ALS First Response

[edpmedic]

I'm interested to hear what others think about the positives and negatives of fire based ALS first response. Discuss pt outcomes, response times (how that affects pt outcomes), the financials regarding staffing and deployment, the FD doing both first response and txp, or only first response with a county third service EMS, or private provider doing the transports.

My dept has 37 paramedic staffed engines, the same number of ALS ambulances, 14 of which are double medic, a few squads that have medics, and four BLS buses. Due to our EMD, and how the OMD has tweaked it, many calls are categorized as ALS. Engines get diapatched on most ALS calls, and all MVA's. The county wants at least two medics onscene for every ALS call. If no engine is available, an EMS Capt. can be the second medic, and if it's a double medic PTU, a BLS ambulance will be dispatched instead of the engine, or perhaps a truck or squad, depending on who's closest.

[TNFF319]

I am pro ALS. I work for a rural county as a Paramedic. We have response times of over 20 minutes sometimes. The ability to have an ALS unit on scene prior to a transport vehicle could be critical. All my cardiac arrest saves have been with a response times of less than 5 minutes. I also like having a second medic to consult. We all know patients do not always have a normal presentation. My volunteer F.D. does a first responder BLS response. I have wished many times I had EMT equipment not to mention ALS gear. It is hard to justify to tax payers why you need ALS equipment. They only care when it directly effects them.

[edpmedic]

I agree. Many in the non fire-based EMS world speak out against fire based ALS first response, saying that response times have not been proven to be of any benefit to pt morbidity/mortality. I don't know if I buy that. Non FD EMS people also stand to gain from discrediting FD first response, since the fire service has a large market share of EMS, and will absorb the local EMS into their dept if it benefits the local jurisdiction financially and logistically.

If nothing else, dual role FD's save money on staffing and deployment, and also give medics versatility in the dept, which prevents burnout and also serves to keep one's interest in EMS. When you think about it, the average single role medic burns out in around seven years, give or take. If you can get off the box half of the time, you won't grow to resent the ambulance tour, which happens eventually no matter how much you're into EMS.

[emt161]

I agree. Many in the non fire-based EMS world speak out against fire based ALS first response, saying that response times have not been proven to be of any benefit to pt morbidity/mortality. I don't know if I buy that.

Of course not. It doesn't help you.

If you can get off the box half of the time, you won't grow to resent the ambulance tour, which happens eventually no matter how much you're into EMS.

This isn't the case in most fire departments that I have knowledge of, you're either on the bus or you're not. You can bid to a fire company if you've got the seniority, but there's no scheduled jumping back and forth.

And whose to say that a firefighter who's off the box half the time looks forward to his "on" time anyway? Just because there's some BRT time built into his schedule doesn't make him a better medic, or a medic who's head is in the game when he's on the box.

[L-Webb]

I'm interested to hear what others think about the positives and negatives of fire based ALS first response. Discuss pt outcomes, response times (how that affects pt outcomes), the financials regarding staffing and deployment, the FD doing both first response and txp, or only first response with a county third service EMS, or private provider doing the transports.

My dept has 37 paramedic staffed engines, the same number of ALS ambulances, 14 of which are double medic, a few squads that have medics, and four BLS buses. Due to our EMD, and how the OMD has tweaked it, many calls are categorized as ALS. Engines get diapatched on most ALS calls, and all MVA's. The county wants at least two medics onscene for every ALS call. If no engine is available, an EMS Capt. can be the second medic, and if it's a double medic PTU, a BLS ambulance will be dispatched instead of the engine, or perhaps a truck or squad, depending on who's closest.

Why two medics for every ALS call? Can EMTs there do IVs, Fluid and some drugs or are they B only?

[edpmedic]

Of course not. It doesn't help you.



This isn't the case in most fire departments that I have knowledge of, you're either on the bus or you're not. You can bid to a fire company if you've got the seniority, but there's no scheduled jumping back and forth.

And whose to say that a firefighter who's off the box half the time looks forward to his "on" time anyway? Just because there's some BRT time built into his schedule doesn't make him a better medic, or a medic who's head is in the game when he's on the box.

Let's say that ALS first response is has no benefit in pt outcomes. Then I suppose that response times in general don't matter, either. That's an issue for EMS txp as a whole, then. ALS first response has other benefits, though:

You can function well with less transport units. We could say that a properly funded EMS system will have enough ambulances to cover the call volume plus any significant spikes, but we know this typically isn't the case. I've worked for hospital based EMS, muni third service EMS, and the privates as well. Just look at System Status Management and the Public Utility Model. They actually cost more money, and since they're getting by with the bare minumum, any spikes in call volume cannot be addressed. Here's Dr. Bledsoe's take on SSM:

http://www.emsworld.com/article/arti...siteSection=14

You have extra manpower, and another medic to take with you to the hospital if needed (and still keep the engine in service). How many broken down medics do you know? Having extra hands to lift pts and carry equipment lessens the wear and tear on your body.

Having an ALS engine in station removes the need for the ambulance to relocate out of station during times of high call volume.

There are times when an ambulance has an extended txp time; the engine medic can initiate ALS care. The gravity of the call may not typically be urgent, but I have seen the engine medic mitigate an anaphylaxis, or turn around a tight asthmatic on occasion, as well as work a few codes before the bus arrives.

The onscene times are shorter. Besides the extra manpower, the engine medic can perform ALS interventions to speed things along.

With a dual role EMS txp FD, money is saved on staffing and deployment.

In EMS, the shelf life of a medic is maybe 7 years, give or take. The back and forth allows for a full career w/o burnout, and keeps you fresh. Getting up two or three times a night, and being out of the station for 1 1/2 hours or more for each call gets old. The depts in my region allow the medics to go back and forth. It isn't a matter of doing your time or anything like that. We actually get medics that like EMS. Some have EMS degrees, too. The thing is, I didn't see myself doing EMS only as a full career. I was almost six years in when I got on at my FD. I could have done maybe another three or four years, then went into nursing or something if I couldn't get off the road. Now, I look forward to my ambulance shifts, just like I look forward to my engine shifts. We have some that don't like EMS, but we also have others that only want to do txp. Many who do EMS for 10-15 years don't like EMS anymore either. It matters not if you work in a FD or elsewhere. The EMS field is highly transient, and being able to get a break from the call volume and the drama increases the medic's enthusiam for the job, and their shelf life as well. I work with three others from my old hospital, and others that came from single role systems all say the same thing - "I'd never go back, unless I was desperate." I love it that I can be a Hazmat Tech and ride a heavy rescue, that I can get into Peer Fitness, that I can get get into fire investigations if I want to get off the road. So many different directions you can go, that aren't available with EMS only.

[edpmedic]

Why two medics for every ALS call? Can EMTs there do IVs, Fluid and some drugs or are they B only?

We're a nearly all ALS txp system. We have 14 double medic units, which are used for training interns as a third rider, and 23 "one and one" medic units, with four BLS units. We don't use EMT E's (A's elsewhere). Only P's and I's as ALS.

[backsteprescue123]

In the county where I work there are roughly 30 ALS Engine Co., 6 ALS Truck Co., 20 BLS Ambulance, 15 ALS Medic Units, and 10 County Life Squads (ALS). (just some quick guesstimation)

If an ALS call comes in, the closest first responder rig will be dispatched along with a county life squad. If it is a true ALS call then the Life Squad will transport even though a first responder Medic Unit was also on the call. If no Life Squads are available (which happens quite often) the first responder Medic Unit will transport. Often times we have to wait some time to get a life squad on scene depending on call volume and having ALS first responder companies has saved countless lives. Within the past month I can think of at least 3 instances that I have worked where if it had not been for the ALS first responder, the pt would not have made it.

[BoxAlarm187]

This isn't the case in most fire departments that I have knowledge of, you're either on the bus or you're not. You can bid to a fire company if you've got the seniority, but there's no scheduled jumping back and forth.

Complete opposite throughout this area. I don't know of any career departments that don't rotate their personnel between the BRT and the ambulance on a regular basis. Our medics on on the ambulance three out of every seven tours.

And whose to say that a firefighter who's off the box half the time looks forward to his "on" time anyway?

Because generally, they do.

Just because there's some BRT time built into his schedule doesn't make him a better medic, or a medic who's head is in the game when he's on the box.

What about medics in a EMS-only system that don't have their head in the game?

After reading your anti-fire-based-EMS posts for quite sometime, I realize that I've never asked you what happened in the past that's made you resent it so much?

[Gadfly]

Problems with FD- paramedic first response where the EMS transport service also provides paramedics (which is a different beast than EMS based fire suppression):

1. Paramedic oversaturation. Why isn't every fire fighter rotating between engine and, say, haz-mat or engine white water rescue or engine and any other specialist assignment? In part, simply because eventually you have too many people providing the specialized service that experience goes down. Would you rather have the paramedic intubating a loved one that has 1 intubation a year, or 1 intubation a month?

2. Time saved. Especially in urban areas, how much time is saved between the first responder arrival and arrival of the ambulance paramedics? Additionally, wouldn't the best answer be, if it is significant in areas with high call volume, to increase the number of ambulances available? The fire service wouldn't say, add 2 man brush trucks through out the city because 2 man brush trucks are cheaper than 4 man fire engines simply because it means putting water on a fire (albeit from the outside) sooner? A band aid isn't a cure for an arterial bleed.

3. Cost. A lot of paramedic level supplies are there because there's a chance that they may be needed. How many supplies and medications are being replaced because of the duplication of supplies needed to support both a first response and an ambulance response to the same incident?

[Gadfly]

After reading your anti-fire-based-EMS posts for quite sometime, I realize that I've never asked you what happened in the past that's made you resent it so much?

While I'm not EMT161, I'll answer this for my self. Ever taken a serious look at EMS in Southern California? Why is it that one of the most "mother may I" and restrictive counties in California (Orange County) is set up so that only fire fighters can operate as paramedics? We're talking about a place that still requires base hospital contact on everything worse than a stubbed toe, where paramedics aren't allowed to interpret 12 lead EKGs (they defer to the machine interpretation), and a only recently had aspirin added to their chest pain protocol (an intervention that in many places across the country is an EMT level intervention).

When the fire service is the only game in town for paramedic level care by system design, and the care provided is absolute rubbish, why would someone come to any other conclusion, especially when other nearby fire service dominated systems (like Los Angeles) are essentially just as bad?

[emt161]

After reading your anti-fire-based-EMS posts for quite sometime, I realize that I've never asked you what happened in the past that's made you resent it so much?

Chest pain patients walking down three flights of stairs carrying their own oxygen bottles. Trauma patients transported on backboards they aren't strapped to. "Everybody's a No-Neck." CPR done 3 compressions at a time inside a car that's being cut, then the patient folded in half to fit out the door onto the board (padded with 5 layers of sheets so they didn't have to clean it later), then raced off to the truck where they sat for 15 minutes performing ALS interventions 1 mile down an open road from a trauma center. ALS engines using LP12s as a $25,000 blood pressure machines. Arrest with a down time of no more than 10 minutes being written up as rigor and lividity. BS calls turfed to private ambulances, which is fine, except when the crew gets there the patient hands them a post-it note with the chief complaint and "120/80 60 20" because the FD is long gone (funny, last week's BS patient had the exact same vitals.....). ER complaints about patient care resulting in every drunk in town and few that aren't being scooped up and dropped off at the ER for hours until the doc cries uncle.

I know, I know. I'm being picky.



Edit: plus essentially what Gadfly said.

[BoxAlarm187]

BS calls turfed to private ambulances, which is fine, except when the crew gets there the patient hands them a post-it note with the chief complaint and "120/80 60 20" because the FD is long gone (funny, last week's BS patient had the exact same vitals.....).

We'd be fired on the spot for something like that. I'm not kidding. Years ago, a company officer in a neighboring department did this, and was fired several days later. And forget getting another FD job, the Commonwealth would be more than happy to take your EMS license as well.

I know, I know. I'm being picky.

I don't think you're being picky - it sounds like you work in an environment where the firefighters are being "forced" to deliver EMS. Furthermore, it sounds like there's little accountability or quality assurance within the FD.

I have to say that I don't think it's fair to lump all fire-based EMS (be it first responder or transport) into that frame-of-mind though. I work for an agency with a BC of EMS, we employ a highly-respected RN as our quality assurance officer, each shift has two paramedic supervisors that (amongst a myriad of other things) keep in contact with the local ER's to ensure that good patient care is being delivered by our field units, and a chief that makes it widely known that not taking EMS as seriously as firefighting is completely unacceptable.

In contrast with your previously mentioned examples: A local EMS agency transport three MVC victims to the hospital one one ambulance - two secured to backboards, and one sitting in the front passenger's seat wearing a KED. A paramedic with another agency asked the FD members that were with him at a call to hold the patient down so he could perform a cric - the patient was A&O with a patent airway. Yet another agency left a patient alone in the back of an ambulance while they picked up dinner.

It's clearly not about watch the patch says on our shoulder, it's about being accountable.

[BoxAlarm187]

When the fire service is the only game in town for paramedic level care by system design, and the care provided is absolute rubbish, why would someone come to any other conclusion, especially when other nearby fire service dominated systems (like Los Angeles) are essentially just as bad?

Clearly, there are some FD's in the US that need to be fixed. I know nothing of LAFD EMS, or any other west-coast EMS for that matter, but I am sure that there are FD EMS agencies across the US that need fixing. That being said, there are also private and third-party EMS agencies out there that aren't worth a damn either.

Your post and 161's help me get a better understanding where some of the resentment comes from, but I hate to think that all fire-based EMS systems are being thought of with this same umbrella that might exist in SoCal.

[Gadfly]

Your post and 161's help me get a better understanding where some of the resentment comes from, but I hate to think that all fire-based EMS systems are being thought of with this same umbrella that might exist in SoCal.

Better understanding? Ok, how about this.

Personally, I could see myself supporting fire based EMS, if certain issues (mostly cultural) are fixed. As far as employment, my current career path in terms of EMS/medicine makes the difference between fire, third service, private, or other largely irrelevant, provided the system is willing to evolve. When I was working as an EMT in Southern California, the 'fire service or nothing' aspect of paramedic level 911 care was one factor, but there was certain other issues that were more global that shut down any thought of me staying in EMS.

Issue 1: If a fire service wants to be the primary EMS provider, then EMS needs to be a sub specialty like swift water, or haz mat, or any of the others. Requiring everyone to be a paramedic as either a written or unwritten (when hundreds of people are apply to a handful of spots, if being a paramedic gets "points," then it is a de facto requirement. Oversaturation with paramedics is a problem, and when every apparatus seems to be a "ALS first response" unit, then you have too many paramedics. I do not want someone treating me who is only a paramedic because it was a requirement to get hired.

To put it another way, if someone was hired who only wanted to be a paramedic, and in order to run 911 calls had to become a fire fighter, had no interest in fire fighting, and only did the absolute bare minimum training, would you trust him with your back on an interior attack? After all, he met the same FF1/FF2 (or what ever) requirements that you did? If not, why are you forcing someone with that attitude on the public?

Secondly with this is intervention dilution (I hate the term "skills" with a passion). EMS in the US is massively screwed up in part because the base level is too light on education and too limited in train in interventions. There is no reason why the lowest level of provider that is approved to work alone (the "EMT" level in most states. Note: This is not a "I am EMT, hear me ROAR" argument) shouldn't be able to run a diabetic emergency. The EMT should, with appropriate education and training, be able to start an IV and give dextrose. The vast majority of EMS interventions are low risk. The high risk, high reward, low use interventions like intubations needs to be limited. Unfortunately, the only level EMS provider worth a darn in most urban EMS environments is the paramedic, which means a lot of people allowed to do high risk, low use interventions in order to have enough people to make sure the high use, low risk interventions are covered. Make something between EMT-I/85 and I/99 (with appropriate education) the base level, and that's fixed. To put a picture on this problem, would you want someone intubating you that hasn't intubated in 6 months?

How does fire based EMS fit into this? So in order to have proper coverage you already have some intervention dilution. Now, let's throw a lot more paramedics into this equation since we've got a lot more people than a 2 man ambulance crew or paramedic squad showing up (especially in areas where the fire department provides ambulance service or has a squad vehicle for their paramedics instead of the engine) along with a 4 man engine crew where multiple members of the engine crew are also paramedics. Proverbially, it's throwing gasoline on the intervention dilution fire.


Issue 2: Misuse of resources. If ambulance response times are unacceptable, then fire engine first response is not the answer. More ambulances (regardless of who is running them) is the answer. If fire engines are being delayed getting to a fire, is more ambulances or trucks the answer just so that something with flashing lights is present?

Also, if for what ever reason fire department first response is required (and I don't agree with the "fire department provides paramedics, private company provides 2 EMTs and an ambulance" game out here. Want to run EMS, run ambulances), there's absolutely no reason to send an engine. Why would I want a $750,000+ engine running that gets God know how many gallons to the mile to a call it patently wasn't designed for (unless the patient is on fire) when a $30,000 F-150 (stocked, and that's still being generous with the price) would work just as well. Yes, it would require splitting a crew up and only having the engineer on the engine if the crew is on a medical call, but that's largely irrelevant since the crew would be out of service regardless of if it's 3 members and a pickup truck on a medical call with the engine in the bay or 4 members on an engine at a medical call.