Serious Question: Why Does Fire-based EMS sometimes produce such low results?

[FiremanMike]

I don't see the benefit in having an ALS team lead, myself, and why do you need a medic for airway & for access + drugs? Can't the medic get access (via IO, probably), then throw a rescue airway in? BVM should be more than adequate initially. Heck, you could probably just throw on an NRB in most adult arrests of cardiac origin for the first couple minutes.

If we want to get really serious about trimming the fat, you don’t need any paramedics on the scene of a cardiac arrest.. high quality chest compressions, a BVM, and an AED are all that’s needed, if wer is being honest..

 

[Summit]

If we want to get really serious about trimming the fat, you don’t need any paramedics on the scene of a cardiac arrest.. high quality chest compressions, a BVM, and an AED are all that’s needed, if wer is being honest..

So... why not do that?

 

[FiremanMike]

So... why not do that?

<shrug> dunno..

If I'm forced to give a real answer, I'd say it's because Paramedics are out and about and will be on scene. If paramedics are on scene and not doing paramedic crap, then does that put them into any scenario of medicolegal liability, given todays standard of care?

 

[DrParasite]

. If paramedics are on scene and not doing paramedic crap, then does that put them into any scenario of medicolegal liability, given todays standard of care?

does that mean every fire department that doesn't have paramedics on their engine are at risk for medicolegal liability, given todays standard of care?

And if a paramedic (or RN, MD, trauma surgeon, who just likes being on the ambulances etc) is working as an EMT (based on job, not actual credentials), should he or she be functioning based on his knowledge or job description? Even moreso, if you have an EMT who has been there for 5 years, and recently completed his paramedic school but isn't a released paramedic medicolegal liability is he or she at risk for when he doesn't even attempt an IV or tube or give drugs that are outside of his positions scope of practice for his job, but not for his personal certification? Do you see how far down the rabbit hole we can take this?

I'll go ahead and play devils advocate and present a model (of many) that you ideally get for an in-hospital code.
1-2 docs
1-2 nurses
0-1 RT
Maybe 1 pharmacist to mix up TPA (usual etiology and response times are different in a hospital vs field)
Several bodies to do compression, hold mask, record, lab courier

You have a RN running the monitor/IO/drugs.
You have a MD running the code often with a RN copilot. Their job is to stand back, manage, and think.
You have the RT or another doc (anesthesia) on airway or establishing central access, a-lines.
You have ancillary personnel for compressions, bagging, recording, run labs

Hospital's have a scribe somewhere too.

I like the idea of a paramedic "code commander." He is in charge, he watches the monitor for any rhythm changes, he directed people when to push drugs. and what drugs to push, he presses the shock button. Maybe a second paramedic to actually give the drugs, establish IO, and intubate (and two of these things are one and done move on). one you have the tube, ventilate it and hand off to BLS. otherwise, king airway and move on. And do you really call a doc during a code? aren't most things standing order? maybe to pronounce, maybe if there is something weird, maybe if your out of ideas and want a second opinion..... and even if you do, it's a once and done thing.

despite what the IAFF propaganda says (and I don't blame them for it, because it serves their interests only, which is their job), don't need a medic to get history, ventilate, do compressions, attach defib pads or speak to the family.

 

[FiremanMike]

does that mean every fire department that doesn't have paramedics on their engine are at risk for medicolegal liability, given todays standard of care?

And if a paramedic (or RN, MD, trauma surgeon, who just likes being on the ambulances etc) is working as an EMT (based on job, not actual credentials), should he or she be functioning based on his knowledge or job description? Even moreso, if you have an EMT who has been there for 5 years, and recently completed his paramedic school but isn't a released paramedic medicolegal liability is he or she at risk for when he doesn't even attempt an IV or tube or give drugs that are outside of his positions scope of practice for his job, but not for his personal certification? Do you see how far down the rabbit hole we can take this?
Hospital's have a scribe somewhere too.

Given our current legal system, I think the obvious answer to all of those questions is "maybe". With that said, and in my non-lawyer trained opinion, none of those rise to the same level of liability of a properly credentialed paramedic on scene of a cardiac arrest who has immediate access to ALS interventions that are the current standard of care but elects not to use them. Now, if we're talking about the medical director taking a stand and changing their protocols, then they may be operating outside of the standard of care, but within their scope of practice. The medico-legal liability in that case would fall back to the medical director.

I like the idea of a paramedic "code commander." He is in charge, he watches the monitor for any rhythm changes, he directed people when to push drugs. and what drugs to push, he presses the shock button. Maybe a second paramedic to actually give the drugs, establish IO, and intubate (and two of these things are one and done move on). one you have the tube, ventilate it and hand off to BLS. otherwise, king airway and move on. And do you really call a doc during a code? aren't most things standing order? maybe to pronounce, maybe if there is something weird, maybe if your out of ideas and want a second opinion..... and even if you do, it's a once and done thing.

despite what the IAFF propaganda says (and I don't blame them for it, because it serves their interests only, which is their job), don't need a medic to get history, ventilate, do compressions, attach defib pads or speak to the family.

I don't disagree with you on any of these points. We didn't choose to go "all paramedic" because we pushed that it was a requirement that every position on every run MUST be a paramedic, we did so because we wanted to add paramedics to give our paramedics at the time a break every now and again, then at some point it just became logistically more sensible to make everyone a paramedic, to where we are now that you can't even apply without your paramedic card in hand.

 

[EpiEMS]

it just became logistically more sensible to make everyone a paramedic

I don't know about that...it's a pretty straightforward optimization problem. You can figure out how many medics you need in total to have, say, N medics on every shift.

 

[FiremanMike]

I don't know about that...it's a pretty straightforward optimization problem. You can figure out how many medics you need in total to have, say, N medics on every shift.

Firefighter A is a FF/EMT who retires. Do we only interview FF/EMTs to replace him? What if one of the Firefighter/medics wants to "drop their card" an ride out the rest of their days on the fire truck. Who sets the process for "dropping your card" and what does it look like? What if one of the interview candidates is really a stand-out candidate, best we've ever seen, but he's a firefighter/medic. Do we hire him and tell him he'll be making FF/EMT pay and not riding the ambulance?

We have 2 ambulances and a fire truck. We decide that we want to have 5 paramedics per shift, 2 on each ambulance and 1 on the fire truck. One of them goes home sick or is off on injury. Do we now saddle the 10 paramedics off the other crews with the overtime coverage?

We decide we want 5 paramedics but we want to get really fancy and actually staff 6 paramedics on each crew, but we'll tell the 6th guy that he's only getting the FF/EMT rate because he's not actually working as a paramedic that day, he's just the back-up for sick call. So then the backup ff/medic steps up and intubates on the next arrest because he was sitting near the head, does he get to put in for FF/medic pay for that shift now? What about his skill degredation for being "just the back-up medic"?

Sure, it sounds simple to just say "you need x medics, so have x medics" but nothing is ever as simple as we want it to be. We have 11 guys per shift with a minimum of 9, at some point they just said "you know, it's just easier to make everyone a medic, train everyone to the same standard, and rotate everyone equally between the trucks".

 

[EpiEMS]

@FiremanMike Fair point, it is seems like a simple enough solution. It's probably not the most efficient way to do things, but simplicity has a value.

 

[Bullets]

So... why not do that?

I need a paramedic to pronounce.

As it stands now, when my BLS agency responds to arrest, we dont break out the BVM until 10 minutes into the arrest. Its just compression, AED and NRB(actually a HFNC).

 

[Tigger]

So I'd say 4 paramedics would be ideal for the way we roll. 1 to be the team lead, 1 for the intubation/airway management, 1 to mind the monitor, and one to get the IV/IO and push the drugs. This way every one of those roles is filled by someone who is trained and legally able to carry out what needs to be done in their assignment. So the other two guys will be the chest compressors, at least until its time to move to the autopulse/lucas. Sure, it's overkill that the chest pushers are paramedics? Sure, I suppose, but is it enough to get up in arms about over saturation? Nah.

This is going to be a long post. @FiremanMike I am not trying to start a fight. I respect you, your knowledge, and what you do for your agency. After the first paragraph this is really just going to turn into a repressed rant that's been building for months, please know that it isn't directed at you so much as an example of what some of us deal with.

I'm going to use the above to maybe illustrate a point. Here (and legally I might add), I can have an EMT drill the IO/start an IV and push the drugs I request. I can have an EMT manage the airway until I am at a point (if there is one) that I want to intubate. I can have an EMT show me the monitor and then charge and deliver a shock. These are all money skills. They were things I was very comfortable with before I set foot in paramedic school. The reason? That's how our system operates. That is my experience, it is no doubt different than yours. Your place sounds like it has its crap together when it comes to EMS. I have no doubt there are many fire departments that do as well. But you cannot keep citing your own agency as proof that not all fire agencies provide bad EMS. We get it, it's not 100%. But do you really suppose it's a coincidence that so many here have had watched a lower level of EMS be provided than by that of their own, co-responding service?

As alluded to, prehospital care in my area of Colorado is not like SoCal or the other much maligned areas of fire based EMS. The system is pretty well done and the guidelines actually change when practice does. Significant money, time, and resources are put into EMS by all parties in the system and it shows. But still, the care provided by the fire departments throughout the system is often below that of the single role providers.

Since you have shared your experiences, I will share mine. CSFD sends most of their paramedic students to a less than awesome program in Denver only because it is accelerated (I was fortunate to go to my program the year they sent their guys to the local program, truly have some lifelong friends (and good medics) from it). They then have a joke of an FTO period before they are released as a medic. Fortunately they're usually the only medic on their piece. Compare this to AMR, who will only pay for medic school if you went to the local (and better credentialed) program and pass an extensive FTO process that had well defined standards and FTOs who received additional training for their role to include EMS Instructor certifications. AMR now runs their own paramedic program, I hope the same initial educational standards are met but I have no reason to think they would not be.

In addition to the usual CE, there are several mandatory training events (usually regarding guideline updates) that all system paramedics must participate in. CSFD pulls companies out of service to do theirs, AMR employees must come in on their days off. Yet still, who is responsible for the vast majority of public M&M write ups that are published each month? You guessed it. Nevermind the fact that the per provider their medical division is three times as large. Or that they routinely get placed out of service to get education time from a well trained and equipped division. Lessons just aren't taken to heart, likely because their is no internal pressure to practice good medicine. Their is no self policing. At AMR, if I make a mistake, my peers will make sure I have the education to ensure it does not occur again. It'll still get to clinical education, but at that point it's likely water under the bridge. If you keep making mistakes, you'll get demoted to a transfer ambulance, and then you'll be terminated. CSFD? They'll promote you to lieutenant and remind you that officers needs not maintain their medic. Recently I ran a call in which a BLS truck company had administered several ALS medications prior to my arrival. They then proceeded to argue with me (the only medic on scene) about how their treatment path (dex) was more appropriate than mine (IM epi) for the about to arrest status asthma patient. There was no formal discipline aside from their medical supervisor lieutenant sitting them down and telling them not to do that again. If a BLS crew at AMR did that, they would be immediately terminated. Why is this difference acceptable? Why are they unwilling to maintain high standards? I mean you know it's bad when a medical division captain comes to your new hire AMR orientation and tells you that you are going to have to be on your game because his guys are not.

There are more than a handful of good fire medics. But watching them get belittled on scene by their (mostly EMT/FF) peers for being "too smart" is awful to watch. How do you think those guys feel about delivering in-station medical training to the rest of their crew? I interned at their busiest station for a change of pace. My preceptor made an effort to run scenarios with me everyday using their training equipment. Everyday someone had a less than encouraging comment for us. I could give two about the actual comments, it's the attitude that is worrisome. I think I spent as much time doing EMS training as I did learning to force doors there. There is not just no institutional want to be really good at EMS, like there is the want to be really good at forcible entry or smoothly deploying a department lay. While the majority of the line staff are "only" EMTs, the majority of their calls are "only" medicals.

And AMR is just a part time job. 36 hours a month maybe. But after four years, I haven't seen a lot of change. Meanwhile, at my full time job we were the only paramedics in the service area until a few years ago. The one paid fire district we cover decided they wanted a medic on each shift of four. Mind you they average being on scene without us for less than four minutes, but still, those four minutes multiplied by their yearly 6-700 medical runs equalled a lot of total minutes and boom, an ALS program was funded. One of their medics had worked part time on ambulance running 1500 total calls a year prior to this. The other two have no prior experience. None of them are willing to go get it. None of them will ever get the experience they need with that call volume and they certainly don't have the education to make up for it. Again, there just isn't an institutional want. Meanwhile, my employer all but mandated that I maintain employment as a part time medic for AMR (we only run 25-700 a year) and had me attend every single call out of the busy station for year. While awful, I sure learned. Vastly different agencies, but somehow the EMS only agency maintains and enforces the high standards while fire does not.

I am sure I sound a bit salty and certainly biased. But here's a twist, I also work part time as an FF/Medic. It's a little district with one cross staffed ambulance, but I kinda dig it honestly. The FFs treat the medic well and participate in our daily trainings. They take pride in their part of running the ambulance. I know first hand that it's possible to run a solid FD EMS service because I work with one. I think they are an anomaly, and I am happy to be here. But at the end of the day, given the choice between a fire and and a medical, you know what they'd rather be doing, whether it's real or training.

And I don't sit at home and type these sorts of things and leave it at that. All of my jobs involve running relatively often with small FDs that provide some EMS. Most of them don't do much better than an average job. I figure you can't complain about that unless you try to change it. So I started teaching for one of medical direction hospitals. I do monthly CE training and get the opportunity to dispel myths and encourage these places to embrace and take pride in EMS. I don't think I'm personally having much of an effect, but I am trying to be a part of the solution. I don't want to watch a good system be brought down by low standards pressed forth by fire departments.

TLDR; Locally, throughout the whole large system, the fire departments simply lack any pride in doing EMS well.

 

[jbiedebach]

*Disclaimer: This isn't a slight against firefighters, and it's not necessarily targeting the high-functioning fire departments out there that do the right things, or even the fire-medics that actually do their jobs the right way.
*Disclaimer 2: I'm not a firefighter, not particularly interested in being a firefighter.

So we hear a constant stream of anecdotes from across the nation, mostly from larger cities with big fire-based EMS systems, and there's a pretty common thread- systems operating at the limits of their operational capacity constantly, long shifts, provider and patient abuse, and terrible medical practice. So, why is this happening?

I am a firefighter and a medic and an ER tech/nursing student so I have seen all sides of it. I would say the primary challenge is money. Large fire departments spend less per capita than midsize departments. Example: Dallas spends about $190 per resident on FD/EMS. Plano spends about $226. That may not sound like a big difference but the extra $36 per resident is about 19% of DFD's budget. Imagine what they could do with a 20% budget increase. Stack on top of that the fact that big cities have older buildings (more prone to fire) and a larger indigent population (much harder on EMS) and the result is a much busier FD/EMS system (less time for training and recovery between calls) with less money, typically older equipment and fewer personnel than a smaller suburban department.

Another example: Dallas runs about 3700 calls per station in a year. Plano runs just over 2100. Divide that by 121 (number of shifts in a 24/48 year) and you get 30 calls/station per shift (this number is not what it seems because Dallas runs a number of double company houses) vs Plano = 17 calls per station/shift.

Bottom line Plano has more money, people and time to do less work. Which system do you think is going to produce a better outcome?

 

[DrParasite]

As it stands now, when my BLS agency responds to arrest, we dont break out the BVM until 10 minutes into the arrest. Its just compression, AED and NRB(actually a HFNC).

Not saying your wrong (in fact, this was a discussion at the bar several years ago when I went to DC for EMS Today between me an a paramedic education down in Georgia), but who directed you could do this? I haven't seen any studies that says this is more effective, the AHA doesn't say to do this, and as of 3 years ago, it wasn't standard practice in NJ.

Like I said, not saying your wrong, but want to know who supported this decision (as has some documentation behind this) so I can bring it up with my medical director.

 

[EpiEMS]

Bottom line Plano has more money, people and time to do less work. Which system do you think is going to produce a better outcome?

Being over-resources can produce pernicious effects, too. Too many medics, too few skills performed per medic, lower quality outcomes.

I haven't seen any studies that says this is more effective, the AHA doesn't say to do this, and as of 3 years ago, it wasn't standard practice in NJ.

That CCR isn't more effective? I have seen some evidence that it may be, especially for cardiac origin OOHCA (e.g. this Yang et al. 2012 and Mosier, et al. 2009). Even if it is only equivalent to CPR, it's definitely easier - logistically, anyway.

 

[DrParasite]

That CCR isn't more effective? I have seen some evidence that it may be, especially for cardiac origin OOHCA (e.g. this Yang et al. 2012 and Mosier, et al. 2009). Even if it is only equivalent to CPR, it's definitely easier - logistically, anyway.

I've read the studies that continuous compression are better (although I didn't know it was called CCR, had to look that up).

But I didn't know if any agency had stopped doing CPR for cardiac arrests and switched to CCR as a standard procedure for cardiac arrests. Nor did I know of anyone in NJ that no longer initially uses a BVM for cardiac arrests, and instead using a NRB or HFNC for the first 10 minutes.

 

[EpiEMS]

@DrParasite CCR is actually protocol for a number of places - we have it in our CT protocols for adult cardiac arrest of suspected cardiac etiology (Protocol 3.2A) & it's also in the National Model Clinical Guidelines (page 102).

 

[Bullets]

Not saying your wrong (in fact, this was a discussion at the bar several years ago when I went to DC for EMS Today between me an a paramedic education down in Georgia), but who directed you could do this? I haven't seen any studies that says this is more effective, the AHA doesn't say to do this, and as of 3 years ago, it wasn't standard practice in NJ.

Like I said, not saying your wrong, but want to know who supported this decision (as has some documentation behind this) so I can bring it up with my medical director.

Our medical director. All of his agencies use this protocol. It has caused some friction with our ALS providers and our and their medical directors were fighting for some time about it. He has cited Yang and Mosier as well as some others. I will get them from him. There are a couple other agencies that do this, IIRC Philly FD was the biggest agency doing this. It is very helpful for us to not have to worry about BVM until additional units arrive, as most of the cops arent CPR trained and less than enthusiastic about doing anything on EMS calls.

Ill post the links when i get them

 

[VentMonkey]

I still standy by less paramedics is a win/ win. I don’t really care if it’s in an all fire-based EMS system or not. Having a handful of skillfully qualified paramedics regardless of the system it is ran by can surely be worth more than what we all know hasn’t been shown to do much—flooding the field with paramedics.

Fire guys, I don’t understand what is so hard to comprehend about this idea; it’s by no means new and works quite well in many of the systems that practice this way. This means third service, private, or fire-based—less paramedics alongside of better qualified, and God willing, better educated EMT/ AEMT’s.

So what if I have 5 guys around me who can do skills that I will get to at some point in a code that, again, in reality hardly matter right then and there. Am I saying paramedics should be obsolete? No, I’m saying flooding the market with them should be an obsolete practice.

Am I saying if the the BLS ambulances are 5 minutes from the ED should they load and go with good CPR, and an SGA? Absolutely. Maybe that would free up an ALS car for the next highly acute call. I prefer efficiency, and not just sufficiency.

 

[EpiEMS]

as most of the cops arent CPR trained and less than enthusiastic about doing anything on EMS calls.

Cops without CPR? Crazy stuff...

Am I saying if the the BLS ambulances are 5 minutes from the ED should they load and go with good CPR, and an SGA? Absolutely.

I don't love doing compressions while moving...once we get a LUCAS, sure, I'm ok with that. But generally, shouldn't we (BLS folks) be working on scene for a couple of cycles (3)?

Btw, I'm of the opinion that cardiac arrests are really the ultimate BLS call...everything that actually works to improve neurologically intact survival to discharge is a BLS skill (defibrillation, compressions, and...eventually...ventilations)

 

[VentMonkey]

I don't love doing compressions while moving...once we get a LUCAS, sure, I'm ok with that. But generally, shouldn't we (BLS folks) be working on scene for a couple of cycles (3)?

Nor do I, and yes A) Lucas/ AutoPulses would be ideal, and B) giving BLS criteria to call or ask a doc for termination orders would also be extremely helpful.

I wasn’t implying hauling every DB off to the ED blindly. I sort of rushed through the post because I just got off, and I am admittedly tired.

Tiered right, a capable AEMT/ EMT configuration with 12-lead capabilities, ASA, and the ability to either intercept with an ALS chase car, or bypass that idea and head directly to the PCI facility is wrong why?...

 

[EpiEMS]

giving BLS criteria to call or ask a doc for termination orders would also be extremely helpful.

Agreed! Something like 5 cycles, no shockable rhythm, no bystander CPR, not witnessed...etc.