Another two models are ALS engines doing first response with BLS or ALS fire department transport. But the key to the more recent models is the concept of ALS engines. However, be mindful, in some departments, ALS is not limited to engines. Some departments have truck companies, squads and quints that are ALS capable.
The roots of using engine companies for first response can probably be traced back to the 1970s TV series "Emergency." The delivery model in the series typically would show paramedic/firefighters assigned to a rescue unit delivering ALS care, supported by a four-person engine company. Besides bringing what was typically emergency room care to the side of the patient, viewers saw an engine company used in a non-fire role. This approach was adopted by many communities virtually overnight.
The concept of delivering ALS from engines can take on several names - ALS engines, paramedic engines or assessment engines. Even the concept can take on different meanings in different communities. The term ALS or paramedic engines in some communities has been applied to anything beyond "first-aid" capable, all the way up to carrying everything an ALS ambulance would carry except the stretcher. What may be considered a paramedic engine in one community would not be considered an assessment engine in another community.
Taking it a step further, some fire departments have combined concepts and developed transport-capable engines or ladders. The concept of using engines as ALS first responders makes sense. Most communities have a low incidence of fires while they respond to an exorbitantly high number of EMS calls. Even then, those fires are usually small and quickly extinguished by one handline.
Some communities developed ALS companies because of economics. By upgrading an existing engine company to the paramedic level, a fire department can eliminate hiring additional personnel, buying another vehicle (ambulance), and the additional fuel and maintenance costs associated with running an ambulance while still providing ALS service. The startup costs can easily save a fire department over $200,000.
Some departments run with the configuration of one EMT and one paramedic on the ambulance and a minimum of one paramedic on the engine company. Thus, the department has ALS first response and ALS transport. If the patient is critical, the paramedic on the engine company accompanies the paramedic from the ambulance to the hospital while the EMT assigned to the ambulance drives.
In some cases fire departments upgraded engine companies to ALS-capable to increase service levels and upgrade performance. In the case where the first-response company is ALS this theory advocates "front-loaded ALS" delivery, possibly allowing the ambulance to take longer responding to the scene. Studies done by the American Heart Association have shown improved survival rates in cardiac-arrest victims when ALS intervention time is shortened.
Another component to increasing service levels occurred in some communities when an engine company's response district was remote from the closest ALS ambulance because of geographics. To compensate for this deficiency, some departments converted the engine to ALS capable, to compensate for the prolonged response time of an ALS ambulance.
Private ambulance companies that have a public/private cooperative with a fire department also like the concept of paramedic engines. Under their management concepts, the cost and risk of providing ALS is shifted to the fire service.
Obviously, there are costs - drugs and monitor-defibrillators, for example - associated with maintaining ALS equipment that departments would not otherwise incur. Additionally, some private companies have advocated prolonging their response times because ALS is already being delivered by the fire department. The standard for the private industry has been to arrive on a scene within eight minutes and 59 seconds, 90% of the time. But with the introduction of ALS engines, some private companies have negotiated for and received up to 14 minutes and 59 seconds, 90% of the time. This "cost-shifting" to the fire service can add up to significant profit for private-ambulance companies.
The other benefit to the private-ambulance industry with ALS engines is the "risk-shifting" that occurs when the fire service assumes the ALS component of delivery. Obviously, there are risks associated with providing advanced treatment, including wrong medications, intubating the esophagus or other risk procedures that can lead to lawsuits.
The ever-increasing role fire departments have taken on with respect to providing EMS should be a clear sign that EMS should not be segregated, but integrated into the department. EMS being delivered by a fire department significantly increases that department's visibility to the public. This visibility and increased productivity certainly provide momentum for strong community support.
Gary Ludwig is the chief paramedic for the St. Louis Fire Department and is currently serving his fourth term as an elected member of the EMS executive board for the International Association of Fire Chiefs. He was awarded Missouri's EMS Administrator of the Year for 1998.
