It rings like the lament of the disgruntled parent, "Why can't you be more like your big brother?" In small jurisdictions across the country, chiefs are being taken to task over why they don't or can't provide Advanced Life Support ambulance service to their communities. "They do it in Phoenix," says the public. "They're doing it in New York."

"Give me the budget of Phoenix or New York, and I'll show you the best ambulance service this country has ever seen" is the likely reply. Sadly, these demands are made by those who don't understand the financial and personnel constraints placed on fire chiefs as they're asked to do more and more with less and less.

In spite of these obstacles, chiefs will do what they've always done. In the fire service's true spirit of improvisation under pressure, they will create yet another quality public service from paper clips and duct tape.

For example, although it's taken years and several city council and fire department administrations to achieve, there's an als ambulance service on the high plains of southern Wyoming that serves as a benchmark for fire-based ems among smaller departments.

Small resource pool The Laramie (Wyo.) Fire Department provides the ambulance service to Albany County, which covers about 4,300 square miles and is home to nearly 35,000 people in the southeastern part of the state. Our four ambulances cover portions of adjacent jurisdictions where response times are short or where als ambulance service isn't available.

In addition to ems, the Laramie Fire Department also provides hazmat, extrication and specialized rescue for the entire county, and fire suppression to a fire district that encompasses most of the county's southern half.

Like most small or rural fire departments, Laramie has limited resources. Our department has just 33 line personnel with seven staff positions and a minimum line staffing of nine. At full strength, daily assignments are two three-person engine companies, one three-person truck company, one two-person ambulance crew, and a chief officer who responds to full-response assignments.

The ambulance crew is attached to the truck company at fire scenes, creating a five-person truck company. The ambulance crew's primary responsibility at fire scenes is to provide medical care, but when none is required, they carry out typical truck functions. Equipment operator and firefighter positions on the truck company are vacated during minimum staffing of nine, leaving a three-position truck company that includes the ambulance crew.

In 1998, the Laramie Fire Department's call volume totaled 2,252, including 559 fire, hazmat and service calls, and 1,693 medical calls. The department's total budget was $2,436,671, consisting of $2,153,298 for personnel, $223,021 for capital purchases, and $60,352 for other expenses.

With such a small pool of resources, the Laramie Fire Department has had to make some creative decisions to provide an als ambulance service for its customers. The service as it stands has taken more than two decades to develop, largely because of a lack of working models from which to draw information. Over those years, however, the system has grown from a one-ambulance, six emt-Basic service to what it is today.

Staffing concerns Ambulance operation is a stressful business, especially in the early stages. The sheer load of the new service can overwhelm personnel used to a low or moderate call volume, and learning new skills and techniques as a service grows can lead to burnout in ambulance attendants. Chief officers need to recognize this potential problem and take measures to counteract the stress.

The Laramie Fire Department combats these challenges to morale by rotating personnel through the ambulance duty. Each firefighter rotates between the duty ambulance and one of the suppression apparatus. In this way, no one group of firefighters is saddled with the responsibility of operating the ambulance all of the time. The ambulance workload, roughly 75% of the total call volume, is shared by all firefighters.

Out-of-service time, an ongoing concern in rural areas with long response and transport times, also has an effect on staffing. It's common for ambulances in Laramie to be tied up for two to three hours during a call.

To maintain staffing of at least nine, the Laramie Fire Department uses an emergency callback system. Off-duty personnel who voluntarily carry pagers are the first to be called back to fill staffing deficiencies, with additional callback by telephone if more personnel are needed. It's department policy to recall personnel whenever calls are responded to outside the city limits.

Another staffing concern arises when we look at our response times, an issue for ambulance services since the beginning of emergency medicine. In the metropolitan setting, response times of 20 to 30 minutes are usually unacceptable, but these run times would be welcome in rural areas. It's not uncommon for us to respond up to 70 miles away.

To counteract delayed treatment due to lengthy responses, Laramie coordinates with about a dozen Basic Emergency Care and emt-b volunteers in outlying areas. These personnel act as first responders and are paged out in conjunction with the ambulance. The Albany County sheriff's office also has personnel who are qualified to respond and provide interim care to patients until the ambulance arrives.

Laramie plays an active role in training these first responders by coordinating and teaching bec and emt-b courses as well as emergency medical dispatch for the county's dispatchers. In such a remote area, it's imperative that agencies and citizens work together to provide the best possible service.

In addition to preserving morale, ambulance rotation allows the department to operate an als pumper program. In-city calls for chest pain, shortness of breath or unconsciousness are dispatched with an ambulance and a first-response pumper.

Each pumper is staffed with at least one of the emts regularly assigned to the ambulance, and each is equipped with an abbreviated array of als equipment. On arrival of either unit, als treatment can begin immediaely.

When the engine crew assists the ambulance crew with transport, the first-responding emt often retains control of patient care. This eliminates the need to pass on much of the information from the first responder to the ambulance crew, which in turn lessens the chance of vital information getting lost in the transition and streamlines the entire patient care scenario.

The als pumpers and ambulance duty rotation address another issue common to many fire-based ambulance services: skill retention. In services where personnel are assigned away from the ambulance for extended periods, their ems skills inevitably deteriorate. Rotating personnel into four to six ambulance shifts per month allows them to practice skills and remain proficient. als pumpers also allow company and equipment officers to be involved in patient treatment.

A beneficial trade-off One reason Laramie can afford to offer als service with its limited resources is that it operates at the emt-Intermediate level rather than at the paramedic level.

Wyoming's State Office of Emergency Medical Services has allowed the department to operate as a pilot organization in expanding the scope of Intermediate skills, making it possible to build a very advanced emt-i service. A push within the U.S. Department of Transportation to expand the scope of emt-i skills nationwide should make this option more generally available.

The skills and knowledge of our emts are further augmented by departmental requirements for Advanced Cardiac Life Support and Pediatriac Advanced Life Support certification for the highest-level ems personnel. While the state's protocols concerning patient treatment still govern the department, we believe that personnel perform better in als situations when armed with the additional knowledge provided by the acls and pals curriculums.

An obvious advantage of training our personnel to the emt-i level is cost. Small call volume and limited resources dictate that the ambulance service must be able to maintain a consistently high level of training without taxing its budget with exorbitant training costs. It's also much less expensive to maintain personnel at the emt-i level, as the recertification requirements are fewer.

Of course, departments electing to operate als services without emt-ps must accept a trade-off in terms of service level, but that gap, in statistical terms, isn't as large as one might think.

In data collected by the Wyoming Department of Health during 1997, there were 10,617 als field treatments performed in the state during that year. Of those, only 267, or 2.5%, fell outside the realm of emt-i skills. The department's administration and the medical director have determined that this small percentage of treatments doesn't justify the time and money needed to expand and maintain als service at the emt-p level.

Unfortunately, qualitative ecg interpretation, a necessary skill for rural settings with long transport times, falls exclusively into Wyoming's emt-p protocols. Many Laramie Fire Department emts are comfortable with the field interpretation of ecgs through ongoing participation in acls training, but the state protocol prohibits use of this skill by emt-is.

A new program of cardiac monitoring that uses a 12-lead ecg with cellular fax capability is being implemented to address this conflict. Now, emts in the field can fax ecgs to the emergency room, allowing er physicians to interpret the ecg tracing and to either prescribe field treatment or ready the er staff for administration of thrombolytic or other therapy immediately on the patient's arrival.

This program is in its infant stage and hasn't yet been tested adequately, but we hope that it will provide a useful link in the quest for timely treatment of heart attack patients.

Hospital involvement Another interagency cooperative that enhances the county's ambulance service exists between the fire department and the hospital district. In 1978, the department entered into an annually renewed contract with Ivinson Memorial Hospital that assigns each party certain responsibilities to the ambulance service.

Under this contract, the hospital:

* Administers and collects all patient charges for ambulance service.

* Maintains biomedical equipment.

* Supplies a medical advisor from the emergency physician staff.

* Provides professional liability insurance for the emts.

For its part, the fire department:

* Maintains ambulances and other equipment.

* Provides personnel to operate ambulances and equipment.

* Trains personnel.

* Houses ambulances.

Shared responsibilities include purchasing ambulances and equipment, providing vehicle insurance, and contributing to the purchase of professional liability insurance for the emergency physicians.

Another shared responsibility is providing for additional personnel during the hospital's low staffing hours. Barring emergency calls, the emts assigned to the duty ambulance are available at the hospital during those hours to assist the staff in whatever capacity they can. In return, the hospital provides sleeping quarters for the emts and garage space for the duty ambulance during those hours.

The city's financial contribution to this agreement in 1997 was roughly $422,000, and the hospital's was about $437,000. The hospital's costs not only cover ambulance operations, but also include a subsidy for fire suppression coverage. The total expenditures for the als program that year were $859,000. These costs are recovered through patient charges and tax revenue.

This alliance has proved to be perhaps the most important to the prosperity of the als service. Outside contractors aren't needed for biomedical equipment maintenance or patient billing and collections. In addition, the hospital provides a wealth of training opportunities for the department's ems personnel. Training side by side with the er staff helps cultivate a better, more streamlined working environment.

Implementing an Advanced Life Support ambulance service is a major undertaking for any fire chief, especially for those with limited staffing and financial resources. But even those with big budgets and staffs, like the "big brothers" of Phoenix and New York, have issues to deal with. Smaller departments face obstacles that are no larger nor smaller, only different.

One course for defeating the obstacles to smaller departments has been plotted in Laramie, and it can provide a possible path for most similar jurisdictions. We can't all be like our big brothers, but we can provide quality als ambulance services to our communities.