Listening to the EMS Garage podcast (Episode 45) discussing the Los Angeles County cuts to service, the conversation turned to the reason to have Paramedics on the fire engines.
The panel spoke of various reasons for the cutbacks, then took an interesting turn when the commentators had this exchange:

“They (Los Angeles) have Paramedics on their engines.”
“Why? Why would you do that? …There is no benefit. Why is there tiered response to medical calls?”
“They do it to support their staffing”
“It does nothing for the patient.”

This initially get me hot under the collar. I’m sure if asked to clarify their conversation there would be more explanation. At least I hope so.

Why is there a tiered response to medical calls? Why is there a tiered response to fire calls? Or to police emergencies? Why do we combine the abilities of different resources to aid as many as possible?

I am not for all ALS fire resources. Let me get that out now, before some of the single role folks start fuming. This debate has been going on for a long time, time to get it out here in the open and discuss it on it’s merits.

If you support public access defibrillation then you recognize the need for early intervention in cardiac cases. Get a trained set of eyes with a med kit in there ASAP. If the system in place has Paramedics arriving with or before Fire ALS resources, then I call into question the need for Fire Based ALS in that community. Then again, what happens when all the ambulances are busy? Who will administer that epinephrine to the kid who got stung? Who will cardiovert the woman on the bus? There are so many ifs, that having an insurance policy is not a bad idea. Could these be handled by supervisors already in place by the EMS provider?

I believe in a scaled response model, be it tiered or provided by a single service, but I reject the idea that my responding and treating patients from the fire engine is doing “nothing for the patient.”

Countless times I have initiated ALS care still waiting for an ambulance to arrive on scene.

Countless times I have been dispatched to BLS scenes miscoded by dispatch or exaggerated by the caller. As a trained Paramedic I can advise dispatch to slow down or reassign the ambulance to better the system’s ability to respond to legitimate emergencies.

In many communities it seems the answer to keeping the fire department in business has been to throw a patch and a monitor on a truck and claim they “save lives.” I’ve heard it said that the Fire Service is a budget looking for a mission and EMS is a mission looking for a budget. I like to think both are necessary, but no necessarily together in their missions. Some communities have strong private agencies who provide training and support for their crews, others not so much. In that case, it falls on the municipality to provide the ALS care. If that means putting competent Paramedics on a fire engine that is already responding, then so be it.

Too many cooks can spoil the soup. But when time can make a difference between an asthma attack and a resuscitation, I choose the early recognition and adequate treatment.

We’re all on the same team here, folks. Sure I’m a Firefighter/Paramedic instead of a Paramedic, but I try hard to keep up on both skills. That doesn’t make me any less of a care giver. I’m not slacking on my 12-lead skills because I had a tower ladder drill this morning, it just means that I can provide a service in a time of need as well as being available for a less common emergency (Fire.) I am very interested in learning more about breaking the Paramedic off of the fire crew for certain calls, whether that be in an APP model like Wakefield or a FRU model like the UK. Again, location specific based on community, topography and resources available.

I had to laugh when I listened to the next installment of the podcast, Episode 46, with the discussion of police officers with AEDs being a good idea because they can respond so quickly.

One or the other. Either an early intervention is good, or it is not. Why stop at AEDs? Why not encourage Paramedics to cross train as Police Officers? Because every police officer that responds to a medical call is taken off the streets from being a law enforcement resource.

Every bell I get to a medical takes my suppression unit out of it’s pre-determined roll as well.

A perfect example of a tiered response happened at my suburban home last year. You can get the full story HERE, but the first responder on the scene was a police officer in a car who happened to be a licensed Paramedic, but not for his agency. Then the ALS engine arrived and began treatment, still no ambulance to be heard. When the major carrier rig did arrive, they were the professionals I expected and did a great job. Why not get a trained set of eyes on the scene as soon as possible?

The response mandates are backwards in my mind as well. We have to respond to BLS calls in 5 minutes, but ALS in 9? Think about that. We’re required to be faster for the folks who don’t need us as much? That is based on the BLS before ALS model which , unfortunately, is the cheapest way to provide EMS. Get an EMT on scene and hope a medic can respond. I hear on the radio all day long “Engine 99, do you need an ambulance code 2 or code 3? – Code 3” then the ambulance later clears on a refusal or a no merit.

I say dump that thinking right now. We need to break the mold of BLS first with an ALS chaser. Flip that model. Get ALS in the door first, then BLS can augment at ALS discretion.

There I go dreaming again, right? The privates think the FD is taking all the money and slacking on treatment and the FD thinks the privates are a bunch of folks who couldn’t pass the firefighter test. Let’s move past that. There are those on each side looking to go to the other side, always will be.

CK over at Life Under the Lights speaks of lifting the bar in EMS education so that the first person in the door in an emergency has the training and capabilities of modern day paramedics. Then CK would like to get the current Paramedic skills and training lifted towards the PA level. I was hesitant to get on board with that thinking at first, but if the only thing holding us from that reality is money, let’s do it.

But that isn’t our problem in EMS is it? Our problem is the folks passing through. Too often we are seen as a way point onto other careers. This was also a topic of discussion on the EMS Garage and I’m glad there are others that feel the way I do about it. So few reach the level of Paramedic and say “This is where I want to be” so they have no stake in making the system better. they’re on the way to RN or PA or whatever and are looking to get an adrenaline fix.

The point of this rant is that I take personal offense to the comments on the podcast that I have no effect on patient care when arriving on the scene in a big red truck instead of a big red ambulance. The commentators meant no personal offense, I know that, but I would like to remind them they have a very large audience who is looking for role models and leaders for the next 20 years of EMS. All care givers need to work together to find what works best in their communities and strive to make it so.

Am I obsolete in the Firefighter/Paramedic role? Maybe. But currently, the model making the most difference is a tiered response from a public/private partnership.

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