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

[46Young]

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.

 

[46Young]

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.

 

[46Young]

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.

 

[JPINFV]

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?

 

[denadog]

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.

 

[usalsfyre]

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.

 

[Handsome Robb]

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.

 

[denadog]

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...

 

[denadog]

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...

 

[usalsfyre]

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.

 

[Handsome Robb]

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. *

 

[JPINFV]

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.

 

[Fish]

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.

 

[Fish]

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

 

[Fish]

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.

 

[Tigger]

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.

 

[46Young]

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?

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?

 

[46Young]

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.

 

[46Young]

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.

 

[46Young]

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.

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.