EMS vs. Fire · Workload Reality · FY24–FY27
On a busy shift, a city medic unit doesn't return to the firehouse. There's no downtime. No real meal break. Restocking happens in parking lots between calls. This isn't a complaint — it's arithmetic. At peak-hour utilization with hospital offload, the math shows EMS units are committed more than 100% of available shift time. The gap in call volume per unit is documented. The gap in pay is documented. These aren't opinions.
UHU = Unit Hour Utilization. Industry standard: below 50% = healthy reserve capacity. 50–60% = busy but manageable. Above 70% = operational strain. Above 80% = unsustainable per NAEMSP/ACEP. All UHU figures modeled from FY24 transport volumes and estimated response data. Transport avg: 60 min. Hospital offload delay: +30 min avg. Fire UHU: response volume shown as reference only — call duration data not available to model fire UHU. Peak-hour model for EMS: 65% of calls concentrated in 12-hr window.
Unit Hour Utilization — industry benchmarks vs. STLFD reality Outer bar = all committed time · Inner bar = transport time only
Call-load comparison — annual responses per unit/company, same 24-hr clock Apples to apples — no shift-length assumptions
EMS works 12-hr shifts · Fire works 24-hr shifts · All figures shown as responses per unit per 24-hr calendar day and per year to eliminate shift-length bias. Fire responses include all types: working fires, alarms, auto-aid, medical assists, service calls. EMS responses are city-handled only (private diversions excluded).
0 min
True downtime on a busy EMS shift
Restock happens between calls. Eating happens in the cab. Decompression doesn't happen.
15 min
Minimum restock after each transport
Gloves, linens, airway supplies, O2 check, medication reconciliation — in a parking lot
30+ min
Average hospital offload delay per transport
Unit committed at hospital. Cannot respond. Counts against UHU.
Peak hrs
Call volume spikes mid-morning through early evening
New calls arrive before prior calls clear. Cascading NUA. Per FY24 Annual Report.
Clinical Scope · Public Risk · Recognition
When EMS is unavailable, a fire engine responds to the medical call. That engine can check a pulse. It can do CPR. It can use an AED. It cannot push medications, intubate, interpret a 12-lead, or transport. For the patients who need the most — cardiac arrest, stroke, septic shock, major trauma — the time between engine arrival and ambulance arrival is when outcomes are decided. An unavailable EMS unit is not a delayed convenience. It is a clinical gap.
Scope of practice per Missouri DHSS EMS licensure (EMT, AEMT, Paramedic) and RSMo Chapter 190. Fire suppression BLS scope per NHTSA National EMS Scope of Practice Model and STLFD operational protocols. Clinical outcome data: American Heart Association ACLS guidelines, AHA 2023 Heart Disease and Stroke Statistics, Brain Attack Coalition stroke guidelines.
Clinical capability — what each unit can actually do When the engine shows up instead of EMS, this is what's missing
| Clinical Capability | 🚑 City EMS Paramedic | 🔥 Fire Engine (BLS) — when EMS unavailable |
|---|---|---|
| CPR / AED | ✓ Yes | ✓ Yes This is the ceiling for most engine company medical response |
| Oxygen therapy / BVM | ✓ Yes | ✓ Yes |
| Naloxone (Narcan) | ✓ Yes — plus full OD reversal protocol | ✓ Yes Limited protocol only — no follow-on medication management |
| IV / IO access | ✓ Yes — peripheral & IO | ✗ No |
| 12-lead ECG interpretation | ✓ Yes — STEMI identification & cath lab activation en route | ✗ No Can apply AED — cannot interpret, cannot activate cath lab, cannot transmit |
| Advanced airway (intubation / SGA) | ✓ Yes — ETT, King LT, surgical airway | ✗ No BVM only · no definitive airway management |
| Medication administration | ✓ Full formulary Epinephrine, amiodarone, dopamine, nitroglycerin, morphine, fentanyl, midazolam, dextrose, albuterol, and 30+ others per protocol | ✗ No Narcan only per narrow protocol · all other medications = unavailable |
| Stroke recognition & intervention | ✓ CPSS / BE-FAST / glucose management / hospital pre-alert / LVO screening | ⚠ Recognition only Can identify stroke symptoms · cannot intervene · cannot pre-notify stroke center · cannot manage glucose |
| Cardiac arrest: ACLS protocol | ✓ Full ACLS Epinephrine q3-5min · amiodarone / lidocaine · advanced airway · 12-lead · ROSC management | ⚠ BLS only CPR + AED only · no medications · no advanced airway · survival odds fall sharply beyond 4–6 minutes without ACLS |
| Obstetric emergencies | ✓ Field delivery · neonatal resuscitation · eclampsia management (Mag sulfate) | ⚠ Assist only Can support delivery · cannot manage complications · no medications |
| Pediatric emergencies | ✓ Weight-based dosing · IO access · pediatric airway management | ✗ BLS support only |
| Controlled substances / DEA liability | ✓ RSMo license · personal DEA accountability · chain of custody per call | ✗ Not authorized |
| Transport to definitive care | ✓ Primary purpose of the unit | ✗ Fire engines do not transport Patient waits on scene for available ambulance — which may already be on another call |
What NUA actually means for patients Time is tissue. Minutes are outcomes.
Cardiac Arrest
Survival drops 7–10% per minute without ACLS. Fire can do CPR + AED. Every additional minute waiting for EMS is a measurable reduction in survival odds. In a NUA event, that wait is not 2–3 minutes. It can be 15–20+ minutes per the fire chief's own statements.
Stroke
"Time is brain" — 1.9 million neurons die per minute in large vessel occlusion. tPA and mechanical thrombectomy are time-sensitive. EMS pre-notification activates the stroke team before arrival. A fire engine can recognize the stroke. It cannot activate the cath lab or manage the patient en route.
Major Trauma
The "golden hour" is a ceiling, not a target. Hemorrhagic shock, tension pneumothorax, traumatic arrest — these require rapid transport to a trauma center. A fire engine can splint and hold C-spine. It cannot transport. Every minute on scene waiting for EMS is a minute not in the trauma bay.
Respiratory Failure
COPD, asthma, CHF exacerbation, anaphylaxis — these require bronchodilators, BiPAP support, epinephrine, and often definitive airway management. None of these are available from an engine crew. A patient in respiratory failure can decompensate to cardiac arrest within minutes without intervention.
Pediatric & OB Emergencies
Neonatal resuscitation, pediatric respiratory distress, obstetric complications — all require weight-based medication dosing, specialized airway management, and protocols that go far beyond BLS. Engine crews are not trained or equipped for these interventions.
Septic Shock
Sepsis has a mortality increase of 7% per hour without intervention. IV fluid resuscitation, lactate assessment, and antibiotic initiation require ALS capability and rapid transport. Recognition without intervention is not treatment. A fire engine cannot do either at an ALS level.
Note for the record · EMS Week 2026
The City of St. Louis issued no public statement, message, or recognition for EMS Week 2026.
National EMS Week is observed annually every May. It exists specifically to recognize the paramedics and EMTs who staff the ambulances, transport the patients, generate the billing revenue, and keep the city's medical response system functioning — often without going back to the firehouse for an entire 12-hour shift.
In 2026, the City of St. Louis — whose EMS division handles 85,500 calls annually, generates $20 million in revenue, and runs on 159 employees who paid for their own training — issued no public acknowledgment. No press release. No social media post. No statement from the mayor's office. Nothing from the department.
The same week, the EMS division's GEMT revenue was projected to contribute $10.68 million to the Fire Department's $96 million budget.
Make of that what you will.
We generate the revenue.
We carry the workload.
We fund our own training.
We go NUA so they don't have to.
And nobody said a word.
St. Louis City EMS paramedics and EMTs hold state licenses, carry controlled substances under personal DEA accountability, perform invasive procedures, manage cardiac arrests, activate cath labs, deliver babies, and transport 50,000 patients a year — while running at utilization rates that mathematically exceed the capacity of the deployed fleet during peak hours.
The engine crews know it too. They'll tell you privately. But they're getting a better deal, so publicly they're quiet.
EMS generates $20 million a year. EMTs start at $43,004. Paramedics start at $52,286. A probationary firefighter who finished a free, paid academy last week starts at $60,918. After 20 years, an EMT earns $64,506. A 20-year fire private earns $85,670. There is no EMS title that reaches the Senior Dispatcher ceiling of $102,544.
Board Bill 24 is on the table. The GEMT money exists. The budget documents are public. The workload numbers don't lie. The UHU math doesn't lie. The capability table doesn't lie.
The city has the information. The question is whether it has the will to act on it.
St. Louis City EMS · The Full Picture · FY24–FY27
St. Louis City EMS handles approximately 56,570 responses per year with 159 employees — 356 responses per person. Fire handles 115,000 total responses with 573 employees — 201 per person, including false alarms and automatic aid standbys. EMS generates $15–20M annually. EMTs start at $43,004. Fire privates start at $60,918.
Data note: Hard-source figures (FY26/FY27 AOP, FY24 Annual Report) are labeled SOURCED in green. Figures derived from the estimated 28–35% private diversion rate are labeled INFERRED in yellow — these are calculated estimates, not official City figures. Billable transports (43,500) and billable non-transports (3,439) are official hard-source figures. City EMS response estimate uses the midpoint diversion rate of 31.5% applied to FY24 actuals.
Confirmed EMS workload — FY24 actuals SOURCED · FY26/FY27 AOP & FY24 Annual Report
82,585
Total EMS calls for service · FY24
All dispatches including private
SOURCED43,500
Billable transports · FY24
119/day · 60+ min committed each · official figure
SOURCED3,439
Billable non-transports · FY24
Treat & release · care rendered
9.4/day · still a full patient contact
SOURCED~56,570
Estimated city EMS responses
After private diversion (midpoint 31.5%)
155/day · not an official figure
INFERRED76.9%
Transport rate of city responses
43,500 transports ÷ ~56,570 responses
INFERRED~12.9
City EMS responses per ambulance per day (12 units)
~6.5 per 12-hr shift · field-verified range 6–12
INFERRED~356
Estimated city responses per EMS FTE per year
56,570 ÷ 159 employees
INFERRED273
Confirmed billable contacts per FTE per year
(transports + billable non-transports)
46,939 ÷ 159 · hard-source only
SOURCED159
EMS employees handling all of this · FY24
FY26 budgeted: 160 · FY27: 159
SOURCEDFire suppression workload — all types combined Includes alarms, auto-aid, service calls, medical assists
115,000
Total fire responses · FY26/27 budget
331/day · all types
SOURCED59,000
Fire/suppression runs
Includes false alarms · not all working fires
SOURCED56,000
Medical runs by fire · "assists"
Engine co. BLS only · no Rx · no IV · no transport
SOURCED201
Total responses per fire FTE · FY26/27
115,000 ÷ 573 employees · all types
SOURCED6.4–6.7
Median / mean fire company daily responses (2023 company data)
Busiest: E-02 at 13.9/day
SOURCEDHead to head — FY24 actuals & FY26/27 budget EMS outperforms on every clinical metric
| Metric | 🚑 City EMS | 🔥 Fire Suppression |
|---|---|---|
| Annual calls (system) | 82,585 total dispatches SOURCED ~56,570 estimated city EMS responses after private diversion INFERRED | 115,000 total responses SOURCED All types including false alarms, auto-aid, service calls |
| Confirmed patient contacts / year | 46,939 billable (sourced) SOURCED Transports + billable non-transports · every one assessed, treated, documented | Not directly comparable Fire medical "runs" are engine assists — BLS level only, no transport. Fire does not bill for medical responses. |
| Responses per FTE | ~356 (inferred) / 273 billable (sourced) SOURCED 273 confirmed billable contacts · ~356 if using diversion-adjusted total | 201 total responses SOURCED Mixed types · includes alarms and non-patient-contact responses |
| Revenue generated | $15.4M FY24 → $20.1M FY27 SOURCED Direct billing + GEMT reimbursement · EMS-linked revenue streams per AOP | $0 direct revenue SOURCED Receives $10.68M GEMT (FY27) generated by EMS activity per AOP budget line |
| Training cost to employee | $10k–$20k+ out of pocket 12–14 months · 500+ unpaid clinical hours · state license |
$0 — fully employer funded 18–24 week paid academy · on full salary throughout |
| Clinical scope | Paramedic: RSMo license · controlled Rx · IV access · advanced airway · cardiac monitoring · OB · toxicology | EMT-level only (BLS) · Narcan exception · no IV · no advanced airway · no medication administration beyond scope |
| System saturation / NUA | 200+ NUA events/month reported (Fox 2, Sept 2023) · no reserve ambulances · no mutual aid | Reserve apparatus available · suppression coverage maintained through brownout policy |
| Entry pay (FY26 CBA) | EMT: $43,004 · Paramedic: $52,286 SOURCED | Fire Private: $60,918 SOURCED $8,632–$17,914 above EMS entry · same city · same ordinance · different ladder |
| Division budget FY27 | $15.19M for 159 employees SOURCED | $96.13M for 780 employees SOURCED Includes $10.68M GEMT generated by EMS per AOP budget line |
St. Louis City EMS · Pay & Revenue · FY26–FY27
In FY27, EMS-linked revenue streams are projected at $20.1M. The GEMT allocation alone — $10.68M — flows to the Fire Department budget. Fire privates start at $60,918. EMTs start at $43,004. The EMS employees generating that revenue are on a completely separate, lower pay ladder. Board Bill 24 would be the first ordinance to allow any of this money back toward EMS salaries.
Revenue caveat: The statement "EMS revenue exceeds EMS expenditures" reflects AOP budget line items — EMS billing ($9.41M) + GEMT ($10.68M) vs EMS program budget ($15.19M). GEMT fund accounting is complex; not all GEMT revenue flows directly to EMS or Fire payroll one-for-one. The honest framing: EMS-related revenue streams approach or exceed EMS division operating expenditures per the city's own published AOP.
EMS revenue — where it comes from, where it goes · FY27 AOP projections SOURCED
$9.41M
Direct EMS billing revenue · FY27
From ~50,000 transports
Billed to patients, Medicare, Medicaid, insurers
SOURCED$10.68M
GEMT Medicaid reimbursement · FY27
Federal match for EMS Medicaid transports
This line flows to Fire Dept budget per AOP
SOURCED$20.09M
Total EMS-linked revenue streams · FY27
Per Annual Operating Plan
Generated by 159 EMS employees
SOURCED$15.19M
EMS division budget · FY27
What EMS actually receives back
$4.9M more in revenue streams than appropriated to EMS
SOURCED$10.68M
GEMT revenue — allocated to Fire Dept · FY27
Generated by EMS activity
Per AOP Fire budget line · not directly to salaries
SOURCED11.1%
Of the entire Fire Dept total budget funded by GEMT generated via EMS · FY27
$10.68M of $96.13M fire budget
SOURCED$4.9M
EMS revenue streams above EMS appropriations
Per AOP line items · FY27
Funds dept-wide obligations while EMS remains underpaid relative to fire
SOURCEDThe pay ladder — entry to top step · proposed FY26 CBA rates SOURCED · Local 73 wage schedule
Top step comparison — 20 years of service SOURCED
$85,670
Fire Private · 20 years
Same ordinance as EMS
Ceiling for fire private scale
$82,342
Paramedic Crew Chief · 20 years
EMS supervisor ceiling
$3,328 below fire private after 20 years
$74,672
Paramedic · 20 years
$10,998 below fire private after 20 years of service
$64,506
EMT · 20 years
$21,164 below fire private top step · no equivalent to $102k senior dispatcher
Regional market — same license, drive 20 minutes These agencies recruit from the same pool
$52,286
City of St. Louis · Paramedic entry
Baseline
$69–99k
Mehlville FPD · Critical care paramedic
+$17k–$47k vs city · +$7k cert differential
$60–80k
Christian EMS · Paramedic
+$8k–$28k vs city
$84,756
SCCAD · St. Charles County
Surge Div · Day one · same credential
+$32,470 vs city · 62% premium · more than city Crew Chief top step
Board Bill 24 · Introduced May 21, 2026 · Alderwoman Daniela Velazquez · Co-sponsored by 5 aldermen
The first ordinance that would allow GEMT funds to reach EMS salaries
BB24 amends Ordinance 71135 to allow GEMT reimbursement funds (Special Fund 1116) to supplement Fire Department salaries and personnel-related expenses, subject to Public Safety Committee approval by resolution. Currently, GEMT funds are restricted to capital assets and equipment only. In FY27, Special Fund 1116 is projected to receive $10.68 million. The fiscal note lists impact as indeterminate — no cap on salary use is specified. It has not yet passed.
EMS generates the revenue.
EMS carries the workload.
EMS pays for its own training.
The money goes to fire.
FY27 projection: 159 EMS employees will handle ~85,500 calls, transport ~50,000 patients, generate $20.1M in EMS-linked revenue, and start new hires at $43,004.
Same year: 780 fire employees receive $96.13M in budget appropriations — including $10.68M in GEMT generated by EMS Medicaid transports — and start new hires at $60,918.
EMS paramedics self-fund 12–14 months of training. They carry controlled substances under a state license and personal DEA liability. They go NUA with no reserve units and no mutual aid. They generate revenue that partially funds a division compensated $8,600–$17,900 more at entry — and $10,998–$21,164 more at top step after 20 years of the same city service.
This is in the city's own budget documents. Published. Every year.