Types of EMS Systems

There are basically five ways that communities go about providing EMS for their citizens:

Fire Department - This is probably the most common of all the options. The fire department has historically been concerned with protecting life. It has offered or provided first aid at fires or other emergencies for most of it's existence. Most consider it only natural that the fire department increase their training and resources to provide more advanced care for the sick or injured. Firefighters are trained to be able to perform several jobs. Communities started training firefighters and taking over medical care in the mid seventies. This happened in both paid and volunteer fire departments although it may have taken a little longer for programs to be implemented in some volunteer systems. In these systems the fire department often responds initially AND provides transportation to the hospital.

Some fire departments have fought against this concept. They don't feel that firefighters should do "double duty". In some fire departments you will find job divisions between trucks and engines. If you are a "truckie" you don't work on an engine, EVER! They can't imagine working on a MICU one day and on an engine the next. Many of these departments are in the more unionized states.

There are many variations of this.

The LA County Fire Department provides EMS and rescue through the use of "Rescue Squads". See below.

The Irving, Texas, Fire department has a somewhat rare program. The fire department provides the ambulance service. There are two firefighters (driver rank) on the MICU, at all times. But in addition to this, every fire engine is also ALS equipped and will have at least one paramedic and two EMTs at all times. Very often you will find at least two paramedics on all fire engines. There can be as many as four paramedics on a fire engine on any given day. Furthermore, the truck companies are responsible for manning the reserve MICU's, if they are needed. This means that there are also paramedics on the trucks. In Irving, you get at least one paramedic, with all the necessary equipment and medications, on virtually every call. If an MICU and an engine is dispatched, the first arriving company will have a paramedic, regardless of what kind of fire apparatus it may be.
See, http://www.ci.irving.tx.us/Fire/

Private Ambulance Service - Some cities have elected to contract out all Emergency Medical Services to private companies. This is probably the second most popular choice. There are large nationwide companies who provide ambulance services to communities. The state of Louisiana has a famous, statewide, service who serves communities and rural areas. This one company employs hundreds, if not thousands, of people. Some fire departments may consider having their fire apparatus respond on medical calls, with the private ambulance service as a form of having the fire department provide EMS ALSO.

It has been brought to my attention that there is a further division of the private EMS types of systems. This is the type of system that is run out of hospitals. In some communities there are ambulances that are part of the area hospital. They are worth noting because they do have some differences. The focus on money (or profit) is different because of the revenue that is received from the patient being admitted for treatment. For this reason the EMS division often does not need to directly show a profit. There is also, sometimes, more medical oversight then you might find in other systems. The actual differences might be slight, but probably worth noting. Many, but not all, air ambulance services are run by hospitals.

Note: It is also possible for the entire fire department to be a private enterprise. A few cities have chosen to contract out fire and rescue services rather than use municipal or civil service employees. The jury is still out on this concept. The largest city ever to do this, Scottsdale, Arizona, has just decided to abandon the practice and go to a municipal fire department.
Story here: http://www.azcentral.com/community/scottsdale/articles/0212sr-fire12Z8.html

Note: A variation of both of the above systems might be where the fire department has trained medical personnel and equipment on all apparatus and responds to all emergency medical calls, but who contracts out to a private ambulance service for transport. This is often referred as a "First Responder" system. This should not be confused with ECA training which can be called "First Responder" training in some systems. It does not have to be an MICU or an "Ambulance" that brings Advanced Life Support to the patient. Some departments have dedicated paramedic units, that are not ambulances. This is not that unusual. LA County has done this since the early 1970's. The show "Emergency" was based upon this department and concept. Today, 57 of the many cities, in and around LA County, contract with the Los Angeles County Fire Department which staffs a total of 163 engine companies, 31 truck companies, 79 paramedic rescue units, and numerous other pieces of specialized apparatus. http://www.lacofd.org/

There is a fine line between sending fire apparatus on medical calls with the ambulance, and being able to say that the fire department provides primary EMS and saying that EMS is provided by a private company. Virtually all fire departments send fire apparatus on at least some calls. These include automobile accidents, heart attacks, unconscious persons etc. These incidents often require more personnel than the two people on an ambulance can handle. An example of a city that sends fire apparatus on all medical calls can be found in Ft. Worth, Texas. In Ft. Worth, all firefighters are trained to the EMT level. Some are trained as paramedics. http://www.fwfd.net/

The Irving, Fire Department provides EMS, through the fire department, which includes fire apparatus responding on medical calls. But all of Irving's engines are ALS equipped. See above.

Third Service - A few communities have elected to create a "Third Service" for providing EMS. This means that a city has a Fire Department, A Police Department, and an EMS department. When someone is hired for that department, that is where they stay. Being a paramedic who decides to become a firefighter, means starting over. The EMS personnel receive little or no training in fire suppression operations. Austin Texas is a major example of this concept. In 1977 the City of Austin expanded it's EMS service to include all of Travis county. So while the fire department is a city function, EMS is a countywide service, run by the city of Austin.
See: http://www.ci.austin.tx.us/ems/

Common issues expressed with private or third service EMS systems.

Some unique problems with the Private Ambulance or Third Service concepts do occur. One of these concerns the living conditions and hours worked by the personnel in each occupation. Often the medical personnel and firefighters are housed in, or work out of, the same buildings. Federal law allows firefighters to work 53 hours a week before paying overtime is required. EMS workers, who are not ALSO firefighters are only allowed to work forty hours a week before you have to pay them overtime. This means that firefighters will usually work 24 on/48 hours off, while EMS workers put in something like eight hour days with rotating night shifts. This apparently breeds resentment and can prevent bonds and comradeship from forming. The two occupations sometimes don't get along. There is also a problem because firefighters are often paid more than private EMS workers (who appear to work more days a month.) If you let EMS workers work 24/48 then they get so much overtime that they end up being paid more than firefighters. If you have a schedule like 10/14 or 24/72 for EMS, they may only work 40 hours a week. But this means that they receive much less pay each week than firefighters OR they receive the same amount for less hours. This causes problems with shift schedules and things like eating arrangements. You also hear of people becoming territorial about their jobs. For whatever reasons, it's rare for these two agencies to get along. Firefighters tend to look down upon the EMS crews, for some reason, and the EMS people feel like the firefighters are not 100% about patient care. There are probably other reasons why this just does not seem to go smoothly. There are probably examples, somewhere, of this system working well, but you don't hear of them very often.

It is common to see a fire department take over EMS from a private service. It is rare to see a private service take over from a fire department. You might see a small community decide to contract with a private ambulance service rather than have their volunteer fire department try to do it. But this is usually just a step in the town's growing process.

In fairness, there are people who will express that EMS has evolved past the point where it should part of another service. They might argue that the job or scope the fire or police departments along with the advancements in prehospital care has created a complexity in all the jobs that deserves specialized training. They feel that each job deserves people who are dedicated to that job alone. Who knows what the future may bring?

Police Department EMS - While this does occur, it is somewhat rare. A few cities have decided to make EMS part of the police department. Here are some examples of PD EMS. (Do you know of others?)
New Castle, Delaware
Gretna, LA

The Public Safety Officer (PSO)- This person is a Police Officer, Firefighter, and Paramedic all rolled into one. There are police officers, in some communities, who carry firefighting gear in the back of their cars. If a fire call comes in, they drive there and, much like Superman, change into another role. In some systems the MICU may have the word "Police" on the front and the paramedics carry firearms. One example of this would be DFW Airport. With four staffed fire stations, covering 30 sq miles, this airport is a small city. (It's larger than the island of Manhattan.) In some communities people will work 24 hour shifts but break it up as 8 hours as a police officer on patrol, 8 hours as a paramedic in an MICU and 8 hours as a firefighter. This can include a change of uniform between each job. But if a major event happens, requiring a large number of police or firefighters, you could be detailed to do any job. In other systems there are strange combinations of jobs and hours on duty. A person may work 10 hours one day and 14 the next. There may be people who will work their 40 hours just on Friday, Saturday and Sunday. The variations are endless. This system appears to work in only the smaller communities.

Other Types of EMS Systems

I should also point out that there are a few state or province run EMS systems. There are also federal or national employees whose job it is to be firefighters or EMS personnel. All military bases have fire departments and so does NASA. But that is a whole different subject. Some nations even have a national fire or EMS service. The ambulance service in the UK is run by the National Health Service. In many countries of the world, the Red Cross operates any emergency ambulance service you may encounter. You can find just about any variation or system, you could think of, if you look long enough.