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

[terrible one]

To add to that above,

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.

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.

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?

 

[abckidsmom]

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.

 

[JPINFV]

^
Yes... the squads are pickups.

 

[denadog]

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.

 

[usalsfyre]

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.

 

[JPINFV]

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?

 

[Tigger]

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.

 

[denadog]

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?

 

[JPINFV]

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.

 

[denadog]

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...

 

[usalsfyre]

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.

 

[denadog]

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.

 

[Tigger]

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.

 

[Aprz]

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.

 

[Handsome Robb]

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.

 

[systemet]

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.

 

[Fish]

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.

 

[Fish]

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

 

[Fish]

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.

 

[Fish]

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.