Fire service emergency medical services (EMS). Fire service advanced life support (ALS). Sounds pretty good. Feels pretty good to say. These words almost go together as well as peanut butter and jelly. Some fire departments may say that they go together like cheese and wine (or whine). It does not matter what type of system you are involved in - volunteer or paid - EMS delivery has become a way of life and an expectation for today's firefighters. Lets look at three factors that have moved us from basic life support first responder companies to full-fledged ALS companies with all of the bells and whistles. These three factors are: public expectation, decline in volunteerism, and consolidation of services.
The Highway Safety Act of 1966 that created the U.S. Department of Transportation (USDOT) and the National Highway Traffic Safety Administration (NHTSA) also provided financial support to states to improve their EMS programs and to develop ALS training courses. Dr. Eugene Nagel conducted one of the first recognized paramedic training programs when he trained Miami firefighters at the University of Miami School of Medicine in 1967. This was the beginning of the delivery of advanced life support procedures outside of a hospital by non-physicians.
When we compare the age of prehospital ALS care to the evolution of the American Fire Service with a history of 250+ years, we can see that prehospital ALS is merely a youngster who is rapidly maturing. Throughout our proud history, fire departments were called upon to provide basic levels of emergency medical care, and in some cases to provide transport for victims of accident or illness. Some of the initial prehospital ALS programs were fire service based, however, many more were operated by hospitals, private businesses, or volunteer rescue squad agencies.
During the early 1970's when ALS programs were emerging, people were exposed to the television heroics of Johnny and Roy and the members of Station 51. This show, Emergency!, was followed by many more, like Emergency 911, and more recently the reality based shows like The Bravest. The people that we serve today have expectations of you and your department's service capability in part due to television exposure. There should be no doubt that a motivator for fire service ALS has been to meet citizen expectations, community standards, and/or just to keep up with the Jones' (the neighboring department).
Decline in Volunteerism
Another force in moving ALS equipment to the engine company (or ladder, heavy squad, etc.) has been the decline in volunteer ambulance agencies. Across America, recruitment and retention of volunteer members, whether purely EMS, fire, or both, is a hot topic. Checkout the next conference brochure or ad that you come across and almost certainly there will be a class or workshop on this topic. Even paid organizations are searching for ways to improve recruitment and retention. This decline in volunteerism - for whatever reason(s) - has caused fire service leaders to answer the call of citizens and politicians alike. As is frequently the case, when a community need arises, the fire department is looked upon for the answer. We have embraced this challenge and we are learning and growing everyday.
Consolidation of Services
Many of today's ALS fire departments were born out of economic necessity. The mantra "do more with less" could have been the battle cry of city and county administrators during the 1980's. As a result, combining EMS and fire service delivery into one package was a sought after answer. This merging of services may involve the fire department taking over operations from contract (private) EMS or 3rd agency EMS services. These models brought EMS under the fire department umbrella of coverage. The manner of service delivery under the umbrella is not necessarily the same from department to department. Some fire departments maintain separate fire and EMS divisions. Others have partially combined programs. Another merger fashion is for the two distinct divisions to fully merge so that a new department is born. Firefighters and paramedics in this type of set-up are fully cross-trained and serve dual roles. Regardless of the make-up of the ALS delivery model, the end result is the placement of traditional ALS gear on nontraditional ALS vehicles, i.e., the engine company.
Regardless of the cause that brings ALS to your fire truck, the fact is that it is here to stay. If your department is on the path to ALS delivery - hold on. The ride will be fantastically enlightening and rewarding. There are growing pains to overcome, just like the awkwardness of a first date and a new personal relationship. Over time and with the proper leadership and attitudes, the growing pains will fade and the awkwardness will wane. In another 150 years, as a few more generations are brought up through the fire service that delivers ALS care, our great- grandchildren will find it hard to believe that we ever did it differently.
Future articles will look at the many issues related to delivering ALS from nontraditional apparatus. We will review the pros and cons. We will discuss issues like the delivery of patient care, the implications for the company officer as the supervisor on these types of calls, command and control of multiple patient incidents, and equipment, training, and on-going continuing education needs of the ALS engine company crew. We will meet these goals through review of actual incidents and case studies. By sharing lessons learned, together, we can assist each other on this journey.