ALS for Trauma? slide presentation

ALS for Trauma?

Ambulance Staffing in Fire-Based EMS

Ambulance Staffing in Fire-Based EMS

By Alan Perry

December 25, 2013

The growing sophistication of pre-hospital medical care is driving the use of better research and the adoption of evidence based measures for patient care. It also relies on high quality data, and a greater degree of consistency and teamwork from providers, perhaps pushing the limits of the conventional two-man Medic. It may be time to break this tradition and begin deploying EMS assets the same way Fire assets are deployed, with a clear crew structure that is only to be broken up in extreme circumstances. I'm talking about a Medic Company, a senior EMS provider as the company officer and a ALS/BLS crew of two. Fielding this type of unit is both practical and revolutionary, allowing the team to perform at a higher level and reducing the instances of deploying multiple additional assets to "assist" them. Instead of a medic being a dreaded shift assignment a crew/officer would be assigned to it providing the same continuity and familiarity with the apparatus that engine assignments currently enjoy exclusively (this is called ownership).

The advantages of having more than one provider in the back of an ambulance for an ALS transport should be obvious and indisputable. Yet I still encounter resistance to the practice among my co-workers. I work in a Fire-based EMS environment with EMT-staffed ambulances and ALS providers on the engine companies. Not all engine companies have 4-person staffing, and they are not all in close proximity to a hospital. There are two possible outcomes depending on the Company Officer’s attitudes toward EMS services.

A)  The Company Officer moves all of the paramedics gear to the ambulance, takes one provider off the medic and moves his/her gear to the engine, the ALS provider rides the call in alone with the EMT driver. The engine company returns to service BLS, Once the patient is turned over and the unit is restocked the provider is brought back to his/her station, transfers their gear and returns to the engine.

B) Depending on the staffing level and proximity to the hospital; the Company Officer does not re-arrange personnel or gear, leaves an additional provider on the medic to assist with the "ALS" patient, follows the medic to the hospital remaining on the call, or goes out of service until the ALS provider is returned to the station.

These two options represent the cultural divide in thinking in an organization that puts Fire Protection above Patient Care. To better illustrate all of the variables let me break it down into Pros and Cons with a couple of stipulated facts:

*ALS patients are by definition more likely to need multiple and/or invasive procedures to assess, monitor and treat.

*The ability to record timely and accurate information aids in treatment. improves the accuracy of documentation and usable data collection.

     * One person cannot reliably perform multiple interventions, assessment, documentation and communications in a <15 minute transport.

To put this in its proper perspective we have to acknowledge that we are primarily an EMS service that provides Fire and Rescue services as well. We document the value of the property we save but rarely consider the value of the lives we impact. This may eventually change, like our ways of thinking.  let’s do what is best for the patient.

Thanks,

Alan

Fire Based EMS Advantages

Advantages and Strengths of Fire Based EMS

By Alan Perry 7/12/2013

Introduction

I have frequently questioned the commitment of the fire service when it comes providing emergency medical services (EMS). I have observed through my own experiences that the fire service has reluctantly accepted provision of this service as a necessary evil in order to secure funding for its own programs and preservation of career firefighter positions. I am a career paramedic/firefighter in a large municipal fire department, my initial training as a paramedic was obtained while I was a volunteer in a neighboring city because my city did not encourage volunteerism. I eventually sought employment in my home town as a paramedic/firefighter and was given some preference in hiring due to my paramedic certification. My department began as separate EMS and Fire divisions which merged before I was hired with separate career paths for fire and civilian EMS personnel. Over the years through attrition the numbers of civilian employees have dwindled to but a handful with the majority of supervisory EMS positions being filled by aspiring Fire company officers who have not given up their ALS certifications. The EMS command structure falls completely under the Fire chain of command with no parallel structure or career path for EMS. Our current staffing model is dictated by the Fire Administration’s desire to have one ALS provider available in each station, ambulances are staffed with two BLS providers, ALS is available by simultaneous dispatch or requests for an ALS provider via an engine company response. In this way the best use is made of the departments limited ALS resources. There are many other models used in the fire services ranging from this extreme to all ALS apparatus and systems where even officers are expected to do some time on the “box”. If anything, we are flexible. We almost universally, as part of our fire based culture, play down and degrade the value and importance of the EMS services we provide. We portray this duty as a punishment or undesirable assignment even though it accounts for over 80% of the services we provide. These observations aside, I believe the fire service is in a better position to provide EMS services due to the culture, resources and stability the fire service possesses.

The fire service culture

Normally I would count this as a negative, but I have come to realize that the fire service does many things right when it comes to producing an atmosphere of cooperation and teamwork. There is also the mentality that no job is too daunting or extends beyond the capabilities of the fire service. These attitudes have been tested, and although applied slowly to the practice of EMS, it is changing. The fire service has the correct mind set needed to take on the challenges facing changes in EMS that are occurring now and those on the horizon, the test will be if it can react with sufficient agility to maintain control of its own system.

The resources of the fire service

The nature of the fire department is to handle any emergency, of any kind, at any time. We train for every conceivable type of scenario. Because of this fact the fire service is the best prepared to handle any type of patient presentation, and equipped to begin treatment immediately even in the most difficult circumstances. The additional training and equipment available allows for safer and more effective treatment of patients and minimal risk to providers. One of the biggest strengths of the fire service is its ability to organize and mobilize resources both physical and human. Through unions and public goodwill we frequently can convince both the public and government officials that our needs should be met in the public’s best interest if our cause is a just one. The fire service can bring extreme amounts of physical and human resources to bear when disasters occur locally, regionally or nationally. The agility of the fire service will be tested in the near future, challenging our ability to improve and keep up with changes in EMS. The political power of the organization can be used to improve EMS systems or expended trying to maintain the status quo.

The stability of the fire service

Fire departments are paramilitary organizations that rely on rigid command structure both in emergencies and routine operations. Because of this fire departments are able to produce more consistent and reliable results, personnel at all levels are held accountable for their actions. Individual preferences, variations and freelancing are minimized, safety procedures are followed, and most actions other than local EMS protocol are based on established national standards creating little variation from one department to the next. Fire departments are publicly funded, they are required to submit and adhere to budgets and long-term plans. The finances and activities of the fire department are very public. Fire departments do not get into trouble quickly or without the public’s participation. These facts make fire departments inherently more stable and free from the vacillations in financial and leadership performance often plaguing non-profit and volunteer organizations engaged in providing EMS services. This stability in leadership, oversight and financial affairs make fire departments much better suited to provide a stable environment for the improvement of EMS service and system development.

Conclusion

I believe that in spite of my past experience with the fire service, it is far better suited to take on the challenges facing EMS at this time. Those in the fire service have become acclimated to EMS as much more than a “box” that takes people to the hospital. They realize it is an important service that greatly affects the lives of those we serve. The fire service possesses all the resources needed to confront the changes EMS is facing now and in the foreseeable future. My hope is that we will be able to do so with the agility and efficiency required, after all the fire service as a whole is a huge organization, it has traditionally been very slow to change. The only obstacle remaining is the Fire Service Culture, if we can change our attitudes toward EMS across our organizations from the top down, no one will dispute our ability.

Be Safe,