# Staff Systems with More EMTs and Fewer Paramedics



## Tigger (Apr 9, 2015)

This article generated a lot of activity on a facebook page that I occasionally find myself on. Please do us all a solid and be better than them and read the article before you comment. 

The crux of the article: 


> We don't need Roy and Johnny on steroids, we need them just the way we first met them: well-trained, frequently seeing the worst patients and strategically employed.


http://www.jems.com/articles/print/...tems-with-more-emts-and-fewer-paramedics.html

I agree that there are way too many paramedics in most systems. I work (part time) in a system where every fire apparatus responds with at least one paramedic (usually two) with the balance of the crew being EMTs. The ambulance responds with one paramedic and one EMT. Very rarely do I think this benefits patient care and its well proven that it certainly increases skill dilution, making all of the paramedics less effective providers. ALS first response has never been proven to increase patient outcomes either. 

I don't agree with the author's final comment that is highlighted above. I am very firmly of the thought that every patient deserves the opportunity to be assessed immediately by a paramedic. There is nowhere else in the developed world that routinely places a provider with less than 200 hours of education as the primary caregiver. It's just not enough education, and our patients deserve better than that. 

I have many more thoughts on this issue, but first, what say you?


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## NomadicMedic (Apr 9, 2015)

Agree. Put paramedics on chase trucks and have them respond to meet (or beat) the ambulance at the scene. If not needed, they leave. Most calls need an ambulance, fewer need a paramedic.


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## Tigger (Apr 9, 2015)

In your previous system, were paramedics dispatched to every call? Do you think that the EMTs in that system were able to accurately determine what calls would and would not benefit from a paramedic?

When I worked on a BLS truck in Boston, many of my coworkers had no idea when to call for medics and when not to. Clear and obvious stroke? Boogie to the hospital, no sense in waiting for ALS when we could just be at the hospital. Yet many of them thought that every stroke needed an IV prior to arrival. Ugh. Meanwhile you have grandma who is altered, hypotensive, and tachycardic. Nah we'll just BLS that in, she's old so she probably is always a little out of it. More ugh. 

My thing is that while few calls truly *need* a paramedic, many patients can still benefit from one. Sure, no one died from pain or vomiting. But if we can treat it, shouldn't we?


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## PotatoMedic (Apr 9, 2015)

I will say it is education dependent.  I went to king county's EMT school, and I can say they really taught us sick/not sick well since king county relies heavily on EMT triage for medic evals.  So yes.  I do think emt's can be taught when to and when not to call for als.  Does that run a risk of missing patients or giving a stable pt a medic? Yes.  But if you want less medics that is a risk you will have to take.


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## NomadicMedic (Apr 9, 2015)

Pre screening and PMD goes a long way. In my previous,system medics only went on Charlie, delta and echo calls. Most BLS was pretty medic dependant though. The ability to triage to BLS after an evaluation is where the real value lies.


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## chaz90 (Apr 10, 2015)

Ahh. Now here's a topic to which I can relate!

We are not dispatched to every call. We are dispatched on all Charlie, Delta, and Echo responses automatically, with dispatcher discretion to add ALS for Omegas, Alphas, and Bravos. BLS can obviously request or cancel us on any call they desire. 

The PMD system has some known issues, but I don't fault it for at least trying to prioritize and tier response plans. BLS varies in what they do and do not transport prior to arrival of ALS. The system as a whole pretty much expects them to request medics for any CVA unless the hospital is closer than the medics. I have no problem assessing these stroke patients at what I imagine is a slightly more thorough level than some of our EMTs and getting an IV and labs before arrival at the ED, but our local BLS (especially the departments closest to all three hospitals) are more than happy to cancel medics based on proximity and transport alone for any call. 

I do have a problem with some of the patients we are cancelled on due to "proximity" or simply never dispatched. I strongly believe many of our respiratory patients can benefit from stabilization and treatment prior to arrival at the ED and any movement at all in some cases even if the hospital is 2 minutes away. I despise getting requested for pain control that is worsened on movement only to have BLS move them and make us intercept them somewhere. I wish we had the means to make sure they wait on scene as these isolated ortho injuries aren't time sensitive and could certainly benefit from medication prior to movement. I've also intercepted a couple unconscious diabetics who I was forced to treat in an ambulance rather than wake them up gently on scene and happily make them a PB&J as they sign the refusal paperwork. Don't even get me started on intercepting cardiac arrests with CPR in progress because BLS just wanted to load and go to the hospital like it's 1950. I think these scene management problems could be mitigated by having the paramedic on scene of the transport unit so the BLS personnel staffing the ambulance don't panic when they run out of things to do/talk about and just load the patient into the ambulance and drive as they revert to what they know. 

I think some of these finer points of the treatment side of EMS that doesn't involve immediate emergent transport to the hospital is lost on a few of the local BLS providers. Basically, I don't think the local BLS community as a whole understands when paramedics can help and when we have our hands tied. In some ways, we as ALS don't even present a unified front. There's constant variation between what individuals do prior to transport and based on hospital distance, so in some ways it's unfair to blame BLS for not understanding what I prefer as an individual. 

I do believe we're making some slow progress, particularly with the good paid BLS crews that we interact with on a daily basis. I explain why we do the things we do with these providers, and the ones who are receptive to learning are improving. Our biggest hindrance in getting BLS crews to recognize when and when not to call for paramedics is the low volume departments and/or the old volunteers that only come take calls every few weeks or months. 

In spite of these issues, I remain a big fan of our tiered, dual response system. I love not getting tied up in clearly BLS calls that simply need a ride to the hospital, and I think the ability to release a patient to the care of BLS after an ALS assessment is invaluable. I see a much higher average acuity of patients in this way, I manage more critical patients for longer periods of time than most of my ambulance bound fellows, it lets us work with a paramedic partner yet still keep our district covered with an ALS resource when one of us transports a patient, and it slows burnout from the continual grind of BLS patients that don't need us. I run enough calls to avoid boredom (well, sometimes) but have enough downtime to avoid burnout, which is perfect. One of the biggest problems with this? You can't bill for an ALS transport when the paramedic didn't transport.


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## chaz90 (Apr 10, 2015)

TLDR? See DEmedic's post.


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## Tigger (Apr 10, 2015)

DEmedic said:


> Pre screening and PMD goes a long way. In my previous,system medics only went on Charlie, delta and echo calls. Most BLS was pretty medic dependant though. The ability to triage to BLS after an evaluation is where the real value lies.


Absolutely. There is no reason why a paramedic needs to accompany every patient to the hospital. 

I guess I just wonder how many "missed opportunities" there are for better care if a paramedic responds to all calls. We are all well aware of EMD and its downfalls, to include both overtriage (I breathed dust and now I'm coughing equals delta level respiratory) and the other end with many alpha level illness calls being legitimately ill people. I have no idea if ALS response to everything would measurably improve outcomes, alas I am just rambling here. 

I like our Paramedic/Basic ambulances. Everyone gets the opportunity to be assessed by someone with legitimate education. Tiered systems have always seemed backwards to me in that you are trusting the least educated provider to understand when someone with more education is needed. The flip works much better, I trust that a paramedic has the knowledge to know a BLS transport is appropriate.


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## RocketMedic (Apr 10, 2015)

Would ED tr7age work if it was run by the cafeteria line cook?


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## Handsome Robb (Apr 10, 2015)

This is a system specific question towards @chaz90 and @DEmedic . Are ALS units dispatched to all MVAs (or TCs, whatever the local area calls them) or only specific ones? Ours tend to vary in dispatch code between Bravo and Charlie. 

I think that skill degradation is an issue but I also think that there are ways to afford our patients all an ALS assessment. Now whether it's cost effective or not is a completely different story. We run I/P staffing and rarely P/P. Only one of three of our FDs is ALS currently. The I/P ambulance staffing allows every patient to have a Paramedic on scene at any call in the County however we are allowed to triage down to our ILS partners.


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## chaz90 (Apr 10, 2015)

Handsome Robb said:


> This is a system specific question towards @chaz90 and @DEmedic . Are ALS units dispatched to all MVAs (or TCs, whatever the local area calls them) or only specific ones? Ours tend to vary in dispatch code between Bravo and Charlie.



Nope. We only go on Delta level MVAs from dispatch. These are only the high mechanism accidents (rollover, ejection, head on, involving a motorcycle), reported entrapment, or patients reported unconscious. We're also dispatched if it's coded out as an MCI.

We don't have Charlie level MVAs. Everything is either a 29B or 29D.


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## Carlos Danger (Apr 10, 2015)

I can see it both ways.

First, I've always thought a system like what Chaz and DE describe is the ideal system design. Common sense (and the literature, in most cases) dictates that EMT's can handle most EMS calls perfectly adequately. Research also shows that more paramedics = skills dilution. Why spend more money than we need to on a bunch of paramedics and multiple sets of ALS equipment, when relying mostly on BLS ambulances and staffing just a handful of paramedics per system on QRV's seems to work well?

On the other hand, some say just the opposite: that ideally, EMT's have little or no place in an ALS 911 response system. Why _not_ have a paramedic - or two - on every 911 ambulance? What's the downside? Not talking about sending an engine with 4 paramedics on it to everything so that you end up with 5 or 6 paramedics to every call; just the one or two on the ambulance. It isn't like a paramedic is some super-expensive, highly specialized, scarce resource that must only be summoned from the ivory tower when things are really, really bad. Under-triage or lack of availability of ALS when needed is a real risk in the first system design, but it becomes a non-issue in the paramedic-only one. Skills dilution can and should be mitigated by better initial and ongoing training, not by limiting an important public-safety resource.

I think you can make a good argument for either approach. Personally, if I were to work full-time as a ground paramedic again, I would undoubtedly want to be in a system that uses the first design. But if I'm being completely honest, that's mostly because I think it would just be a more fun system to work in and I'd have to deal with fewer BLS calls.....it's not necessarily because I think it's an inherently better design.


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## Shishkabob (Apr 10, 2015)

I used to think the same way, but as experience and education have continued I now think having a medic on most trucks, if feasible, is reasonable.  Yes, Paramedics are meant for the actual life threats, but there's something to be said for pain relief, nausea relief, and catching the odd zebra.  Keep some BLS trucks for the extremely obviously stupid "I want a flu shot" calls (if you can't outright refuse transport).

Shoot, last year I had a psych call where the patient was convinced they had been cursed because they couldn't walk.  History of paranoid schizophrenia, reflexes intact, hell I saw them move their legs!  On a hunch I threw on an EKG and saw... sine waves.  Hello K+ of >9.3.  What about the old lady with diarrhea for a week?  Oh hey look, runs of v-tach with a K+ of less than 2.   An EMT, with their current levels of education, would not have caught those, nor have understood the idea behind catching them.  


Now I am of the idea that a medic should be on most trucks, but have specialized Paramedics (Advanced Practice Paramedics, Critical Care Paramedics, etc) on fly cars sent to back up units on the more serious calls (arrests, major trauma, etc).  This way those medics see more of the critical people more often and thus have more experience with them and are able to help the truck by being yet another experienced Paramedic with maybe a bit more skills / drugs at their disposal.


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## RedAirplane (Apr 10, 2015)

I heard a Podcast about a new EMS model with community paramedics making house calls. The BLS trucks would run 911 with a slightly expanded scope and if ALS was truly needed (CP, arrest, major trauma, etc) then one of the paramedics would divert from a house call to intercept the ambulance on-scene or enroute. 

At first I thought this was weird, but the more I think about it, the more it makes sense. Of course, I can't imagine community paramedics intubating their house victims often, so I'm not sure how to address that aspect of the article.


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## medicsb (Apr 10, 2015)

Linuss said:


> I used to think the same way, but as experience and education have continued I now think having a medic on most trucks, if feasible, is reasonable.  Yes, Paramedics are meant for the actual life threats, but there's something to be said for pain relief, nausea relief, and catching the odd zebra.  Keep some BLS trucks for the extremely obviously stupid "I want a flu shot" calls (if you can't outright refuse transport).
> 
> Shoot, last year I had a psych call where the patient was convinced they had been cursed because they couldn't walk.  History of paranoid schizophrenia, reflexes intact, hell I saw them move their legs!  On a hunch I threw on an EKG and saw... sine waves.  Hello K+ of >9.3.  What about the old lady with diarrhea for a week?  Oh hey look, runs of v-tach with a K+ of less than 2.   An EMT, with their current levels of education, would not have caught those, nor have understood the idea behind catching them.
> 
> ...



Ermagerd!  Get a 12 lead for every psych patients... because they might have hyperK!?  (>9.3 is not compatible with life... either that was a lab error or someone needs to write the case up for publication.) 

At this point, out of nearly 1000 patients that I've seen in the past 9 months (many whom I've measured BMPs/chem-7s on), I have maybe heard aof 1 o 2 w/ a K <2.  And the ones close to 2 were not little old ladies with diarrhea (one was a young DKA pt. who continued to drop her K despite multiple repletions that required an IJ so we could run K in as fast as possible).  Sure, it can and does occur, but not with any regularity to justify a paramedic be sent to every person with diarrhea.  If BLS arrives and notes the patient to have an irregular HR or episodes where the pt. gets very tachycardic, then sure, call for ALS.  But these "what if" scenarios play more to ones emotion than logic.  

Ultimately, I think the answer to the over-arching problem is to better train the primary responders, whether the EMTs, or upgrading to AEMTs, but paramedic-for-all is silly and wasteful.


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## Tigger (Apr 10, 2015)

I lived in New Zealand for six months and spent some time studying their EMS system while I was there for my thesis. Their base paramedic has a scope somewhere between an AEMT and I99, and it's a three year degree. If that's what we can have for a base level provider, I am all for tiered systems. But to think that someone with a 150 hours of training and limited diagnostic tools can determine who legitimately needs further care seems silly to me.


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## medicsb (Apr 10, 2015)

Tigger said:


> I lived in New Zealand for six months and spent some time studying their EMS system while I was there for my thesis. Their base paramedic has a scope somewhere between an AEMT and I99, and it's a three year degree. If that's what we can have for a base level provider, I am all for tiered systems. But to think that someone with a 150 hours of training and limited diagnostic tools can determine who legitimately needs further care seems silly to me.



I do agree that 150 hours is too little for EMT, but I do not think it takes 3 years of schooling (or even 1) to differentiate between need or no need for a paramedic.


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## Tigger (Apr 11, 2015)

To add to that, most NZ paramedics are more than capable of managing most calls themselves. Their scope is less than that of US paramedics, but includes the more high frequency assessments and treatments.


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## Aprz (Apr 11, 2015)

medicsb said:


> I do agree that 150 hours is too little for EMT, but I do not think it takes 3 years of schooling (or even 1) to differentiate between need or no need for a paramedic.


The three years of training is _not_ only to differentiate between the need for a paramedic (in New Zealand, an intensive care paramedic (ICP)) or not. They are better trained and equipped to assess and treat everyday calls compared to US EMTs.


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## Shishkabob (Apr 11, 2015)

medicsb said:


> Ermagerd!  Get a 12 lead for every psych patients... because they might have hyperK!?


  Not the point, not the intention, not what I said.  In fact I can count the number of times I've done 12leads on psych patients that haven't overdosed on 1 finger.



> (>9.3 is not compatible with life... either that was a lab error or someone needs to write the case up for publication.


  Confirmed multiple times via i-stat and actual lab data.  But what do I know, I was just there.

Shoot a quick 3 second Google revealed someone with a 14.0.  (http://acutecaretesting.org/en/jour...record_breaking_serum_potassium_concentration)

Or heck, studentdoctor has a thread on it, with quite a few above the 10 range (sure, anecdotal)  (http://forums.studentdoctor.net/threads/whats-the-highest-k-youve-seen.347703/)

You're right... it's not compatible with life, except for when it is. 




> Sure, it can and does occur


 Than why are you incredulously questioning it?  But that wasn't the point anyhow; what's an EMT going to do for someone who's dehydrated after several days of diarrhea?

Some people get trauma.  Some people get strokes.  I get odd-as-hell cardiac calls.




> But these "what if" scenarios play more to ones emotion than logic.


  Logic also says a low priority sick person should never be a cardiac arrest, but alas.



> but paramedic-for-all is silly and wasteful.


  Disagree.  All Paramedics (that FDs love to do) is wasteful and potentially dangerous; Paramedic for all ensures a Paramedic is always available if needed, instead of an unnecessary, avoidable, delay.


It's oft said when you hear hoof beats, think horse and not zebra.  When I hear hoof beats I think horse but look for a zebra.


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## triemal04 (Apr 11, 2015)

I really hope that you actually treated both those patients or that they had an event during your transport that required an intervention...otherwise your arguement falls flat on it's face.  Can you clarify that please?


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## RocketMedic (Apr 11, 2015)

Linuss, you also bring up an excellent point- an EMT is ill-suited to ride even a pony, much less a zebra. They are best for sheep.


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## RocketMedic (Apr 11, 2015)

Well, Triemal, a paramedic is the difference between "bs old lady with bags packed" and "rapid access to definitive care with ED staff alerted to real danger", so yes, I'd say it made an impact.


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## NomadicMedic (Apr 11, 2015)

So, this comes back to the "not everyone needs a paramedic, but everyone deserves a paramedic"


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## 46Young (Apr 11, 2015)

I've worked in hospital based third service controlled by the FD (NYC), municipal Third Service (Charleston County SC), and now in a dual role fire based system. I will always be partial to a tiered system, where here are two medics on the ambulance, and that ALS ambulance only gets dispatched to ALS call types, such as arrests, diff breathers, unconscious, cardiac conditions, etc. They should not be running sick calls, falls, most MVC's, EDP's, and drunks that are conscious. In this type of system the medics will rapidly become proficient. The problem is, much of the country prefers the medic/EMT txp unit, where they are subject to any type of call. I feel bad for the medic students that I mentor, because at least 80% of our patients are non-acute, and not challenging for us in the least.

Since the preference has gone away from running a tiered system, and I'm subject to working in an all-ALS (medic/EMT ambulance) fleet, I prefer to have ALS suppression units run first response. Does ALS first response affect patient outcomes? Maybe a little. While waiting for the txp unit I've treated Anaphylaxis several times, and ran a few codes for a few minutes, probably less than ten, but that's not typical. What I value from this system is that when an engine or ladder company is on-scene with me, I now have six people to do the work rather than two. If you train with the crews that you typically run with, pt. care with 5-6 people on-scene can be smooth and efficient, rather than chaotic with people stepping all over each other.

The value is that diagnostics/treatments, and movement to the ambulance, typically occurs 10-15 minutes quicker than if it were just my partner and I on-scene. If I need the suppression medic, I can take them for a ride with no issues. For reference, my on-scene times for a patient that requires monitor/IV/non-ambulatory typically run 15-20 minutes before I leave for the hospital. When I worked in NYC, any pt. requiring ALS kept us on-scene upwards of 30 minutes in many cases. The suppression crew saves me an average of 10-15 minutes for ALS patients, and likely 5-10 minutes on more non-acute patients. If I run the typical 5-6 transports, that's a savings of over an hour a day of in-service time. In a large system, that's equivalent to having an extra ambulance on the road (or several). In addition, the lifting is spread out, and as the txp medic, it's nice to have all your diagnostics and typically a line done without you having to touch the patient, which is nice at 0230 in the morning when you're burnt. These benefits are cost-neutral with the exception of fuel, medic pay, and ALS equipment on the suppression piece. The engine would have otherwise been idle in the majority of cases.

ALS first response suppression units may not have much of an effect on pt. outcomes, but it does make the on-scene to txp process much quicker, and spreads the work around, using resources that would likely have been idle otherwise.


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## Shishkabob (Apr 12, 2015)

triemal04 said:


> I really hope that you actually treated both those patients or that they had an event during your transport that required an intervention...otherwise your arguement falls flat on it's face.  Can you clarify that please?



I shouldn't have to explain basic treatment modalities of hyperkalemia or vtach in the pre-hospital setting.  Each was treated as appropriate for the given circumstance. 

Anyhow, sometimes it's realizing that it's best to not do anything.


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## triemal04 (Apr 12, 2015)

Linuss said:


> I shouldn't have to explain basic treatment modalities of hyperkalemia or vtach in the pre-hospital setting.  Each was treated as appropriate for the given circumstance.
> 
> Anyhow, sometimes it's realizing that it's best to not do anything.


I don't want you to explain what treatements were needed, just IF any treatements were given.  The reason I bring this up is because, if nothing was done and no adverse events occured, it becomes harder to say that having a paramedic treat those 2 patients was truly needed.  Unless you are completely confident that those things would have been missed and/or had a severe delay in discovery at the hospital...did the presence of a paramedic instead of an EMT matter?

(I don't mean to say that early recognition of a problem without treatement is worthless; it's very valuable and can help to get the hospital keyed into what's going on quicker.  But there are times when it's given to much value.)


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## triemal04 (Apr 12, 2015)

46young-

But how much of that making things easier comes soley from having more help on scene, not from having more paramedics on scene?  With a single patient, 2 paramedics are more than enough to take care of all interventions and treatements in a quick, efficient manner; the EMT's (if well trained) can be used to assist, and if needed and with a little prompting, get at least the initial info that's needed from any family or bystanders that are present.  Believe me, I'm all for having extra hands to help out, but I don't see any reason for the extra help to be anything more than EMT's.


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## medicsb (Apr 12, 2015)

Linuss said:


> Not the point, not the intention, not what I said.  In fact I can count the number of times I've done 12leads on psych patients that haven't overdosed on 1 finger.
> 
> Well, thank god you're not.  Too bad you can't let BLS take them in while you make yourself available (or better yet not even get dispatched in the first place).  Your anecdote is of an out-lier.  You had some hunch and caught something.  It's an interesting case for sure and I assume there was more to the story and physical exam other than him saying he cant move his legs when he indeed could move his legs.
> 
> ...


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## RocketMedic (Apr 12, 2015)

Why do you assume EMT will be any less burned out? They are simply easier to replace.


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## Tigger (Apr 12, 2015)

DEmedic said:


> So, this comes back to the "not everyone needs a paramedic, but everyone deserves a paramedic"


Perhaps not a paramedic but certainly more than the assessment that a 150 hour technician can provide. 

Sometimes it's patently obvious that this in fact not necessary, but how do you know that until you get to the patient. It's not anyone is ever surprised by a bs sounding call being a legit patient.


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## Shishkabob (Apr 13, 2015)

The thing is, as EMS transitions from emergency medicine to a "Mobile Healthcare" perspective, Paramedics become more of a necessity, and there's less and less space for EMTs.  If all you want EMS to do is drive people to the hospital, sweet, get all the EMTs you want.   Minimal treatment, minimal diagnostic abilities, minimal ability to divert to more appropriate facilities will be available. But if you want EMS to transition in to the role we were thrust in to long ago, with less acute medicine and more generalized healthcare, than a Paramedic is a necessity.


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## NomadicMedic (Apr 13, 2015)

I used to feel that every patient should be seen by a paramedic, but years of running to poorly coded "emergencies" has changed my mind. What we really need is better pre dispatch screening, an alternative nurse line, the ability to triage non emergent cases to a simple transportation unit and fewer paramedics in fly cars that can respond to truly emergent calls and treat if needed.

It'll never happen, due to politics, health care costs and the litegious society we live in... but it's a lovely thought.


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## RocketMedic (Apr 13, 2015)

Disagree, DEmedic. You and I both know that system would be exploited shamelessly for maximum profit and minimum care if it's widened.


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## DrParasite (Apr 13, 2015)

outside of for pain control, what calls require a paramedic for treatment?  In many systems, EMTs are giving albuterol, benedryl, Epi 1:1000, aspirin, oral glucose, and able to defib using an AED.

Any unconscious person (for all causes), reported cardiac problems, reported respiratory problems, what else NEEDs a medic?ma

And while i'm sure you can name several, how many call would be dispatched as ALS calls?  last time I looked at the Priority dispatch criteria (which can be found here: http://wiki.radioreference.com/index.php/Medical_Priority_Dispatch_System) the majority of calls would still fall in the A & B sections, with only C, D & E being ALS dispatch criteria.


Linuss said:


> The thing is, as EMS transitions from emergency medicine to a "Mobile Healthcare" perspective, Paramedics become more of a necessity, and there's less and less space for EMTs.  If all you want EMS to do is drive people to the hospital, sweet, get all the EMTs you want.  Minimal treatment, minimal diagnostic abilities, minimal ability to divert to more appropriate facilities will be available. But if you want EMS to transition in to the role we were thrust in to long ago, with less acute medicine and more generalized healthcare, than a Paramedic is a necessity.


I agree with Linus (I think).  If you are looking at mobile healthcare, where paramedics are tracking patient conditions, performing non-emergency assessments for prescheduled appointments, alternative destinations/not everyone needs to go to the ER,  more interventions outside of the ER and more treat and release situations, than I would agree, paramedics are much more of a necessity. 

But the majority of EMS calls can be handled with two EMTs and a comfy ride to the ER, with no increase in mortality.  If you have the paramedics available in a chase car for those calls that require ALS interventions, and ensure they only see sick patients you will get a better caliber medic.

I do think, however, that the 150 hours of didactic education is enough for EMTs.  What I think is missing is a clinical component of 120 hours, where the EMT student is evaluated by a paramedic or experienced EMT to judge if the EMT has the clinical abilities to assess patients, determine sick vs not sick, and demonstrate competence in BLS interventions and documentations.  And if they aren't able to, they don't become EMTs.


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## Carlos Danger (Apr 13, 2015)

Linuss said:


> Shoot, last year I had a psych call where the patient was convinced they had been cursed because they couldn't walk.  History of paranoid schizophrenia, reflexes intact, hell I saw them move their legs!  On a hunch I threw on an EKG and saw... sine waves.  Hello K+ of >9.3.  What about the old lady with diarrhea for a week?  Oh hey look, runs of v-tach with a K+ of less than 2.   *An EMT, with their current levels of education, would not have caught those, nor have understood the idea behind catching them.*



Everyone has (or certainly has at least heard) stories about "that one time" that "it was a really good thing" we put the patient on the monitor / requested ALS / used the KED, etc.

Some of them are undoubtedly true, but many of them end up exaggerated either for effect or because over time, we tend to remember things as being a bigger deal than they were. Not saying that's the case with this particular story; just saying that it's a common phenomenon. It's one of the reasons why anecdotes are poor justification for sweeping policy or protocol changes.

I think we often exaggerate the ability of paramedics to detect and treat these more obscure or complex medical problems. Of course we can do more than EMT's, but we are still severely limited in our diagnostic and management ability, due to the narrow scope of our education, our lack of diagnostic equipment, our small formulary (who carries potassium?), and the limitations that are inherent in working out of a metal box on wheels. 

Even when we are able to find and treat something like this, it often doesn't change outcomes, as compared to just waiting until the patient is in the ED.

I'm not arguing against the paramedic-on-every-call system design, I'm just saying that I don't think examples such as this support it very well.


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## Tigger (Apr 13, 2015)

DrParasite said:


> But the majority of EMS calls can be handled with two EMTs and a comfy ride to the ER, with no increase in mortality.  If you have the paramedics available in a chase car for those calls that require ALS interventions, and ensure they only see sick patients you will get a better caliber medic.



Measuring interventions based only on mortality is not a very good indicator of service provided. 

Sometimes a comfy ride to the ED requires pharmacological intervention, and we should be willing to provide that, not ignoring patient's symptoms.


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## Altered Mental Status (Apr 14, 2015)

This may just be because I'm a Navy gal but I believe in roles and SOPs. I also believe in drills to stay sharp and I wonder why we don't do more of that.

EMTs are not "ambulance drivers." We can't lose sight of that. There's a reason the standard is not to have an EMR driving the box with a provider in the back and it's because we need another able-and-educated care provider doing more than just collecting insurance cards and cleaning the stretcher. 

I personally agree with Tigger's assessment that every pt deserves care and transport by a team that can handle the full scope. In my mind, the ideal set-up is one-medic-one-EMT per unit. There's a care "caste system" onboard the rig, just like there would be at the hospital with both members of the care team having active roles in care for the pt and everyone knowing their roles.

Skills dilution can be avoided with regular drills and more lab time at refresher because honestly? Even if we could find the most ideal dynamic/combination, there are going to be gaps and we owe it to the patient to eliminate those--to not default skill/competence to be driven by random factors like "what symptoms showed up in the truck over the course of this particular year." I don't think the addition of drill time and lab time needs to be a huge inconvenience to an already-taxed staff of providers. There are ways to incorporate these into the existing system with little added invasion. Additionally, I think the EMT/Medic team dynamic encourages mentorship and growth as well as better EMTs. There are career-EMTs who don't WANT to be Paramedics but who know their job AND my job well enough to be exactly where they're needed down to muscle-memory movements all the time. That's amazing and it doesn't happen when those EMTs are on BLS trucks.

We're slowly but surely moving towards a system where perhaps someday, providers will do house calls. We'll be paid for non-transport care or transport to non-ED facilities. Skills dilution be damned. That transition is likely to happen much more easily when an ALS team is the standard. It's not our job to worry about the billing aspect of that. It's our job to get into the habit of providing only and all of the necessary interventions to Tx the pt in front of us.

Just my $0.02.


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## RocketMedic (Apr 16, 2015)

Surprisingly insightful, AMS. 

Yesterday, I took an IFT run. Hour-long routine transfer for appendicitis. Totally stable. Sure, I could have turfed it to my partner and it could have been a BLS call, but when the ED's meds wore off and pain returned, the patient was certainly glad to have a paramedic with him. That's the difference between paramedics and basics. I can do things that actually help outside of first aid.


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## 46Young (Apr 16, 2015)

Altered Mental Status said:


> This may just be because I'm a Navy gal but I believe in roles and SOPs. I also believe in drills to stay sharp and I wonder why we don't do more of that.
> 
> EMTs are not "ambulance drivers." We can't lose sight of that. There's a reason the standard is not to have an EMR driving the box with a provider in the back and it's because we need another able-and-educated care provider doing more than just collecting insurance cards and cleaning the stretcher.
> 
> ...



Your viewpoints are valid. However, I've worked in a tiered system, an all-ALS third service system, and my current fire based all-ALS system. In the tiered NYC system BLS were dispatched to ALS calls if the medics had an ETA of more than ten minutes, or if the medics needed extra hands. The BLS learned their craft well as a result, as they were responsible for pt. care for 5-10 minutes before medics arrive. They would also learn to take the BLS abd. pain or sick call and recognize that they need ALS occasionally, based on presentation and Hx. You can't learn that in a lab. As a medic, I ran at least three patients in grave condition every day, usually more - arrest, cardiac rhythm disturbance, MI, critical asthma or COPD, APE, unconscious, "real" calls. In the other two all-ALS systems, I would be lucky to get one day's worth of NYC real ALS patients in three weeks to a month, depending on the area.

In NYC, we developed a good flow with our skills - the questions and assessment were smooth, inclusive, and polished, my hands worked real quickly with IV's, drawing up meds, dropping a tube, various types of lung sounds on a frequent basis, things like that. You can't reproduce that effectively in a lab environment, especially the lung sounds and the tube, and we do have Sim Man at our training center. It's not the same as a real person. Now, since critical patients are few and far between, the assessment and skills become more goofy and less polished, the flow is gone, and things like drawing meds and airway management become more clumsy. Meanwhile, the BLS are not able to think for themselves, past doing their usual vitals or obvious needed intervention. Many know what to do, but always need to ask a medic if it's acceptable, instead of acting autonomously, as they would be on a BLS unit.

I do understand that how we train is how we function in the field, but the lab only helps to an extent. Running BLS 90% of the time, or doing VOMIT most of the time (Vitals, O2, Monitor, IV, Txp), flattens out the learning/experience curve significantly. No one's learning much by taking vitals and and ECG on mostly stable patients day in and day out.


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## 46Young (Apr 16, 2015)

RocketMedic said:


> Surprisingly insightful, AMS.
> 
> Yesterday, I took an IFT run. Hour-long routine transfer for appendicitis. Totally stable. Sure, I could have turfed it to my partner and it could have been a BLS call, but when the ED's meds wore off and pain returned, the patient was certainly glad to have a paramedic with him. That's the difference between paramedics and basics. I can do things that actually help outside of first aid.



Would you be able to start BLS, then just switch roles and make it ALS if pain management is needed? We have a policy that if BLS rides as attendant to the hospital, and the pt needs ALS, we can switch, no repercussions for initially judging the pt. BLS.


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## RocketMedic (Apr 16, 2015)

46Young said:


> Would you be able to start BLS, then just switch roles and make it ALS if pain management is needed? We have a policy that if BLS rides as attendant to the hospital, and the pt needs ALS, we can switch, no repercussions for initially judging the pt. BLS.


We certainly could, but an all-BLS or tiered system cannot do that.


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## Carlos Danger (Apr 16, 2015)

RocketMedic said:


> We certainly could, but an all-BLS or tiered system cannot do that.


Basics can't do anything for pain?


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## RocketMedic (Apr 16, 2015)

Remi said:


> Basics can't do anything for pain?



Tylenol PO here.


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## 46Young (Apr 16, 2015)

Remi said:


> Basics can't do anything for pain?



Cold packs, padding, and positioning isn't going to cut it when IV/IN pain management is required, especially when the pt at the sending facility had pain mgmt on board, and needed a maitenance dose enroute, as was the case with Rocketmedic.

A burn victim, someone with abd. pain, or an injury needs Fentanyl or MS. Versed for cardioversion or someone with repeated IACD firings. A feW months ago, while waiting for the helo, I gave a double GSW victim Fentanyl to take the edge off.

There was a thread here a while back about whether or not to give drug seekers pain management. The conclusion is that it's barbaric to allow a patient to remain in suffering, even if it's withdrawal instead of a more proper reason, and it's also barbaric to slam narcan to totally take away an opiod's effects on an addict. Just enough to keep them breathing well.

BLS'ing a junkie that c/o pain in order to get some opiod on board, even though it's wrong, is still barbaric.


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## Carlos Danger (Apr 16, 2015)

46Young said:


> Cold packs, padding, and positioning isn't going to cut it when IV/IN pain management is required, especially when the pt at the sending facility had pain mgmt on board, and needed a maitenance dose enroute, as was the case with Rocketmedic.



In that scenario, the sending should have used a more appropriate analgesic, or timed it better. Perhaps they would have if they knew the patient was going by BLS.



46Young said:


> A burn victim, someone with abd. pain, or an injury needs Fentanyl or MS. Versed for cardioversion or someone with repeated IACD firings. A feW months ago, while waiting for the helo, I gave a double GSW victim Fentanyl to take the edge off.



None of those examples are good arguments against a tiered system, since every one of them would have a paramedic dispatched anyway.



46Young said:


> There was a thread here a while back about whether or not to give drug seekers pain management. The conclusion is that it's barbaric to allow a patient to remain in suffering, even if it's withdrawal instead of a more proper reason, and it's also barbaric to slam narcan to totally take away an opiod's effects on an addict. Just enough to keep them breathing well.
> 
> BLS'ing a junkie that c/o pain in order to get some opiod on board, even though it's wrong, is still barbaric.



Honestly, I think the pendulum has swung too far in this area. It used to be that analgesia rated as a very low priority and we did a poor job of providing it even when really needed. Now though, I think we take the "everyone deserves fentanyl" sentiment too far. Not every twinge of discomfort requires an opioid. I would agree that it's generally better to err on the side of providing analgesia when it isn't really needed vs. not often enough, but the shotgun approach where we narc everyone up isn't necessarily a good thing. But this is a topic deserving of its own thread.


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## Tigger (Apr 16, 2015)

I would also submit that tiered systems do not have much of a place in rural areas. Here if the paramedic was not on the first arriving ambulance, it would frequently take half an hour to get a paramedic if a BLS ambulance requested it once they arrived on scene and that is not effective.


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## 46Young (Apr 16, 2015)

Remi said:


> In that scenario, the sending should have used a more appropriate analgesic, or timed it better. Perhaps they would have if they knew the patient was going by BLS.
> 
> 
> 
> ...



If they don't seem to be in any significant amount of pain, I'll defer pain management to the ER. "10/10" said with a straight face and a 0 to 2 on the FACES scale can wait until after triage, for example. I'm liberal with pain management only if it appears that they can really benefit from it, not so much for every little thing. If they appear comfortable, I reason that the ED can hopefully find a non-opiod route to treat them, so that they're not impaired afterwards. I lump in Zofran with comfort care - it's miserable to be nauseous, and even more uncomfortable to vomit. I'm more liberal with Zofran than anything else, for the most part. I don't even need to drop a lock for that one.

I greatly favor a tiered system over an all-ALS system. If a patient needs pain managemernt, call for ALS. For sick calls and abd. pain, if they're stable with no orthostatic changes and clear L/S, they can go BLS. A 12-lead should be performed for any pain between the neck and umbilicus, as well as possible atypical MI signs such as dizziness and nausea. You don't need medics for that either - put a monitor on every BLS unit, have the BLS obtain a 12 -lead, preferably two, and transmit to the receiving ED for interpretation. That's what they do in rural areas where ALS coverage is inconsistent or non-existent. The cost of the monitor should be less than the pay differential between a medic and an EMT, as well as the cost to stock ALS equipment and meds.

Even strokes were BLS in NYC. If they could maintain their airway, and were not hypotensive, they went BLS, a diesel bolus being the priority. That's actually how I roll here - quick vitals and stroke assessment, move to the rig, check BGL, then a line and 12-lead if I have time. That's the only time I don't get the 12-lead on-scene within 5 minutes.


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## 46Young (Apr 16, 2015)

Tigger said:


> I would also submit that tiered systems do not have much of a place in rural areas. Here if the paramedic was not on the first arriving ambulance, it would frequently take half an hour to get a paramedic if a BLS ambulance requested it once they arrived on scene and that is not effective.



You are correct.

I forgot to mention that a tiered system is most appropriate in a dense urban area, and that becomes more undesirable the more you move towards a rural system. The same goes for FD ALS first response - useless in the city, limited usefulness in suburbia, but invaluable out in the sticks where the ambo is 30-45 minutes away, and the fire station is 5-10 minutes away.


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## 46Young (Apr 16, 2015)

Documentation tip for pain scale - if the pt. calmly says 10/10, but is a 1 on a FACES scale, I go with the FACES scale instead of numeric. Our software gives that choice, but I suppose you could write that in if you need to. That way, QA/QI isn't trippin out over why I didn't medicate the 10/10 pain when it was really a 1 or a 2.


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## CentralCalEMT (Apr 29, 2015)

I highly agree that tiered systems are extremely beneficial in urban areas. I think in some cases, in urban areas, ALS can be detrimental if you get a medic who wants to play paragod for 30 minutes on scene when a hospital that is a level 1 trauma center/STEMI center/stroke center, etc is a block away. 

I also agree that this system has very limited usefulness in a rural setting, unless the rural area was well staffed with adequate numbers and types. I think it would be easier to find a unicorn than a well staffed rural system. Because there are so few ambulances, and ALS fire is non existent in many areas, I think rural systems should be all ALS if possible. My area is all ALS. But then again we have 4 ambulances for 1,200 square miles.


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## NomadicMedic (Apr 29, 2015)

CentralCalEMT said:


> I highly agree that tiered systems are extremely beneficial in urban areas. I think in some cases, in urban areas, ALS can be detrimental if you get a medic who wants to play paragod for 30 minutes on scene when a hospital that is a level 1 trauma center/STEMI center/stroke center, etc is a block away.



That's a QI issue. Any system that routinely allows it's medics to have 30 minute scene times when a "level 1 trauma center/STEMI center/stroke center, etc is a block away" has bigger issues.


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## MrJones (Apr 29, 2015)

While I agree with the concept of fewer medics and more EMTs it's with a caveat. EMT as we know it today has to go away (actually, become the standard for First Responder), with what we currently call AEMT becoming the base level for EMTs.


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## Carlos Danger (Apr 29, 2015)

MrJones said:


> While I agree with the concept of fewer medics and more EMTs it's with a caveat. EMT as we know it today has to go away (actually, become the standard for First Responder), with what we currently call AEMT becoming the base level for EMTs.



Why what do AEMT's do (that basics don't) that impacts outcomes?


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## NomadicMedic (Apr 29, 2015)

I think the base level should be paranedic, with a PCT as an assistant. The PCT training would consist of EVOC, patient movement, customer service and tge skills needed to be a paramedic assistant. 

Basic IFT would be done by two PCT and anything that required care would be attended by the paranedic. 

But that's a perfect world.


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## Brandon O (Apr 29, 2015)

46Young said:


> Documentation tip for pain scale - if the pt. calmly says 10/10, but is a 1 on a FACES scale, I go with the FACES scale instead of numeric. Our software gives that choice, but I suppose you could write that in if you need to. That way, QA/QI isn't trippin out over why I didn't medicate the 10/10 pain when it was really a 1 or a 2.



The Wong-Baker scale is NOT meant as a "what does the patient look like?" chart that can magically transform a symptom into a sign. It's meant for patients who aren't in command of numerical scales to let them point at the icon representing their current pain.


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## EpiEMS (May 1, 2015)

Remi said:


> Why what do AEMT's do (that basics don't) that impacts outcomes?



This is a really good point.
On one hand, it would bring us closer in line with international standards for minimum scope of practice...on the other, I would be hard pressed to think of many life saving level differences. Maybe D50? Maybe?


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## RefriedEMT (May 1, 2015)

Tigger said:


> I would also submit that tiered systems do not have much of a place in rural areas. Here if the paramedic was not on the first arriving ambulance, it would frequently take half an hour to get a paramedic if a BLS ambulance requested it once they arrived on scene and that is not effective.



I would have to agree with you on this a little because I worked in thurston county jumping calls in Olympia, Tumwater, Rainier, and Yelm and 99% of the time we needed a medic for an unstable pt or pt that was in extreme PX we would be policy 27'd which means that the medics are busy/too far away and we need to BLS them to the ED while they scream bloody murder all the way there.


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## escapedcaliFF (May 3, 2015)

I just read up on a company trying out Paramedic chase SUVs. Basically their thinking is have paramedics in chase SUVs available instead of overstaffing ALS ambulances. Idea is BLS can call for ALS if needed and a paramedic shows up in the SUV and assumes control while one of the basics jumps in the SUV and follows to ED. The company claims they have cut response times and cost associated with calls. Short of like what LA Fire dose but different in some aspects.


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## NomadicMedic (May 3, 2015)

escapedcaliFF said:


> I just read up on a company trying out Paramedic chase SUVs. Basically their thinking is have paramedics in chase SUVs available instead of overstaffing ALS ambulances. Idea is BLS can call for ALS if needed and a paramedic shows up in the SUV and assumes control while one of the basics jumps in the SUV and follows to ED. The company claims they have cut response times and cost associated with calls. Short of like what LA Fire dose but different in some aspects.




See: the entire state of Delaware.


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## escapedcaliFF (May 3, 2015)

I was unaware of this. I just know of the one I talked about and the  practices of LA Fire hijacking and dominating all ALS with their medics.


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## NomadicMedic (May 3, 2015)

There's a whole big world of EMS, everyone does it a little differently.  Keep looking til you find the one that fits you best.  

I still believe DE's paramedic system is one of the best.


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## escapedcaliFF (May 3, 2015)

Yep everyone dose it a bit different and some to a new level of crazy like Komifornia. I am very pleased with Arizona protocals as it more broad scoped and I don't feel like a chauffeur as much.


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## DrParasite (May 3, 2015)

DEmedic said:


> See: the entire state of Delaware.


See: almost the entire state of New Jersey, except they have two medics in every SUV instead of just one.


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## NomadicMedic (May 3, 2015)

DrParasite said:


> See: almost the entire state of New Jersey, except they have two medics in every SUV instead of just one.



Delaware staffs every paramedic unit with two medics.


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## RedAirplane (May 3, 2015)

How about capes? Yea, it'll be annoying in bad weather, but it'll allow for a show of heroism and a much faster response time than helicopter or jet pack. Also not prone to traffic jams, unless you count air traffic.


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## chaz90 (May 3, 2015)

DEmedic said:


> Delaware staffs every paramedic unit with two medics.


Well, everything except ME110. They're special though.


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## NomadicMedic (May 3, 2015)

chaz90 said:


> Well, everything except ME110. They're special though.



Right, but they still SEND two. Hahahah


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## MrJones (May 3, 2015)

Remi said:


> Why what do AEMT's do (that basics don't) that impacts outcomes?


Let's see....

Laryngoscopy
Orotracheal Intubation
Cardiac Monitor Strip Interpretation
Manual Defibrilation
Peripheral IVs
Intraosseous initiation w/ lidocaine administration for pain relief
Peripheral IV blood samples
Sub-Q/IM Epi
Non-patient assist nitroglycerin
IN medications
Needle chest decompression
Administer Benadryl, Benzos, Glucagon, Narcotics

I imagine the list changes from state to state, but I'd say that's a fairly representative sample.


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## escapedcaliFF (May 3, 2015)

MrJones said:


> Let's see....
> 
> Laryngoscopy
> Orotracheal Intubation
> ...



Arizona is kinda different protocals depending on how rural and access to care. In the rural areas protocals for basics are way more broad then say the Phoenix Valley area.


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## Carlos Danger (May 3, 2015)

MrJones said:


> Let's see....
> 
> Laryngoscopy
> Orotracheal Intubation
> ...



I wasn't looking for a list of ILS skills; I asked what do they do that actually positively impacts outcomes.


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## triemal04 (May 3, 2015)

MrJones said:


> Let's see....
> 
> Laryngoscopy  nope
> Orotracheal Intubation nope
> ...


Granted, there are exceptions to the above, but most of the things you listed are not a "standard" part of what an intermediate EMT (by one name or another) would do.  And if you are talking about the actual AEMT level...hell no.


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## MrJones (May 4, 2015)

triemal04 said:


> Granted, there are exceptions to the above, but most of the things you listed are not a "standard" part of what an intermediate EMT (by one name or another) would do.  And if you are talking about the actual AEMT level...hell no.


Really? That list came directly from an AEMT Scope of Practice document.


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## MrJones (May 4, 2015)

Remi said:


> I wasn't looking for a list of ILS skills; I asked what do they do that actually positively impacts outcomes.


And you don't think that the performance of those skills can actually positively impact outcomes?

Fascinating.


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## Carlos Danger (May 4, 2015)

MrJones said:


> And you don't think that the performance of those skills can actually positively impact outcomes?
> 
> Fascinating.



For someone who refers to themselves as an iconoclast, I'm surprised you are not more critical of the benefit or necessity of many of the things we do in EMS.

Rather, you seem to assume that just because some regulatory agency decides to allow a skill to be placed on a list of "things we are allowed to do", that said skill is important enough to dictate system design?

I'm not saying that every individual skill needs to have been validated as necessary by numerous RCT's in order to be worth including in protocols. But we are talking about giving authority for the performance of invasive skills to very minimally trained clinicians.......in that case, I think the protocols we give them ought to adhere to what we know is important and works.

All sorts of ALS interventions are unproven as beneficial, so we should not assume that just because the EMT-I can "do more", that the care they provide is necessarily better for patients than that provided by an EMT.


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## MrJones (May 4, 2015)

Remi said:


> For someone who refers to themselves as an iconoclast, I'm surprised you are not more critical of the benefit or necessity of many of the things we do in EMS....



My initial comment and subsequent responses had nothing to with the "...benefit or necessity of many of the things we do in EMS." You asked what AEMTs can do, and EMTs can't, that impacts outcomes. I answered. You added 'positively' as a qualifier after I responded with a rather specific list that directly addressed the question as posed.

Just sayin'.... 

Every skill I listed - from an approved State scope of practice document - is a skill that an AEMT can perform and an EMT cannot, and each impacts outcomes in one way or another. Whether that impact is positive or negative depends on any number of factors, and a Paramedic can just as easily muck it up as can an AEMT.

Now, had you asked the less argumentative and more pertinent question "why do you believe that EMT as we know it today has to go away...with what we currently call AEMT becoming the base level for EMT" I would have noted that, while AEMT is still a relatively minimal level of medical training, it still goes beyond the training and education that an EMT receives and results in a provider who can do much more to assist with patient care (and is theoretically capable of handling more complex calls without the necessity of paramedic intervention). Additionally, I see it as a step in the right direction towards raising the standard of training for all levels - from EMT to Paramedic.


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## triemal04 (May 4, 2015)

MrJones said:


> Really? That list came directly from an AEMT Scope of Practice document.


....no...no it didn't.  (except for glucagon and narcan, those are in there)  Your particular state might have added certain things onto the AEMT level, but you might want to peruse what the "stock" AEMT can do, as put out and tested by the national registry.  It's just another name for the old I-85; IV's, couple meds (mostly IM) and an EGD.

As far as what is beneficial; the ability the give IM narcan, glucagon, epi and nebulized albuterol will, or could if used appropriately, pay off.  If a portable delivery system for nitrous every becomes available again that also has benefits.

The rest...meh.


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## 281mustang (May 4, 2015)

MrJones said:


> Let's see....
> 
> Laryngoscopy
> Orotracheal Intubation
> ...


 What state(s) allow 'advanced EMT's' to give narcotics? Not calling you out, I'm just genuinely curious...


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## medicsb (May 4, 2015)

46Young said:


> I forgot to mention that a tiered system is most appropriate in a dense urban area, and that becomes more undesirable the more you move towards a rural system. The same goes for FD ALS first response... invaluable out in the sticks where the ambo is 30-45 minutes away, and the fire station is 5-10 minutes away.





CentralCalEMT said:


> I think rural systems should be all ALS if possible. My area is all ALS. But then again we have 4 ambulances for 1,200 square miles.



Part of the argument that many (like me) have for tiered systems is as much about providing the best experience for the paramedic in to maximize outcomes as it is for targeting the right resources to the right patient.  This doesn't change just because the setting is "rural".  If a population is so spread out that you're 30-45 minutes from the nearest ambulance, what makes you think you'll have an engine ready to respond?  In those circumstance we're talking about such a low call volume for that department and any paramedic assigned to an engine is going to be horribly under-experienced, thus should probably NOT be providing "ALS" level care beyond what may be in the AEMT scope of practice.

Just because the area is rural does not mean you are entitled to the same standards of care as a more populated area because it just isn't possible.  That's a sacrifice one makes when they choose to live in a rural setting.  Even rural critical-access hospitals are not at all expected to provide the same advanced care one might expect of a small community hospital in a more populated setting.  Rural EDs are frequently not staffed with EM-trained physicians.  The ICUs (if there is any) are often not staffed by intensivists.   Specialists may only come to the hospital to work a few weeks a year.  The surgeons likely only perform the most basic of surgical procedures.  Again, these are things one must accept if you want to live away from other people.


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## MrJones (May 4, 2015)

triemal04 said:


> ....no...no it didn't.  (except for glucagon and narcan, those are in there)  Your particular state might have added certain things onto the AEMT level, but you might want to peruse what the "stock" AEMT can do, as put out and tested by the national registry.  It's just another name for the old I-85; IV's, couple meds (mostly IM) and an EGD.
> 
> As far as what is beneficial; the ability the give IM narcan, glucagon, epi and nebulized albuterol will, or could if used appropriately, pay off.  If a portable delivery system for nitrous every becomes available again that also has benefits.
> 
> The rest...meh.



....yes...yes it did.

But, having no desire to see this thread turn into an argument over a peripheral issue I'll stop there. You may have the last word if you so desire.


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## triemal04 (May 4, 2015)

MrJones said:


> ....yes...yes it did.
> 
> But, having no desire to see this thread turn into an argument over a peripheral issue I'll stop there. You may have the last word if you so desire.


Thank, I'll take the last word.  I know you're trying to be sarcastic and play the bigger man, but still...gracias. 

And as this thread is about lowering the number of paramedics, what an EMT (or AEMT as the case may be) can or cannot do would seem to be pertinent.  Don't you think?

Now, it is very possible that your particular state has a provider inbetween an EMT and paramedic that can do the things you listed, they may even be called an AEMT; it's certainly done in some states so it wouldn't be a shock.  As far as what you listed being *"a representative list"*, or part of the* intended* scope from the national registry...not so much.  It only takes a casual look to determine that.


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## Carlos Danger (May 4, 2015)

MrJones said:


> My initial comment and subsequent responses had nothing to with the "...benefit or necessity of many of the things we do in EMS." *You asked what AEMTs can do, and EMTs can't, that impacts outcomes. I answered. You added 'positively' as a qualifier after I responded with a rather specific list* that directly addressed the question as posed.



I am confident that your reading comprehension skills are better than that. That I was referring to how AEMT's affect _positive_ outcomes as opposed to EMT's is quite clear, given the context.



MrJones said:


> *Now, had you asked the less argumentative and more pertinent question "why do you believe that EMT as we know it today has to go away...with what we currently call AEMT becoming the base level for EMT"* I would have noted that, while AEMT is still a relatively minimal level of medical training, it still goes beyond the training and education that an EMT receives and results in a provider who can do much more to assist with patient care (and is theoretically capable of handling more complex calls without the necessity of paramedic intervention). Additionally, I see it as a step in the right direction towards raising the standard of training for all levels - from EMT to Paramedic.



My question was not argumentative at all - it was a pertinent and reasonable question and very much on topic.

The reason I didn't ask why you think EMT training should go away is because I didn't care to know why you think that. I asked what I asked because it's what I wanted to know. If you didn't want to answer, you didn't have to.


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## Smitty213 (May 4, 2015)

281mustang said:


> What state(s) allow 'advanced EMT's' to give narcotics? Not calling you out, I'm just genuinely curious...



One that I am aware of and have the documentation to prove is Ohio... I have heard rumor of other states as well, but I can't find good documentation on it.
http://www.publicsafety.ohio.gov/links/ems_scope_practice.pdf   Bottom of page 5


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## escapedcaliFF (May 5, 2015)

CentralCalEMT said:


> I highly agree that tiered systems are extremely beneficial in urban areas. I think in some cases, in urban areas, ALS can be detrimental if you get a medic who wants to play paragod for 30 minutes on scene when a hospital that is a level 1 trauma center/STEMI center/stroke center, etc is a block away.
> 
> I also agree that this system has very limited usefulness in a rural setting, unless the rural area was well staffed with adequate numbers and types. I think it would be easier to find a unicorn than a well staffed rural system. Because there are so few ambulances, and ALS fire is non existent in many areas, I think rural systems should be all ALS if possible. My area is all ALS. But then again we have 4 ambulances for 1,200 square miles.



See the issue with all ALS ambulance in rural settings is if BLS Fire shows and determines ALS is needed odds are air medvac is needed and can deffiently provide expedited transport where  an all ALS ambulance service might not provide the best level of patient care cause they will feel ground ambulance transport is warranted when air medvac is probably  better for patient outcome. I have seen this first hand in rural settings. An all ALS ambulance company being short staffed cause they feel 1 hour plus time to a trauma center is acceptable. What happens if it's all ALS ambulance service and your short staffed cause your transport times are long and a MCI happens? Just makes sense to me that it's better to have a mix to avoid such situations as ambulance companies will always go after the high profits of long transports. Also I have seen the chopper beat ALS ambulances multiple times especially when the ambulance is coming from the other side of their AOR. It's better to have a BLS ambulance on scene instead of waiting for the magical ALS ambulance which is still 20 plus minutes out.


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## Tigger (May 5, 2015)

escapedcaliFF said:


> See the issue with all ALS ambulance in rural settings is if BLS Fire shows and determines ALS is needed odds are air medvac is needed and can deffiently provide expedited transport where  an all ALS ambulance service might not provide the best level of patient care cause they will feel ground ambulance transport is warranted when air medvac is probably  better for patient outcome. I have seen this first hand in rural settings. An all ALS ambulance company being short staffed cause they feel 1 hour plus time to a trauma center is acceptable. What happens if it's all ALS ambulance service and your short staffed cause your transport times are long and a MCI happens? Just makes sense to me that it's better to have a mix to avoid such situations as ambulance companies will always go after the high profits of long transports. Also I have seen the chopper beat ALS ambulances multiple times especially when the ambulance is coming from the other side of their AOR. It's better to have a BLS ambulance on scene instead of waiting for the magical ALS ambulance which is still 20 plus minutes out.



First of all your posts are nearly impossible to understand.

Secondly, what in the world are you talking about? If the patient needs a paramedic then they need a helicopter? No, absolutely not. Do not pass go, do not collect 200 dollars, just no.


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## escapedcaliFF (May 5, 2015)

Tigger said:


> First of all your posts are nearly impossible to understand.
> 
> Secondly, what in the world are you talking about? If the patient needs a paramedic then they need a helicopter? No, absolutely not. Do not pass go, do not collect 200 dollars, just no.



Obviously your missing the point of what I'm saying. I'm applying the above to rural settings with limited facility's.


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## Tigger (May 5, 2015)

No, I don't think so. I work in a rural system with very limited facilities. We fly an average of (I think) 50-60 patients a year out of our 1500 transports. There are many interventions that a paramedic can provide that do not need to be followed up by a helicopter. Expedited transport very, very rarely makes a difference. 

Perhaps you should elaborate.


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## escapedcaliFF (May 5, 2015)

Tigger said:


> No, I don't think so. I work in a rural system with very limited facilities. We fly an average of (I think) 50-60 patients a year out of our 1500 transports. There are many interventions that a paramedic can provide that do not need to be followed up by a helicopter. Expedited transport very, very rarely makes a difference.
> 
> Perhaps you should elaborate.



Yes a medic can do a lot of interventions. Im not debating this. When I hear rural I think of where I grew up with a call volume about a quarter of that and the farm equipment taking of limbs is not uncommon.


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## Tigger (May 5, 2015)

Nonetheless, you need to defend the statement that:



> see the issue with all ALS ambulance in rural settings is if BLS Fire shows and determines ALS is needed odds are air medvac is needed and can deffiently provide expedited transport where an all ALS ambulance service might not provide the best level of patient care cause they will feel ground ambulance transport is warranted when air medvac is probably better for patient outcome.]
> 
> What outcomes are improved?


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## escapedcaliFF (May 5, 2015)

Im just pointing out that an all ALS is probably not the best choice for rural America. It's better to have something than nothing. Say for example your company covers 2,000 square miles and ALS is 30 mins out but BLS is close by and can get them loaded on a chopper in 10 mins. The nearest hospital that can handle a major trama is 2 hours away. Would you honestly think driving 2 hours ALS is a better idea than a 30 minute chopper ride? I just think that there are way to many outside influence on an all ALS service and money being a big one.


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## Tigger (May 5, 2015)

Why do you have to have all ALS? We provide ALS service to our 600 square miles with BLS first response from volunteers. The super rural areas have transporting BLS ambulances that will rendezvous with us. Works just fine and does not place an excessive burden on air medical. Even most ALS calls are not time sensitive in the ways that EMS seems to think they are.


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## MrJones (May 5, 2015)

In this corner - hypothetical situations specifically formatted to support the contention that all ALS and airmed are the answer for rural EMS.

And, in this corner - actual rural EMS experience and data.

Ladies and gentlemen, place your bets at the window.


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## RocketMedic (May 5, 2015)

So a hypoglycemic coma needs a helicopter?


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## Handsome Robb (May 5, 2015)

HEMS AMA FTW!


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## Angel (May 5, 2015)

tigger, idk why, but i like it when you get all riled up...


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## Tigger (May 5, 2015)

I want EMS to become a respected part of healthcare so that I can have a career that I love for a long time. Comments like the above seek to take that away from me. Therefore they must be destroyed.


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## PotatoMedic (May 5, 2015)

Angel said:


> tigger, idk why, but i like it when you get all riled up...


"Meow" ...?


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## Angel (May 5, 2015)

and here i was thinking that was subtle...bahaha 
for real though, i have a lot (more) respect for you after that weird, sexual harassment justification post by escapedcaliff


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## Carlos Danger (May 6, 2015)

I think using HEMS as the primary ALS to a given area is feasible and even makes good  sense......IF certain conditions are met. Those conditions primarily being low ALS utilization (you can't be calling a helicopter every other day for diabetic wake ups), cost control of some sort (helos are very expensive, but I don't think it's right to be sending out $20,000 bills for an ALS rendezvous that normally would cost a few hundred dollars), and that the BLS services have some sort of backup plan for when HEMS isn't available, such as _some_ way to manage severe pain, for instance.

Might be doable and cost-effective in really sparsely populated areas with few EMS responses. I think it's relatively common in other parts of the world.

A few posts back, medicsb made the point that you can't live out in the middle of nowhere and expect the same availability of service that you would have in the suburbs. I think that's worth keeping in mind when thinking about system design in really rural areas.


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## Tigger (May 6, 2015)

Remi said:


> I think using HEMS as the primary ALS to a given area is feasible and even makes good  sense......IF certain conditions are met. Those conditions primarily being low ALS utilization (you can't be calling a helicopter every other day for diabetic wake ups), cost control of some sort (helos are very expensive, but I don't think it's right to be sending out $20,000 bills for an ALS rendezvous that normally would cost a few hundred dollars), and that the BLS services have some sort of backup plan for when HEMS isn't available, such as _some_ way to manage severe pain, for instance.
> 
> Might be doable and cost-effective in really sparsely populated areas with few EMS responses. I think it's relatively common in other parts of the world.
> 
> A few posts back, medicsb made the point that you can't live out in the middle of nowhere and expect the same availability of service that you would have in the suburbs. I think that's worth keeping in mind when thinking about system design in really rural areas.



I would imagine that in the rest of the world that the costs associated with air medical are much lower given every other developed country's funding mechanisms for healthcare.


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## EpiEMS (May 7, 2015)

Tigger said:


> I would imagine that in the rest of the world that the costs associated with air medical are much lower given every other developed country's funding mechanisms for healthcare.



Interesting question, actually. Costs, broadly considered, might not necessarily be lower, but the price individuals pay directly out of pocket certainly is.
After all, a helicopter costs pretty much the same anywhere, as do, ALS practitioners (at least, they cost the "same" within an order of magnitude -- a physician at $200k, a nurse at $75k and a paramedic at $50k are not all that different from a systemic perspective, not really). However, at the point of service, if you will, you or I in the U.S. "pay" a lot more out of pocket than somebody in the UK, say, might.


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## Carlos Danger (May 10, 2015)

Tigger said:


> I would imagine that in the rest of the world that the costs associated with air medical are much lower given every other developed country's funding mechanisms for healthcare.



Well, I'm not talking about putting up a HEMS base just to serve as ALS backup to a given area. I mean in an area where one exists already, adding a handful of "ALS" flights a month in an area that doesn't have paramedics probably wouldn't break the bank. 

I saw a study or article years ago on this.....I don't remember the details, but it basically showed that if utilized correctly, a helicopter can actually be more cost-effective than ground units. This is because you can cover such a large area with a helicopter that you can effectively replace many ground ALS and CCT units with a single HEMS base. The two keys to that working properly were weather and utilization. Obviously you have to be talking about an area where weather is reliably good, so that you don't have to worry about the helicopter being unavailable for weather all the time. Utilization meant primarily that you couldn't call it for just anything (like is done now, in many places) - you had to redefine the indications for ALS/CCT.


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## Clare (May 11, 2015)

In NZ roughly we have about 1,200 EMTs, 700 Paramedics and 300 Intensive Care Paramedics.


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## CentralCalEMT (May 11, 2015)

I think t


escapedcaliFF said:


> See the issue with all ALS ambulance in rural settings is if BLS Fire shows and determines ALS is needed odds are air medvac is needed and can deffiently provide expedited transport where  an all ALS ambulance service might not provide the best level of patient care cause they will feel ground ambulance transport is warranted when air medvac is probably  better for patient outcome. I have seen this first hand in rural settings. An all ALS ambulance company being short staffed cause they feel 1 hour plus time to a trauma center is acceptable. What happens if it's all ALS ambulance service and your short staffed cause your transport times are long and a MCI happens? Just makes sense to me that it's better to have a mix to avoid such situations as ambulance companies will always go after the high profits of long transports. Also I have seen the chopper beat ALS ambulances multiple times especially when the ambulance is coming from the other side of their AOR. It's better to have a BLS ambulance on scene instead of waiting for the magical ALS ambulance which is still 20 plus minutes out.



It sounds like a provider problem and not an ALS/BLS problem. If that services understaffed ALS, what makes you think they will appropriately staff BLS? It sounds like better response time standards are the answer for that problem. Where I work, we use industry standard response times. My agency had over 98% response time compliance to all zones this last quarter for example, so it is possible. I do not disagree that it is better to have a BLS ambulance on scene rather than no ambulance. It is always good to have the transporting unit on scene as soon as possible. They can rendezvous if it is necessary. If your provider shuns or doesn't support rural BLS ambulance first response then again, it is a provider problem. My service provides training and CEs to the few volunteer BLS services we have in my area for free, and driver training. We restock them for free whether it is a nasal canula, or quick combo AED pads. We refill their O2 for free. They are always welcome to come train with us on drills and they sometimes do. However....most of the county areas do not have the volunteers, funding, or the desire to be in the BLS ambulance business, so we are the only ambulance responding through no fault of our own. Considering our ALS units are 1:1 staffing, the cost of our 4 units, even if we went to all BLS, would still be great enough that we wouldn't have the funding to add even one more BLS unit 24/7. With so few ambulances, the conversion to BLS simply doesn't add resources with the cost savings. (Paramedics do not make that much more than basics here and ALS medications are not that expensive in the grand scheme of things.)

Also, in reply to a couple of other posters........

I also do not buy the argument that just because you are in a rural area you should not have the "big city" resources. If it is cost effective and needed, then there is nothing wrong with an ALS system. Yes the isolated mountain cabin with someone who is purposely trying to live off the grid miles from civilization will not get the service someone in a major urban center will, neither will the desert dweller who lives in the middle of nowhere miles down a dirt road and I can agree with that. Most of those people do not call EMS that often at all. If you try and avoid people by living in the middle of nowhere with no industry or agriculture then it makes sense nobody will stick resources there. However, most people in rural areas are not that type of people.

One thing to consider:

Many rural areas are vitally important and have hardworking people who provide a desperately needed resource that can not be produced in mass in the cities. It is a resource that the production of has many work related accidents. That resource is FOOD! Simply put, our country needs both city and rural areas. I work in California's Central Valley. This area produces 25% of the nations's food. We have numerous small farm towns here. Every one of them has access to ALS EMS. Until them fancy city folk can grow their own food in congested, overbuilt urban areas, us rural folk are needed. Why, because you are a farmer, rancher, field worker, rural truck driver for a packing house, etc. are you not deserving of the same care available in the cities? You work hard, pay taxes, and provide a needed resource.  I also think a small percentage of my more urban counterparts almost picture us (rural ALS services) as redneck cowboys with P cards who are either doing needless interventions for the heck of it because we do not know better, or who freak out when we get an actual emergency because we are soooooo inexperienced. I can tell you that while every service has it's better and worse paramedics, most rural EMS workers are skilled and knowledgeable. I have worked urban EMS in the past and the level of care in my rural area at least is excellent.

For all the people who have hopes and dreams of HEMS being readily available and able to replace some ALS and CCT units, that is a perfect world scenario. My region has 2 ALS helos for over 12,000 square miles. Additionally, we have dense fog which grounds helos for days at a time. The fog also slows down response times and lengthens transport times. Why should someone not get ALS level care because of the weather? The fog is a daily occurrence in my area so it is not uncommon or unforeseen. In those cases ground transport is the only option, and if it is a critical patient being transported for an hour, then ALS is better. That is just my opinion of my rural area. There is no one size fits all in EMS. We are a country of 50 states with thousands of jurisdictions each with it's own unique problems and challenges.


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## RocketMedic (May 12, 2015)

You're not alone. I am 50 miles south of Houston in a town of 30k and a region of 45k with a single "meh"-quality hospital, and we can't fly anyone due to weather.


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