# Studies on ALS first response and tiered vs. all-ALS



## 46Young (Nov 11, 2011)

Does anyone have any links to studies to the efficacy or ineffectiveness of ALS first response in pt outcomes?

Does anyone have any studies on the tiered BLS/ALS vs an all ALS system?

Background:

My department has 41 ambulances - 37 ALS, four BLS. 15 ALS are double medic, 14 have an EMS officer as one of the medics, and are for training. The remainder are medic/EMT staffed. We have 37 engines that have a medic and ALS equipment as minimal staffing. We have eight Heavy Rescues, which may or not be ALS. We have seven EMS Captains, which are all medics, and also carry ALS equipment. We also have 14 Truck companies that are BLS.The population is 1,080,000 or so, on 395 sq. miles. 

We use a version of EMD that was changed to include many more calls as ALS. On each first due ALS call we have an engine or medic response. On a second due, an engine from that first due will respond. On highway incidents, we get an engine and medic for each direction, and a rescue/BC/EMS Capt. if it's a possible pin job. EMS Captains are dispatched on all cardiac arrests, and on all ALS calls where the medic on the medic/EMT ambulance is the sole provider. The county has a policy of requiring two medics on every ALS call.

I feel that this is overkill. We used to have a tiered system. All of our medic/EMT buses used to be BLS. having every engine ALS is also overkill, IMO. I'd like to see studies that would show that we don't need ALS engines (or to the contrary). I would also like to see studies that advocate a tiered system (or to the contrary).

Examples of systems in use as an example would be useful as well.

Thanks.


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## atropine (Nov 11, 2011)

I think that LA CO FD does a great job with their current systme. They have a BLS engine on every call, and ALS squad and a BLS ambulance, so if ALS is not needed the engine can cancell them prior their arrival, or after an assesment had been made and the pt. does not require ALS, then the pt. may go by BLS ambulance. They have been doing this for years.


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## medicdan (Nov 11, 2011)

atropine said:


> I think that LA CO FD does a great job with their current systme. They have a BLS engine on every call, and ALS squad and a BLS ambulance, so if ALS is not needed the engine can cancell them prior their arrival, or after an assesment had been made and the pt. does not require ALS, then the pt. may go by BLS ambulance. They have been doing this for years.



Wait, 3 apparatus on EVERY call? Isn't that a bit much? If you like ALS first response, put a medic or two in an SUV, why send a million dollar engine, squad and ambulance on every call?

46Young, I've been looking for data like this for some time, and not been able to find much... it's clear that no two systems are designed the same way, and the variables that measure "outcome" are so big. 

How many hospitals are in your service area? Level/Type? Transport time? Where are ambulances based? staged? what's the system response time (call to apparatus on scene? What percentage of calls are "ALS'd"?


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## KingCountyMedic (Nov 12, 2011)

We have had a Tiered Response System since we started 40 years ago. We do tons of studies and our numbers are pretty darn good. Having a Paramedic on every rig on every street corner is bad for the patient and the Medic. 

Paramedics on all the rigs is all about the $$$! You stick an IV and throw on the heart monitor you just doubled the bill in most places. Also a Firefighter/Paramedic is worth more money to the Union than a Firefighter EMT

The Medic overpopulation in our land is a huge problem and it's dumbing down our profession.

http://en.wikipedia.org/wiki/Seattle_&_King_County_Emergency_Medical_Services_System


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## JPINFV (Nov 12, 2011)

emt.dan said:


> Wait, 3 apparatus on EVERY call? Isn't that a bit much? If you like ALS first response, put a medic or two in an SUV, why send a million dollar engine, squad and ambulance on every call?



I was driving home a few days ago and saw 4 (LACo engine company, truck company, medic squad, and private service BLS ambulance) on a call. Considering that as I was approaching was when the ambulance arrived (code 3), and about a minute later (I could hear the siren, so I pulled into a parking spot after passing the building they were responding to), the squad arrived (also code 3), I doubt that it was a fire alarm.


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## usalsfyre (Nov 12, 2011)

Seen similar in this area, the most ridiculous of which was a truck, an engine, a BC and a medic unit shutting down three of four interstate lanes for a motorcyclist that was down on the shoulder. I understand the roadway safety thought, but the best way to keep from getting hit is to GET OFF THE FARKING ROAD which should have been easy to do in this case.


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## Fish (Nov 12, 2011)

atropine said:


> I think that LA CO FD does a great job with their current systme. They have a BLS engine on every call, and ALS squad and a BLS ambulance, so if ALS is not needed the engine can cancell them prior their arrival, or after an assesment had been made and the pt. does not require ALS, then the pt. may go by BLS ambulance. They have been doing this for years.



La CO FD, and LA City are two of the worst EMS systems in the nation. They have some of the smallest and most restricted protocols and have horrible performance Data.

3 Apparatus on every call is doing the tax payer an injustice, that is inefficient. There is no need for a tax payer to pay for that many apparatus and that many personnels salaries, pension, benefits to show up to every call.

"they have been doing this for years" and it is outdated, and the cities are as broke as the EMS system.

Here is a link for the OP
http://www.ems1.com/fire-ems/articl...ween-quick-EMS-response-and-survival-chances/


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## terrible one (Nov 12, 2011)

atropine said:


> I think that LA CO FD does a great job with their current systme. They have a BLS engine on every call, and ALS squad and a BLS ambulance, so if ALS is not needed the engine can cancell them prior their arrival, or after an assesment had been made and the pt. does not require ALS, then the pt. may go by BLS ambulance. They have been doing this for years.



LA county is the epitome of an archaic, inefficient, costly service with no evidence based data to support any of their current practices. Having multiple apparatus dispatched simultaneously with multiple paramedics is not quality patient care. 
They could simplify their entire system saving millions of dollars to the tax payers and improve patient care by creating an EMD program and reducing the number of providers/equipment required to each call. Yet they continue to rely on hypothetical sceanrios requiring an engine/squad/ambulance on EVERY patient.


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## 46Young (Nov 13, 2011)

KingCountyMedic said:


> We have had a Tiered Response System since we started 40 years ago. We do tons of studies and our numbers are pretty darn good. Having a Paramedic on every rig on every street corner is bad for the patient and the Medic.
> 
> Paramedics on all the rigs is all about the $$$! You stick an IV and throw on the heart monitor you just doubled the bill in most places. Also a Firefighter/Paramedic is worth more money to the Union than a Firefighter EMT
> 
> ...



Agreed.

When you look at my department, we easily have the resources to do what you do:

http://en.wikipedia.org/wiki/Fairfax_County_Fire_and_Rescue_Department

You also have five times the land, and a 40% higher population.

Where can we access your department's studies?


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## 46Young (Nov 13, 2011)

emt.dan said:


> Wait, 3 apparatus on EVERY call? Isn't that a bit much? If you like ALS first response, put a medic or two in an SUV, why send a million dollar engine, squad and ambulance on every call?
> 
> 46Young, I've been looking for data like this for some time, and not been able to find much... it's clear that no two systems are designed the same way, and the variables that measure "outcome" are so big.
> 
> How many hospitals are in your service area? Level/Type? Transport time? Where are ambulances based? staged? what's the system response time (call to apparatus on scene? What percentage of calls are "ALS'd"?



Seven area hospitals, four of which are Stroke/CVA centers, one of which is a Level One Trauma Center. Response times are around 8 minutes, last I've heard. The ambulances are all based in our fire stations. Probably upwards of 70% of our calls are "ALS'd." 

The wikipedia link in my above post gives a little more info.


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## 46Young (Nov 13, 2011)

usalsfyre said:


> Seen similar in this area, the most ridiculous of which was a truck, an engine, a BC and a medic unit shutting down three of four interstate lanes for a motorcyclist that was down on the shoulder. I understand the roadway safety thought, but the best way to keep from getting hit is to GET OFF THE FARKING ROAD which should have been easy to do in this case.



It's standard practice to take one lane more than you what the accident covers. Many MVC vs first responder or vs parked apparatus and many more close calls make this necessary, however inconvenient this may be. Really, if you give these animals an inch, they'll gun it right past (or through) you.

But, for a shoulder, it should have only been one lane, maybe two tops since you have responders using the first lane. Always one more than you need.


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## usalsfyre (Nov 13, 2011)

46Young, I get closing lanes down while the incidents going on. What I don't get is blocking the lanes, then having all the units "hang out" in the roadway for 30+ minutes when it's a patient that could easily be packaged and gone in ten, especially when your about six minutes from a major Level I trauma center. 

If your really concerned about getting hit, get off the road as quickly as possible. Otherwise blocking lanes is just paying lip service to safety. Not only will you reduce your exposure, your citizens will appreciate it.


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## 46Young (Nov 13, 2011)

usalsfyre said:


> 46Young, I get closing lanes down while the incidents going on. What I don't get is blocking the lanes, then having all the units "hang out" in the roadway for 30+ minutes when it's a patient that could easily be packaged and gone in ten, especially when your about six minutes from a major Level I trauma center.
> 
> If your really concerned about getting hit, get off the road as quickly as possible. Otherwise blocking lanes is just paying lip service to safety. Not only will you reduce your exposure, your citizens will appreciate it.



We're all about getting off the road as soon as possible. Besides there being much better places to socialize, it's also very dangerous.

When I'm riding as OIC of the medic, we look to be off the scene in under ten minutes. The engine only stays there long enough to block for us.


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## Fish (Nov 13, 2011)

46Young said:


> Besides there being much better places to socialize,



Like Chipolte, over a burrito bowel?


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## JPINFV (Nov 13, 2011)

Fish said:


> Like Chipolte, over a burrito bowel?




I hope the fire departments have a good supply of Chipolte-away.


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## denadog (Nov 13, 2011)

terrible one said:


> LA county is the epitome of an archaic, inefficient, costly service with no evidence based data to support any of their current practices. Having multiple apparatus dispatched simultaneously with multiple paramedics is not quality patient care.
> They could simplify their entire system saving millions of dollars to the tax payers and improve patient care by creating an EMD program and reducing the number of providers/equipment required to each call. Yet they continue to rely on hypothetical sceanrios requiring an engine/squad/ambulance on EVERY patient.



If you have to pay the firefighters to be on the rig and in the station whats wrong with them running 6 or 7 medical calls a day and usually arriving on scene to provide patient care in the first couple of minutes before the paramedics can get there? The fact is that the closest rigs with EMTs are fire engines and they can usually BLS a call by canceling the squad and then let the private ambulance transport.  On ALS calls the squad can usually handle with the ambulance and let the engine or truck go available to run another call.  How could you save money any other way without drastically increasing response times? Put two medics on every engine in the county and pay them way more? This system seems to make sense to me and as a citizen who lives in LA County Fire service area I can't say that myself, my family, or anyone I know has ever had a poor experience with LA County Fire EMS or the private ambulances.


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## JPINFV (Nov 13, 2011)

1. Increased cost of fuel and wear and tear on rather expensive pieces of fire fighting equipment. 

2. Increased pay, because the fire fighters aren't going to do it for free.

3. It reduces pressure to demand more ambulances, thus reducing the number of ambulances in the system, unless we want to start demanding that engines can transport.

4. Who responds to the fires when the engine is on an EMS run?

5. Who responds to EMS calls when the engines are on fires?


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## Fish (Nov 13, 2011)

JPINFV said:


> 1. Increased cost of fuel and wear and tear on rather expensive pieces of fire fighting equipment.
> 
> 2. Increased pay, because the fire fighters aren't going to do it for free.
> 
> ...



Agreed, squads and squads only should respond to EMS runs. It does not require a half million dollar fire fighter apparatus


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## abckidsmom (Nov 13, 2011)

Fish said:


> Agreed, squads and squads only should respond to EMS runs. It does not require a half million dollar fire fighter apparatus



You mean ambulances?


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## Fish (Nov 13, 2011)

abckidsmom said:


> You mean ambulances?



Well and ambulance to, but that post was referring to LA COunties system of sending a squad and an Engine and then a private service sending the ambulance, i was stating that no need for the engine as far as FD is concerned. A squad and a Squad only(only with the private service ambulance) can handle it.


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## terrible one (Nov 13, 2011)

To add to that above,



denadog said:


> The fact is that the closest rigs with EMTs are fire engines and they can usually BLS a call by canceling the squad and then let the private ambulance transport.



That fact is because there are more fire engines than ambulances. That fact is followed by the fact that the fire departments has a better union and lobbysist that are able to sway politicians and the public that their communities will fall apart with a fire engine every other block. 
Common sense - if 80% of your calls are medical in nature, and rising, while fire related incidents continue to decrease why do communities need more and more fire engines and less and less ambulances?
Also what percent of BLS calls with arriving BLS or ALS engines cancelled the squads? Probably a hard piece of data to retrieve, but I bet you it is less than you think. 



denadog said:


> How could you save money any other way without drastically increasing response times?



Easy. Elminate the squads and increase the number of ambulances. Put the paramedics on the ambulances.



denadog said:


> Put two medics on every engine in the county and pay them way more? This system seems to make sense to me and as a citizen who lives in LA County Fire service area I can't say that myself, my family, or anyone I know has ever had a poor experience with LA County Fire EMS or the private ambulances.



In theory having every response vehicle staffed with only paramedics makes sense. However, the paradox of that involves education and training. If every vehicle only has paramedics how long before their skills decrease to a dangerous fashion? How often is each one involved in starting IVs, pushing meds, and intubating? Then converse that data with any statistical data showing an increase in patient care with an increased number of paramedics on scene. Then also factor in the cost of paying paramedic/firefighters to EMT/firefighters. Now state why does it make sense again?

Not everyone shares your experience and in fact your personal experience is an invalid arguement against having multiple apparatus arrive to your emergency. Could you not have had a pleasant experience if only 3 man engine showed up? What about just an ambulance?


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## abckidsmom (Nov 13, 2011)

Fish said:


> Well and ambulance to, but that post was referring to LA COunties system of sending a squad and an Engine and then a private service sending the ambulance, i was stating that no need for the engine as far as FD is concerned. A squad and a Squad only(only with the private service ambulance) can handle it.



I'm guessing a squad is an SUV or pickup type vehicle?  Around here a squad is a big, expensive heavy rescue.

I can agree with you that the standard medical call needs an ambulance and a couple of extra people, max, regardless of how they arrived.  I think that concerns for having the fire crew on an actual fire truck for the duration of their shift makes more sense, because in some busy systems, they can go from EMS call to EMS call, and if they were in a different vehicle, they'd have the added time in the response of going back to the station to get the engine when they got a fire call.


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## JPINFV (Nov 13, 2011)

^
Yes... the squads are pickups.


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## denadog (Nov 14, 2011)

I know that when 80% of your calls are medical it, at first glance, seems better to have more ambulances than fire engines but in Southern California, this system works because of the need for so many fire resources at such short notice.  When there are three alarm structure fires and huge brush fires you actually do need all those fire engines.  Also, there are serious advantages to having EMTs that run medical calls on fire engines working under captains when there are larger incidents, fire calls with rescues, MCIs, and larger scale traffic collisions.  I think having professional firefighter/EMTs and FF/PMs that work and practice together for all kinds of emergencies (including medical) as a team and are versatile and great at working together is an ideal arrangement and thats what the LA County system provides for. 

The public and the politicians love that short response time… having full-time fire resources roll on medicals gets EMTs on scene in about 5 minutes, usually with paramedics and an ambulance close behind.


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## usalsfyre (Nov 14, 2011)

So we utilize a resource that's expensive and somewhat ill suited to a purpose because "it's there"? 

Fire is probably overstaffed greatly in most places based on modern construction.


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## JPINFV (Nov 14, 2011)

Can we stop using a system that has declared their average paramedic as hopelessly incompetent at interpreting 12 leads as a model or saying that such a system "works"? Yes, I'm looking at you, Los Angeles, Orange, and Riverside counties.
When a system is staffed with people so incompetent that the regional EMS office has said that they'd rather their paramedics just call the base station when the monitor says "***Acute MI Suspected***," any competence is just an illusion, and the population simply doesn't know any better.

Furthermore, if competent medics in Los Angeles existed in any sort of significant quantities, why aren't they revolting about the fact that their system treats them as being incompetent? Why aren't they telling their LEMSAs that they're mad as hell and they aren't going to take protocols that treat them like idiots any longer?


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## Tigger (Nov 14, 2011)

I can't say I can understand why some fire departments staff their engines with more than 1 paramedic if there is an ALS ambulance coming as well. There just isn't a need 90% of the time to have the second medic if the ambulance is going to be there in a reasonable and timely fashion. Four medics on an engine is probably going to equal four medics who have not independently attended a lot of sick patients. Here the engines are staffed with four; an Lt, Driver/Operator, FF/PM, and FF/EMT-IV. Everyone is at least an EMT-IV, but you do not have to be a medic to be an Lt. or D/O, and many drop the medic responsibility once they are promoted (which is fine if you ask me). As a result of this, and a great training division, we have competent fire medics here. 

I don't have a huge problem with the FD running engines to EMS calls. Their response times are pretty quick, with times usually less than seven minutes. From what I am told, that just doesn't put much wear on these units, which are based on commercial trucks designed to do 10 times the mileage before they are retired than a fire engine will ever do. Sending 2 members of the engine company in a pickup saves some wear and tear, but it also takes the company out of service, yet there are two guys doing nothing back at the station. It seems better to keep the crew together so that they could take another run in district once the patient has been stabilized and care transferred to the ambulance crew.


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## denadog (Nov 14, 2011)

usalsfyre said:


> So we utilize a resource that's expensive and somewhat ill suited to a purpose because "it's there"?
> 
> Fire is probably overstaffed greatly in most places based on modern construction.



No not just because "its there"… because they have the training and they know how to work well as a team and are versatile enough to deal with medical/fire/rescue emergencies.  How are firefighter/EMTs ill suited to respond to medical emergencies?


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## JPINFV (Nov 14, 2011)

The question is, how many hats can one person wear especially if EMS is to become a profession? There's a reason you don't see many neuro-cardio-thoracic-orthopedic surgeon psychiatrists around.


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## denadog (Nov 14, 2011)

JPINFV said:


> The question is, how many hats can one person wear especially if EMS is to become a profession? There's a reason you don't see many neuro-cardio-thoracic-orthopedic surgeon psychiatrists around.



Ya but those guys are freaking coldblooded doctors...


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## usalsfyre (Nov 14, 2011)

denadog said:


> No not just because "its there"… because they have the training and they know how to work well as a team and are versatile enough to deal with medical/fire/rescue emergencies.  How are firefighter/EMTs ill suited to respond to medical emergencies?



I don't know, a half million dollar apparatus with four people who have the equivalent of an advanced first aid class doesn't sound like a cost efficient way of providing service.

If we were TRULY worried about speed of response PD would first respond for EMS, but I don't see anyone advocating that. Let's be honest, the majority of FDs do EMS first response to make their run numbers look better.


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## denadog (Nov 14, 2011)

usalsfyre said:


> I don't know, a half million dollar apparatus with four people who have the equivalent of an advanced first aid class doesn't sound like a cost efficient way of providing service.
> 
> If we were TRULY worried about speed of response PD would first respond for EMS, but I don't see anyone advocating that. Let's be honest, the majority of FDs do EMS first response to make their run numbers look better.



So its more cost efficient to pay those four guys by the hour and leave their $500,000 apparatus sitting in the station all day? And if all cops were EMTs and had AEDs and airway management in their cars then that'd be *****in but I guess thats actually not cost efficient.


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## Tigger (Nov 14, 2011)

usalsfyre said:


> I don't know, a half million dollar apparatus with four people who have the equivalent of an advanced first aid class doesn't sound like a cost efficient way of providing service.
> 
> If we were TRULY worried about speed of response PD would first respond for EMS, but I don't see anyone advocating that. Let's be honest, the majority of FDs do EMS first response to make their run numbers look better.



Maybe it is not advocated as strongly as Fire-based first response, but it still happens in a lot of places. Where I grew up, the police are the only full-time emergency services agency, so it makes sense to send them on medicals. A 40 hour class and an AED within 5 minutes is a lot better than waiting 10-15 for an ambulance. Did they use that as a justification for a raise when it came time for collective bargaining? Yes. Did it work? Absolutely.


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## Aprz (Nov 14, 2011)

denadog said:


> So its more cost efficient to pay those four guys by the hour and leave their $500,000 apparatus sitting in the station all day?


Have 'em get an SUV-like vehicle to respond to medical emergencies and cut their pay. They are paid too much for the number of people who can do the job, the months of schooling they have, and are willing to do it for cheaper. Respond to medical emergencies using an SUV-like vehicle, it'll save gas and the roads. Respond to fires with a fire apparatus. If the firefighters must immediately respond to a fire call from a medical call, have a firefighter from the station drive the fire apparatus to the call, and the firefighters leaving the medical call can meet them on scene. In California, there is an oversaturation of firefighters, you could probably cut a bunch of 'em out of the picture without hurting response times/use 'em to staff more ambulances. For some medical emergencies, people don't need an EMT, paramedic, or firefighter, but rather an ambulance ride to the hospital stat. Maybe an ambulance should get to scene first instead of fire.


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## Handsome Robb (Nov 14, 2011)

In most of our area we arrive prior to or with fire except for the outlying areas. Now they do beat us from time to time but definitely not always. Every ambulance is ALS with either I/P or P/P staffing plus most of our units have 3rds on them with all the EMT students, TAIs/TAPs, Medic Interns.

Our average response is ~5 minutes, we are considered "late" by the county after 8:29 for priority 1 calls, 10 minutes for priority 2 and 15 for priority 3.


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## systemet (Nov 14, 2011)

KingCountyMedic said:


> We have had a Tiered Response System since we started 40 years ago. We do tons of studies and our numbers are pretty darn good. Having a Paramedic on every rig on every street corner is bad for the patient and the Medic.



Your system is very impressive, and your numbers and published research are compelling.  However, I think you overstate your case.

I don't think that there's much research that clearly shows better outcomes with tiered response ALS versus all-ALS.   



> The Medic overpopulation in our land is a huge problem and it's dumbing down our profession.



I think the "dumbing down" of our occupation has been done at the educational level, by a lack of demanding enough standards, a willingness to accredit programs with minimal clinical and academic hours, and a general lack of any concerted efforts by paramedics and EMT to demand better education.

I don't think having more paramedics is necessarily a bad thing.  But we do need to identify which skills are most critical and vulnerable to deterioration over time, and develop strategies to either limit these skills to a select group of practitioners or provide adequate training to keep them competent.


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## Fish (Nov 14, 2011)

JPINFV said:


> Can we stop using a system that has declared their average paramedic as hopelessly incompetent at interpreting 12 leads as a model or saying that such a system "works"? Yes, I'm looking at you, Los Angeles, Orange, and Riverside counties.
> When a system is staffed with people so incompetent that the regional EMS office has said that they'd rather their paramedics just call the base station when the monitor says "***Acute MI Suspected***," any competence is just an illusion, and the population simply doesn't know any better.
> 
> Furthermore, if competent medics in Los Angeles existed in any sort of significant quantities, why aren't they revolting about the fact that their system treats them as being incompetent? Why aren't they telling their LEMSAs that they're mad as hell and they aren't going to take protocols that treat them like idiots any longer?



That monitor is correct only 62% of the time, and A LOT of CA counties have protocols that state, you cannot call a STEMI unless the monitor says so. In our County we turned off the Monitors interpretation, we read the 12-Lead ourselves and we have a 97% accuracy rating at calling STEMIs in the field.


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## Fish (Nov 14, 2011)

denadog said:


> No not just because "its there"… because they have the training and they know how to work well as a team and are versatile enough to deal with medical/fire/rescue emergencies.  How are firefighter/EMTs ill suited to respond to medical emergencies?



Anyone can work well as a Team, a road crew works well as a team picking up trash off the side of a freeway


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## Fish (Nov 14, 2011)

denadog said:


> So its more cost efficient to pay those four guys by the hour and leave their $500,000 apparatus sitting in the station all day? And if all cops were EMTs and had AEDs and airway management in their cars then that'd be *****in but I guess thats actually not cost efficient.



It is cost effificient to have cops do it, and you know what It has been tried before and the Fire Union poop'd their bunker pants! THey had a huge march on City hall. And that program got scratched.

Cops arrive first on scene for all Cardiac arrest here and start CPR, they are usually there for about 2-3 minutes before us and FD, wouldn't that be splended if they had an AED, BVM, and maybe some basic meds.


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## Fish (Nov 14, 2011)

denadog said:


> I know that when 80% of your calls are medical it, at first glance, seems better to have more ambulances than fire engines but in Southern California, this system works because of the need for so many fire resources at such short notice.  When there are three alarm structure fires and huge brush fires you actually do need all those fire engines.  Also, there are serious advantages to having EMTs that run medical calls on fire engines working under captains when there are larger incidents, fire calls with rescues, MCIs, and larger scale traffic collisions.  I think having professional firefighter/EMTs and FF/PMs that work and practice together for all kinds of emergencies (including medical) as a team and are versatile and great at working together is an ideal arrangement and thats what the LA County system provides for. .



Lets be honest, if a ALS squad is sent to a Medical call and misses a Fire in their district. Who cares? You guys have over 100 stations in LA County and another bazillion in the City. Somone else can respond with an engine from the neighboring district and get there within a good response time. And why does someone need a Capt. telling them what to do on a Medical call? The two medics responding to a Medical in no way need an officer to supervise them, handeling a Large MCI is not something only an officer can handle, it is just who has handled it traditionally.


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## denadog (Nov 14, 2011)

Fish said:


> Cops arrive first on scene for all Cardiac arrest here and start CPR, they are usually there for about 2-3 minutes before us and FD, wouldn't that be splended if they had an AED, BVM, and maybe some basic meds.



Where is this?


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## medicsb (Nov 14, 2011)

systemet said:


> I don't think that there's much research that clearly shows better outcomes with tiered response ALS versus all-ALS.
> 
> I think the "dumbing down" of our occupation has been done at the educational level, by a lack of demanding enough standards, a willingness to accredit programs with minimal clinical and academic hours, and a general lack of any concerted efforts by paramedics and EMT to demand better education.
> 
> I don't think having more paramedics is necessarily a bad thing.  But we do need to identify which skills are most critical and vulnerable to deterioration over time, and develop strategies to either limit these skills to a select group of practitioners or provide adequate training to keep them competent.



While there is little evidence to help answer the tiered response vs. all-ALS response (the the very little that exists supports tiered response).  There is a lot of research that shows that a physician, nurse, PA, etc. who performs certain procedures or sees certain patients more often see fewer complications, shorter lengths of stay, and lower mortality.  There is evidence that medics who intubate more frequently and more likely to be successful.  There is evidence that frequent experience with cardiac arrest is associated with improved survival.  The only way to increase sick patient contact in the prehospital setting is to limit the number of paramedics.  Based on evidence from other areas of medicine, it isn't hard to imagine that paramedic experience influences patient outcomes.


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## Tigger (Nov 14, 2011)

denadog said:


> Where is this?



All over the country...


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## systemet (Nov 15, 2011)

medicsb said:


> While there is little evidence to help answer the tiered response vs. all-ALS response (the the very little that exists supports tiered response).



Can you point me in the direction of this?



> There is a lot of research that shows that a physician, nurse, PA, etc. who performs certain procedures or sees certain patients more often see fewer complications, shorter lengths of stay, and lower mortality.



And I agree that this is intuitively reasonable.  One example could be the operator-dependence of PCI.  But whether this extends to improved outcomes in EMS, and whether the benefits of having limited number of more skilled paramedics outweighs the benefits of having every patient assessed by someone with more than 100 hours of training doesn't seem to be clear.




> There is evidence that medics who intubate more frequently and more likely to be successful.



Yep, I've read that.  But that was based on a surrogate outcome, e.g. intubation success, not on a measure of mortality / morbidity from a condition sensitive to poor airway controlled, e.g. closed head injury.




> There is evidence that frequent experience with cardiac arrest is associated with improved survival.



If you have a reference for this, I'd also be interested.  I'm not trying to attack you, in any way.  I'm just looking for more resources.  

I have seen an association in one trial between the time to intubation and ROSC at the hospital, but nothing in terms of real survival.  If there's something out there I've missed -- and it's quite possible there is -- I'd be interested in seeing it.



> The only way to increase sick patient contact in the prehospital setting is to limit the number of paramedics.



Pretty much, or decrease cycle time.



> Based on evidence from other areas of medicine, it isn't hard to imagine that paramedic experience influences patient outcomes.



I agree that this is intuitively reasonable for some conditions.  But I question whether the research has shown this yet.

An all ALS model does offer the benefit of pain control for everyone, a better assessment, a higher incidence of 12-lead screening, etc.  This may outweight the benefit gained from improvements in airway management.  Or it may not.  It's hard to know for sure at this point.  Lots of ideas that were intuitively reasonable have been questioned once the research has been done.


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## Fish (Nov 15, 2011)

denadog said:


> Where is this?



I was under the impression that this happened all over the Country, It has happened in the 3 system I have worked in. PD has to arrive anyway to every death, so why would they not arrive code 3 first and start compressions?


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## JPINFV (Nov 15, 2011)

Fish said:


> PD has to arrive anyway to every death



No... they don't. Not every death is a coroner's case.


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## Fish (Nov 15, 2011)

JPINFV said:


> No... they don't. Not every death is a coroner's case.



Yes they do, because it is up to PD to decide if it is going to be a Coroner's care or not. I have never been on any type of death that PD did not arrive at. Even the 102 y/o who died in their sleep, PD shows up does an investigation and determines if a Coroner needs to be invovled.


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## JPINFV (Nov 15, 2011)

Fish said:


> Yes they do, because it is up to PD to decide if it is going to be a Coroner's care or not. I have never been on any type of death that PD did not arrive at. Even the 102 y/o who died in their sleep, PD shows up does an investigation and determines if a Coroner needs to be invovled.



So you've never seen a death in a health care facility.


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## Fish (Nov 15, 2011)

JPINFV said:


> So you've never seen a death in a health care facility.



Yes, and PD shows up. Last month we had a Code out of a Nursing home, We arrive on scene first because we happened to be eating at a Resturant that was apprx. 0.2 miles away from the nursing home, next to show up was One officer, next to show up was the engine, and the next three people who showed up were two cops and a battlion chief(who happened to be in the area so he swung by.) We got pulses Back, pakaged for transport, lost pulses again, and tansported anyway since we were already on the way to the ambulance, First officer on scene said he would follow up at ER, but did not see a need for a Coroner since it was an elderly lady with a long Medical History.

I don't know how man Codes I have been on, I would guess over 150? I can't tell you how many we transported and how many we didn't and how many required a Corone because I can't remember. But what I can tell you, is whenever I have been at a Code, so has law enforcement. Usually they are first to arrive and last to leave if we pronounce on scene,


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## Fish (Nov 15, 2011)

JPINFV said:


> So you've never seen a death in a health care facility.



Now obviously PD does not respond to Codes in Hospitals, not unless the Hospital request them for a criminal investigation.


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## DrParasite (Nov 15, 2011)

Fish said:


> Now obviously PD does not respond to Codes in Hospitals, not unless the Hospital request them for a criminal investigation.


No, but PD does need to respond to every unattended death.  at a home with a hospice nurse, for another example, typically does not get a cop either.

but 99 year old granny who is found dead in her bed in the AM does need a cop, to determine if she died of natural causes or because her husband smothered her with a pillow because he wanted a divorce and she wouldn't give him one.

Nursing homes/SNF's are a gray area.  I've been involved in investigations at them (detectives called me while i was on vacation in vermont), and others where they didn't.  but I would wager 99% of unattended deaths, with the person being unattended by a health care professional (RN or higher) should require a PD presence.

BTW, lots of volunteer/rural/suburban EMS systems have PD as the first responder; it typically makes more sense than the FD, since PD is already on the road, usually closer to the scene, and can initiate CPR and Defib in less than 8 minutes.  Not so much for the urban areas though.


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## Fish (Nov 15, 2011)

DrParasite said:


> No, but PD does need to respond to every unattended death.  at a home with a hospice nurse, for another example, typically does not get a cop either.
> 
> but 99 year old granny who is found dead in her bed in the AM does need a cop, to determine if she died of natural causes or because her husband smothered her with a pillow because he wanted a divorce and she wouldn't give him one.
> 
> ...



Yeah every unattended Death has LE respond


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## JPINFV (Nov 15, 2011)

Fish said:


> Now obviously PD does not respond to Codes in Hospitals, not unless the Hospital request them for a criminal investigation.




...so PD doesn't always show up for all codes...


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## Fish (Nov 15, 2011)

JPINFV said:


> ...so PD doesn't always show up for all codes...



Leave it up to you,

Be logical, did I really need to clarify by saying every out of hospital code? I truely thought that was something you would have figured out on your own. next time I will be more specific for you.


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## JPINFV (Nov 15, 2011)

The reason I brought it up is every prehosptial code I've seen brought into the ED where resuscitation failed had the ED staff make the decision based on preset criteria on whether they could release to a funeral home or had to call a coroner.


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## Fish (Nov 15, 2011)

JPINFV said:


> The reason I brought it up is every prehosptial code I've seen brought into the ED where resuscitation failed had the ED staff make the decision based on preset criteria on whether they could release to a funeral home or had to call a coroner.



Sure, but on scene before the patient was brought into the ER, PD was on scene. Then when they find out the patient is being transported and to what hospital they follow up with the Doc to see what his opinion is along with the Medics opinions. The Dr alone cannot decide this, he was not at the original scene.


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## JPINFV (Nov 15, 2011)

Again, it depends on the circumstances. Not every original scene is going to occur on the street, and I highly doubt that the average cop knows enough about medicine to make even an uneducated guess as to whether a patient at a non-hospital health care facility was suspicious or not unless the staff beat the patient to death. So, again, the police routinely show up to cardiac arrests at health care facilities outside of the hospital?


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## Fish (Nov 15, 2011)

JPINFV said:


> Again, it depends on the circumstances. Not every original scene is going to occur on the street, and I highly doubt that the average cop knows enough about medicine to make even an uneducated guess as to whether a patient at a non-hospital health care facility was suspicious or not unless the staff beat the patient to death. So, again, the police routinely show up to cardiac arrests at health care facilities outside of the hospital?



Like I said before, I have never been to a Cardiac arrest(mind you I only go to arrest outside of the hospital, and also not a hospice patient at home with hospice on scene.) That the Heat did not also show up to, I can't ever think of a time that I have responded to a Code and the 5.0 didn't respond with us.


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## 46Young (Nov 15, 2011)

JPINFV said:


> The question is, how many hats can one person wear especially if EMS is to become a profession? There's a reason you don't see many neuro-cardio-thoracic-orthopedic surgeon psychiatrists around.



A paramedic course doesn't take too much brain power to get through, compared to other medical degrees. It's not rocket surgery. The didactic material in the fire academy, or even the fire science curriculum isn't exactly challenging either. The FF/medic has to have completed both before being qualified as a FF/medic. A four year degree in just about anything would take more effort than learning the basics of what a FF/medic is responsible for. OTJ drills and field experience reinforce their education. It isn't too difficult to keep proficient in both sides. After being OTJ for a few years, some of us can go TROT or Hazmat. TROT is six weeks of class and practicals, aazmat is two weeks. After that class, you'll get in station training on cut jobs before being cleared to ride the Heavy Rescue. After that, I'll agree that you're spreading yourself a little thin, but the material collectively isn't as much as a four year degree, let alone a Masters.


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## usalsfyre (Nov 15, 2011)

Perhaps everyone would be better off if paramedic did require some brain power...

:deadhorse:


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## 46Young (Nov 15, 2011)

Tigger said:


> Maybe it is not advocated as strongly as Fire-based first response, but it still happens in a lot of places. Where I grew up, the police are the only full-time emergency services agency, so it makes sense to send them on medicals. A 40 hour class and an AED within 5 minutes is a lot better than waiting 10-15 for an ambulance. Did they use that as a justification for a raise when it came time for collective bargaining? Yes. Did it work? Absolutely.



In busy urban systems, the police are typically very busy. When I worked in NY, unless we had a violent EDP, or a shot/stab, PD was generally unavailable. I listened to their frequencies. They always had multiple jobs holding, especially in the evenings and overnights. 

The FF's are more available, and definitely have a much lower net utilization percentage than the police units. Sure, it's 3-4 people in an expensive rig, but they would likely be idle otherwise, so the first response program results in a higher net utilization for these units. A few miles on the engine is certainly less expensive (not better, but less expensive) than buying extra ambulances, equipping them, and hiring/training and paying the crew to staff them.


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## 46Young (Nov 15, 2011)

Fish said:


> It is cost effificient to have cops do it, and you know what It has been tried before and the Fire Union poop'd their bunker pants! THey had a huge march on City hall. And that program got scratched.
> 
> Cops arrive first on scene for all Cardiac arrest here and start CPR, they are usually there for about 2-3 minutes before us and FD, wouldn't that be splended if they had an AED, BVM, and maybe some basic meds.



Easily the most inefficient system I've seen is the Nassau County Police Department in Long Island, NY. They staff their ambulance with one EMT-CC or medic, and that's it. All cops are EMT-D. When they get a call, they send a bus or two, the cop arrives, abandons their cruiser, and drives the bus to the hospital. After the call, the medic drives the cop back to their car.


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## 46Young (Nov 15, 2011)

medicsb said:


> While there is little evidence to help answer the tiered response vs. all-ALS response (the the very little that exists supports tiered response).  There is a lot of research that shows that a physician, nurse, PA, etc. who performs certain procedures or sees certain patients more often see fewer complications, shorter lengths of stay, and lower mortality.  There is evidence that medics who intubate more frequently and more likely to be successful.  There is evidence that frequent experience with cardiac arrest is associated with improved survival.  The only way to increase sick patient contact in the prehospital setting is to limit the number of paramedics.  Based on evidence from other areas of medicine, it isn't hard to imagine that paramedic experience influences patient outcomes.



In some systems, they think that if they can just barf 2-4 paramedics on each call, between all of them, someone will have a clue.


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## JPINFV (Nov 16, 2011)

46Young said:


> A paramedic course doesn't take too much brain power to get through, compared to other medical degrees. It's not rocket surgery.




I won't argue that that is true under the current system, however...

1. Do you see the current situation with EMS being defined as a medical taxi service (i.e. transport based reimbursement) as sustainable, especially given the current level of reimbursment and how even that is declining? 

2. What do you think about the concept of community paramedicine as a means to move EMS more into prevention than reaction? Do you think that will eventually become a standard component of any serious professional EMS system (much like, say, fire code enforcement, inspection, and preplanning)? 

3. If EMS is ever to be valued past more than a quick ride to the hospital, does the current educational standards in any way match up with those demands?


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## denadog (Nov 16, 2011)

Tigger said:


> All over the country...



Ya but not in most big cities… unless its a traumatic full arrest or something suspect PD is not going to respond Code 3 and might even get a delayed response if there are a lot of calls pending.  It would never be cost effective to put an AED and airway supplies in every LAPD car.


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## usalsfyre (Nov 16, 2011)

denadog said:


> Ya but not in most big cities… unless its a traumatic full arrest or something suspect PD is not going to respond Code 3 and might even get a delayed response if there are a lot of calls pending.  It would never be cost effective to put an AED and airway supplies in every LAPD car.



As opposed to using EMS runs to prop up the purchase of fire apparatus? Building construction and fire codes have changed over the years(although not enough) and it's very arguable whether interior attack is justifiable as a regular tactic anymore.

PDs prioritize calls too. Make cardiac arrest the same priority as say a shooting or burglary in progress. You'll get a quick response.


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## Handsome Robb (Nov 16, 2011)

denadog said:


> Ya but not in most big cities… unless its a traumatic full arrest or something suspect PD is not going to respond Code 3 and might even get a delayed response if there are a lot of calls pending.  It would never be cost effective to put an AED and airway supplies in every LAPD car.



Most arrests will get a LEO or 2, every pediatric call, arrest or not gets a LEO. We don't have time to sit around babysitting a body waiting for the coroner, PD takes possession of the body so we can go back in service. 

We have multiple documented PD saves through CPR/AED or tourniquet application... Albeit we aren't anywhere near LA size but we are a decently sized urban area averaging 80,000 EMS 911 calls/year.


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## denadog (Nov 16, 2011)

JPINFV said:


> 2. What do you think about the concept of community paramedicine as a means to move EMS more into prevention than reaction? Do you think that will eventually become a standard component of any serious professional EMS system (much like, say, fire code enforcement, inspection, and preplanning)?



I know that there is a lot of preplanning that goes into EMS especially when they are integrated into fire departments.  Many larger fire departments have EMS Chiefs that usually help decide how emergencies will be responded to (ex. tiered vs. all-ALS) as well as ways to help the public during medical emergencies.  I know of one fire department that has a program where they hand out free vials with special stickers on them and the citizen places a list of all their past history, medications, and allergies inside the vial so if they have a medical emergency and can't communicate with paramedics, someone can just open the vial and look at the info.  Other than things like that I don't know how you could relate code enforcement or inspection into EMS without seriously offending or invading peoples privacy...


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## denadog (Nov 16, 2011)

usalsfyre said:


> As opposed to using EMS runs to prop up the purchase of fire apparatus? Building construction and fire codes have changed over the years(although not enough) and it's very arguable whether interior attack is justifiable as a regular tactic anymore.
> 
> PDs prioritize calls too. Make cardiac arrest the same priority as say a shooting or burglary in progress. You'll get a quick response.



Tell everyone interior fire attack isn't justifiable anymore when theres a baby on the second floor and the house is ready to flash over and the first in company is 8 minutes away...


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## usalsfyre (Nov 16, 2011)

denadog said:


> Tell everyone interior fire attack isn't justifiable anymore when theres a baby on the second floor and the house is ready to flash over and the first in company is 8 minutes away...


Spare me the histrionics. Honestly how often is that the case? Have you ever made a grab? When was the last time you were on a scene where one was made? In 5 years full time and ten years total of activity in the fire service, I never made a fire where a rescue was performed. 

Further, I never once said interior attack shouldn't ever be performed. But going in and making a grab in a confirmed life safety situation getting the heck out is entirely different than "saving" the burned out hulk of a house, which is the majority of what you see with interior attack. Buildings have been built to burn for 40 years or more.

You sound like a kid who wants to get on with an FD and has bought 100% into what your told. Let a building fall on someone you know when they should have never been inside in the first place. It'll change your perspective.


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## Handsome Robb (Nov 16, 2011)

denadog said:


> Tell everyone interior fire attack isn't justifiable anymore when theres a baby on the second floor and the house is ready to flash over and the first in company is 8 minutes away...



How many firefighters die needlessly each year for reported trapped occupants when there is actually no one inside the building?

If a house is ready to flash you shouldn't be going into it, even if there are trapped occupants, that includes babies. If it flashes with you inside it kills you *and* the baby, 3 dead, you, your partner and the occupant or 1 dead...just some food for thought.

*I have no formal fire training whatsoever, just a general knowledge from my own reading and multiple friends in the fire service. *


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## JPINFV (Nov 16, 2011)

denadog said:


> I know that there is a lot of preplanning that goes into EMS especially when they are integrated into fire departments.  Many larger fire departments have EMS Chiefs that usually help decide how emergencies will be responded to (ex. tiered vs. all-ALS) as well as ways to help the public during medical emergencies.  I know of one fire department that has a program where they hand out free vials with special stickers on them and the citizen places a list of all their past history, medications, and allergies inside the vial so if they have a medical emergency and can't communicate with paramedics, someone can just open the vial and look at the info.  Other than things like that I don't know how you could relate code enforcement or inspection into EMS without seriously offending or invading peoples privacy...




I highly suggest that you look up what community paramedicine is. It's a tad bit more than deciding to use some sort of EMD protocol or vials of life.


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## Fish (Nov 16, 2011)

46Young said:


> Easily the most inefficient system I've seen is the Nassau County Police Department in Long Island, NY. They staff their ambulance with one EMT-CC or medic, and that's it. All cops are EMT-D. When they get a call, they send a bus or two, the cop arrives, abandons their cruiser, and drives the bus to the hospital. After the call, the medic drives the cop back to their car.



That sounds like a cluster!

I would just be happy if they carried an AED that way when they responded and arrived at the scene of Cardiac Arrest before us they could shock if indicated and increase survival rates.


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## Fish (Nov 16, 2011)

denadog said:


> I know that there is a lot of preplanning that goes into EMS especially when they are integrated into fire departments.  Many larger fire departments have EMS Chiefs that usually help decide how emergencies will be responded to (ex. tiered vs. all-ALS) as well as ways to help the public during medical emergencies.  I know of one fire department that has a program where they hand out free vials with special stickers on them and the citizen places a list of all their past history, medications, and allergies inside the vial so if they have a medical emergency and can't communicate with paramedics, someone can just open the vial and look at the info.  Other than things like that I don't know how you could relate code enforcement or inspection into EMS without seriously offending or invading peoples privacy...



Brochacho, that in no way is the same as Community Paramedicene. Community Paramedics are the pro-active portion of an EMS system they go to Chronically Ill, Mentally Ill, 911 Abusers Houses and reach out to them. Provide on scene treatment, non-emergent transports to fill perscriptions(sometimes even picking up perscriptions for them) making sure patients are taking their meds, staying healthy, etc etc all in an effort to avoid a 911 call and improve the overall health of the Community


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## Fish (Nov 16, 2011)

denadog said:


> Tell everyone interior fire attack isn't justifiable anymore when theres a baby on the second floor and the house is ready to flash over and the first in company is 8 minutes away...



Oh Lawd! If I had a Nickle for everytime I heard a Fire Fighter pull the ole Baby in a burning building card.

Tell me now, of the amount of fire responses that Fire Depts go to, how many actually end up being fire and not just a false alarm? And of those that end up being Fires, and of those Fires that do happen how many of them have someone trap'd inside of them? The number is closer to Zero than you might think. Either there is never anyone inside, or the person inside burned up a LONG time ago and not even a 30 second engine response was going to save them. I will add this in too, most Fires don't even require an Interior Tac, most Fires are so invovled by the time that FD arrives and no one is inside so they go defensive and just surround and drown. I will tell you what, if  ever have a Fire at my house that spreads beyond one or two rooms let that sucker burn! That is why I have insurance, I would rather have a new house built from the bottom up then a half burnt house with the walls tore apart because the Fire Dept. was looking for Hidden Fire in it. You can't get that smell out.


Denadog, I have been in for a little bit and I have never responded to a Fire that had someone trapped. I did however respond to a car Fire once that had someone burn up in it, but then again. It was a murder and the person was already dead and tied up and stuffed in the trunk. Then the car was set on Fire.


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## Tigger (Nov 16, 2011)

denadog said:


> Ya but not in most big cities… unless its a traumatic full arrest or something suspect PD is not going to respond Code 3 and might even get a delayed response if there are a lot of calls pending.  It would never be cost effective to put an AED and airway supplies in every LAPD car.



So if it works in the suburbs and rural areas it can't work in the cities? There is no reason why a police based first response is not viable in urban areas, other than the fact that other services already cover that responsibility. Some place like LA county would certainly benefit from such a situation, as the police can get there before or at the same time as any other first-responding agencies most of the time if sufficient priority is given to medical calls.


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## 46Young (Nov 16, 2011)

JPINFV said:


> I won't argue that that is true under the current system, however...
> 
> 1. Do you see the current situation with EMS being defined as a medical taxi service (i.e. transport based reimbursement) as sustainable, especially given the current level of reimbursment and how even that is declining?
> 
> ...



1 - No, I don't. Unless your population mostly has private insurance, we're being reimbursed for pennies on the dollar, when you average in the porr Medicare/Medicaid reimbursements, and the scourge of uncompensated cases.

2 - Sounds good to me. I've mentioned this to my OMD, but he feels that the paramedic's education is not adequate to fufill that role. It would be a great position for broken down medics, older medics who no longer want to work the streets, or light duty for the pregnant. EMS in many places right now address the call volume by putting out more units, and trying to get the most reimbursement possible through call volume. It's obviously unsustainable.

3 - Nope. American paramedic education is geared towards 911 prehospital emergencies only. I feel that our education is not even appropriate for IFT. Nearly all of what an IFT medic needs to learn about that side of the job is learned on the fly. For example, when we promoted to paramedic back at my old hospital, we were only allowed to do the most stable IV lock/monitor/O2 txps, and assist CC Medics on train wrecks. After we did a year, we were allowed to run everything else that was not CCP dependent. In their eyes, it took at least a year to learn the ins and outs of IFT txp, the meds, procedures, etc. Really, how many medic programs cover vents, what a loading does/maintenance dose for Heparin is, how to manage a hypotensive pt on propofol when they're beginning to buck the vent, how to manage Cx tubes, how to txp a pt with a Baloon Pump, etc?


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## 46Young (Nov 16, 2011)

usalsfyre said:


> As opposed to using EMS runs to prop up the purchase of fire apparatus? Building construction and fire codes have changed over the years(although not enough) and it's very arguable whether interior attack is justifiable as a regular tactic anymore.
> 
> PDs prioritize calls too. Make cardiac arrest the same priority as say a shooting or burglary in progress. You'll get a quick response.



At least in our county, all EMS revenue goes into the County's general fund. Then again, we spend a bundle to have the best apparatus and medical equipment. This is obviously more the exception than the norm.

With the type V (modern stick homes) construction, and synthetic materials/plastics etc, houses fail much quicker, without the telltale warning signs, they burn much hotter and faster, and the products of combustion are much deadlier. Really, if we're not there in ten minutes or less from when the fire began (it can go unreported for some time), we're going to search, then surround and drown if it's much more than a room and contents.


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## 46Young (Nov 16, 2011)

NVRob said:


> How many firefighters die needlessly each year for reported trapped occupants when there is actually no one inside the building?
> 
> If a house is ready to flash you shouldn't be going into it, even if there are trapped occupants, that includes babies. If it flashes with you inside it kills you *and* the baby, 3 dead, you, your partner and the occupant or 1 dead...just some food for thought.
> 
> *I have no formal fire training whatsoever, just a general knowledge from my own reading and multiple friends in the fire service. *



I think what denadog was trying to say is that while the incidence of confirmed structure fires are way down, the importance of a timely response when that emergency does occur is still just as important. We have no way to predict when and where these fires will occur.

When we arrive onscene, we're absolutely going to do a primary search, unless everyone is reported to be out of the house, and also accounted for. This is our mandate. What we do before going in is look at the conditions, and determine if an area of the structure is tenable before committing to a search. Obviously if a room or floor is fully charged with thick smoke for a while, or if the thermal imager shows oven like temps, no one unprotected could possibly be viable, so we wouldn't search that area. Obviously if most or all of the house is engulfed, we're not going to search. If it's newer construction, and it's the fire has spread through the void spaces, it will fail soon, so we're not going to make an interior attack. On the same token, a home can be fully charged with smoke, and the fire can be little more than a room and contents (not affecting the structural members, thus no immediate threat of building collapse). 

Basically, if there is the chance of a victim being insidee, and the conditions are such that the victim could still be viable, we have to risk our own necks to search. If the conditions are untenable, the victim will be dead anyway, and we can write them off. 

Also, if we're working a fully involved garden apartment or townhome unit, hitting it with master streams (large GPM exterior lines), and going inside to mop up (even spraying from the doorway then treading carefully), we can save all the exposures on either side.

Here's an example of a flashover while crews were making an interior attack, with a report of a possible trapped occupant:

http://www.youtube.com/watch?v=30SCtOHUGhc

This was a couple of minutes after entry. The room can flash quickly. It can look okay one minute, and be going off the next. It happens that fast. The Truck company was upstairs searching, and they were okay. E422 were pulled out from the front entryway by R426. Everyone was okay. We have really good gear. No burns on this one. We also saved the row by containing the fire to the end unit, BTW.


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## 46Young (Nov 16, 2011)

Fish said:


> Oh Lawd! If I had a Nickle for everytime I heard a Fire Fighter pull the ole Baby in a burning building card.
> 
> Tell me now, of the amount of fire responses that Fire Depts go to, how many actually end up being fire and not just a false alarm? And of those that end up being Fires, and of those Fires that do happen how many of them have someone trap'd inside of them? The number is closer to Zero than you might think. Either there is never anyone inside, or the person inside burned up a LONG time ago and not even a 30 second engine response was going to save them. I will add this in too, most Fires don't even require an Interior Tac, most Fires are so invovled by the time that FD arrives and no one is inside so they go defensive and just surround and drown. I will tell you what, if  ever have a Fire at my house that spreads beyond one or two rooms let that sucker burn! That is why I have insurance, I would rather have a new house built from the bottom up then a half burnt house with the walls tore apart because the Fire Dept. was looking for Hidden Fire in it. You can't get that smell out.
> 
> ...



I addressed this with post # 79.

Also, we learned from the Charleston 9 that we don't risk our lives to save property. Potential victims, absolutely, but not property alone. It's all risk-reward.


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## Fish (Nov 16, 2011)

46Young said:


> I addressed this with post # 79.
> 
> Also, we learned from the Charleston 9 that we don't risk our lives to save property. Potential victims, absolutely, but not property alone. It's all risk-reward.



I am glad your department has taken that stance, I am tired of seeing area Fire Departments trying to do interiors on a fully involved wharehouse. That is absolutely irresponsible in my opinion, if someone died from that it wuld be a needless death. Why die to save some wood pallets and RV parts?


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## Fish (Nov 16, 2011)

46Young said:


> I think what denadog was trying to say is that while the incidence of confirmed structure fires are way down, the importance of a timely response when that emergency does occur is still just as important. We have no way to predict when and where these fires will occur.
> 
> When we arrive onscene, we're absolutely going to do a primary search, unless everyone is reported to be out of the house, and also accounted for. This is our mandate. What we do before going in is look at the conditions, and determine if an area of the structure is tenable before committing to a search. Obviously if a room or floor is fully charged with thick smoke for a while, or if the thermal imager shows oven like temps, no one unprotected could possibly be viable, so we wouldn't search that area. Obviously if most or all of the house is engulfed, we're not going to search. If it's newer construction, and it's the fire has spread through the void spaces, it will fail soon, so we're not going to make an interior attack. On the same token, a home can be fully charged with smoke, and the fire can be little more than a room and contents (not affecting the structural members, thus no immediate threat of building collapse).
> 
> ...



Haha, I had to turn down the volume on that video if you know what I mean.

What would you say the ratio of Fires to fires with victims trapped are? Not possible, bu confirmed. And have you ever personally pulled someone out of a Fire Ladder 49 style? Better yet, have you ever gone to a bar and get drunk in your FD apparell like they do in the movie?


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## atropine (Nov 16, 2011)

Better yet, have you ever gone to a bar and get drunk in your FD apparell like they do in the movie?[/QUOTE]

Yeah multiple times, and strip clubs, they always say here comes that OCFA guy again


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## 46Young (Nov 16, 2011)

Fish said:


> Haha, I had to turn down the volume on that video if you know what I mean.
> 
> What would you say the ratio of Fires to fires with victims trapped are? Not possible, bu confirmed. And have you ever personally pulled someone out of a Fire Ladder 49 style? Better yet, have you ever gone to a bar and get drunk in your FD apparell like they do in the movie?



Back in the day, we used to have what you call "still alarms." This was when there was a call for a building fire, but it was unconfirmed. The dispatch would be just an engine and a truck. Now, any report of any kind of fire or smoke in a building automatically becomes a box alarm, with a dozen or so units. Most of the time, it's food on the stove or less. So, true structure fires, particularly ones that have progressed past room and contents are infrequent. 

We haven't had too many reported trapped in our county. The people here are typically middle to upper class, have some common sense, have smoke detectors, CO alarms, practice sound fire prevention, etc. We don't have the same frequency of neglect and ignorance that we find in poorer areas. We don't generally get people falling asleep on the couch with a lit cigarette, leaving the oven on then leaving the house, using space heaters improperly in the house, relatively few homes illegally petitioned for occupancy by 10-20 renters, etc. So  no, I haven't made any grabs. Everyone's usually out by the time we get there. 

As far as getting hammered in our uniforms, the county prohibits members wearing uniforms/gear in any manner that reflects poorly on the department's image. We're not even supposed to go shopping for dinner supplies for the shift in our bunker gear. We have clearly specified SOP's for uniforms and appearance.


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## 46Young (Nov 16, 2011)

Fish said:


> I am glad your department has taken that stance, I am tired of seeing area Fire Departments trying to do interiors on a fully involved wharehouse. That is absolutely irresponsible in my opinion, if someone died from that it wuld be a needless death. Why die to save some wood pallets and RV parts?



Nowadays, a unit officer would be accountable in court if they gave an unsafe/unreasonable order that got someone on their crew hurt or killed. We also have various operating manuals that are not too unlike EMS protocols. They function as guidelines for fireground operations and other emergencies. These are based on NFPA standards, and can be used in court as well.


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## denadog (Nov 16, 2011)

usalsfyre said:


> Spare me the histrionics. Honestly how often is that the case? Have you ever made a grab? When was the last time you were on a scene where one was made?
> 
> You sound like a kid who wants to get on with an FD and has bought 100% into what your told. Let a building fall on someone you know when they should have never been inside in the first place. It'll change your perspective.



Yes I have been to a fire where a rescue was made and the coolest thing about it was that the Firefighter dragged the lady out onto the lawn and took off his breather and started treating her because he was also an EMT… even rode in the ambulance.  And yes you are right about me and I think one of the best things about the fire service is that you are such a versatile resource and able to be used for all kinds of emergencies including medical, my passion for EMS is equal to if not greater than that for fire prevention and suppression.  

I have a lot of respect for you as a Firefighter and I am sure that you bring a lot more knowledge to this than me.  The whole reason I am on here is to learn and hear other people's perspectives on EMS and firefighting.


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## Fish (Nov 16, 2011)

atropine said:


> Better yet, have you ever gone to a bar and get drunk in your FD apparell like they do in the movie?



Yeah multiple times, and strip clubs, they always say here comes that OCFA guy again[/QUOTE]

I bet them strippers are all over you to, because they know how high of a paycheck OCFA gets. :glare:


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## Fish (Nov 16, 2011)

46Young said:


> Nowadays, a unit officer would be accountable in court if they gave an unsafe/unreasonable order that got someone on their crew hurt or killed. We also have various operating manuals that are not too unlike EMS protocols. They function as guidelines for fireground operations and other emergencies. These are based on NFPA standards, and can be used in court as well.



I expect every Fire Fighter to be running away just like me while the Guns and Ammo store goes up and flames and bullets start flying out of it. Not go inside screamin save the Winchesters!!!!!!


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## DrParasite (Nov 16, 2011)

Fish said:


> I expect every Fire Fighter to be running away just like me while the Guns and Ammo store goes up and flames and bullets start flying out of it. Not go inside screamin save the Winchesters!!!!!!


and oddly enough, if the guns and ammo store goes up, the bullets maybe be exploding, but not having the projectile actually shot out of the bullet.

Scary?  yep.  life threateningly dangerous?  not so much.


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## Fish (Nov 17, 2011)

DrParasite said:


> and oddly enough, if the guns and ammo store goes up, the bullets maybe be exploding, but not having the projectile actually shot out of the bullet.
> 
> Scary?  yep.  life threateningly dangerous?  not so much.



Isn't it something like only the automatic ammo will be the only ammo to actually take flight? Your average pistol round, shot gun shell, will just pop


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## DrParasite (Nov 17, 2011)

no, it's none of them.  

the rounds shoot because the primer gets struck by the hammer of the firearm, causing the gunpowder to explode and push the projectile part of the bullet forward.  

when the bullets explode in the fire, it is only because of the heat, so they explode, but don't shoot like when the primer is struck.

will you need to change your shorts?  almost definitely.  will you actually be shot?  very unlikely.


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## JPINFV (Nov 17, 2011)

Exploding is exploding, be it cooking off or the primer being struck. The biggest difference is going to be the lack of a firing chamber and barrel to channel the explosion and dramatically increase the pressure. PV=nRT. With a barrel/firing chamber, the initial volume is very small, hence pressure goes up with the temperature. However without a barrel/firing chamber, V is very large in comparison, hence less of an increase in pressure.


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## Meursault (Nov 17, 2011)

DrParasite said:


> and oddly enough, if the guns and ammo store goes up, the bullets maybe be exploding, but not having the projectile actually shot out of the bullet.
> 
> Scary?  yep.  life threateningly dangerous?  not so much.



I've seen descriptions and photos of a number of incidents where rounds misfired then exploded after being ejected. There were some injuries, mostly from cartridge fragments. I'm told that, without the chamber to confine a round, you essentially have a tiny brass pipe bomb; the force is distributed more or less evenly and ends up blowing the cartridge apart rather than propelling the bullet forwards. It's probably somewhat less dangerous than bullets flying everywhere would be, but I wouldn't want to be anywhere near it.


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## Fish (Nov 17, 2011)

MrConspiracy said:


> I've seen descriptions and photos of a number of incidents where rounds misfired then exploded after being ejected. There were some injuries, mostly from cartridge fragments. I'm told that, without the chamber to confine a round, you essentially have a tiny brass pipe bomb; the force is distributed more or less evenly and ends up blowing the cartridge apart rather than propelling the bullet forwards. It's probably somewhat less dangerous than bullets flying everywhere would be, but I wouldn't want to be anywhere near it.



Makes sense to me, I have never actually seen or heard a bullet go by me. Just heard the pop pop and went FML! I a sitting behind the Ambulance and eating some jerkey while the Fire Boys put the Wet stuff on the Hot stuff.


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## RocketMedic (Nov 18, 2011)

Burning ammo is sort of dangerous, but my fear in those situations is burning solvents and reloading supplies. A keg or ten of gunpowder going off is a lot more serious than a box of 45ACP, and in many sporting-goods and gun stores, there's literally dozens or hundreds of kilos of gunpowder for reloaders and such.


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## usalsfyre (Nov 18, 2011)

Understand that modern smokeless powder does not "explode" per say, only burns rapidly in a controlled manner. Powder when ignited outside of a case will just sorta burn. The much bigger concerns in a reloaders house are any black powder or, especially, primers which ARE an explosive compound.


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## RocketMedic (Nov 18, 2011)

Exactly- but you can't prove that it's not blackpowder or primers unless you're literally reading every keg and know what you're looking for. Best to avoid the whole issue by maintaining distance and very, very aggressive drowning IMO.


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## Fish (Nov 18, 2011)

I do not know much about guns or ammo, I was never in the Military, and I do not own a gun. All I know is that when I hear pop pop pop, I run around with my hands flailed up in the air screaming the North Koreans are attacking! Until someone tackles me, stabs me in the bum with a syringe containing Geodon and pets my head telling me everything is ok, and that it is time to go sleepy sleep now.


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## RocketMedic (Nov 18, 2011)

Lol ive got loaded guns in arms reach now. Texas ftw


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## DV_EMT (Nov 18, 2011)

atropine said:


> I think that LA CO FD does a great job with their current systme. They have a BLS engine on every call, and ALS squad and a BLS ambulance, so if ALS is not needed the engine can cancell them prior their arrival, or after an assesment had been made and the pt. does not require ALS, then the pt. may go by BLS ambulance. They have been doing this for years.



Depends on where you're running as well. I know that McCormick runs ALS units as well as BLS. Usually LACoFD has an ALS Truck show up just in case its a BLS ambulance (provided that its not a ALS LACoFD Rescue unit).


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## Luno (Nov 19, 2011)

*Here ya go... *



denadog said:


> Yes I have been to a fire where a rescue was made and the coolest thing about it was that the Firefighter dragged the lady out onto the lawn and took off his breather and started treating her because he was also an EMT… even rode in the ambulance.  And yes you are right about me and I think one of the best things about the fire service is that you are such a versatile resource and able to be used for all kinds of emergencies including medical, my passion for EMS is equal to if not greater than that for fire prevention and suppression.
> 
> I have a lot of respect for you as a Firefighter and I am sure that you bring a lot more knowledge to this than me.  The whole reason I am on here is to learn and hear other people's perspectives on EMS and firefighting.



FireFighters are a waste of good EMS resources because EMS lacks the balls to confront the bloated IAFF/union system and to stand up for itself.  There is absolutely no reason to send a fire truck to treat someone who needs to go to a hospital, when they can't transport the person to the hospital.  Let's see... 

500,000 for the engine before EMS equipment
Salary x 3 or 4 FFs
That's the cost for one vehicle

120,000 for an ambulance before EMS equipment
Salary x 2 for EMS

That's roughly 2 ambulances for 1 fire engine, so using that logic, that's like saying "these people get big paychecks, and don't really have much to do, so let's give them more to do," instead of the logical conclusion that you don't really need them, and you can get the practically same result for much less expenditure.  And we wonder why as a country we are running out of money?  And the ability to fund two ambulances instead of one fire engine would also decrease response time to medical emergencies.  There, you've got a perspective...  

FF = Waste of EMS resources if they don't transport, because either the patient needs to go to a hospital, which they can't provide, or they need to stay home which they usually don't advise.

Disclaimer: this is strictly referencing a professional (paid) environment, not a volunteer (still professional) environment


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## medicsb (Nov 19, 2011)

Sorry for the delayed response.  Medical school tends to provide just enough time to make comments, but not so much to respond more indepth.   This response hasn't been mulled over as much as I'd like.  I still have a few private messages to respond to, which are aging quickly.  I hope to get to those over Thanksgiving break.  Anyhow...



systemet said:


> Can you point me in the direction of this?



Cardiac arrest survival as a function of ambulance deployment strategy in a large urban emergency medical services system.
Persse DE, Key CB, Bradley RN, Miller CC, Dhingra A.
Resuscitation. 2003 Oct;59(1):97-104.
PMID:14580739



> And I agree that this is intuitively reasonable.  One example could be the operator-dependence of PCI.  But whether this extends to improved outcomes in EMS, and whether the benefits of having limited number of more skilled paramedics outweighs the benefits of having every patient assessed by someone with more than 100 hours of training doesn't seem to be clear.



I don't think that EMS is some out-lier whereby experience doesn't matter like it does for the rest of medicine.  Time and time again, experience is shown to matter in medicine.  This should be the base assumption for EMS until something shows different.



> Yep, I've read that.  But that was based on a surrogate outcome, e.g. intubation success, not on a measure of mortality / morbidity from a condition sensitive to poor airway controlled, e.g. closed head injury.



See the HE Wang study below.



> If you have a reference for this, I'd also be interested.  I'm not trying to attack you, in any way.  I'm just looking for more resources.



The effect of paramedic experience on survival from cardiac arrest.
Gold LS, Eisenberg MS.
Prehosp Emerg Care. 2009 Jul-Sep;13(3):341-4.
PMID:    19499471

http://www.emsworld.com/news/10411131/study-fewer-paramedics-means-more-lives-saved
The abstract for this was published in an issue of Academic Emergency Medicine in 2006.  The full study was never published, unfortunately.



> I have seen an association in one trial between the time to intubation and ROSC at the hospital, but nothing in terms of real survival.  If there's something out there I've missed -- and it's quite possible there is -- I'd be interested in seeing it.



Out-of-hospital endotracheal intubation experience and patient outcomes.
Wang HE, Balasubramani GK, Cook LJ, Lave JR, Yealy DM.
Ann Emerg Med. 2010 Jun;55(6):527-537.e6. Epub 2010 Apr 14.
PMID:  20138400
(This study used survival to discharge as the outcome for multiple conditions associated w/ intubation.)



> I agree that this is intuitively reasonable for some conditions.  But I question whether the research has shown this yet.



"All-ALS" has not been shown to be better than a tiered approach with fewer ALS resources.  All-ALS is more expensive.  How can one justify the cost of an all-ALS system?   Shouldn't we use the cheaper option until more evidence is available to justify the increased expenses?



> An all ALS model does offer the benefit of pain control for everyone, a better assessment, a higher incidence of 12-lead screening, etc.  This may outweight the benefit gained from improvements in airway management.  Or it may not.  It's hard to know for sure at this point.  Lots of ideas that were intuitively reasonable have been questioned once the research has been done.



All-ALS, in a fashion similar to places outside the US does make sense.  In the US, it tends to be all or nothing.  There is not reason to send a paramedic with the US skill set to every patient.  Now, if you want to send a paramedic with high yield skills - e.g. pain management, 12 lead, NTG, albuterol, ASA, etc. to every patient and then reserve a paramedic with a "higher" skill-set, then great.  Maybe AEMT should become the standard ambulance staffing with Paramedic back-up?  

Anyhow, I wish I had time to dig through more sources, but I've got to get studying for a bioethics final... a;ewhg;lakfhgl


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## systemet (Nov 21, 2011)

medicsb said:


> Sorry for the delayed response.  Medical school tends to provide just enough time to make comments, but not so much to respond more indepth.   This response hasn't been mulled over as much as I'd like.  I still have a few private messages to respond to, which are aging quickly.  I hope to get to those over Thanksgiving break.  Anyhow...



No problem man.  This has taken me a while to respond to as well.



> Cardiac arrest survival as a function of ambulance deployment strategy in a large urban emergency medical services system.
> Persse DE, Key CB, Bradley RN, Miller CC, Dhingra A.
> Resuscitation. 2003 Oct;59(1):97-104.
> PMID:14580739



This is interesting, but I'm not sure about the statistics.  They see significance when they use a Fisher's exact test, but when they report confidence intervals, their survival to hospital discharge is 0.02-1.06, and their alive at 1 year is 0.5-148.6.  They also only got 24 "resuscitation attempts in the "uniform deployment" model, so it seems like it might be a little underpowered.

If there is a real difference here, it's very interesting -- because traditionally we've seen the factors that determine outcome be things like CPR, defibrillation, etc.  Not typically ALS therapies.  It seems like the tiered response group here were quicker at starting IVs and intubating -- but the p value for defibrillation is 0.29.  Although they couldn't capture time to AED defibrillation, which might actually explain the difference in survival, without needing to invoke differences in deployment.



> I don't think that EMS is some out-lier whereby experience doesn't matter like it does for the rest of medicine.  Time and time again, experience is shown to matter in medicine.  This should be the base assumption for EMS until something shows different.



On the surface this sounds reasonable, and maybe the burden of proof should be on those who say that an all-ALS model is better.  I'm not sure.  But if we're talking only about cardiac arrests, the idea that ALS intervention impacts outcomes isn't supported by the bulk of available evidence.  

There's a point to be made here, and it's that if we have restricted ALS resources that are busier, we're also giving something up.  Maybe we're no longer getting 12-leads on borderline presentations of MI, e.g. "weak and dizzy all over", "abdo pain", and we're no longer getting pain control to the same number of people, and perhaps we're getting less aggressive treatment of respiratory distress (ALS shown to have an improvement on outcome versus BLS-symptom relief in one OPALS subgroup).  So if we have a tiered model, we may be giving something up as well.




> ]The effect of paramedic experience on survival from cardiac arrest.
> Gold LS, Eisenberg MS.
> Prehosp Emerg Care. 2009 Jul-Sep;13(3):341-4.
> PMID:    19499471



The numbers are a little messy here as well.  Lot's of confidence intervals that cross unity.  They're reporting a 95% confidence interval for the OR of 1.00-1.04, and this is looking at a decent number (n=699).

I mean, it's hard to know.  There might be something there.  But it might be just noise.  When they're starting to make statements like, 

_"We found that every additional year of experience of the medic in charge of implementing procedures such as intravenous line insertions, intubations, and provision of medications was associated with a 2% increase in the likelihood of survival of the patient (95% CI: 1.00–1.04). The number of years of experience of the paramedic who did not perform procedures but instead was in charge of treatment decisions was not significantly associated with survival (odds ratio [OR] 1.01, 95% CI: 0.99–1.03)."_

It's hard to know if they have something.  It would be great if they did.  I'd love this -- but it's hard to be convinced.  And it's really hard with all this King County stuff to know if we can generalise it to other systems -- because not a lot of environments have the same level of PAD or community CPR, and very few communities are posting similar survival rates.

(I'm assuming here that survival is survival to discharge, or 1 year or something relevant -- they don't explicitly state that, but I'm willing to give them the benefit of the doubt)

It could be that the region just has that good a system that they've removed a lot of the noise associated with differences in CPR / PAD / First response, and now we're seeing the real benefit of ALS.  Or it might be nothing.




> Out-of-hospital endotracheal intubation experience and patient outcomes.
> Wang HE, Balasubramani GK, Cook LJ, Lave JR, Yealy DM.
> Ann Emerg Med. 2010 Jun;55(6):527-537.e6. Epub 2010 Apr 14.
> PMID:  20138400
> (This study used survival to discharge as the outcome for multiple conditions associated w/ intubation.)



I like this better than the other two papers.  This is a little more convincing.  There's a certain argument that the patients treated by the providers with greater ETI experience might be closer to bigger trauma centers -- but it seems like when they looked at the rural responders as a subgroup the association was even stronger.




> "All-ALS" has not been shown to be better than a tiered approach with fewer ALS resources.  All-ALS is more expensive.  How can one justify the cost of an all-ALS system?   Shouldn't we use the cheaper option until more evidence is available to justify the increased expenses?



I'm not sure if all-ALS is much more expensive.  Are the tiered response agencies running dual-medic?  If so, a lot of all-ALS systems run medic / EMT.  Staffing costs may also be minor, at some places there'a a 20% difference in starting EMT versus starting medic pay.

It's hard to argue here that we're using the most medically rational deployment structure.  There's a lot of demand from taxpayers for a paramedic response to every call, and I don't think this area has been adequately researched to know which model is superior.




> All-ALS, in a fashion similar to places outside the US does make sense.  In the US, it tends to be all or nothing.  There is not reason to send a paramedic with the US skill set to every patient.  Now, if you want to send a paramedic with high yield skills - e.g. pain management, 12 lead, NTG, albuterol, ASA, etc. to every patient and then reserve a paramedic with a "higher" skill-set, then great.  Maybe AEMT should become the standard ambulance staffing with Paramedic back-up?



Maybe.  It's hard to know.  I wonder if maybe we shouldn't keep the current training structure but have paramedic as the base-entry level.  We could remove RSI, give better instruction on NIPPV, perhaps introduce some decent BiPAP, retain 12-lead capable providers on each ambulance, but cut back on the scope a little.  Then develop a high tier medic with advanced airway management skills, and focus them on the critical calls.

I think we need to be able to deliver a provider to every call that can obtain and interpret a 12-lead, and give pain control.  But maybe they don't need to be able to intubate.



> Anyhow, I wish I had time to dig through more sources, but I've got to get studying for a bioethics final... a;ewhg;lakfhgl



Thanks for the references.  I may have to re-think my position a little.


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## fortsmithman (Nov 21, 2011)

Luno said:


> FireFighters are a waste of good EMS resources because EMS lacks the balls to confront the bloated IAFF/union system and to stand up for itself.  There is absolutely no reason to send a fire truck to treat someone who needs to go to a hospital, when they can't transport the person to the hospital.  Let's see...
> 
> 500,000 for the engine before EMS equipment
> Salary x 3 or 4 FFs
> ...




My service uses a crew of 3 to 4 for our units.


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## Fish (Nov 21, 2011)

fortsmithman said:


> My service uses a crew of 3 to 4 for our units.



On the Ambulances?


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## Handsome Robb (Nov 21, 2011)

fortsmithman said:


> My service uses a crew of 3 to 4 for our units.



Why? 2 is plenty. Where does everyone sit forward or rearward facing and belted in when enroute or returning?


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## fortsmithman (Nov 21, 2011)

Fish said:


> On the Ambulances?



Yes on an ambulance we use 3 to 4 members.  The only time we use 2 members if it's a medevac ground support.


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## fortsmithman (Nov 21, 2011)

NVRob said:


> Why? 2 is plenty. Where does everyone sit forward or rearward facing and belted in when enroute or returning?



Out of the 3 or 4 1 in the drivers seat (we hope) 1 in the passenger seat. and one in one of the two jump seats and we have a bench seat in the back that can hold 2 belted in people go to my profile here in EMTLife and I have a pic of the back of one of our ambulances.


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## Handsome Robb (Nov 22, 2011)

fortsmithman said:


> Out of the 3 or 4 1 in the drivers seat (we hope) 1 in the passenger seat. and one in one of the two jump seats and we have a bench seat in the back that can hold 2 belted in people go to my profile here in EMTLife and I have a pic of the back of one of our ambulances.



I feel sorry for the person sitting in the bench seat if something bad happens. I'm not attacking you I just don't understand the though process behind it. Belted in or not sitting laterally in an MVA will not end well.


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