Going ALS

A funny thing happened with the advent of the television show "Emergency!" in 1971. Not only did fire departments and citizens across the country see this new concept of a paramedic/firefighter, but they also saw the engine company running medical calls with the squad. What a unique and novel approach to effectively utilizing your resources.

Overnight, many fire departments began exploring the use of fire apparatus as a first responder to deliver quicker medical care or to lend additional support at the scene. However, in the last 10 years, there has been a push to go to the next step.

Your department is now considering going to that next step. Your department has talked about it for years. It has been kicked around the administration offices, in shift meetings and finally some city council people are starting to talk about it. Going to that next step means shifting basic life support (BLS) engines to advanced life support (ALS) engines. This quantum leap should not be done short-sighted or with little thought. For many fire departments, it is a major step. This is one of the most frequent topics of the e-mails I receive from readers looking for assistance.

The first question that needs to be asked is why do you want to go to ALS engines? Many traditional EMS systems are designed with BLS first response and then ALS transport. Typically, the BLS engine arrives, begins basic life support, and then the ALS transport arrives, raising the care level to advanced life support. But studies have shown the clear advantage of early intervention with ALS with respect to better survival rates. As a result of these studies, many fire departments have "front-loaded" their first responder programs with ALS engines. Better and faster advanced life support means better service to your citizens.

To be successful, careful attention needs to be given to many details. Many steps need to be accomplished before you even run your first run if you are to be triumphant in your endeavor.

Many components need to be addressed - some simultaneously before the first ALS response is made. First, check with your state office of EMS to see what requirements need to be met in order to operate a first responder ALS engine company. Many states have different requirements for first responder vehicles versus ground transport vehicles.

Does your state require a license to operate an ALS first responder service? If it does, you will probably be required to a have a physician who serves as a medical director. Some other requirements you might see from states include the need to have a quality assurance program, background investigations on paramedics working for your service or applying for a license from another state agency to carry narcotics.

Once you have determined what the state requirements are, you will need to address a multitude of other issues. Do you have enough paramedics? Obviously you cannot operate an ALS first responder program without paramedics. Enough paramedics also means having enough paramedics to cover all shifts, including vacancies created by paramedics because of vacation, illness, injury, etc. You cannot have the engine operate ALS one day and then BLS the next day. Once you establish a level of care in the community, you must maintain that level. Major lawsuits have been won over the last five years on behalf of plaintiffs when what was supposed to be an ALS engine showed up with no paramedic, even though the ALS equipment was on the apparatus.

Another issue that needs to be addressed is the funding equation. Is there sufficient funding in the budget or is your government body willing to provide the additional funding to go ALS? Since paramedic/firefighters are professionally educated at a higher level than firefighters, compensation needs to reflect the higher education level. Besides additional salary, going ALS also means buying advanced life support equipment, including a monitor/defibrillator. Some monitor/defibrillators with all the whistles and bells can reach $35,000 each. Don't forget to buy more monitor/defibrillators than ALS engines. What happens if one malfunctions? Do you run without a monitor/defibrillator for several shifts or weeks while it is getting repaired? Or do you use one of the spares while it is in the shop? Don't forget - you need to maintain a level of care in the community.

What protocols will you be operating under? How do you secure the controlled substances (medications) on the apparatus? How do you replace the medications that you've used? Is there a quality improvement program in place to ensure that your paramedics are delivering the highest possible level of care? How do you maintain license and certification levels for paramedics in the department?

Is the transport agency you work with also ALS, or does the paramedic have to jump off the engine and go to the hospital because the ambulance crew is BLS and ALS procedures have been initiated on the patient? If the paramedic/firefighter goes to the hospital with the patient in the ambulance, does the engine have enough manpower to go back in service or does it stay out of service until the paramedic/firefighter is back on the engine? These are many of the questions that need to be answered prior to starting a first responder ALS program.

In many communities where the fire department provides first response and a private ambulance company transports, the private ambulance company actually encourages the fire department to start up an ALS first responder program. Why? In many of these communities, the private ambulance company has a contract. Within the terms of the contract are requirements that the private ambulance company must meet in the community. Besides issues of insurance, monetary terms of the contract, plus others, there is usually a requirement that the company has to have an ALS ambulance on the scene within a certain period of time. In many cases, it is eight minutes, 59 seconds, 90% of the time. However, if the engine company is ALS, "the clock stops" for the private ambulance company and is averaged into its overall response time.

Some communities have even raised the response time requirement for the private ambulance to 13 and 14 minutes since an ALS engine is already on the scene. With contractual response times of 13 and 14 minutes, private ambulance companies can have fewer ambulances on the street, thus saving money. In some of these communities, the fire department charges the private ambulance company for "stopping the clock" through first responder fees.

Another issue to address is documentation. Operating as an ALS engine company requires accurate and detailed documentation of patient treatment. If the fire service does anything poorly, it is documentation of patient encounters. Unfortunately, that documentation is later used as a basis in a lawsuit to determine what transpired on the scene. My experience with a variety of departments has mostly shown poor documentation procedures by paramedic/firefighters on their patient encounter forms. Hopefully, your quality assurance program addresses the issue of proper documentation. Remember, if it was not written down, it was not done.

Going ALS can certainly be a benefit to the community and the patient, but it should not be done on a whim or with little thought and planning. Following a strategic plan with clear objectives will certainly help achieve your goal.