get up to 120 degrees. While they haven’t experienced significant flooding, he said they do get streams of water coming into the tent when it rains.

“Having any degree of moisture – even though it really only happens during the rain, is not ideal by any means,” he said.

He worries about how the weather can damage their equipment.

He also said the station only has two bathrooms, which can create challenges as people are getting ready to start their shift.

“As people come and people go, bathrooms are really important,” he said. “Enough showers are really important. A place where you can clean your equipment, get carcinogens off your protective equipment… modern fire stations facilitate that.”

He also said with a permanent fire station, they could add an additional engine to solely fight brush fires in the area.

Without that, he said he’s concerned about the areas above and adjacent to Fire Station 51 which include Encanto and Skyline.

“If you were to take Imperial all the way out and it turns into Lemon Grove Avenue — it’s everything from the end of Imperial to the 94, drive that whole area, there is no fire station in that neighborhood,” he said.

He said these rural areas have big houses, few fire hydrants, and canyons full of brush. The other closest station would be Fire Station 12 about three miles west in Lincoln Park, or Fire Station 26, about five miles away on the other side of the 94 freeway near Chollas Park.

“ My biggest fear is because it’s [southeastern San Diego] at the periphery of the city, and there’s a lack of fire stations and coverage… It is gonna be very hard if there were to be a canyon fire in through there,” he said.

Candace Hadley, spokesperson with San Diego’s Fire-Rescue Department, said Fire Station 51 “is a fully operational station.”

She said the fire engine, personal protective equipment lockers and exercises space are housed “in the sprung structure designed for long-term to permanent use.”

When firefighters work their shifts, they stay inside the mobile trailer which has individual sleeping quarters, restrooms, a day room and kitchen.

Moran said the most important thing is having a fire engine in that area.

“We were able to fill that gap by identifying that location, putting in the temporary facility, knowing that funding had to have been secured and identified in the future,” he said. “We would love to build a fire station overnight or within a year. Sometimes that’s just not feasible. Really what’s important to us is providing that service to the community where we showed a need for it.”

In 2011, the city’s emergency response time goal was six minutes, in line with national standards. This includes one minute for dispatch, one minute for the crew to leave the station, and four minutes to travel to the incident.

Our reporting from 2013 found that nine times out of 10, the department couldn’t meet that goal even half the time. Several months later, Fire-Rescue relaxed response times to seven minutes and 30 seconds. Fire responders aimed to arrive at medical emergencies in that time frame, nine times out of 10.

Fire-Rescue data shared with Voice shows emergency response time improved in the Skyline area after Station 51 opened in 2015.

From 2012 to 2018, emergency response time decreased by an average of 27 seconds, from five minutes and 53 seconds to five minutes and 26 seconds. Echo-level calls, or the most critical calls, decreased by 30 seconds.

However, additional Fire-Rescue data reveals that on average, emergency response times in Skyline are higher compared to when the station opened 11 years ago.

The average response time in 2015 was five minutes and 34 seconds. In 2025, that went up 11 seconds, to five minutes and 45 seconds.

Hadley said incident calls are up by approximately 27 percent citywide compared to 2015, and in Skyline, specifically, there has been a 19 percent increase.

“There are so many variables in what can affect our response times and our response or the volume of responses that we receive. I would say in layman terms there’s really not a solid predictor of whether calls are gonna increase or decrease,” said Moran.

Moran said things like weather, topography, and distance to the incident can affect response times.

“Is it hot and dry and windy out — and now there’s a vegetation fire in the area that’s pulling resources that’s obviously gonna affect the response time for medical aids that occurred during that other emergency.”

But a recent report by the city auditor’s office shows Fire-Rescue did not meet its current arrival time standard of six minutes and 30 seconds largely due to slow turnout times. Turnout times are the amount of time it takes for a crew to leave a station after receiving an emergency dispatch.

According to the report, only 69 percent of fire units in District 4 — where Station 51 is located — arrived within the city’s standard arrival time. between fiscal year 2023 and fiscal year 2025.

In a statement, Duardo said the audit does not consider budgetary challenges faced by the fire department.

“This ‘audit’ does not take into account the significant underfunding and understaffing that’s been plaguing San Diego Fire-Rescue for years — impacting response times, plus exhaustion and burnout for the firefighters we count on to be there when lives are on the line.”

Councilmember Foster still voiced concerns about the station remaining temporary.

“When you have poor facilities, over time that can lead to other health issues. That creates gaps and issues with staffing,” he said.

It’s unclear when the permanent Fire Station 51 will be built.

In 2013, then-interim Mayor Todd Gloria announced a multi-million-dollar bond to fund the permanent fire station and other infrastructure projects. This included $1 million toward funding design plans for the station. Fire-Rescue and City Planning Department spokespeople told Voice to file a public records request for information about the money.

City officials completed a design for a permanent station in Skyline in fiscal year 2026. The project is still pending funding. When Fire Station 51 first opened, the temporary station was a quicker and cheaper solution to reach underserved communities than building new permanent fire stations. Today, the cost to build Fire Station 51 has more than doubled to nearly $28 million according to the Fire-Rescue 2025 budget.

“In the meantime, necessary repairs and maintenance at the existing facility will continue to ensure uninterrupted service until construction of a permanent station can begin,” said Hadley in an email statement to Voice.

At a Feb. 19 meeting on the city’s capital infrastructure planning outlook, city officials shared fire stations have a $273.9 million shortfall of funding over the next five years.

Last year, the city had to close a $300 million budget deficit. We asked Fire-Rescue officials if they would consider adding more temporary fire stations like Fire Station 51 around San Diego to fill coverage gaps.

They said there’s no current plans to do that.

“The personnel cost is really the largest expense of a fire station,” said Moran. “We’re zeroing in on the term temporary, but temporary doesn’t necessarily mean cost saving on a operational standpoint.”

San Diego Mayor Todd Gloria is proposing a $27 million hike in funding for the Fire-Rescue department with a budget of up to $547 million this year, the Union-Tribune reported. While the increase would help fund overtime and staffing to meet response time goals, the department still faces cuts.

City Officials Promised to Open a Permanent Fire Station in Skyline. 11 Years Later Firefighters Are Still Running Calls Out of a Tent Despite the delay, fire officials say the temp fire station is providing the same level of service to the community as other fire stations.