Thoughts on two-tier EMS systems?

[jmp6753]

Where I work we have all ALS ambulances. Two of the the major fire departments have ALS crews. It really is crazy. The fire departments scare the public into voting for their EMS levys because they believe that the ambulance company may have no ambulances available (which happens very rarely). By contract the ambulance has to be on-scene within 7 mins and 59 seconds of the call being received. Yes there are way too many cooks in the kitchen. By MPD protocol, the transport paramedic is in charge upon their arrival.

I ran a call recently where it was a non-emergent response for a fall. Grandma rolled out of bed and has back pain. The fire department sent a $1,000,000 tillered ladder truck, with 4 paramedics and I arrived with a paramedic partner and a paramedic intern. 7 medics for a bls back pain call. Just a little over kill.

[toutdoors]

Our city uses two tier response. FD is BLS engine, even though we have a good number of medics, we only provide BLS. The private ambulance is ALS, and does the transport. So it is a no brainer. FD has scene control in regards to safety, extrication, technical rescue and what not, the ambulance medics have final say in pt care. With the exception of a couple of ambulance medics who are grouchy, or down right rude at times to the FD, one is truly burning out, and the other; well she has always been that way.

A few of our fire medics, myself included, work part time for the ambulance, so we have a pretty good rappport with eachother. In general, there is good team work here for both parties, I truly believe that we work very hard at providing a team approach to ensuring quality patient care. If the EMT's can do anything to help the medics, they almost without fail jump in with both feet, and are more than happy to do what is asked. Of course we have had a few bumps along the way, every now and then you get the call where one service feels something was not right with the performance of the other service, and the issue is normally addressed and actions taken.

There is another part time medic at the ambulance that works on a different full time FD about 70 miles from us, and he says his FD and the private ambulance in that town are like cats and dogs. He used to work full time as a medic until he got hired on the FD. He said he was amazed at how the disdain for the other agency is so apparent where he now works full time. I am glad I work where I do, after hearing some of the other horror stories from other medics or firefighters, the grass is not always greener on the other side.

[Richard B the EMT]

It may just be a matter of semantics, but I was under the impression that a "two-tier" system was ALS and BLS ambulances, and a "First Responder" system had, for example, Fire preceding the ambulance (a rule that Fire typically puts in place to artificially extend EMS response times while shortening their own).

The viewpoint of the FDNY is to get someone there to start some kind of help for the patient. As for our "3 tier" system, the EMTs and Paramedics are usually from the FDNY, even if we are not cross-trained fire fighters. The situation from my EMS station is, my 4 BLS, and 2 ALS units, are from the same "House", as is one of the 6 CFR-D Engine companies that might be assigned to a call within the response district.

[p3medic]

How much time does the engine company spend at a cross street location? Not much I bet.

[Dustdevil]

How much time does the engine company spend at a cross street location? Not much I bet.

Yeah, all the glory and perks with none of the work or responsibility.

That's the motto of the fire service.

[Don1977]

Yeah, all the glory and perks with none of the work or responsibility.

That's the motto of the fire service.

Sounds like some medics I know and there motto....

[pguy280]

Having worked two tiered system for a time many years . I found it to have many advantages and disadvantages. The main advantage was the quick response whether it was a BLS or ALS unit. The main disadvantage that I saw was the no ALS after midnight theory that some ALS providers had and the abuse that the BLS crews took. Yes we can triage down here in mass. The scene control is clearly outline in NIMS 100 an 700 wcich is a federal mandate for all providers to have even us fire monkeys have to have it. This is so that multiple agency response is coordinated and that all involved know there position in the chain of command. No i am not crazy this is how its suppose to work however it does not always work that way I know.

I think a meet and greet with both the fire monkeys and the ems providers goes a long way for both groups. This allows us as providers to do whats inmportant (Patient Care). I challenge all to try this and see if I am correct. I have been in those shoes and went to see the fire monkeys during a hostile take over from Fire to private provider. I explained my position of trying to do my job and that I had a family to provide for to. This went very well for me and my partner as we were spoken about to the other fire companies as the only two medics who actually knew what was happening there. We were included in the dinners and outside affairs as well. So I guess what I am saying is a little education can make a difference. We all have our crosses to bare and those folks only make things harder. Try and be part of the solution not the problem. Keep up the great work out there and be safe.

[firemedic37]

BLS Rescue (EMT-B Level) rolls on all 911 medical calls with an ALS Ambulance (Paramedic Level). Rescue usually gets on scene first and starts assessment, ambulance gets on scene and takes over patient care. Fire Department always has scene management however they always talk to the ambulance if their is a patient involved, such as vehicle extrication or confined space. Most of us are on both the Fire Department and Ambulance so we get along great.

[TylerHastings]

WHere I live is the exception to the rule IMHO in the state of etch-a-sketch (CA) in so far as we have a two tier system fire responds as a First response and for all TC's and as needed for manpower. It seems to work very well for all of us in so far as the fact that on medical calls and most trauma calls excluding TC's and Rescues EMS has command now on TC's Fire has command until extrication is completed.

[Kiwiology]

Here in Kiwi we are moving to a hybrid Canadian-Australian model of tiering our response.

Rural areas served by our volunteers will get BLS as a first response (our BLS is much more expansive than purist American BLS)

Paid areas or crews providing backup to a BLS volunteer crew (80% of our national workload is paid staff) will either be Paramedic or Intensive Care Paramedic. A "Paramedic" will do everything except a few fancy ALS skills like (at the moment) IO cannulation, midazolam, amiodarone, ketamine, pace and a few cardiac meds.

Under the new system the only difference between a Paramedic and an Intensive Care Paramedic treatment of cardiac arrest is that the IC Paramedic will intubate them whereas the Paramedic will use an LMA.

I am told Paramedics will be getting amiodarone for cardiac arrest and midazolam IN or IM for seizures, they already have adrenaline, morphine, naloxone, cardioversion etc.\

The logic behind this is to create a "super skilled" base level which can handle all but the most challenging calls (life threatning asthma, patients needing intubation/RSI, dysrhythmias etc) and essentially keep Intensive Care for them.