ALS saturation

[vquintessence]

We see a lot of outcry for ALS, whether it's from this forum or the public who may not even know what it really is. Arguably, most everyone wants it, for noble reasons or otherwise. This has led to a significant saturation of Paramedics nationwide. Many cities provide only ALS staffing. The state of FL has only ALS staffing (so I'm told). A huge majority of towns have primary ALS services.

Nationally speaking, why are there statistically so FEW tiered systems? Do we need a paramedic attendant for every call? Be it the AMI, the drunk, the elderly fall with injuries, the OD, the low-grade fever, the psychiatric emergency, the abd pain with diarrhea, the hyperglycemia, etc, etc.

Will having a Paramedic for every city/town, that averages about half a dozen EMS calls a day, be able to maintain the knowledge, clinical skills and experience s/he needs? Now what happens, when there are 4+ paramedics on scene? Do all of them on scene truly maintain the knowledge and skills necessary, when there are 3+ other people on scene to default to?

What about the EMT's? How many truly have "dedicated 911" shifts? What about the one's who can expect to enjoy a laid back IFT day, but sometimes will be thrown to the wolves as the only responding unit to APE where the pt is literally spewing fluids? Hell, lets say the responding unit are paramedics who haven't treated a truly critical person in months. Is this fair to the pt?

Sorry for the fifty open ended questions... ultimately it boils down to:
Is over-saturation of paramedics a good thing for the pt and public?

p.s. This is not aimed at rural services; they manage with what they can get.

 

[marineman]

I don't see an over saturation of medics in my area but yes I feel there should be at least one medic on every call to assess the patient. Falls seem to be a big area that many think sending a medic is a waste of resources, I won't get into it here but there have been several good posts about falls explaining possible complications that require a minimum of an ALS assessment (a post by Vent comes to mind if you want to search for it). I really like my dual medic staffing so I can agree with 2 medics on a scene but don't know why you would have or need 4 on a scene unless it's an MCI. I feel it's only fair to the patients to at a bare minimum be assessed by the highest level of provider possible. In my area most of our first responders are EMT-B which is fine but sending only a basic to a call is unfair to our patients.

We all know if you don't use your skills you lose them, this is where CME's come in. When you're on a call you owe it to your patient to already have a good handle on any skills you will be performing. Arriving on scene of a PNB is not the appropriate time to practice your intubations. It is your job if you feel shaky in a skill (intubation is one that comes to mind with statistically low success rates in the field) you need to find a way to train and master your skills, here all you have to do is ask and they will schedule you for an OR rotation any time to practice in a controlled environment. So losing skills by not using them should not be a problem if you take an active roll in continuing and maintaining your education.

 

[triemal04]

Oversaturation is a very real and serious problem. You touched on it yourself above; having 4 paramedics for a single pt is idiocy. Unfortunately, like so many things, people tend to think that more=better, when that's really not the case.

But, to few is also not a good thing. Finding the balancing point between these is the problem and, unless a service is really willing to look at their numbers (total calls, call type, treatements, outcomes, responce times, transport times, CE hours) and figure out the right number for their area, the easier choice is to simple hire more medics.

 

[Ridryder911]

All are very good points. Should there be a Paramedic on every response YES! Should there be two, three or four...NO!

Every patient needs to be assessed or triaged care should be supervised by Paramedic level. Does this mean every patient needs a Paramedic level for transport, no but should have access if need be.

I agree such places as Florida have demonstrated that ALS can be provided everywhere but as well has demonstrated over abundance can lead to poor proficiencies. As well have demonstrated just because something is required; we need to be assure we have quality as much as quanitity.


R/r 911

 

[Seaglass]

I like seeing at least one medic per patient in 911 calls, because you never know when something's going to be uglier than it sounds. So I'd rather see too many medics than too few, as a general rule... but having too many can be a big issue for the reasons everyone's mentioned.

I agree that a system with a lot of medics needs to be very supportive of continuing education. Rotating shifts can help, too--some nights of the week are usually much busier than others.

 

[motomedic]

oversaturation is an understatment out here in california. Fire departments pull up and all 3 to 4 ppl that get off are paramedics making 6 digit salaries. I guess thats why we are in the bugdet trouble that we are in haha. prob not but as a new paramedic like myself its comforting to know that I will have another medic to bounce treatment off. so in that aspect of things saturation is nice. but do we need an engine crew of medics prob not. thats my thought. cheers!!

 

[HotelCo]

I'm seeing posts from people who say there can be too many paramedics. Where is everyone that voted No, in the poll?

 

[Akulahawk]

oversaturation is an understatment out here in california. Fire departments pull up and all 3 to 4 ppl that get off are paramedics making 6 digit salaries. I guess thats why we are in the bugdet trouble that we are in haha. prob not but as a new paramedic like myself its comforting to know that I will have another medic to bounce treatment off. so in that aspect of things saturation is nice. but do we need an engine crew of medics prob not. thats my thought. cheers!!

I'm also a Paramedic in Sacramento. ALS is definitely overdone here. The Fire Departments have a goal of putting a medic on every first response apparatus. While this is a laudable goal, this results in a Paramedic who's on an engine that responds with a Medic unit (ambulance) that typically has 2 Paramedics on it. The medic riding in the engine basically works as a firefighter who gets an extra stipend for being a Paramedic. The liklihood that medic runs a call is pretty low. In the urban areas, this is definitely a waste of resources. Stations that have a Reserve Medic unit, or are rural, should have at least 2 medics on every shift. The reason for this is being able to staff that Reserve in a pinch or having a second provider on certain calls. To complete the staffing of the Reserve Medic, another station backfills and a single person drives that unit to the scene.

In our system, we utilize our ALS 911 units first, then we go to our Private ALS Providers, and then from there, any transport unit. We don't have transport engines...

 

[Aidey]

All are very good points. Should there be a Paramedic on every response YES! Should there be two, three or four...NO!

Every patient needs to be assessed or triaged care should be supervised by Paramedic level. Does this mean every patient needs a Paramedic level for transport, no but should have access if need be.

I agree such places as Florida have demonstrated that ALS can be provided everywhere but as well has demonstrated over abundance can lead to poor proficiencies. As well have demonstrated just because something is required; we need to be assure we have quality as much as quantity.

This, basically.

In a time were expenses and budgets are an issue, oversaturation of Paramedics worsens the issue I think. When paramedics are getting paid a minimum of $10,000 more a year than the EMTB/FFs (at least in my area), having 3 out of 4 guys on an engine be paramedics is unreasonable. When you look at how much that is going to cost the department in a year, vs having 1 paramedic per ALS engine, per shift it's going to be a big difference.

I think that in the case of FDs the position of Paramedic should be one that is attained, like Captain, rather than forced. That enforces a limit on the number of paramedics, and it means that people are competing for the spot, increasing the chances of getting a quality paramedic who actually wants to be a paramedic. Rather than some guy who was forced through the program by the department.

I do agree that every pt needs a paramedic assessment. People who call 911 are notoriously bad at accurately describing the pts condition, and lower educated providers can't see something they don't know exists.

Someone mentioned falls as a good example, and I agree. There are so many things that need to be checked, especially in the elderly. Did they fall because of a medical condition? Is it a pre-existing condition or new onset? Plus they can sustain much worse injuries than people would expect. One of my last fall from standing pts ended up with a broken hip and dislocated shoulder.

 

[TransportJockey]

Here in ABQ we get medic oversaturation on almost every call. Two tier system in which FD has control on scene (and FD runs 2 medic rescues), and a private transport company which takes over for the transport to facility (1-2 medics per unit). If it's a bad enough call an engine can be dispatched (most of the time 1 medic, sometimes only EMT-Is though), add to that if it's a bad one, the field sup can respond in their SUV (medic)...

And if it's on the border with county, their rescue might show up (another medic). That's not counting if their's a medic intern with either the private or with county FD...

 

[MrBrown]

I agree fundamentally every community should have access to advanced life support and that if run correctly it could be provided by the fire department.

That said .... no to Paramedics riding fire trucks, no to every fire truck having a paramedic, no to non transporting fire-department based ALS. no to requiring every firefighter to be a paramedic, no to allowing paramedic education straight from Dodge (cookbook type medic mills), no to faceless medical directors and yes to strict data monitoring, QA/QI, CE and skill competency!

 

[Ditchmedic]

Even the larger services in the local "big cities" are looking for medics. When med control requires a medic/medic truck, medics are in short supply. When a medic can make considerably more as an RN the shortage becomes greater. I am sure some metro areas have to many, but not around here.

 

[Ditchmedic]

I agree fundamentally every community should have access to advanced life support and that if run correctly it could be provided by the fire department.

That said .... no to Paramedics riding fire trucks, no to every fire truck having a paramedic, no to non transporting fire-department based ALS. no to requiring every firefighter to be a paramedic, no to allowing paramedic education straight from Dodge (cookbook type medic mills), no to faceless medical directors and yes to strict data monitoring, QA/QI, CE and skill competency!

I agree whole heartedly. Our service requires all medics to be firefighters, so they all go off and pee on a fire, leaving the ambulance uncovered. Happens all the time unless a non-fire fighter such as myself is around for the second hit.

 

[RescueYou]

ALS is a fantastic thing to have in a community. If you have the Paramedics to do it, go for it. I've never heard of someone refusing care because there were too many or only Paramedics on a scene and no EMT-Bs. It only takes 1 Paramedic on a truck with an EMT to make it an ALS truck (pending you have the supplies), but more than 1 won't do any harm on a BLS call and may be handy if it's an ALS call.

 

[MrBrown]

ALS is a fantastic thing to have in a community. If you have the Paramedics to do it, go for it. I've never heard of someone refusing care because there were too many or only Paramedics on a scene and no EMT-Bs. It only takes 1 Paramedic on a truck with an EMT to make it an ALS truck (pending you have the supplies), but more than 1 won't do any harm on a BLS call and may be handy if it's an ALS call.

You are missing the point entirely my friend. Paramedics (ALS) are a good thing, yes, but unfortunately so much emphasis (read: too much) has been placed upon making Paramedicine a "skills" vocation as opposed to a "health" or "medical" profession.

Most of my argument against "ALS saturation" is aimed at the major fire services who wrongly aim to put a paramedic on every fire truck; this firefighter with a paramedic card doesn't ride an ambulance and probably doesn't have much patient contact and leads to poor skills retention.

A paramedic on every fire truck (or maybe arguably even every ambulance) leads to poor skill utilisation (too many cooks spoil the broth) and in the case of the fire service the medical oversight/QA and QI is piss poor.

 

[RescueYou]

I agree fundamentally every community should have access to advanced life support and that if run correctly it could be provided by the fire department.

That said .... no to Paramedics riding fire trucks, no to every fire truck having a paramedic, no to non transporting fire-department based ALS. no to requiring every firefighter to be a paramedic, no to allowing paramedic education straight from Dodge (cookbook type medic mills), no to faceless medical directors and yes to strict data monitoring, QA/QI, CE and skill competency!

yes to having the option to have a paramedic on each firetruck. no to requiring every firefighter to be a paramedic. yes to paramedics riding firetrucks IF guaranteed first on-scene for an ALS only call.

be mature and just agree to disagree in some areas.

 

[MrBrown]

yes to having the option to have a paramedic on each firetruck. no to requiring every firefighter to be a paramedic. yes to paramedics riding firetrucks IF guaranteed first on-scene for an ALS only call.

be mature and just agree to disagree in some areas.

I'm not totally against the fire service putting paramedics on an engine ... you however must balance it with the fact that as an engine based medic he or she is probably not transporting which lessens clinical exposure, is expected to commit time and effort to keeping current with the science of firefighting and medicine which I think are both full time jobs in thier own right and that the major Fire Service orginisations don't have a good record of fire-based ALS.

 

[daedalus]

There has got to be a sweet spot between places like Florida/ Southern California, and places with all BLS response.

(Florida and the greater Los Angeles area have like 400 billion paramedics per square mile).

 

[cm4short]

Why is it that there are so many paramedic in populated areas when a hospital is close-by; and there are fewer medics in areas where hospitals are far and few. Shouldn't it be the opposite. Because, longer transport=more patient care. Shorter transport= the patient dies on-scene because all the medics wanted to get their hands* dirty*.

Also, with the current system we have now; where everything is a code 3 response. How many actually benefit from having an ALS response? I mean, if a taxi cab were to show up; would there outcome be any different? I'd say no for 90% of the time.

 

[MrBrown]

There has got to be a sweet spot between places like Florida/ Southern California, and places with all BLS response.

(Florida and the greater Los Angeles area have like 400 billion paramedics per square mile).

Yep ... I think there should be some sort of compromise. An adequate but lean number of ALS providers keeps exposure high and therefore presumably skills and knowledge up; look at Tulsa and Seattle.

Why is it that there are so many paramedic in populated areas when a hospital is close-by; and there are fewer medics in areas where hospitals are far and few. Shouldn't it be the opposite. Because, longer transport=more patient care.

That I think will be one of the key issues moving forward with EMS: how do we get more knowledgable and skilled providers out into the rural areas? Remote Australia and Canada are doing some good work intergrating staff into the primary care setting; watch that space.

Shorter transport= the patient dies on-scene because all the medics wanted to get their hands* dirty*.

Then fail upon those providers for being shallow and skill hungry!

Also, with the current system we have now; where everything is a code 3 response. How many actually benefit from having an ALS response? I mean, if a taxi cab were to show up; would there outcome be any different? I'd say no for 90% of the time.

Oh please please please can we get rid of this whole eight minute or eleven minute and 59 second or whatever you have respond target!! It's not clinically significant!!!

I would say a tiny percentage of our patients require ALS and an even tiner percentage would benefit from this whole overdone response target hype!