Controversy for the day.

Here’s another crazy idea for EMS.  I’ve heard it from several people in the past and I think I could get behind it.  What do y’all think?

Let’s separate the emergency response side of EMS from the pure interfacility transport realm.  Emergency calls and emergent responses to healthcare facilities (e.g. nursing homes and physician’s offices calling for a patient to be taken to the emergency department of a hospital) would continue to receive ambulances staffed by emergency medical technicians and paramedics.   Non-emergent interfacility transfers would receive a response from a transfer system.  Transfer systems would be staffed by nurses’ aides and vocational nurses who have received extra training and an endorsement in patient movement, patient transport, and vehicle operations.  As for the true “critical care” patients, the ones on multiple medications and/or ventilatory support, the minimum standard should be a true critical care paramedic.  In other words, a paramedic with a true critical care background (and yes, I realize there are a ton of competing critical care certifications) and possibly backed up by nursing and/or respiratory care practitioners.

A while back, I blogged about owning what you excel at.   EMS excels at providing emergent/acute care interventions on an unscheduled basis.  In other words, 911 calls and emergency responses.  Let’s focus on that.


  1. I like this a lot, but what about dual-purpose systems? You’d have to compensate the loss of scheduled income somehow.

    • theambulancechaser says:

      There are currently fire-based systems where fire and EMS are separate paths. Why couldn’t an “ambulance service” have separate emergency response and non-acute transport divisions?

  2. I agree. From what I understand, Canada moved to a system like that. Very little, if any part of initial EMS education covers taking people home to nursing homes or to and from dialysis. Unfortunately that’s were the money is, at least for now, and the private services in many would not survive from strictly 911 calls.

  3. YankeeMedic says:

    From a business perspective, this makes more sense today than when I first promoted the idea. The only problem I keep running up against is the division of education vs. the pathway. It is difficult to get paramedics to jump from the street to the clinical IFT arena without allowing the street folks to participate in lower level emergency transfers. Perhaps having CCT paramedics available to both street calls and IFTs would promote the pathway.

  4. Joshua Powell says:

    CNAs and LVNs have no ambulance training. EMTs do, let the EMTs continue to do these transfers. Changing it would result in the needles loss of jobs for thousands of BLS providers. You would also have to train these CNAs and LVNs on ambulance operations and they would expect more pay which companies could not afford with the current reimbursement rate. Moreso, alot of CNAs and LVNs are small females, do you really expect them to lift these obese patients. Most private companies do transfers and emergencies. Are you going to have some cars only for dialysis and wound care and some only for emergencies? Private companies cannot afford that. If I am not mistaken, you have only done 911. I see where you are coming from that point of view. But go do dialysis, Dr appts and wound care and you will see why this will not work.

  5. Disagree!!

    First, have you read the AAA guide to high performance EMS? Why duplicate resources? Both types of calls require a fully staffed and stocked ambulance. Having a separate transfer system is a waste of said resources. Why have a system full of 911 ambulances all dressed up with nowhere to go and a transfer system that is overloaded?

    Also, EMS nationally has been set up to allow us to excel at unscheduled acute care situations, but those are not the bulk of what is transported. Even EMS education focuses on acute care. Perhaps we should step back and evaluate what we actually do and set up the system so we excel at filling the need in the community served-IE changing the shape of the peg, rather than forcing that square peg into the round hole.

    So I challenge you- start from scratch. Look at your community, it’s out-of-hospital/office healthcare needs, and set up a brand new system to address them. While I believe it would still have some ambulances, I also believe that it would employ nurses, NP’s/PA’s, social workers, and mental health specialists in a variety of capacities, vehicles, and locations, and many fewer ambulances. Perhaps in this system, transfers could be addressed differently, and perhaps accomplished more efficiently.

  6. Skip Kirkwood says:

    There is some merit to this. Personally, I wouldn’t cite the AAA “High Performance” guide as authoritative – it is the bible by which EMTs and paramedics are ground in to dust.

    The issue is that MOST ambulance “markets” are not large enough to sustain two separate organizations, and you also loose operational flexibility. In other environments, this has already happened – public sector handles 911, while private sector handles IFT (most of NC works this way). Ditto with many big cities – public, fire 911, with private IFT.

    Most private operators, given their way, would only do IFTs, because they can be sure to get paid (or not run the calls). They call that “skimming the cream.” 911 is much more “iffy.”

    The last issue is, new EMTs and medics want to do 911. The only reason quite a number of private operators do 911 at all is to have some attraction for staff. Few really want to do IFTs at all.