By Dr. Ken Lavelle, MD, NREMT-P
One of the logistical questions for EMS response to a working fire is, ‘How many ambulances and what type?’ Much of this is geographically based – for example, in New Jersey the Advanced Life Support units are in fly cars and are fewer in number. Having a paramedic standing by at a fire may make ALS unavailable for the large part of a county. Another region may be all ALS, which makes the, ‘what type?’ question moot.
Let’s look at a scenario.
A BLS unit is dispatched to a working fire in an old general store in the next due local. The primary EMS is out on another assignment. This is the only ambulance dispatched. Initial reports are for a commercial building well involved, and it quickly reaches three alarms. The primary EMS unit becomes available and the initial unit is recalled. At this point almost 100 firefighters are in service on the fireground, being covered by this one EMS unit.
Is it enough?
In order to answer this question we have to look at what tasks must EMS do at a fire. There are three primary tasks:
• Care and transport of injured civilians
• Care and transport of injured firefighters
• Rehab
At any EMS operation, there needs to be an EMS Branch Director that will report to the Incident Commander. There needs to be an ambulance ready to transport an injured firefighter at all times. Once a firefighter is down and care commences, another crew needs to be ready to step into the stand-by role. If this backup crew must be dispatched from the station, there will be an unnecessary delay and gap in coverage.. If there are injured or trapped civilians, there needs to be an ambulance to transport each person injured. So even if there are no civilians injured, at least two ambulances and one additional provider to fill the Branch Director role should be on sene.
How many providers are needed in rehab? One person will need to be in charge of the sector. Then there needs to be enough staff ready to assess firefighters as they come into the sector so it can be done efficiently. If any of them have complaints, they may need a more involved evaluation which will require more staff. So it is not unreasonable to have at least 4 providers in rehab in addition to the sector leader.
So where are we? For a well-involved structure fire that will require rehab, at least 10 providers staffing two ambulances is ideal. It may be possible to combine some roles, at least initially, but it is unlikely that fewer than six providers will be able to accomplish the necessary tasks. If civilians are injured or there is reported entrapment, then add additional crews on for each. So does that initial single crew meet the needs? Not at all.
What level of care – ALS or BLS?
Command roles can typically be filled by BLS staff. However, there is no way to anticipate if an injured firefighter will have only a sprained ankle or a cardiac event, so the transport ambulances and treating crews should be ALS.
In rehab, the highest medical level needs to be present to make return-to-duty decisions. We have discussed the need for this in previous columns. If the Medical Director/Fire Surgeon is available for scene response, they should be in the rehab sector. If not, a paramedic should be making these decisions based on established protocols and/or phone consultation with a physician. Staff taking vitals and documenting in rehab can likely be BLS.
So both transport ambulances should be ALS, and at least one additional ALS provider in the rehab sector. My recommendation? For a working structure fire, at least two ALS ambulances and an officer should respond for initial action. An additional ALS and BLS ambulance should respond to set up the rehab sector. If staff are able to respond to the scene, or ambulances have more than two providers on the truck, these additional rehab ambulances may be able to be omitted. Don’t forget to ensure that your local is covered for other EMS assignments as well. In most communities, mutual aid will be required, so sit down with your neighboring agencies ahead of time to discuss operational details.