ALS First Response

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Originally Posted by emt161

Tell me again how "running an EMS system so we can have more firefighters/dues-paying union members" is SO much higher on the moral food chain than "running an EMS system for profit"?

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It's both. A fire department that has both ALS first response and ALS transport with crosstrained members will certainly have more dues paying members. But there are cost saving measures involved with that:

Dual role providers cut down on OT, forced or otherwise, by alleviating staffing issues. Departments that plan well to achieve their staffing and deployment objectives will typically have one or two pad personnel per station. These pad personnel can be detailed to fill suppression spots or EMS spots, as vacancies dictate. This allowance for pad personnell is sorely lacking in EMS only organizations, who prefer instead to dole out forced OT to cover sick leave, vacation leave, injury leave, etc.

Many, many EMS only organizations seek to staff and deploy the least amount possible to save on costs. The fire service is no different in many cases. Since minimal deployment is standard for the field, the fire service chooses to use otherwise idle suppression apparatus to augment their EMS response, regardless if the calls are of a time sensitive nature or not. The personnel and apparatus are already in place, so it only makes sense to increase their net utilization hours to boost the jurisdiction's EMS delivery. The only extra cost involved is for the paramedic incentive pay for one person per ALS company, and the ALS equipment. No additional people have to be hired, and no new vehicles need to be purchased. Sure, adding ambulances would me a much better way of improving EMS delivery, but single role EMS departments refuse to do this, so it would be unreasonable to expect the fire service to do the same. In addition, the public has come to expect this level of service in many areas. When I'm the engine medic, and we're onscene for a diff breather, MI, CVA or something potentially time sensitive, one of us will explain that we're the engine crew, that we have nearly the same ALS capabilities as the ambulance, and that we're there to start treatment until they arrive. I've yet to hear a citizen complain that we were ther instead of the ambulance; they were just happy to have us there to help them.

Costs are saved in hiring by preventing burnout, injury leave, permanent disability, and other forms of attrition. When I worked single role EMS, it was typically just me and my partner lifting and carrying everything. We had six floor walkups with the chair, our air, our bags, and the monitor. There are tight apartments and stairs that we had to navigate on our own with no spotters. We did it, but it will eventually burn you out or cause you to throw out your back, blow out your shoulder, knee, etc. With our dual response, we have 5-6 people to share the load rather than just two. If I'm riding as OIC, I'm not doing any lifting at all, except maybe one of my bags. That is huge in preventing breakdown or burnout. Being able to go between EMS and suppression also prevents burnout. The average EMS only person lasts only 7-10 years before leaving the field. The fire service has many who keep their ALS certs for much longer, typically for their entire career if they can switch between roles. Reduced injury and attrition saves money in hiring and OT.

To suggest that suppression coverage be scaled back and replaced dollar for dollar for the EMS side due to call volume numbers shows a profound ignorance of suppresion operations and why timely coverage is vital. Also, some may say that suppression vehicles on an EMS run can prevent them from running fire calls, which is their main function. Good departments plan for this through proper staffing and deployment, mutual aid agreements, and modified dispatch protocols during times of high call volume. When I'm the ambulance OIC, if the pt's condition isn't of a time sensitive nature, I can handle with just myself and my partner. If another call comes in, be it suppresion or another EMS incident, I'll release the engine from our call. It's my call to do that, not the engine OIC, btw.

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Originally Posted by edpmedic

The fire service is no different in many cases. Since minimal deployment is standard for the field, the fire service chooses to use otherwise idle suppression apparatus to augment their EMS response, regardless if the calls are of a time sensitive nature or not. The personnel and apparatus are already in place, so it only makes sense to increase their net utilization hours to boost the jurisdiction's EMS delivery. The only extra cost involved is for the paramedic incentive pay for one person per ALS company, and the ALS equipment. No additional people have to be hired, and no new vehicles need to be purchased.

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Emphasis added.

Paramedic equipment, which includes many perishable medications that are often hardly used to begin with (just based on call makeup), isn't cheap or free. Similarly, more use of the apparatuses means more wear and tear and higher fuel costs. It's hardly free and for non-time sensitive calls (which are the case more often than not and the calls that are time sensitive are often not quite as time sensitive as we'd like to believe), you're providing a service of dubious benefit. If cutting non-essential first response saves fuel and maintenance enough to save a fire department job or keep the library open, then it's something that needs to be considered. Just because the engine is sitting around otherwise collecting dust does not mean that it's a free lunch solution for long response times. This is, of course, ignoring the wrong tool for the job issue.

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Sure, adding ambulances would me a much better way of improving EMS delivery, but single role EMS departments refuse to do this, so it would be unreasonable to expect the fire service to do the same. In addition, the public has come to expect this level of service in many areas. When I'm the engine medic, and we're onscene for a diff breather, MI, CVA or something potentially time sensitive, one of us will explain that we're the engine crew, that we have nearly the same ALS capabilities as the ambulance, and that we're there to start treatment until they arrive. I've yet to hear a citizen complain that we were ther instead of the ambulance; they were just happy to have us there to help them.

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So because the citizen who is ignorant of how EMS works is happy, then that's fine? Additionally, out of those things you've mentioned, only the patient with difficulty breathing is time sensitive from a first response standpoint. STEMIs and CVAs are time sensitive from a transport standpoint, unless you've added a cath lab or CT scan and neurosurgical capabilities to your fire engine. Saying a fire first response saves CVA lives is like saying an ambulance first response to a structure fire saves lives because the ambulance carries a fire extinguisher. It's simply the wrong tool for the job and having the 'circle of death' standing around on scene does not stop any sort of meaningful clock.

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Costs are saved in hiring by preventing burnout, injury leave, permanent disability, and other forms of attrition. When I worked single role EMS, it was typically just me and my partner lifting and carrying everything. We had six floor walkups with the chair, our air, our bags, and the monitor. There are tight apartments and stairs that we had to navigate on our own with no spotters. We did it, but it will eventually burn you out or cause you to throw out your back, blow out your shoulder, knee, etc. With our dual response, we have 5-6 people to share the load rather than just two.

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...however not all calls are on the 10th floor of some sort of small slum like apartment. Targeted response? OK. Every response? Waste of resources. Additionally, lift assists do not need paramedics, they need people who can lift, so there's no need for a first response set of paramedic gear to maintain.

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If I'm riding as OIC, I'm not doing any lifting at all, except maybe one of my bags. That is huge in preventing breakdown or burnout. Being able to go between EMS and suppression also prevents burnout. The average EMS only person lasts only 7-10 years before leaving the field. The fire service has many who keep their ALS certs for much longer, typically for their entire career if they can switch between roles. Reduced injury and attrition saves money in hiring and OT.

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Wee... lots of people with paramedic certs not providing paramedicine! Sounds like the perfect recipe for skill degradation and dilution. I'm going to go out on a limb and say that not everyone at your department are specialists in hazmat, confined rescue, AND swift water. Why not? After all, once someone gets trained in hazmat they should be able to switch from any other role and back to hazmat freely, just like plenty of fire departments do with EMS.

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To suggest that suppression coverage be scaled back and replaced dollar for dollar for the EMS side due to call volume numbers shows a profound ignorance of suppresion operations

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To suggest that ambulance coverage can be scaled back (or, as often is the case, simply never meeting the demand) because there are fire engines collecting dust shows a profound ignorance of medicine.

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Originally Posted by Gadfly

Emphasis added.

Paramedic equipment, which includes many perishable medications that are often hardly used to begin with (just based on call makeup), isn't cheap or free. Similarly, more use of the apparatuses means more wear and tear and higher fuel costs. It's hardly free and for non-time sensitive calls (which are the case more often than not and the calls that are time sensitive are often not quite as time sensitive as we'd like to believe), you're providing a service of dubious benefit. If cutting non-essential first response saves fuel and maintenance enough to save a fire department job or keep the library open, then it's something that needs to be considered. Just because the engine is sitting around otherwise collecting dust does not mean that it's a free lunch solution for long response times. This is, of course, ignoring the wrong tool for the job issue.



So because the citizen who is ignorant of how EMS works is happy, then that's fine? Additionally, out of those things you've mentioned, only the patient with difficulty breathing is time sensitive from a first response standpoint. STEMIs and CVAs are time sensitive from a transport standpoint, unless you've added a cath lab or CT scan and neurosurgical capabilities to your fire engine. Saying a fire first response saves CVA lives is like saying an ambulance first response to a structure fire saves lives because the ambulance carries a fire extinguisher. It's simply the wrong tool for the job and having the 'circle of death' standing around on scene does not stop any sort of meaningful clock.


...however not all calls are on the 10th floor of some sort of small slum like apartment. Targeted response? OK. Every response? Waste of resources. Additionally, lift assists do not need paramedics, they need people who can lift, so there's no need for a first response set of paramedic gear to maintain.



Wee... lots of people with paramedic certs not providing paramedicine! Sounds like the perfect recipe for skill degradation and dilution. I'm going to go out on a limb and say that not everyone at your department are specialists in hazmat, confined rescue, AND swift water. Why not? After all, once someone gets trained in hazmat they should be able to switch from any other role and back to hazmat freely, just like plenty of fire departments do with EMS.



To suggest that ambulance coverage can be scaled back (or, as often is the case, simply never meeting the demand) because there are fire engines collecting dust shows a profound ignorance of medicine.

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Sorry but I have to disagree! If an ALS engine arrives before the ambo on a stroke or MI it saves a lot of time. The Engine can do a 12 lead prior to the ambos arrival which will decrease scene time. For the stroke the engine can complete a pre-hospital stroke scale prior the the ambos arrival and also decrease scene times. As we know there is nothing we can do for a stroke in the field. In my system we do not give 02 to a stroke/MI unless the SP02 is less then 94% (if you wonder why read up on it). Our goal for stroke scene times are 10 minutes or less. 9/10 times a IV will be started en-route becuase what meds does a stroke pt. need? Also if the engine arrvies first and is able to provide ACS medications such as ASA, & Nitro, 02, the sooner those meds are on board the better the Pt. outcome. There is many times where are ambos are at the hospital or out of the station on a call in another district. Our ALS engine which carry most of the stuff the ambos carry can start Pt. care.

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Originally Posted by TruckSixFF

Our ALS engine which carry most of the stuff the ambos carry can start Pt. care.

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The only items with documentation to support improved patient outcomes by arriving at the patient's side before the ambulance is CPR-trained individuals and an AED. Sorry.

Because I'm a nice guy, I'll spot you a BVM, O2, ASA, and an Epi-Pen.

If we want to be treated like the medial professionals we think we are, we need to stop spending time and resources on things that have no basis in medical evidence. If firefighters don't care about being medical professionals because it doesn't fit their business model, well.... that's another issue entirely.

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Originally Posted by tree68

All valid points.

I would submit that many fire departments got/get into the EMS business because they were worried about the public seeing the BRT's sitting around most of the time, staffed by who-knows-how-many firefighters, waiting for an ever-decreasing number of actual fires (although the AFA's seem to be holding in there).

We don't want the public to wonder if we really need all those BRT's and firefighters. So we start running EMS calls to keep those BRT's fresh in everyone's mind.

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If it weren't for fire based EMS.. many commuinities would not have EMS on either the BLS or ALS level at all...

A for profit company will not station crews in an area unless they can turn a profit. They may respond from a base station, but that response time could be anywhere between 10 minutes to half an hour.

by the way.. my FD started doing EMS runs in the 1950's when the engines were equipped with the old E&J Resuscitators...

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Originally Posted by emt161

The only items with documentation to support improved patient outcomes by arriving at the patient's side before the ambulance is CPR-trained individuals and an AED. Sorry.

Because I'm a nice guy, I'll spot you a BVM, O2, ASA, and an Epi-Pen.

If we want to be treated like the medial professionals we think we are, we need to stop spending time and resources on things that have no basis in medical evidence. If firefighters don't care about being medical professionals because it doesn't fit their business model, well.... that's another issue entirely.

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With all due respect please do not post unless you actually have a clue about what your talking about because it is obvious you don't. There are MANY situations where my ALS engine has started ALS care that directly improved the Pt's outcome. The ambo out of my station runs on average 10 EMS runs a shift...leaving a lot of time for them to be at the hospital, or on a call in another's stations district. For instance I have given atropine and paced a very severe bradycardic Pt., turned around 2 anaphylaxis Pt's with Epi, fluids, and Benadryl , worked a hand full of full arrests before an ambos arrival where we had a IO, ET tube, and a round of meds before the ambos arrival, delivered a baby, and have controlled major bleeding, and given fluid bolus for a Pt. who was in shock after cutting his arm off with a table saw....And not to mention like I stated before, if an ALS engine can do a 12 lead, pre-hospital stroke scale, get medications on board, or even get a Pt. hx prior to the ambos arrival that decreases scene times and improves Pt. outcomes. Also I know when I am on the ambo I love having the ALS engine on every EMS call with me. It is nice to have an extra medic or 2 from the engine because it takes a huge load off the two medic on the ambo. And for the issue of cost...the EMS system supplies us with everything except for a few things such as the cardiac mointers which I believe grants paid for all those. And as far as firefighters not wanting to be paramedics, it is a requirement to be a paramedic to receive an application. If the candidate does not want to be a paramedic, well that's his own fault no one forced him to take the job and there is plenty of guys behind him that would love to have it.

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Originally Posted by emt161

The only items with documentation to support improved patient outcomes by arriving at the patient's side before the ambulance is CPR-trained individuals and an AED. Sorry.

Because I'm a nice guy, I'll spot you a BVM, O2, ASA, and an Epi-Pen.

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And what about the 12-lead capable monitor, RSI meds, cardiac meds, and chilled saline infusion? These are all real-world engine company based treatments that are available.

While any of these treatments by themselves may or may not have an immediate impact on the patient's status, they will have a greater chance of long-term survival and recovery.

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Originally Posted by TruckSixFF

With all due respect please do not post unless you actually have a clue about what your talking about because it is obvious you don't. There are MANY situations where my ALS engine has started ALS care that directly improved the Pt's outcome.

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Anecdotes are not evidence. Time to join the rest of medicine.

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And as far as firefighters not wanting to be paramedics, it is a requirement to be a paramedic to receive an application.

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So basically you're encouraging people to take the fastest, cheapest, easiest medic school they can possibly find so they get the patch and ride the BRT like they actually want. You're doing nothing but contributing to skill dilution and medical care provided by people who don't actually want to be doing it.

In Seattle and Boston, being a paramedic is a promotion that not everyone gets, whether they have it at time of hire or not. Their save rates regularly hover in the mid 40's, their care is consistently on the cutting edge, and research on what's next in EMS happens on their trucks all the time. You don't get that in departments where everybody and the janitor is a paramedic. You can't, because the same quality just isn't there.

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Originally Posted by BoxAlarm187

And what about the 12-lead capable monitor, RSI meds, cardiac meds, and chilled saline infusion? These are all real-world engine company based treatments that are available.

While any of these treatments by themselves may or may not have an immediate impact on the patient's status, they will have a greater chance of long-term survival and recovery.

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Jury is still out on pre-hospital cooling in general- I highly doubt a couple minutes sooner than the ambulance will make a difference if the ambulance's initiation of treatment hasn't made any. Engine 12-leads is a maybe. In the urban department near me that most recently went to ALS engines, there hasn't been a manual BP taken since the monitors hit the trucks. $25,000 vital sign machines. RSI- no way in hell. How are the medics staying current if every idiot with a patch can do it? How many tubes is each medic getting per month? If the medical director doesn't know the first name of every RSI-qualified paramedic, they shouldn't be doing it. Cardiac meds will expire in the box before you use most of them- doesn't sound like a great idea to me. The guys in Florida couldn't even pass a written test they had notice for on what they were carrying on the engine. Sounds like a great idea!

Again, it's all about skill maintenance, QI, evidence-based medicine, etc. ALS engines either detract from or don't meet the findings of pretty much all of them.

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Originally Posted by emt161

Engine 12-leads is a maybe. In the urban department near me that most recently went to ALS engines, there hasn't been a manual BP taken since the monitors hit the trucks. $25,000 vital sign machines.

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Our 911-to-Balloon time is averaging 55 to 65 minutes. We're alerting the ER that we're bringing them a STEMI before the ambulance has even arrived. With an expecation of a 12-lead application within 7 minutes of the arrival of the first unit, there's no way we'd give up a monitor on the engine. And if there are departments using them as a matter of convenience, shame on them.

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RSI- no way in hell. How are the medics staying current if every idiot with a patch can do it? How many tubes is each medic getting per month? If the medical director doesn't know the first name of every RSI-qualified paramedic, they shouldn't be doing it.

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As a matter of fact, he does. We have 524 members, 189 of them are ALS, and 47 of them are RSI qualified. Ironically, the RSI medic on my shift completed his 8 hours of RSI CEU's today, which included both classroom review and scenario-based practical sessions. Who leads the program? The medical director himself.

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Cardiac meds will expire in the box before you use most of them- doesn't sound like a great idea to me.

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If you see the box is going to expire, trade it for one of the boxes on the ambulance. It ain't that hard.

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The guys in Florida couldn't even pass a written test they had notice for on what they were carrying on the engine. Sounds like a great idea!

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Sounds like they need more accountability.

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Again, it's all about skill maintenance, QI, evidence-based medicine, etc. ALS engines either detract from or don't meet the findings of pretty much all of them.

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You're talking to a guy that works for a department that employs two full-time QA managers - one for ALS providers, and one for BLS providers. A department that has installed gyrometers in the ambulances to study the effectiveness of CPR in a moving ambulance. We take EMS seriously, and constantly review our depolyment models to ensure that the most effective EMS is being delivered to our taxpayers - and this often times includes ALS engine companies.

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Originally Posted by DeputyChiefGonzo

If it weren't for fire based EMS.. many commuinities would not have EMS on either the BLS or ALS level at all...

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While true, and something is generally better than nothing, something is often not the best case scenario, just the best practical scenario.

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A for profit company will not station crews in an area unless they can turn a profit. They may respond from a base station, but that response time could be anywhere between 10 minutes to half an hour.

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There are options besides fire based and private for profit based.

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by the way.. my FD started doing EMS runs in the 1950's when the engines were equipped with the old E&J Resuscitators...

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...and the city I grew up in has a subscription program that is justified because "Providing emergency medical services is expensive and outside of traditional Fire Department duties." (Questions 6 and 9) (Microsoft Word doc warning). Oh, and since the fire department can't be bothered (again, one of my chief objections is too many fire departments only want to do half of the job) to provide ambulance service, residents are still charged for the ambulance transport regardless of whether the fire medics ride along or not. Remind me again how this is significantly different than profit based EMS companies?

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Originally Posted by BoxAlarm187

And what about the 12-lead capable monitor, RSI meds, cardiac meds, and chilled saline infusion? These are all real-world engine company based treatments that are available.

While any of these treatments by themselves may or may not have an immediate impact on the patient's status, they will have a greater chance of long-term survival and recovery.

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May I suggest reviewing the OPALS study? There's also a reason why AHA's Emergency Cardiac Care guidelines has essentially de-emphasized ACLS interventions (to the point of even removing atropine from cardiac arrest guidelines in the 2010 release) over the past 5 years?

Also, if your fire department cared about EMS, why are they not running enough ambulances to properly meet demand?

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Originally Posted by BoxAlarm187

As a matter of fact, he does. We have 524 members, 189 of them are ALS, and 47 of them are RSI qualified. Ironically, the RSI medic on my shift completed his 8 hours of RSI CEU's today, which included both classroom review and scenario-based practical sessions. Who leads the program? The medical director himself.

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First off, congrats on not requiring everyone to be a paramedic, and even further limiting the number that can utilize RSI. How many intubations does each of the RSI medics get a month? Now how many intubations would it be if all 524 members were paramedics? That, alone, is one of the main issues since too many fire departments require everyone to be a paramedic, thus diluting the number of interventions to the point where competency is non-existent for most medics.

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If you see the box is going to expire, trade it for one of the boxes on the ambulance. It ain't that hard.

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So they expire on the ambulance instead of the engine? Additionally, if paramedic engine first response presents such a significant time saver, wouldn't the stocks of medications on the engine be used more often than the ambulance medications?

I may be a little late in the game, but I'm going to interject some thoughts into this conversation.

First, many fire-based EMS systems will split the medics' time between the BRT and the bus. The plain and simple reason has to do with pay and FLSA. Firefighters can be put on the 28 day cycle while EMS is on a 40-hour week. If you split that time, you can still use the 28 day cycle which results in less OT. Simple economics.

Second, you can't compare systems to each other no matter how you try. The system we have where I work isn't going to work everywhere, nor is the system you work for. We run ALS first response with two ambulance services in the city, one a tax-based district and the other private. It works fine for us, though it's had its moments. While I think fire-based EMS would work for us as well, I don't see that happening in the near future. The primary thing here is that the EMS system, which entails both the FD and the EMS agencies, works for the patient. We all have the same medical director, so that helps, too.

You can quote whatever study you want, but much like what I just said, you can't necessarily apply that study to every situation. Just because LA does a study doesn't mean that the same result is going to happen in Chicago or vice versa. I've seen a number of these studies throughout the years and none of them apply to every locale.

My favorite was the one a few years ago that said we're spending too much time on scene trying to intubate. While there's some validity to the result, it's not something that you can blanketly say "no more intubating in the field". In our system, it's not uncommon for our medics to have CPR initiated, patient intubated, IV established and a round of meds in the patient prior to EMS arriving. However, it's also not uncommon to see an ambulance sitting outside a house blocks away from a hospital trying to get all that done. The principle is that you have to take ALL of the information from the study and realize the root problem. In this case, sitting on scene trying to get an IV and a tube instead of doing it en route can be detrimental to the patient. But then again, the same doctors that gripe about us getting tubes in the field are often the ones that spend several minutes in the ER trying to get one as soon as the patient arrives.

Lastly, the system as a whole is only as good as the people. If you have medics taking VS and leaving, that's a problem with that agency. I could make the argument based on the information I have in our system that the ambulance crews do the same thing. It's not necessarily the agency, it's the medic. Perhaps its time that instead of complaining you should advocate for a true EMS system that involves all the agencies communicating with each other as patient advocates instead of complaining about each other. While ours isn't perfect, we do have regular meetings with representatives from all the players- the fire department, both EMS agencies, and both ER's- in which we discuss what's best for the system as a whole, not just for each individual agency.

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Originally Posted by Gadfly

Also, if your fire department cared about EMS, why are they not running enough ambulances to properly meet demand?

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Where in the world did you get that from? We have 20 fire stations, and we staff 14 ALS transport units along with 2 paramedic supervisor captains. We're futhermore supplemented by three 100% volunteer EMS agencies, who supply us with (generally) 2 BLS ambulances and 1 ALS ambulance, along with an ALS chase vehicle.

Based upon our statistics and staffing, each ambulance is answering an average 5 calls per shift. This is somewhat biased, based on geography and population, as our slowest answers generally 1 per day, and our busiest 8-10.

It's rare that our first-responder engines are on scene for more than about three minutes prior to the arrival of the ambulance. That's extremely important to our county manager, so BLS and ALS engine company response is here to stay for the foreseeable future. And, keep in mind, he does his own research to validate his desire of fire & EMS delivery - he doesn't simply rely on what we're telling him.

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There's also a reason why AHA's Emergency Cardiac Care guidelines has essentially de-emphasized ACLS interventions (to the point of even removing atropine from cardiac arrest guidelines in the 2010 release) over the past 5 years?

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As dynamic as AHA guidelines are, I wouldn't be shocked to see epi removed and atropine replaced in the next guideline revision. Cardiac guidelines have changed more in the past 20 years than ever before, and as EMS grows out of adolescence, we should expect to see more changes. That being said, I'll hardly hang my hat on the elimination of one drug from a long-stand cardiac arrthymia guideline as a waypoint in the delivery of fire-service EMS.

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First off, congrats on not requiring everyone to be a paramedic, and even further limiting the number that can utilize RSI. How many intubations does each of the RSI medics get a month?

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I've never been a fan of an all-ALS fire suppression model for a number of different reasons.

I truly don't know how many RSI's we're getting per month countywide, but I'll check with our ALS quality assurance coordinator and find out - she stays abreast of that.

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So they expire on the ambulance instead of the engine? Additionally, if paramedic engine first response presents such a significant time saver, wouldn't the stocks of medications on the engine be used more often than the ambulance medications?

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You're a smart fellow, and I know you can't be simple minded enough to think that we'd allow the box to expire on the medic. You simply exchange between the two units on the 25th of the month, and then when the box is used on the ambulance and re-stocked at the hospital in the next couple of shifts, it's good to go again.

We have some engine companies in the outlying regions that use their boxes far more often than others. Again, our county's geography is do diverse, it's hard to make comparisons at times.

187,

Congrats on being in probably the top 1% of fire-based systems. I mean it. If you guys worked here, I probably wouldn't bitch so much.

That said, you're what's known as a statistical outlier, IIRC. You're so far above and beyond the average that using you to make judgements about the whole is almost pointless. And I mean that both literally and metaphorically.