Ambulance Crew Configuration: Are Two Paramedics Better Than One?

What is the appropriate number of paramedics on a call?

  • 1

    Votes: 18 62.1%
  • 2

    Votes: 9 31.0%
  • 3

    Votes: 0 0.0%
  • 4 or more

    Votes: 2 6.9%

  • Total voters
    29

BobBarker

Forum Lieutenant
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It's called 1:1 training. It does not exempt them from the dual paramedic requirement for emergency calls.
Excellent, thanks for clarifying. It's been awhile since I looked so I didn't know it was for training. If they are at a 1:1, are they considered ALS or BLS for IFT purposes?

On a side note for people, I remember one time a person was bit by a dog at a gym in Los Angeles. LAFD dispatched a light force to the call, which is a ladder truck and fire engine together. 6 EMT-Basics on scene, no transport, to treat the smallest wound ever. It was pretty funny seeing LA drivers staring thinking there was a big fire when it was a dog bite.
 
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NPO

Forum Deputy Chief
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Excellent, thanks for clarifying. It's been awhile since I looked so I didn't know it was for training. If they are at a 1:1, are they considered ALS or BLS for IFT purposes?
They are ALS as far as IFTs are concerned. However, most IFT paramedics operate under a slightly resteicted scope. They just have to call 911 for any true ALS stuff they find.

On a side note for people, I remember one time a person was bit by a dog at a gym in Los Angeles. LAFD dispatched a light force to the call, which is a ladder truck and fire engine together. 6 EMT-Basics on scene, no transport, to treat the smallest wound ever. It was pretty funny seeing LA drivers staring thinking there was a big fire when it was a dog bite.
Oh yeah. I've seen a Task Force (plus ambulance) for abdominal pain. That's a ladder truck, 2 engines and an ambulance for what's likely BLS.
 

rescue1

Forum Asst. Chief
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I think a big problem is the relatively limited (in my opinion, given the minimal education--very justified) scope of BLS providers compared with the expansive scope of medics who can treat anything from nausea or mild dehydration all the way to tachydysrhythmias and refractory asthma. This leads to overstaffing ALS because there is a decent sized subset of relatively stable patients who still benefit from ALS care.

If AEMTs or something similar were more broadly available I think a system mostly made up of AEMT staffed ambulances with paramedics available for serious calls either in chase cars or ALS ambos would be ideal. This is similar to the setup in Australia/NZ/Canada. Ideally we'd also have the education and funding they have over there too, but one thing at a time I guess.
 

NomadicMedic

EMS Edumacator
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I think a big problem is the relatively limited (in my opinion, given the minimal education--very justified) scope of BLS providers compared with the expansive scope of medics who can treat anything from nausea or mild dehydration all the way to tachydysrhythmias and refractory asthma. This leads to overstaffing ALS because there is a decent sized subset of relatively stable patients who still benefit from ALS care.

If AEMTs or something similar were more broadly available I think a system mostly made up of AEMT staffed ambulances with paramedics available for serious calls either in chase cars or ALS ambos would be ideal. This is similar to the setup in Australia/NZ/Canada. Ideally we'd also have the education and funding they have over there too, but one thing at a time I guess.

This is the model we’re moving to in my system. I’m a huge fan. Fewer medics seeing sicker patients.
 

Remi

Forum Deputy Chief
Premium Member
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This may have been addressed in the article (didn't read it - sorry), but hasn't research shown better outcomes in systems with fewer paramedics?

The perfect model IMO is one that keeps the number of paramedics down and dispatched only to true emergencies, yet still provides a second paramedic when that may be beneficial (which is almost never, as long as your BLS providers are well-trained). The best way to do that, I think, is with well-trained BLS providers on the ambulances and fly cars staffed with two paramedics.
 

DesertMedic66

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This may have been addressed in the article (didn't read it - sorry), but hasn't research shown better outcomes in systems with fewer paramedics?

The perfect model IMO is one that keeps the number of paramedics down and dispatched only to true emergencies, yet still provides a second paramedic when that may be beneficial (which is almost never, as long as your BLS providers are well-trained). The best way to do that, I think, is with well-trained BLS providers on the ambulances and fly cars staffed with two paramedics.
This. Having fewer medics allows medical directors to make sure they are proficient in their skills and knowledge which may lead to expanded medication and/or skill set.
 

Don

Forum Ride Along
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These comments make for interesting reading.
In my state in Australia we don't have such options. The minimum standard is Advanced care paramedic, so you always work with somebody who can use the same drugs and equipment.
 

NPO

Forum Deputy Chief
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These comments make for interesting reading.
In my state in Australia we don't have such options. The minimum standard is Advanced care paramedic, so you always work with somebody who can use the same drugs and equipment.
Yeah, our system is fragmented. Because each state has control over licensing and setting health care regulations for EMS, each state is free to do whatever they (or their Medical Director) feel is best for their geography and population. This has the unfortunate consequence of having a VERY non-uniform system. Although, there are benefits; because of the VERY diverse geography of our country, it allows for a bit of tailoring to the regional needs.
 

Aprz

Forum Deputy Chief
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I voted for 1, but I wouldn't be against a system with dual medics with one paramedic being a clear lead, and they can trade off on calls still like pilots do in the airline industry. I think the problem with dual medic is that there isn't always a clear leader and there is more fighting rather than working together. I think skill dilution is a problem too, especially in many urban areas with multiple medics responding to every call, but I think they either need to dump EMTs for AEMT or increase the scope for EMT so they aren't simply giving a ride to patient, but can treat basic and common problems (eg be able to give IV fluids, give Zofran). I don't like how tiered systems or EMTs taking calls that patients are under treated to keep the call BLS. There is no reason the patient should be vomiting or in pain all the way to the hospital just because they aren't good enough for the limited ALS resource or the paramedic wants a break.
 

ZombieEMT

Chief Medical Zombie
Premium Member
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I personally like the system we have in New Jersey. I think it is effective for our geography. The individual towns providing BLS and transport allow for the less serious calls to be handled by a lower level provider. ALS is dispatched and available as needed. Its always two ALS providers so the decision can be made on how many are actually needed to treat.

I think we also have to look at some other advantages too. 1. By doing less, we delay less. Many ALS providers waste time on scene when transport to the hospital 5-10 away is quicker. Is it better to spend 20 minutes on scene to fo ALS assessment or go 5 away with BLS assessment. 2. Cost. A lot cheaper to pay two EMTs than two medics. 3. BLS is something when there is nothing. Ive seen other states that have ALS systems that have backlogged calls, BLS transport is better than no transport.

As for under treating a patient. It happens to some extent. Weigh risk to benefit. If in less than 10 to a hospital, is the the patient outcome really worse if I treat for nausea in the field vs the ED?
 

Ensihoitaja

Forum Captain
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I voted for 1, but I wouldn't be against a system with dual medics with one paramedic being a clear lead, and they can trade off on calls still like pilots do in the airline industry. I think the problem with dual medic is that there isn't always a clear leader and there is more fighting rather than working together. I think skill dilution is a problem too, especially in many urban areas with multiple medics responding to every call, but I think they either need to dump EMTs for AEMT or increase the scope for EMT so they aren't simply giving a ride to patient, but can treat basic and common problems (eg be able to give IV fluids, give Zofran). I don't like how tiered systems or EMTs taking calls that patients are under treated to keep the call BLS. There is no reason the patient should be vomiting or in pain all the way to the hospital just because they aren't good enough for the limited ALS resource or the paramedic wants a break.
We run dual medics and one will either drive or attend for the day so in a 4 day week, you get 2 drive and 2 attend days. The attendant is the clear leader, so we solve that problem.
 

Tigger

Dodges Pucks
Community Leader
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I guess I don't understand how whole "well who's in charge with two paramedics on the ambulance?!?!" came to be. I have an EMT partner now, but when I worked with a regular medic partner we either alternated or one of us would just speak up and say it was ours. It wasn't awkward or anything and even working with medics with more experience than I have on this earth it was was very rare to get any toes stepped on.
 

Bullets

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I voted for 1, but I wouldn't be against a system with dual medics with one paramedic being a clear lead, and they can trade off on calls still like pilots do in the airline industry. I think the problem with dual medic is that there isn't always a clear leader and there is more fighting rather than working together.
Ive worked in a dual medic system for over ten years and i can count on one finger and one thumb how many times i saw partners fight or have fought with my partner about who is "in charge". We alternate treats and charting so if its a low ALS call one will do a baseline assessment and while the other asks the questions. If its a critical patient we just kind of do what needs to get done. It doesnt matter who is "in charge" as we bounce ideas off each other and talk it out in the back of the rig.
 

DrParasite

The fire extinguisher is not just for show
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I think the problem with dual medic is that there isn't always a clear leader and there is more fighting rather than working together.
How does it work when you have 2 EMTs an a truck? o_O
 

PotatoMedic

Has no idea what I'm doing.
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How does it work when you have 2 EMTs an a truck? o_O
Well since neither know what to do there is no one to lead so they just load and go! And rock paper scissors who gets to be in the back doing the paperwork!

(Please take this as humor)
 

NomadicMedic

EMS Edumacator
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Our system is moving back to the fly car model. It's a matter of cost savings and finding skilled medics.
 

akflightmedic

Forum Deputy Chief
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I worked for an all ALS county system for many years (pre-fire merger). It was the first time I had ever done this and I loved it. I knew no matter what, I had an equal partner and the day would not suck call volume wise. We traded call for call, simple. Sometimes if there was a report intensive call, the other partner might take two in a row or not count a refusal call as their turn. There was no issue with "who is in charge" because you both do what needs to be done, simple. It facilitated patient care in the sense that nothing had to be delegated or instructed, you both just started doing what was needed. The poster above who said there would be control issues also said "I think", implying no experience with this type of set up.

On MCIs or MVCs it helped out because you could split the assessments and have faster reporting from an ALS need perspective.

Ideally, I love the ALS fly car model. With proper dispatching, every ALS patient will get an ALS assessment FIRST, while a BLS transport unit is en route non-emergent until instructed otherwise. This puts less public at risk, less providers at risk and overall ensures sick patients are triaged down. The dated reverse model I never understood...."send BLS and if needed request ALS"...who does that benefit?

A double medic ALS fly car is near perfection. Two medics, BLS transport rig shows up, one medic goes with that EMT and the other Medic is still in service.
 

Bullets

Forum Knucklehead
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Also known as Delaware.
I dont understand how this works. If we tried this in NJ, after our first call id probably never see my partner again. How do we meet up? BLS is busy and has other calls they need to go to, they cant bring him to whatever call im on. If we split, what happens to my truck? My partner is with BLS 1 at some hospital and now im with BLS 2 going to another hospital? So my truck just gets left on the road in some random town? No were both at two different hospitals, neither with a vehicle?
 
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