Too Many Medics? Debating a Tiered Response vs. All-ALS EMS System

There’s been an ongoing debate in EMS, emergency medicine and fire service literature regarding whether or not having too many paramedics practicing at the ALS level leads to skill degradation and negative patient outcomes.

These concerns have stemmed from the growing number of ALS-only EMS systems across the United States–a departure from more regionalized systems of ALS, where a paramedic unit (or units) served a number of communities that were supported by BLS services.

These systems are largely being replaced by instituting paramedic services in all communities, and includes both paramedics staffing ambulances as well as first responding engine companies. This has led to the “paramedic on every corner” philosophy that’s a good sell to communities and its constituents.

In a recent editorial in Firehouse Magazine, Chief Gary Ludwig argues that more paramedics isn’t necessarily a bad thing.

The argument that scaffolds Chief Ludwig’s argument is that even if paramedics aren’t getting skill maintenance in the field, these skills can be maintained through practice through simulation or in a skills lab setting. He argues that by the same logic, we should have fewer firefighters based on the decreased number of fires in the past 25 years.

JEMS: Ambulance Crew Configuration: Are Two Paramedics Better Than One?

It’s true, fires have decreased in the last few decades, which has led to a change in the landscape of the fire service and the services they provide. It’s true as well that the provision of EMS needs a re-evaluation, providing the services that best meet the needs of the community.

To argue that more is better, however, isn’t really the answer. Better is better, and that all comes down to skills and training. It also means that fewer, highly trained, well-educated professionals should be the ones who are providing it. I think Chief Ludwig would agree: having a small group of excellent firefighters is better than having a whole lot of adequate ones–or worse yet, below-average ones.

Tiered Response vs. All ALS

To answer the question of, “is more really better?”, it’s important to first evaluate the benefits of regional paramedics vs. an all ALS-system. In the tiered response system, paramedic (ALS) units are staffed to cover several regionally approximate communities, one large urban area or some combination of both. This tiered-response model is supported by the provision of BLS care either by the fire service or private EMS.

The benefit of this is that communities can develop excellent BLS providers who can activate ALS when it’s appropriate, using clinical gestalt that’s supported by protocols. This would mostly include emergencies where an immediate intervention, such as airway management, administration of medications, or advanced procedures like needle chest decompression are required. The ALS interventions that are truly time sensitive are few in number and in the tiered response EMS system, ALS services are reserved for these circumstances.

The result of a tiered response system is that the paramedics in this system are typically engaged in the provision of more advanced level care, allowing for maintenance of clinical decision-making, diagnostic acumen and practical skills maintenance.

The volume of EMS calls that are likely to require ALS is actually quite small. The data in the literature on this is now decades old, but it’s estimated that only between 2—20% of calls may require an advanced intervention.1,2,3 Considering the advent of automated external defibrillators, the increased use of epinephrine autoinjectors and naloxone among BLS providers and the de-emphasis of advanced airways and medications in advanced cardiac life support, these figures may be a conservative estimate. Those who are proponents of the tiered response system support that fewer is more, as the paramedics in this system are practicing at a higher volume. The system benefits as well in that patients are triaged more appropriately, which likely has some financial impact as well.

In an all-ALS system, every ambulance–and in some cases non-transporting engine companies–are staffed by paramedics. This increases access to paramedic services for all emergency calls for service. Those who favor the all-ALS system argue that faster on-scene times and more ALS providers on a single scene is beneficial, despite the paucity of data to support it. There’s potentially some advantage to quicker access to ALS, as response times of an ALS unit may be shorter in some critical scenarios. There’s been some argument that more paramedics on scene can lead to better patient care, although the limited research in this area argues this isn’t the case.1

Where the answer lies is difficult to navigate, because the quality and quantity of the literature supporting the all-ALS system is practically nonexistent. Few of the available articles on this topic are authored by the very people it effects the most: the EMS providers. Most EMS research is driven by physicians, which ultimately means we aren’t navigating our own ship.

Skill maintenance seems to focus mainly on intubation, something that–although important–speaks to only a very small part of what EMS providers do. Recognition of critical illness, expert clinical decision-making and diagnostic acumen are rarely accounted for in these research studies, but are likely far more important. This skill set definitely comes from practice and pattern recognition, something that’s difficult to reproduce even in the best simulation setting.

Looking at other medical practice settings, volume does equal mastery. This is true in surgery, in cardiac catheterizations and in anesthesia.5—7 We suspect that the same is true in EMS. Paramedics who practice their trade with greater frequency are more likely to have the necessary skill set when it’s needed the most.

This also shouldn’t be about fire service vs. private or third service, municipal EMS. The fire service can develop tiered response systems that are regionalized and cooperative as well. In fact, some of the best examples of this come from the fire service. This is all about developing the best EMS system, or better yet, developing an EMS system.

Navigating Our Own Ship

What this should look like involves better paramedic training with minimum degree requirements, improved access to ongoing education, as well as a practice environment that can help ensure adequate volume and skills maintenance as clinicians. It also means that we need to be the drivers of the research that evaluates and re-evaluates these programs to ensure efficacy. The focus of this research needs to be on patient-oriented outcomes and needs to clearly demonstrate the efficacy of the system in place.

Chief Ludwig isn’t wrong. Having a large pool of paramedics can be a good thing. They need to be highly trained and there need to be systems in place to ensure skill maintenance.

The product that paramedics deliver extends well beyond simple skills. It includes clinal decision-making, pattern recognition and diagnostic acumen that can’t always be taught in a simulation lab. Just like you don’t need the hazmat unit for every fire call, or a SWAT team for every law enforcement response, you don’t always need ALS either. When you need them, you need them–and you want them to be at the top of their game.

It’s true: “more” is better! But the “more” is: more education, more research and more patient volume.


1. Hagiwara S, Oshima K, Aoki M, et al. Does the number of emergency medical technicians affect the neurological outcome of patients with out-of-hospital cardiac arrest? Am J Emerg Med. 2017;35(3):391—396.

2. Stratton SJ. Triage by emergency medical dispatchers. Prehosp Disast Med. 1992;7(3):263—267.

3. Ryynänen OP1, Iirola T, Reitala J, et al. Is advanced life support better than basic life support in prehospital care? A systematic review. Scand J Trauma Resusc Emerg Med. 2010;18:62.

4. Curka PA, Pepe PE, Ginger VF, et al. Emergency medical services priority dispatch. Ann Emerg Med. 1993;22(11):1688—1695.

5. Ballal RS, Eisenberg MJ, Ellis SG. Training in cardiac catheterization at high-volume and low-volume centers: Is there a difference in case mix? Am Heart J. 1996;132(2 Pt 1):460—462.

6. Fix ML, Enslow MS, Blankenship JF, et al. Emergency medicine resident anesthesia training in a private vs. academic setting. J Emerg Med. 2013;44(3):676—681.

7. Maruthappu M, Gilbert BJ, El-Harasis MA, et al. The influence of volume and experience on individual surgical performance: A systematic review. Ann Surg. 2015;261(4):642—647.

No posts to display