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    Default ALS First Response

    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.
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    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.
    FF/Paramedic

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    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.
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    Quote Originally Posted by edpmedic View Post
    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.

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    Quote Originally Posted by edpmedic View Post
    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?
    Bring enough hose.

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    Quote Originally Posted by emt161 View Post
    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.
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    Quote Originally Posted by L-Webb View Post
    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.
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    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.
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    Quote Originally Posted by emt161 View Post
    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?
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    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?

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    Quote Originally Posted by BoxAlarm187 View Post
    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?

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    Quote Originally Posted by BoxAlarm187 View Post
    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.

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    Quote Originally Posted by emt161 View Post
    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.
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    Quote Originally Posted by Gadfly View Post
    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.
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    Quote Originally Posted by BoxAlarm187 View Post
    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.

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    Issue 3: Internal Culture. If both the front line staff and the executive staff aren't running a fire and EMS department (regardless of the name on the side. I find both sides of the DC FEMS debate to be hilarious since one side thinks that changing the name changes things and the other side doesn't want to recognize that the vast majority of their calls have nothing to do with fire, even when lumped into "EMS" vs "everything else"), then they're dangerous. They're either running an EMS department that dabbles in fire fighting (dangerous on the rare fire scene), or a fire department that dabbles in EMS (dangerous to their patients). If you can't serve 2 masters, stop trying. If a fire scene gets screwed up and someone says, "That's what happens when you let an EMS department fight fires," then the opposite argument is equally valid.

    Issue 4: Education and requirements of the job.
    I'm sure most have seen the EMS Professional Development Model put together by the USFA and FEMA. Here's the problem with it. It takes the strategy/tactics/tasks model used for fire fighting and forces it on EMS. The problem is that the paramedic in charge needs to be doing all of those. EMS is medical care and medical care cannot be cookbook. The education level for paramedics needs to be, at a minimum, an associates degree, and the paramedic needs to be able to justify why they're picking their interventions for reasons other than "protocol." The fact that the US Fire Administration doesn't even think EMS instructors need a college education is nothing short of frightening. I need my paramedic to be able to and empowered to think outside of the box with his interventions, and not limited to "cook book, or call medical control." Medical control for consultation? Good. For "mother may I?" Bad. If the fire service can't support increased education requirements, then I have no use for them.

    To add to the education debate, here's IAFC weighing in on the EMS Education Agenda.
    The IAFC EMS Section would like to see substantiation on why there is an increase in training hours and how the new hour level was determined.
    • While the IAFC EMS Section supports higher education and the aim of increased professionalism in EMS, it is concerned that the general move toward college-based courses, the increase in hours and resulting financial impact will adversely affect departments’ ability (especially volunteer departments) to meet the goals of the standards.
    • Will the increase in education standards further impact the pool of people who can complete the requirements? Will potential student populations with impaired socioeconomic status be adversely affected such that they will be essentially prevented from entering the EMS field?
    http://www.iafc.org/associations/468...ents070731.pdf

    So the IAFC doesn't, apparently, care that EMS education requirements are laughably low prior to the current changes, agrees with college education for paramedics unless it affects their hiring pool, and thinks that the color of the paramedic's skin or how much their parents made is more important than their ability to do the job, including commanding enough knowledge to appropriately do the job. ...and I'm to support this?

    Issue 5: False arguments.

    Fire service EMS advocates conveniently ignore 3rd government agencies, opting to always frame the battle between profit seeking evil private companies and the all cuddly fire service. Ok, I'll definitely grant that from a PR standpoint this is the ultimate way to frame the debate and they're doing an awesome job. It won't, however, win friend and influence people who actually understand EMS. The simple fact is that every agency must "make a profit." Even the fire service needs to make more money, be it fee for service or tax dollar subsidy (which isn't necessarily a bad thing) than they spend. However if I'm paying X dollars for EMS, I expect X dollars for EMS. Not X-Y dollars for EMS and Y dollars being siphoned off for fire protection.

    Fire EMS vs Fire-Police ("public safety"):

    Fire departments argue against "public safety" departments because the intellectual, training, equipment, and day to day demands for fire fighting and police services are drastically different. Yet a gun and a fire hose share just about as much in common as a defibrillator and fire hose. Similarly fire science shares about as much in common with criminal justice as fire science does with prehospital medical care.
    Last edited by Gadfly; 05-25-2011 at 05:05 AM.

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    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.
    Opinions my own. Standard disclaimers apply.

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    Quote Originally Posted by backsteprescue123 View Post
    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)
    What is the difference between an ALS Medic Unit and a "County Life Squad"?

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    Fire based EMS is the only reason I have the job I have. I like it because we all work together whether we're on the bonebox or on the truck, you know the guys that'll be showing up to help. Since we all work together, we all know the equipment so there's no confusion on runs.

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    Fire departments argue against "public safety" departments because the intellectual, training, equipment, and day to day demands for fire fighting and police services are drastically different. Yet a gun and a fire hose share just about as much in common as a defibrillator and fire hose. Similarly fire science shares about as much in common with criminal justice as fire science does with pre-hospital medical care.
    You won't get an answer to that, there aren't any Schaitberger talking points that apply (or slogans that could easily fit on a plywood-mounted posterboard) .

    Quote Originally Posted by tree68 View Post
    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.
    So the reason you want responsibility for pre-hospital medical care..... is so that you can justify spending taxpayer dollars and other valuable resources on personnel and equipment which by their nature are not designed for pre-hospital medical care. Ok.

    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"?

    Since we all work together, we all know the equipment so there's no confusion on runs.
    I'm sure you don't know most of your local police officers, or are familiar with their equipment and procedures, but I bet you get along just fine.

    The answer to not being familiar with personnel and equipment from a two different but co-responding agencies (like, say a fire department and private ambulance company) is training and cooperation.

    But that would mean the FD might have to treat them like human beings.

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    Quote Originally Posted by emt161 View Post
    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"?
    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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    Quote Originally Posted by edpmedic View Post
    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.
    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.

    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.
    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.

    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.
    ...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.


    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.
    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 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
    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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    Quote Originally Posted by Gadfly View Post
    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.
    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.
    Last edited by TruckSixFF; 06-17-2011 at 06:18 PM.
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    Quote Originally Posted by TruckSixFF View Post
    Our ALS engine which carry most of the stuff the ambos carry can start Pt. care.
    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.
    Last edited by emt161; 06-28-2011 at 01:00 AM.

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    Quote Originally Posted by tree68 View Post
    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.
    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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