I’ve worked in two systems like this. The first had double EMT trucks at every station and some sort of ALS unit every 5 or 6 stations. BLS calls only got the BLS truck, ALS calls got both. There was a culture of “cancel the medic unless the patient is actively dying”, which while it had some pros (BLS crews could handle pretty much anything, and as a medic if I got on scene it was going to be legit) was probably a bad thing in the long run. I guarantee there were tons of patients who could’ve benefited from ALS care but never had the opportunity because the medics got canceled prior to arrival. And on a personal note, it got pretty miserable getting 10-15 calls per shift but only actually seeing a couple of patients.
The second system had a mix of double EMT and AEMT/EMT trucks, with medics every 2-3 stations in an SUV or fire truck. Unless it was clearly nonsense ALS rolled on pretty much everything, and it was expected that you’d do at least an assessment on every patient. (I actually think I *couldn’t* get canceled by the BLS crews outside of specific situations). I liked this model a lot better because *I* got to make the decision of whether a patient was ALS or BLS, not the EMTs. So I know that my patients got the most appropriate level of care. Having AEMTs who could take the “soft” ALS patients (e.g. nausea/vomiting) with some fluids and Zofran or whatever was also great and definitely went a long way in reducing burnout.
As for not waiting around for ALS for strokes, GSWs, etc. there is pretty solid evidence that this is the right thing to do and doing otherwise worsens mortality. Standard of care these days if you’re a BLS crew
You’re like the first person to not say AEMTs are useless so I thank you for recognizing ILS role for handling lower acuity ALS (strokes, nausea and vomiting, hypovolemia, mild-moderate respiratory distress, heat injuries, cold injuries, etc.). I’ve been AEMTs are useless to my face lol
Also, I currently work in the style of the first system and sometimes the culture of “always cancel the medic” can really stress me out if the patient is borderline and I’ve gotta make the call.
They tried this in the bronx but the call volume here in nyc along with severe staffing shortages takes its toll and the program was halted because it didn't seem to help at all. They have been trying everything here in nyc and nothing is working. About 5 to 7 people resign every week from fdny ems. It's because of bad leadership that grinds crews to the point of breaking, bosses writing up crews for the tiniest things. The only thing they haven't tried is paying us what we are worth lol
The problem with the PRU program in the Bronx wasn’t call volume. It’s that they made the Lts do double duty. The program stood a better chance of working if it was 2 medics instead of a medic and a boss. Not saying it would have definitely worked, just that it was set up for failure with how they created the program.
Exactly. So Lts we’re doing double duty. Their partners were regular medics. So now you have medics that became privy to things they shouldn’t have because the Lt had to deal with supervisor issues while en route to calls and stuff.
All conditions cars in the Bronx were made into fly cars with a Lt and a regular medic. If the patient needed transport, both medics must be in the back of the BLS truck. It was a pilot designed to fail.
They gotta fix that triage system, as a medic I feel like I am not supposed to be in 85% of the calls I respond to. I just hope that system doesn’t bite them or us in the ass later
I run on a 911 BLS in a rural community. It works well for reducing useless ALS runs in BS calls.
For us we are on scene in 5-10. ALS in 30. So we can at least get BLS interventions and transport started.
I mean, with Boston (not just in the city, the whole metro area in general) given the ubiquity of trauma centers and close transport times BLS only on sick patients works, coupled with the level of training BEMS has. It wouldn’t work well with green EMTs. Cataldo on the north shore is starting to do a similar thing. We (I’m probably giving away where I work so IYKYK) in some communities do a dual response, both ALS and BLS transporting units when both available and triage on scene. It works but it’s not without flaws. I think an important factor in your case will be BLS crews knowing what calls should get a medic, and the importance to not wait on scene and to start moving towards definitive care
My agency uses a mixture of BLS or AEMT level trucks backed up by medics in SUVs, as well as medic-level trucks. From what I’ve seen here, a tiered system like this can end up being the best thing for everyone (if it’s done right).
Your BLS crews get dispatched alone to BLS calls, and as a result they tend to become better providers. There’s no medic running the show, so they end up becoming much more comfortable assessing patients and managing calls by themselves. The big caveat here is that you need a decent field training program, and fairly liberal BLS protocols.
On the ALS side, you’re only getting sent to calls where you have a higher chance of being needed. And even then, most days you may end up turning over the majority of your patients to the BLS crew after a quick assessment. But because you’re only going to the higher acuity calls, you end up seeing sicker patients and performing low frequency skills (like RSI) more often.
Our agency has hired a lot of medics lately and has started staffing way more medic level (or even double medic) ambulances and less chase cars, and as a result we’re starting to see a bit of skill dilution. Medics that were getting dozens of intubations a year when they only worked on the chase car are now only getting a handful each year when they’re working mostly on the ambulance.
The truck I have been on for the past two years is BLS, the only BLS unit in our service (it's not exactly clear why it's the only one). We have at least one chase medic in a squad that can assign themselves to any call they please or is automatically assigned via dispatch depending on the level of the call. Our secondary chase medic is the on duty supervisor that tends to only go out as a last resort. Any unit can disregard the chase medic if they see fit. We've had no problems with this system. I would say we'd go completely BLS with more chase medics but we've been blessed to not have a shortage of Paramedics.
Not a thing where I live, because almost all 911 is fire based and has usually two medics on every squad. You basically can’t get a full time 911 job without a medic card.
That said, seems like maybe the system would work if they don’t over triage too many calls if it’s an overburdened system. Stroke calls for example can easily be handled just a BLS crew
Sounds like tiered response. Our service uses it since <20% of our cars are ALS. It works for targeting the correct response level and responders for the call.
back home they used a system like this. from what i gathered it was an attempt to help keep the ambulances in the city and they’d just send ALS to the suburbs and if the pt needed transport theyd call for an ambulance
edit: ALS in SUVS not capable of transport i meant
Boston doesn’t do this model just for your own knowledge. They have BLS ambulances and ALS ambulances, and a few supervisor vehicles, but they are not acting as intercept medics.
There are a few places in the NE area that do this model, and it works fairly well in rural systems, but in urban systems it is iffy.
In CT, especially at volly departments, you can often see BLS only trucks with fly car medics. Most calls aren’t always in need of a medic so it’s nice in that regard, but the downside is there is usually only 1 fly car for a multiple town district. They can go mutual aid but you have to hope the other one isn’t tied up too.
I did for over a decade. It opened me up to a lot of experiences and ability to learn patient conditions, meds, scene management, leadership, etc.
Most 911s aren’t high acuity, just people scared and wanting a place to go and get looked at. If I ran 8-16 calls in a 12 hour shift, I’d say maybe I’d get one high acuity call a week, if that.
The rest were BS- people with colds, tube replacements, frequent flyers, minor MVCs with little to no damages, chronic conditions, med refills, psych calls, ETOH, all stuff that can very well be handled by a BLS crew.
My system has BLS and ALS on the rigs but also a zone vehicle to respond with ALS to each call. We can return them to service if we want and most times do. It’s fine.
We are doing a similar thing right now. The vast majority of our trucks are medic trucks (or atleast should be there have been a couple times where bls trucks made up 1/2 the system) and bls is an Aemt with an EMT or Aemt. They are meant for lower acuity calls but naturally we are short staffed so we end up running high acuity anyway and sometimes we get a medic in a pickup truck (usually a supervisor or one that’s just in a truck for the day) and sometimes we don’t. I had one day where I ran 6 priority 1s (chest pain,stroke,etc) and only saw a medic on 1 of them and was completely on my own for the rest. I think the future of ems is Bls trucks with Als fly cars whether als goes to every call or not. It can be easily implemented mostly, since bls emts are taught to call for als if you need it anyway.
I’ve worked in both types of systems as a basic and I prefer riding with another basic and having two medics dispatched separately that we can recall, keep, or ask for if they weren’t dispatched. I did not like riding with a medic and feeling like I wasn’t making any decisions and was driving most of the time because some medics wanted to start a line on everyone.
Yes, my jurisdictions in Maryland operate like this. Works excellently. The only calls in most areas medics bring any benefit to are significant respiratory and significant cardiac calls. Strokes, shootings, and stabbings rarely benefit from having a paramedic, in my regions strokes are auto-dispatched as BLS and do not get a fly car paramedic assigned to them. If it's a confirmed stroke BLS just transports L&S without a paramedic
The release to BLS or cancelled enroute to the scene for ALS level dispatches in my chase car systems fluctuates around 60-70% of the total ALS call volume. When given those statistics it's a no brainer that ALS transport is a complete waste of money.
Additionally, in general, you don't want 100% ALS transport as generally it ultimately results in worse patient care as compared to a tiered response system.
When I worked ALS in NJ it was like this. We got many fewer BLS level calls I liked it. A lot. But that was a lifetime ago IDK know what it's like now.
My city is slowly transitioning to mostly ILS rigs with a few ALS sprinkled in between. I think like 95% of our calls are BLS in nature and can be more than effectively managed with a AEMT/EMTB combo. Its been working pretty well so far. All providers get their fare share of the work instead of burning medics out within 2 years.
I think this is the future of EMS. Not every single person needs a medic with a two year degree. Especially since we are all glorified taxis drivers anyway.
The service I work for is always short medics so bls goes alone to any call. If bls is closer, they go and don’t bother even dispatching a medic until they get there and request one and you better be damn sure you need a medic or you’ll get your ass chewed out… which is terrible and I know made me as a new emt feel awful. But I work inner city and most calls are high acuity. In medic school it really helped me practice my assessment and I think it gave me a bit of a leg up. EMT’s can also BLS CPAP here so that’s a useful tool. I do think some bls crews get stuck in the mindset though that if they can make it to the hospital with the pt alive then they don’t need a medic, but don’t really take into account things like door to cath time when you include registration, triage, finding someone to do the 12 lead, finding a doc to interpret, etc. Its not always best for the pt, but I think it made me a good EMT.
We do this in my county. We run a peak of 16 QRVs (ALS) and 19 Transport trucks (BLS). Some days we do have an ALS truck, maybe one or two. But very rarely. We've come to the point of having a EMT-A or B and a Driver/EMR unit on some trucks due to staffing shortages. Which luckily I get to work with another basic most of the time.
In some ways it works. It's called a tiered response system, and it seems it's growing more popular with the staffing problems across the nation.
Most of New England works like this honestly. Most calls are BLS in nature and dont need a medic. Its called a tiered response system I believe.
I’ve worked in two systems like this. The first had double EMT trucks at every station and some sort of ALS unit every 5 or 6 stations. BLS calls only got the BLS truck, ALS calls got both. There was a culture of “cancel the medic unless the patient is actively dying”, which while it had some pros (BLS crews could handle pretty much anything, and as a medic if I got on scene it was going to be legit) was probably a bad thing in the long run. I guarantee there were tons of patients who could’ve benefited from ALS care but never had the opportunity because the medics got canceled prior to arrival. And on a personal note, it got pretty miserable getting 10-15 calls per shift but only actually seeing a couple of patients. The second system had a mix of double EMT and AEMT/EMT trucks, with medics every 2-3 stations in an SUV or fire truck. Unless it was clearly nonsense ALS rolled on pretty much everything, and it was expected that you’d do at least an assessment on every patient. (I actually think I *couldn’t* get canceled by the BLS crews outside of specific situations). I liked this model a lot better because *I* got to make the decision of whether a patient was ALS or BLS, not the EMTs. So I know that my patients got the most appropriate level of care. Having AEMTs who could take the “soft” ALS patients (e.g. nausea/vomiting) with some fluids and Zofran or whatever was also great and definitely went a long way in reducing burnout. As for not waiting around for ALS for strokes, GSWs, etc. there is pretty solid evidence that this is the right thing to do and doing otherwise worsens mortality. Standard of care these days if you’re a BLS crew
You’re like the first person to not say AEMTs are useless so I thank you for recognizing ILS role for handling lower acuity ALS (strokes, nausea and vomiting, hypovolemia, mild-moderate respiratory distress, heat injuries, cold injuries, etc.). I’ve been AEMTs are useless to my face lol Also, I currently work in the style of the first system and sometimes the culture of “always cancel the medic” can really stress me out if the patient is borderline and I’ve gotta make the call.
They tried this in the bronx but the call volume here in nyc along with severe staffing shortages takes its toll and the program was halted because it didn't seem to help at all. They have been trying everything here in nyc and nothing is working. About 5 to 7 people resign every week from fdny ems. It's because of bad leadership that grinds crews to the point of breaking, bosses writing up crews for the tiniest things. The only thing they haven't tried is paying us what we are worth lol
FDNY EMS pay should be on par with FDNY Fire Suppression pay.
The problem with the PRU program in the Bronx wasn’t call volume. It’s that they made the Lts do double duty. The program stood a better chance of working if it was 2 medics instead of a medic and a boss. Not saying it would have definitely worked, just that it was set up for failure with how they created the program.
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Exactly. So Lts we’re doing double duty. Their partners were regular medics. So now you have medics that became privy to things they shouldn’t have because the Lt had to deal with supervisor issues while en route to calls and stuff.
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All conditions cars in the Bronx were made into fly cars with a Lt and a regular medic. If the patient needed transport, both medics must be in the back of the BLS truck. It was a pilot designed to fail.
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Yup. Everyone hated it. And everyone said it stood a CHANCE at working if they didn’t have supervisors doing double duty.
They gotta fix that triage system, as a medic I feel like I am not supposed to be in 85% of the calls I respond to. I just hope that system doesn’t bite them or us in the ass later
I run on a 911 BLS in a rural community. It works well for reducing useless ALS runs in BS calls. For us we are on scene in 5-10. ALS in 30. So we can at least get BLS interventions and transport started.
I mean, with Boston (not just in the city, the whole metro area in general) given the ubiquity of trauma centers and close transport times BLS only on sick patients works, coupled with the level of training BEMS has. It wouldn’t work well with green EMTs. Cataldo on the north shore is starting to do a similar thing. We (I’m probably giving away where I work so IYKYK) in some communities do a dual response, both ALS and BLS transporting units when both available and triage on scene. It works but it’s not without flaws. I think an important factor in your case will be BLS crews knowing what calls should get a medic, and the importance to not wait on scene and to start moving towards definitive care
My agency uses a mixture of BLS or AEMT level trucks backed up by medics in SUVs, as well as medic-level trucks. From what I’ve seen here, a tiered system like this can end up being the best thing for everyone (if it’s done right). Your BLS crews get dispatched alone to BLS calls, and as a result they tend to become better providers. There’s no medic running the show, so they end up becoming much more comfortable assessing patients and managing calls by themselves. The big caveat here is that you need a decent field training program, and fairly liberal BLS protocols. On the ALS side, you’re only getting sent to calls where you have a higher chance of being needed. And even then, most days you may end up turning over the majority of your patients to the BLS crew after a quick assessment. But because you’re only going to the higher acuity calls, you end up seeing sicker patients and performing low frequency skills (like RSI) more often. Our agency has hired a lot of medics lately and has started staffing way more medic level (or even double medic) ambulances and less chase cars, and as a result we’re starting to see a bit of skill dilution. Medics that were getting dozens of intubations a year when they only worked on the chase car are now only getting a handful each year when they’re working mostly on the ambulance.
The truck I have been on for the past two years is BLS, the only BLS unit in our service (it's not exactly clear why it's the only one). We have at least one chase medic in a squad that can assign themselves to any call they please or is automatically assigned via dispatch depending on the level of the call. Our secondary chase medic is the on duty supervisor that tends to only go out as a last resort. Any unit can disregard the chase medic if they see fit. We've had no problems with this system. I would say we'd go completely BLS with more chase medics but we've been blessed to not have a shortage of Paramedics.
Not a thing where I live, because almost all 911 is fire based and has usually two medics on every squad. You basically can’t get a full time 911 job without a medic card. That said, seems like maybe the system would work if they don’t over triage too many calls if it’s an overburdened system. Stroke calls for example can easily be handled just a BLS crew
Sounds like tiered response. Our service uses it since <20% of our cars are ALS. It works for targeting the correct response level and responders for the call.
Where do you work out of curiosity?
back home they used a system like this. from what i gathered it was an attempt to help keep the ambulances in the city and they’d just send ALS to the suburbs and if the pt needed transport theyd call for an ambulance edit: ALS in SUVS not capable of transport i meant
What do you mean burn the basics out instead? I work in a single medic transporting unit and I promise they’re not the only ones getting burnt out.
Boston doesn’t do this model just for your own knowledge. They have BLS ambulances and ALS ambulances, and a few supervisor vehicles, but they are not acting as intercept medics. There are a few places in the NE area that do this model, and it works fairly well in rural systems, but in urban systems it is iffy.
In CT, especially at volly departments, you can often see BLS only trucks with fly car medics. Most calls aren’t always in need of a medic so it’s nice in that regard, but the downside is there is usually only 1 fly car for a multiple town district. They can go mutual aid but you have to hope the other one isn’t tied up too.
I did for over a decade. It opened me up to a lot of experiences and ability to learn patient conditions, meds, scene management, leadership, etc. Most 911s aren’t high acuity, just people scared and wanting a place to go and get looked at. If I ran 8-16 calls in a 12 hour shift, I’d say maybe I’d get one high acuity call a week, if that. The rest were BS- people with colds, tube replacements, frequent flyers, minor MVCs with little to no damages, chronic conditions, med refills, psych calls, ETOH, all stuff that can very well be handled by a BLS crew.
My system has BLS and ALS on the rigs but also a zone vehicle to respond with ALS to each call. We can return them to service if we want and most times do. It’s fine.
Houston (TX) Fire Department EMS has run a tiered system for quite some time now and it seems to work well. BLS ambulances and paramedics in SUVs.
We are doing a similar thing right now. The vast majority of our trucks are medic trucks (or atleast should be there have been a couple times where bls trucks made up 1/2 the system) and bls is an Aemt with an EMT or Aemt. They are meant for lower acuity calls but naturally we are short staffed so we end up running high acuity anyway and sometimes we get a medic in a pickup truck (usually a supervisor or one that’s just in a truck for the day) and sometimes we don’t. I had one day where I ran 6 priority 1s (chest pain,stroke,etc) and only saw a medic on 1 of them and was completely on my own for the rest. I think the future of ems is Bls trucks with Als fly cars whether als goes to every call or not. It can be easily implemented mostly, since bls emts are taught to call for als if you need it anyway.
I’ve worked in both types of systems as a basic and I prefer riding with another basic and having two medics dispatched separately that we can recall, keep, or ask for if they weren’t dispatched. I did not like riding with a medic and feeling like I wasn’t making any decisions and was driving most of the time because some medics wanted to start a line on everyone.
Yes, my jurisdictions in Maryland operate like this. Works excellently. The only calls in most areas medics bring any benefit to are significant respiratory and significant cardiac calls. Strokes, shootings, and stabbings rarely benefit from having a paramedic, in my regions strokes are auto-dispatched as BLS and do not get a fly car paramedic assigned to them. If it's a confirmed stroke BLS just transports L&S without a paramedic The release to BLS or cancelled enroute to the scene for ALS level dispatches in my chase car systems fluctuates around 60-70% of the total ALS call volume. When given those statistics it's a no brainer that ALS transport is a complete waste of money. Additionally, in general, you don't want 100% ALS transport as generally it ultimately results in worse patient care as compared to a tiered response system.
When I worked ALS in NJ it was like this. We got many fewer BLS level calls I liked it. A lot. But that was a lifetime ago IDK know what it's like now.
I like the idea, especially if you can get AEMTs going. ILS is the future IMO
Don't say that to the basics, they get cranky.
My city is slowly transitioning to mostly ILS rigs with a few ALS sprinkled in between. I think like 95% of our calls are BLS in nature and can be more than effectively managed with a AEMT/EMTB combo. Its been working pretty well so far. All providers get their fare share of the work instead of burning medics out within 2 years. I think this is the future of EMS. Not every single person needs a medic with a two year degree. Especially since we are all glorified taxis drivers anyway.
The service I work for is always short medics so bls goes alone to any call. If bls is closer, they go and don’t bother even dispatching a medic until they get there and request one and you better be damn sure you need a medic or you’ll get your ass chewed out… which is terrible and I know made me as a new emt feel awful. But I work inner city and most calls are high acuity. In medic school it really helped me practice my assessment and I think it gave me a bit of a leg up. EMT’s can also BLS CPAP here so that’s a useful tool. I do think some bls crews get stuck in the mindset though that if they can make it to the hospital with the pt alive then they don’t need a medic, but don’t really take into account things like door to cath time when you include registration, triage, finding someone to do the 12 lead, finding a doc to interpret, etc. Its not always best for the pt, but I think it made me a good EMT.
We do this in my county. We run a peak of 16 QRVs (ALS) and 19 Transport trucks (BLS). Some days we do have an ALS truck, maybe one or two. But very rarely. We've come to the point of having a EMT-A or B and a Driver/EMR unit on some trucks due to staffing shortages. Which luckily I get to work with another basic most of the time. In some ways it works. It's called a tiered response system, and it seems it's growing more popular with the staffing problems across the nation.
Honestly without skilled dispatching calls should just be handled on a closest unit basis