Monday, January 10, 2011

EMS 201 for Crime Writers


It seems like time for the second installment of information about EMS (Emergency Medical Services) in the USA, intended to help writers understand things from my own experience working on the local ambulance and being part of the country, state, and national networks that encompass our little unit.

If you missed the first part, you can click on the lick in the bar at the top of the page.  I could easily link to it here, but I'm trying to reinforce the use of the bar.  This may be a lingering mood from working with clients all day; I'm not sure.

At any rate, what I wanted to cover today, in brief, is the typical sequence of emergency response.  I've noticed that this is one area where people typically have no clue other than what they see on TV and piece together from their own experience and their sense of logic.

So here you go in quick form:

1. Person calls 911 or activates LifeLine (who then alert 911).

2. 911 dispatches as necessary police, fire, and ambulance.  Each service often has another dispatcher internal to it that is the contact point for 911.

3. Units arrive on scene (if dispatched) in the same order: police, then fire, then ambulance.

4. If the ambulance that was dispatched offers Basic Life Support only, that crew will make the determination and call their own dispatch to ask for Advanced Life Support or a helicopter transport.

There can be a little variation in this sequence, but honestly not very much.  Here's why:

  • The police can get anywhere faster.  Their cars are faster than our trucks, they have a little more legal freedom, and they are already mobilized and not needed to load up from a station.  The police are are responsible for securing the scene.   If the scene needs the police, even if the other services somehow get there first, they will almost always wait for the police to arrive and make sure the scene is safe.  Our number one priority is not the patient's health; it's the safety of our crew.  If our crew isn't safe, the patient isn't safe either.
  • The fire crew is also the rescue squad in most situations.  That means they are the ones who are responsible for extricating patients from cars and stuff like that.  There is no point in an ambulance getting there first.  They also are often able to respond more quickly, because there are more fire units than there are ambulance units, and so they have a better distribution.
  • The ambulance is where the EMTs or paramedics work.  While many fire crews have EMTs on them, and even some police departments, most jurisdictions defer care decisions to the EMTs who are on ambulances.  It is those folks who make the determination if more advanced services are needed or a helicopter might be appropriate.
So that's the order -- police, then fire, then ambulance, then helicopter (if appropriate).  There are few exceptions to this sequence in most jurisdictions, though obviously not every service is required at every scene.

Finally, a clarification about helicopters.  Helicopters are rarely faster than ambulances.  When they are, it is usually because there is intervening terrain or traffic that makes travel by road difficult.  Otherwise, it is so much quicker to mobilize an ambulance than an aircraft, that there is often not a whole lot of patient time gained in the end.   When that's the case the main reasons to go with a helicopter are (a) to minimize transport time itself, or (b) to expedite delivery of the patient to a specialty center.  Sometimes the total patient care time is not what's critical; what's critical is minimizing the time that the patient is being moved, and sometimes a helicopter can provide that.  Most ambulances cannot  bypass their own hospital system as easy as helicopter, so in a case when the EMT determines a trauma, burn, or other specialty care center is necessary, they may ask for a helicopter to ensure a beeline (almost literally) to that center.

Well, that's it for tonight.  Hope it's helpful, and if you have any other questions, just let me know!


The soundtrack for writing this post was provided by Cracker.


  1. Awesome. This post was very helpful!

    Here is a scenario question for you: Police is at the scene and finds victims with injuries. They ask for EMTs to be rolled out immediately, both for the two felons they kicked the crap out of, and the two victims.

    Does the dispatcher still dispatch Fire? This is a small town small enough to be served by the Sheriff department and not their own police force.

    Also, let's say that the dispatcher doesn't have any knowledge of, but does suspect, that there would be injured victims. Does she "prep" the various EMT/Fire units for when the scene is secure, she can roll them out ASAP?

    And how about if there are reports of shots fired while the police are at the scene, but not from the police themselves. Let's say several people call 911 about the shots but don't see anything. Obviously the police dispatcher is going to do something, but would the Fire/EMTs get ready to roll?

  2. @Anthony - Glad it helped! Let me take your questions in order:

    1) Most towns that size will have a volunteer fire department and it will often be closer than the nearest ambulance unit, even if (as in our county) there are local volunteer ambulances, too. More fire than ambulance. So in a lot of situations like that, fire would very likely be dispatched for, "ambulance assist." They will get on scene first and act as first responders, providing some basic emergency management.

    2) A dispatcher would not be likely to make the call to alert other services, but the police might ask for emergency services to be put on "stand by." Depending on the circumstances, that may meant the dispatcher holds onto it but started figuring out which units to tone out. It could also mean that the dispatcher sends out a radio communication along the lines of, "Jefferson County Medic 2, stand by for tones." And sometimes it can mean that the emergency units are dispatched but asked to approach without lights and sirens and to stop a few blocks away and away a signal to proceed or return to station.

    3) Most of the time if there are reports of shots the police will be dispatched without other emergency services going onto stand-by. Typically, the police will make that call when they arrive on-scene and find a victim. However, if there have been reports or prior calls for domestic abuse or something like that, the police may request EMS support as soon as they get the call to go to that address for shots fired.

    Those answers make sense?

  3. Yes, all of that made sense.

    In a novel I wrote I have an intense chapter (my beta readers favorite, even though it was grim as hell) dealing with a sheriff FTO and her rookie. I had a seasoned police officer review the police procedures, but he missed the Fire/EMT response mistakes I made based on your post.

    I did get the air ambulance being asked for by the senior EMT who responded correct, though. :-)

    Which leads me to this question: can a medical helicopter take more than one patient to the same Trauma Center? If there are two serious victims, would they simply dispatch two?

    Thanks! This was very helpful.

  4. Interesting post. One little question, Nevets. What does EMT stand for? (And no. I'm not mocking either.)

  5. Thats news to me. The order of police, then fire, then ambulance and if needed helicopter. I had always believed the ambulance to be reaching first.

  6. Great post! Very helpful. Sometime it's those sort of details that can trip writers up.

  7. @Anthony - Fortunately, a writer isn't always bound to play the odds. If you get in a situation where there is a local volunteer ambulance, they might be dispatched to a scene like that without the fire being called, even in such a small town. So you might be okay. There is variation among providers in how many patients a helicopter can transport. Many only take one patient, but there are units that can take two. Typically it's preferred that you only take one, even if you have the space, because that way the medical crew aboard don't have to split their attention.

    @Frances - An EMT is an emergency medical technician. Roughly, a paramedic who cannot start IV's, administer most medications, or perform an EKG.

    @Bride - At least, in the US, that's the order they arrive in, and I think most writers do usually think the ambulance will get there first.

    @JB - Glad it's helpful! Details can make a huge difference! I do believe that writers have the ability to err in favor of literary or dramatic purpose, but it makes a difference when you know that's what you're doing instead of just stumbling around.

  8. This is very helpful. Thank you. I don't read many sites about police or forensic procedures in the USA because my mysteries are based either in Britain and Canada and they do things differently there but I love learning new things.

  9. @Clarissa - Yeah, one my my good friends in the lab was from Ontario, and had gotten her previous training in Canada. In our experience it seemed that most of the specific details were the same, but that the big-picture operations and protocols could be very different at times.

  10. I think it would be interesting to outline also if it is a murder scene, what's the procession? Police, ME, detectives, fire, EMTs (though not needed), which?

    This is great though.

  11. Great info! The fire truck is constantly going into the neighborhood across from me and I wondered about that. I'm guessing it's actually a medical response to someone with a chronic illness and ruling out the theory of a very bad cook. :)

  12. @Cameron - There is a lot of variation at murder scenes based on jurisdiction. One common scenario in the US is like this:

    1) Reports of gunfire to 911.
    2) Police dispatched.
    3) Police call for EMS.
    4) EMS determine that the patient has no vital signs and is beyond resuscitation.
    5) EMS contact medical authority, family doctor, or coroner for pronouncement of death.
    6) Doctor pronounces death.
    7) EMS hands over the patient to the police department or the coroner and depart the scene.
    8) Police secure the scene.
    9) Preliminary forensic investigators may arrive on the scene, sometimes including a representative of the medical examiner's office.
    10) Detectives arrive and may supervise and/or participate in the collection of evidence and of testimony from witnesses and the citizenry.

  13. @Carolyn - haha Yeah, most likely there's someone there who frequently either hits Lifeline or 911 complaining of chest pains or possible heart attack, and the fire are dispatched to begin CPR / defib, if necessary.

  14. Thanks :) I am doing some local research as well, but this is an excellent starting point.

  15. @Cameron - Glad to help you get some footing. And local research is always important if accuracy is something you want in your writing. No blog, book, or documentary that is broad and general can ever account for all the whacky local variations you can run into.

    Incidentally, this may be something you already know, but one of the biggest areas of variation is in the relationship between the police and the forensic investigators and labs. That's something that is very much state- and locality-specific.

    As an example, the lab I worked in doing forensic anthropology was part of a graduate school. We had to follow chain of custody rules and file legal reports, but we ourselves were an entirely civilian organization. In many jurisdictions, that would never happen. In ours, we were pretty much it for skeletal analysis.

  16. Thanks for the post--it's helpful to know!

  17. Y'all ever do test runs? When I was working at a grocery store that sat next to a busy street, we would see the ambulance run south, lights and sirens full-on. Then 4-5 minutes later, they'd be back by heading north. This happened once or twice a month, though it seemed more often.

    All I can figure is someone was gathering statistics for rate of response during rush hours.

  18. @G'Eagle - Always glad to help!

    @B - While test runs are not impossible, in most place it's really frowned on to run emergent for testing purposes. Usually those tests are dun in conjunction with real runs. But there are tests in some cases, too.

    More likely, they were getting called out and then called off.

    In our local code dictionary that's a Signal 9. And it drives a body nuts.

    Usually, the reasons for getting a Signal 9 are that you were going to be a second unit and you're no longer needed; another, closer unit hopped in and intercepted the run; the police were only calling you as a precaution and then realized they wouldn't need you; Lifeline calls 911 and lets them know it was an oops; a 911 caller calls back and says, "It's four minutes and you're not here, so I'm going to drive my bleeding, fribrilating mother to the hospital myself" -- or variations on those themes.

    It's very common, especially when you have a dispersed network of EMS responders. In fact, the first four runs I had on the ambulance were signal 9's where we were dispatched for an auto accident with possible injury, but then called off when the police got on-scene and found the vehicle was actually abandoned.

  19. FOUR TIMES? Sounds like beneficent aliens are busy in your neck of the woods, snatching folks from impending doom.

  20. I always learn something when I visit your blog. Great info, Nevets!

  21. This is useful. I have a couple scenes in my novel that are emergency settings, and one of my MC is a paramedic.

    Thank you for this.


  22. This was great, but where we live in the sticks, the fire department always arrives first. And the fire department is made up of trained volunteers. They are paid by the hour so if you call with a medical emergency, your house may be crowded with people. In other emergencies, the sheriff department will show up first, but the fire department is always waiting nearby.

  23. @B - What usually happens is a passerby calls in a car accident, "and I didn't see anyone moving in there; they're probably hurt." And then the cops get there and see that there's no one moving in there because there's no one in there.

    @Jennifer - Glad you found it interesting!

    @Donna - Sounds fun!

    @Marilyn - It gets crowded here, too, because we're also pretty rural. Our police and sherrif are still usually there first, but in several parts of the county the VFD arrives and just waits for the cops. And, of course, the police aren't dispatched for every emergency either.

    We were at one scene where it was, a fire unit, two sheriff units, one police unit, and a homeland security rep. Sometimes there are even two or three ambulance units or two fire units.

    Imagine all of us in the bathroom trying to get a vacuum splint on a patient who fell. Jee whiz.


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