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The Perfect EMS Service "A Vision"

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So I have been tasked with assisting a new EMS service startup company in small metro city serving roughly 95,000.

What I am looking for is input from everyone on operations, pay, dispatch, equipment as if money is no object.

What we have determined thus far:

3 ambulances staffed 24/7

2 backup ambulances

3 stations (new build) with Plymovent exhaust.

3 man crew (2 EMTs/ 1 paramedic)

ABC Kelly shift

1 shift supervisor (ALS Equipped vehicle)

Ambulances will be a Medium Duty Freightliner chassis.(meeting the new NFPA standard)

2 backup ambulances smaller Type I/ II

Supervisor vehicle: F350 4x4 Crew cab

Paramedic pay starting @ $54K

EMT pay $40K

Paid CDL, Critical Care Paramedic, EVOC/ CEVO, AMLS and Child Safety Seat Technician training

Written, practical, physical agility and DOT Medical

$8,000 relocation and hiring preference to those residing in the service area.

The management is looking at streamlined operations without all the brass. Their thinking is they want to get rid of the revolving door and retain employees. They want each employees involved in the decision making that takes place. Their goal is to make EMS a long term career.

Uniforms are Class A which I am not a fan of but it does look professional. I guess.

OK folks now it is your turn. Tell me your wish list and what would be the perfect EMS model?

Equipment, lessons learned, crew make-up, shifts, pay, etc.

Appreciate all responses.

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A mixed system with EMS-based BLS first response along with BLS (EMT/EMT) and ALS (paramedic/AEMT) ambulances as well as Community/Advanced Practice Paramedics and supervisors in fly cars dispatched as requested by providers on scene or according to call type:

Omega: first response only

Alpha/Bravo: first response + BLS ambulance

Charlie: first response + ALS ambulance

Delta/Echo: first response, ALS ambulance, C/APP

C/APP's do Community Paramedic work between emergency calls, ALS ambulances hand over care to BLS units if the patient doesn't require ALS capabilities. Also have some trucks dedicated to BLS/"light" ALS transfers (AEMT/EMT), as well as some critical care capabilities (CCP x2 + EMT) for critical care inter-facility transfers.

Have an ALS:BLS ratio of about 4:10, target highly educated, highly trained paramedics and put them through an intense "on boarding" academy. Six months probationary period under an experienced paramedic.

For vehicles, my picks would be:

Chevrolet Suburban for BLS first response and C/APP's
Type II Sprinter for BLS and ALS ambulances

Type III Sprinter for critical care ambulances

All hi-vis yellow with green battenburg patterns. Blue lights. No bench seats, all should have forward-facing chairs instead with a "stand" in front with drawers and a monitor mount; keep the radio and the bulk of vital equipment on the provider side to avoid providers having to get up during transport.

Scrub tops (durable with a radio mic clip sewed on the front), EMS pants. No patches, just agency logo over left breast and name/cert over right. Make the uniforms ANSI compliant (a safety vest you can't forget to put on).

Alpha/bravo/charlie responses, no lights and sirens.

Delta/echo, lights and sirens as deemed safe to do so by crew.

Lights and sirens transport by clinical supervisor order only.

Entry level payscale

EMT: $34,000

AEMT: $38,000

Paramedic: $45,000

C/APP/Supervisor: $50,000

EMT: Valid certification. 3 month academy + 3 months probation/field training
AEMT: Valid certification. 3 month academy + 3 months probation/field training

Paramedic: Associate's degree minimum. 3 months academy + 6 months probation/field training.

C/APP/Critical-Care Paramedic: Bachelor's degree minimum and/or Associates + CP/CCP certification and/or Medic + RN. 3 months academy + 6 months probation/field training.

Supervisor: C/APP equivalent or relevant management/administrative education.


EMT: Same as state regs.
AEMT: Same as state regs.

Paramedic: Supraglottic airways only.

C/APP: ETI, (maybe) RSI, wound care (simple sutures), port/cath maintenance, limited dispensing, etc.

CCP: Vent management, IV drips, IABP monitoring/management, etc.

On-boarding academy be a mix of online and in person lectures as well as skills lab and would include:

Medical foundations (bio/A&P/patho review for both BLS and ALS)

Pharmacology review (not just EMS meds)


Operational guidelines and policies

Equipment familiarization

EMS defensive tactics (something like DT4EMS, not guns and tasers and all that stuff)

EMT's and AEMT's operate under protocols or paramedic direction. Paramedics and up operate under guidelines with options for alternative care pathways available to them. C/APP follow-ups for high-risk refusals or patients targeted as "at-risk" by call review or internal/external providers.

12-hour shifts rotating between busy and slow stations every month.

An X-box and a copy of the original Star Wars trilogy in every station.

Edited by Bieber
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Thanks Bieber for the reply but still looking for other opinions and wishes.

178 views I know there some items you wish you had or glad you have.

We are looking at the ZOLL Rescue net system for our EPCR's

Would like so see availability of system to use and iPad

Emergency lights on the vehicles? Different brands. Which ones seem to be more eye catching

Federal Q2B with additional Howler siren and Grover stutter air horns

Zico Oxygen tank lift system

Zoll X Series with all the toys

Medication fridge mounted onboard Any good manufacturers.


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If you want to run 3 x 8 hour shifts then you need to let people choose their shift and they do that shift permanently because that roster just burns people out really quick; I know one system that runs 3 x 0700-1530 then 3 x 1530-2300 and then the 3 days off with the people who do 2300-0730 working the nights permanently; I know another place that does 2 x 0600-1500 followed by 2 x 1500-2300 then finally 2 x 2200-0700 and then 3 days off and man those people are so burnt out its not funny, the mate recently quit because he couldn't handle it.

What is used here is generally 2 x 12 hour days then 2 x 12 hour nights and then 4 days off and that system works pretty well and people like the 4 days off. I think if you want maximum results you should do 12 hour shifts and let people choose either days or nights. Me, I am a night person, its great, love them, hate days with a passion.

As for vehicles I think a Freightliner is a bit of an overkill; never have I seen such gargantuan monstrosity as in US. Most other countries use Sprinters (UK, AU, NZ, pretty much all of EU). The UK Sprinters with the curb door are very nice, the NZ sprinters have dual curb door with one for equipment and its great; check 'em out here http://www.111emergency.co.nz/F-I/GSR565.htm. They are also going to cost a hell of a lot less to buy and maintain than a freaking juggernaut Freightliner.

The biggest thing I would stress is having some sort of alternate response to people with complaints that are not a threat to their life; things like toothache, abdo pain, the flu, cuts and bruises, you know, bullshit.

We have a new triage system that basically took all of the thousand MPDS detriments and reassigned them one of five colour codes based upon how time critical the complaint was. They are purple (cardiac or respiratory arrest), red (immediately life threatening), orange (urgent and potentially serious), green (not serious or life threatening) and grey (telephone advice appropriate). Grey calls get a telephone nurse or paramedic and green calls get a paramedic in a car. Only red and purple calls get lights and siren automatically, orange calls get red lights at intersections as needed but other than that orange, green and grey calls are no lights and siren. I know of one agency that goes on a one to everything for frig sake!!

Uniform - two piece polo shirt and cargo pants. High visibility yellow top is a good idea.

What are your fridges for? suxamethonium?

I would be interested in being part of helping set this up; look me up if you like

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Thats not a vision, you are basing your plans on what EMS has been since the 60s. You want vision ??????:

1. Use a first response vehicle staffed with a PA or NP, who can write a prescription and leave them at home, and only call for transport when needed.

2. I-Stat Lab machines to do labwork in the home and a portable x-ray machine; again, dont clog the ER, diagnose at home.

3. EMT-Bs on a car that pick up prescriptions written by the PA/NP and deliver to the patient.

4. If you are remote EMS, use your station as a walk-in clinic, let them drive to you versus you go to them.

5. Find a drug, system, or technology that saves more than 50% of cardiac arrest victims. We still suck at that (as a whole).

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I think your setup sounds pretty good so far.

One thing I would recommend is one Paramedic who is car-based who goes to low-acuity calls with the intent on referring them to their normal doctor, an accident and medical clinic via private transport, or an ED visit via private transport. Or just leaving them at home because they have overreacted to a minor injury/condition and do not need further treatment. If you have one of these vehicles on 24/7, then they can also be available as fast-response when no ambulances are available, or for ALS backup when required. If you only staffed the 3 ambulances with 2 people (1x EMT and 1x Paramedic) then you could put this low-acuity vehicle on with minimal extra cost. It would also ensure that the Shift Supervisor has more time in the office to get their work done.

Use tablets for both Mobile Data Terminals and electronic patient report forms. Work with local hospitals and clinics to enable patient files to be accessed remotely by ambulance crews, and for ambulance crews to send patient report forms and ECG's to the receiving facility.

In terms of equipment, I honestly think it comes down to you making your own decision. Everyone one here will have opinions on Lifepak 15 vs Zoll vs Phillips MRx. Although I would look at electronic Stryker stretchers to reduce crew lifting and workplace injuries. Have you considered bariatric equipment?

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