First responders were dispatched to 460 medical emergencies in the Central Norwegian municipalities of Sør-Trøndelag from 2019 to 2023. They primarily responded to patients with suspected time-critical conditions, that had high prehospital mortality rates. EMS response times to the same incidents were long.

The patient population assisted by first responders in Central Norway had a wide range of serious medical conditions, of which some are beyond the intended use of first responders according to the guidelines for the first responder system; i.e. cardiac arrest, unconsciousness, serious injuries, and risk of hypothermia [18]. One could discuss whether first responders should be used in conditions other than these pre-defined conditions, and if they should receive training, equipment, and possibly even medications to handle the patient population that they actually encounter. In a qualitative study related to Danish first responders by Sørensen et al. from 2023, the interviewees, who were paramedics and anaesthesiologists, saw the value of using first responders in cases of cardiac arrest but not in other medical emergencies [10].

In our study, the index group "Unresponsive adult—not breathing normally" was the largest single group, accounting for 28% of their dispatches. By comparison, this category accounted for 1% of the total GEMS dispatches during the period and 19% of the total HEMS alerts. This makes suspected cardiac arrest the most common cause for dispatching first responders. In some cases, first responders might reduce the time to CPR-D, which is documented to increase the survival after cardiac arrest [17]. Data from the Norwegian Cardiac Arrest Registry concerning cardiac arrest patients in Central Norway from 2019 to 2023, revealed that among 1236 patients with cardiac arrest where CPR was initiated, first responders were the first to attach a defibrillator in 128 out of 1236 (10%) cases [23].

First responders were more frequently used in rural municipalities compared to urban municipalities. One explanation might be that the time-saving benefit of dispatching first responders is smaller in cities, where GEMS usually are readily available or can be diverted. However, in municipalities with long distances and limited prehospital resources, the potential for saving time is greater, especially when multiple emergencies occur simultaneously [2, 7, 11]. Four of the 25 municipalities alone accounted for 51% of the incidents. These municipalities have a total of seven ambulances covering an area of 4.572 square kilometres with a population of 38,748 people. In municipalities such as these, it is plausible that first responders can provide a significant time advantage for patients, especially if EMS are busy.

The response times for first responders were not recorded in the Emergency Medical Information System such as those for EMS. Therefore, we obtained the median response time for FRS on health-related tasks (other than carrying and lifting) from 2019 to 2023 in the same Central Norwegian municipalities from statistics provided by DSB [24]. The data reveal that the FRS had a median response time of 13 min and 36 s for health-related missions during the same period [24]. As stated in the results, GEMS and HEMS in our sample had median response times of 29 min and 10 s, and 28 min and 22 s, respectively. Unfortunately, the data from DSB do not specify whether the FRS personnel were dispatched as first responders or not, thus the observed number of incidents from DSB differ somewhat from our own. However, the data can still provide a good indication of potential time savings by dispatching first responders, which is consistent with international literature on similar systems [6, 7, 9, 11,12,13].

The first responder system in Norway illustrates strategic use of decentralized resources to supplement, but not replace, existing EMS. This is especially important when factors such as long distances, multiple simultaneous emergencies, and limited resources can delay the treatment of critically ill patients [1, 2, 13]. However, certain policy questions are raised by the system. The use of fire and rescue personnel for health tasks could, in theory, affect fire preparedness in municipalities, especially when medical emergencies overlap with fire incidents. Furthermore, concern has also been raised as the FRS has been given responsibility related to emergency medical preparedness, and that the system's cost-saving potential could be used as an argument for deprioritizing GEMS response or downsizing GEMS resources in rural areas. The healthcare system in Norway, as in many other countries, faces resource constraints, and new approaches are sought after. One might question whether the first responder system could serve as a model for creating other innovative models of decentralized care or be expanded to involve other resources in municipalities, such as home care workers. There are strong indications that first responders are being used as an important adjunct for the treatment of urgent critical illness outside hospitals(5,6,7, 9, 13).

The study uses large data resources from the Emergency Medical Information System, while also integrating data from PAS, the Norwegian Cardiac Arrest Registry and DSB to provide actionable insights on the use of first responders. FRS exist in most countries, and we believe that our findings from both urban and rural areas in Central Norway are generalizable and relevant for similar systems abroad. Certain limitations need mentioning. The first being that the data are observational and based on both automatic data storage and manual recording, with the potential for incomplete documentation. Secondly, the study was not designed to assess the medical treatment initiated by the first responders, or to examine patient outcomes after first responder treatment. Thus, the study cannot provide decisive conclusions regarding the effect of first responders as a supplement to prehospital services. Examining the effects of the system could be relevant for future studies. However, data collection might prove challenging, as the National First Responder Guidelines do not require first responders to document their findings and initiated treatment but rather report this information to arriving EMS.