This year’s MEMSA Service of the Year award winner is Monarch Fire Protection District for redefining what a modern fire-based EMS agency looks like, clinical excellence, innovation, and collaboration through programs they have been building for several years.
Founded in 1957, Monarch Fire Protection District serves approximately 100,000 residents across 62.7 square miles in and around Chesterfield, along with portions of Wildwood, Clarkson Valley, Maryland Heights, Creve Coeur and unincorporated St. Louis County. Located about 25 miles west of downtown St. Louis along the Missouri River, the district has direct access to Interstate 64/Highway 40 and borders several surrounding communities.
Today, Monarch operates five stations and responds to more than 11,000 calls each year under Medical Director Dr. Michael DeFilippo of Washington University. Its fleet includes six ambulances, three pumpers, two ladder trucks, a rescue squad, tanker, brush truck, two boats, an EMS Quick Response Vehicle, and a Battalion Chief vehicle. But it is the district’s approach to EMS that has set Monarch apart.
A Dual-Role Model
Monarch is a fire-based EMS system built around a dual-role model. Every firefighter is cross-trained as a paramedic, allowing the district to combine firefighting and rescue expertise with advanced clinical care.
The district has 125 paramedics, including 25 critical care-trained paramedics holding FP-C, CCP-C or C-NPT credentials, as well as two community paramedics. Critical care paramedics operate under advanced protocols covering RSI, POCUS, ventilator management, prehospital blood products, EPOC, and other advanced skills. Beyond the minimum requirements of Missouri State Firefighter I/II and a Missouri State Paramedic License, Monarch requires extensive fire, rescue, and EMS training.
Its EMS onboarding process is designed to establish clinical competency from day one. Training begins with the fundamentals and progresses into advanced credentialing in Pit Crew Airway, rapid sequence intubation (RSI), point-of-care ultrasound (POCUS), finger thoracostomy, ventilator management, IV pump operation, ECMO activation, and blood product administration.
The result is a system where advanced clinical care is not an isolated specialty, but part of the culture of the entire organization.
Taking Critical Care to the Field
Monarch’s critical care program is one of the district’s defining characteristics.
The district operates Point-of-Care Ultrasound (POCUS) on all six ambulances and its EMS Captain vehicle, giving crews the ability to use ultrasound as part of real-time clinical decision-making. This program is supported by a rigorous onboarding, competency, and QA process to ensure imaging accuracy in the field. Applications include assessing fine ventricular fibrillation, cardiac standstill, pulmonary edema, pneumothorax, right-ventricular strain suggestive of pulmonary embolus, intra-abdominal hemorrhage, endotracheal tube confirmation, and intrauterine pregnancy verification, among others.
That commitment to POCUS has already produced significant results. Monarch performed the first prehospital pulmonary embolism response team activation in its region driven by POCUS findings. The activation led to expedited surgical pulmonary thrombectomy, and the patient returned home to his family without residual deficit or injury.
The district has also developed an advanced prehospital blood program, carrying packed red blood cells and plasma into the field. This places Monarch among a very small number of pre-hospital agencies in Missouri providing this level of hemorrhage control in the field.
A New Approach to Airway Management
Monarch’s Pit Crew Airway program is another example of its commitment to disciplined clinical practice. Developed in collaboration with Dr. Phil Moy from Mercy Hospital, this method has proven highly successful and is now being taught at both local and national conferences this year.
The model is paired with paramedic-initiated RSI and incorporates cognitive-aid-driven choreography, deliberate skills practice, pre-event briefing on every activation, and a quality-improvement loop that closes the gap between protocol and bedside. Every intubation is reviewed through video laryngoscopy as part of the district’s quality assurance and continuous quality improvement process.
According to Medical Director DeFilippo, Monarch’s first-pass RSI success rate has held at 100% since the program launched in October. He attributes that result not simply to equipment or protocols, but to the system surrounding the procedure and the emphasis on preparation, teamwork, and review.
Bringing ECMO to the Prehospital Environment
In March 2025, Monarch and St. Luke’s Hospital formally launched a regional ECPR (extracorporeal cardiopulmonary resuscitation) program following months of coordination, training, and protocol development. The results have already spoken for themselves, with several successful activations that have directly impacted the lives of patients in the community who may not have otherwise survived.
Monarch crews are trained to identify ECPR-eligible cardiac arrests in the field, communicate the activation to the receiving team in real time, and execute the time-sensitive transport decisions that make a downstream cannulation feasible. The program represents more than an advanced procedure. It demonstrates Monarch’s willingness to build partnerships and systems around the goal of improving outcomes for some of the most critically ill patients.
Measuring What Matters
Monarch also places a strong emphasis on data and continuous improvement.
The district participates in the MyCARES cardiac arrest registry and works with receiving hospitals to monitor metrics including bystander CPR rates, time to defibrillation, return of spontaneous circulation, survival to admission, and meaningful neurologic outcomes at discharge.
The district’s 2025 CARES year-end data included 33 worked cardiac arrests. Every patient who survived to admission achieved a Cerebral Performance Category 1 or 2 neurologic outcome. This has been independently described in regional press as effectively doubling the national survival average for prehospital cardiac arrest.
Creating a Clinical Leadership Path
Monarch has also changed the way EMS leadership fits within its fire service structure.
The district created the EMS Captain position as a field supervisory and clinical leadership role that operates alongside the traditional fire-side command structure. The position provides a genuine, promotable career track for Fire-EMS clinicians, recognizing clinical excellence as a path for advancement.
The EMS Captain serves as a real-time field supervisor and clinical mentor on complex calls, supports onboarding and skill development for newer clinicians, and provides an operational voice in quality improvement and policy discussions.
For clinicians who want to pursue clinical mastery, the position provides a way to build a career within the fire service they joined.
Sharing Knowledge Beyond the District
Monarch’s commitment to clinical education extends beyond its own crews.
Several of the district’s critical care paramedics travel throughout Missouri to teach POCUS to other EMS providers, physician assistants, and physicians. Monarch also contributes to the educational efforts of the St. Louis Regional Critical Care Consortium, an informal collaboration among local ambulance and fire districts with critical care paramedic programs.
Through these efforts, Monarch is not only developing its own capabilities but helping advance critical care education among other providers.
Serving the Community Beyond 911
While advanced clinical care is a major focus, Monarch’s connection to its community extends well beyond emergency calls.
The district offers Hands-Only CPR, Stop the Bleed, First Aid, Fire Extinguisher, and Pet CPR classes for residents. It also provides wilderness first aid training for area Boy Scouts.
Through the File of Life program, residents can make important emergency medical information available to responders. The Pet Stickers first-responder identification program helps responders identify pets, while free home smoke detector checks are available through the district’s Community Connect platform.
Each June, Monarch hosts its Junior Firefighters Camp, an immersive program introducing middle-school-aged residents to fire and EMS as a career.
The Monarch Firefighters Community Outreach Fund also gives district members an opportunity to support families facing serious injury, illness, or disability. Members volunteer their time and raise funds for organizations including the Muscular Dystrophy Association, the Multiple Sclerosis Society, The Backstoppers, Honor Flight, Wings of Hope, and the Wounded Warrior Project.
Raising the Standard
The district describes its accomplishments as more than a decade of investment in the idea that a fire-based system can deliver critical care medicine, and behind those programs are the people who make them possible.
“We are most proud of the men and women who proudly serve the Monarch FPD 24/7/365 on the frontline apparatus,” said Nick Smith, Deputy Chief of EMS at Monarch. “We have asked every person in this district to raise the bar and create a new standard for the future in EMS. We told them it would not be easy, but they have responded with trust, buy-in, and effort that have led to clinical outcomes that would have otherwise never been possible. They are the true face of the organization and go above and beyond to make Monarch FPD everything it is today.”
For Monarch, the goal is not simply to provide EMS from a fire district. It is to demonstrate what fire-based EMS can become when leadership, training, clinical practice, hospital partnerships, and continuous review are brought together.
As the district puts it, the ceiling on what fire-based EMS can deliver clinically is much higher than the profession sometimes gives it credit for. Building that kind of system takes planning, committed hospital partners, a medical director willing to advance protocols, and crews willing to hold themselves to a rigorous review process.
“Given the right leadership, the sky is the limit in prehospital medicine,” said Smith.
