This presentation will review the significant structural changes that are required for any Fire Based EMS service that is experiencing an increased level of EMS calls including an increase in the overall acuity level. We will outline the processes that we implemented and review the challenges that can be expected to arise. This information will be valuable to any department that has the desire to become a high-performing EMS system that is Fire based. Topics include changes to job descriptions, hiring process changes, tiering of prehospital protocols, administration changes, new equipment, and medical direction changes.