Lately I have participated in many discussions regarding fire-based EMS. As we all know, there are very good arguments to both sides as to whether EMS should be run exclusively by the fire department. So rather than argue about whether or not it should be done, I am going to express my opinion on how fire-based EMS should be run.

Having worked in a single-medic service for my entire career, I tend to favor that type of system. I truly believe that 1-2 paramedics for each call is really all you need. Any more than that and you are just wasting resources. At minimum 1 paramedic on the ambulance would be sufficient. Depending on ambulance availability I suppose having a medic on the engine would be beneficial too. You can refer to my article “Two paramedics are not always better than one” for more on that subject.

I believe that the paramedics assigned to ambulance duty should play a single-function roll. It is very difficult to keep up your skills as a paramedic if your job responsibilities are split between patient care and firefighting. I also say this because I don’t believe that paramedics should have to become firefighters in order to practice in a 911 system.

One big problem with having multiple paramedics on scene is establishing who is in charge. It needs to be made very clear in writing who runs the show. I feel that this responsibility should be given to the transporting paramedic. If they are going to care for this patient all the way to the hospital and have to answer to the doctors and nursing staff, then they should have the final say in how the patient will be cared for.

Being the conservative that I am, I don’t really believe in “special taxes”. Having said that, I do believe that if a community wants to vote to impose such taxes to provide fire-based EMS services, then more power to them. If a special tax is imposed to provide the service, then the department should not be billing the patients. Departments that tax and bill their patients are just asking to be shut down and replaced by a private ambulance service who collects no tax dollars.

I truly do believe that efficient and effective service can be provide by fire-based, third service or private-based EMS, it’s just a matter of doing it right.

Today I am going to discuss the theory that “more is better”. In many cases this true, but no necessarily for EMS systems. In many systems ambulances are staffed with one paramedic and one EMT, while assisted by EMT first-responders. In some systems several paramedics are deployed as transport units as well as first responders. Both systems have their benefits and disadvantages.

In a system where multiple paramedics are deployed on a single call can certainly have its advantages. On critical patients, multiple ALS interventions can be done at the same time. For example; while paramedic-a is starting and IV, paramedic-b can be intubating. Unfortunately there are more downfalls to this system than advantages. Intubation, starting an IV and various other ALS interventions require frequent practice to be proficient. In a system like this, you can expect the amount of ALS interventions performed by a single paramedic to significantly decrease. Lets say that normally paramedic-a intubates 4 times a month. If you put a second paramedic on every call, it is very likely that the number of intubations performed would be cut in half, and so forth as you add more paramedics.

Systems where single paramedics are utilized for emergencies are not exactly perfect either. Being the only ALS provider can lead to increased stress and burnout. It also provides almost no checks and balances. However, this system has many advantages. Being the only paramedic means that you are responsible for patient care, documentation, radio reports, and transport decisions. This produces paramedics that are capable of independent thinking and taking control of situations. There is no deterioration of skills and scene times are typically kept to a minimum. There is also more accountability when one person is responsible for all aspects of patient care. This makes quality assurance much easier. This system also provides a more cost-efficient way to do business. Not having to send multiple paramedics on every call means that more ALS ambulances can be placed in the system for better coverage.

It is to my opinion that a single-paramedic response system shows more benefits than disadvantages, however this does not mean that multiple paramedic response systems can’t be run effeciently. I do believe that certain guidelines can be followed to limit “head butting” and delayed scene times. Assigning a designated leader to take responsibility and assign tasks to other paramedics can help to ensure that calls are run in a timely and effecient manner. This can be as easy as designating the transporting paramedic or the first paramedic on scene to be the patient care leader for the call.

After all is said and done it all comes down to doing whats best for the patient. What works in some systems, may not work well in others. Head-butting and egos do nothing good for the patient or the system. Working together and communicating will be the key to responding to any emergency.

Please feel free to e-mail me if you have any questions or comments.

Thank you,

Sean