Ambulance Crew Configuration: Are Two Paramedics Better Than One?

What is the appropriate number of paramedics on a call?

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    Votes: 18 60.0%
  • 2

    Votes: 10 33.3%
  • 3

    Votes: 0 0.0%
  • 4 or more

    Votes: 2 6.7%

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DrParasite

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When determining the most appropriate complement of ALS crews, serious consideration should be given to five key factors that may significantly influence patient outcomes and system viability:

  1. ALS practitioner proficiency: The first consideration is whether the proficiency of a practitioner’s skill performance improves with increasing experience and patient contact volume. This is especially important to asses regarding critical skills less often used and more difficult to perform, such as endotracheal intubation, IV insertion, rapid sequence intubation or cricothyrotomy.
  2. Treatment time: The second consideration is the impact of the number of ALS providers composing the crew has regarding treatment time at the scene, thereby affecting transport to definitive care, and any resulting impact on the morbidity and mortality of patients.
  3. Error rates: The third consideration to assess is whether the number of ALS providers treating a patient in the field affects the errors committed by those practitioners in the assessment of patients, medications administered or skills performed.
  4. Practitioner shortage: Reports are now commonplace regarding the shortage of paramedics in the country. Modifying ALS crew configuration could expand or contract the labor pool and impact a system’s ability to fully staff necessary units.
  5. Financial sustainability of the EMS system: Because EMS systems use an intense amount of human resources, the cost of which compose a majority of the annual operating expenses for most systems, crew complement is an important consideration for the long-term financial viability of EMS. Does the ALS crew complement substantially affect the cost of operations?
Taking these considerations into account, this article examines the fundamental question: Is an ALS ambulance crew complement of two practitioners, one certified/licensed to the level of emergency medical technician–basic (BLS Provider) and the other to paramedic (ALS provider), adequate to result in acceptable patient outcomes? Further, is this model equal to, worse than or superior to a crew complement of two paramedics?

read the rest here:

https://www.jems.com/articles/2018/...ation-are-two-paramedics-better-than-one.html
 
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NPO

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Interesting article. Some things in it I didn't agree with, but I have to accept that my experiences and my system may not reflect the norm.

Personally, I prefer a Paramedic/Basic for several reasons. 1) I've found it's just easier. No worrying about who's running the call or who's doing what procedures. 2) A good EMT is worth their weight in gold. 3) An ALS/BLS system provides EMTs a stage to learn on. 4) on my most critical patients we aren't on scene or doing stuff in the back (on scene) very long. We are driving. I have 30+ minutes to the nearest basic ER, let's get movin'; a paramedic butt in the driver's seat does me no better than an EMT butt.

That said, we have a very efficient, very effective cardiac arrest pit crew model that sends e paramedics to every cardiac arrest. It works very well. Not because we have 3 medics, but because everyone has a very specific role, because those roles are so specific, we need additional Paramedics so one is not overlapping any other provider's responsibility.

We also generally have the availability of an ALS fly car. One is dispatched on most priority 1 calls, so they aren't far away of you need them.
 
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Summit

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I think highly of Paramedic + AEMT (or EMT with an IV cert in Colorado) ambulance as a 911 staffing model with some EMT/EMT ambulances in the system.

I think more highly of the AEMT/EMT ambulance system with Paramedics in fly cars.

I think poorly of Paramedics on fire engines as part of an EMS system.
 
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DesertMedic66

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For the vast majority of calls a paramedic is not even needed and can easily be handled with an EMT crew.

I’ve had calls where I was the only medic on scene and also had calls where there were 4 medics on scene. The calls where I was the solo ALS provider have always ran the smoothest and allowed me to get of scene quicker.
 

Tigger

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I think generally speaking that one paramedic is just fine for most calls. When I need extra hands I can have fire drive and my EMT partner (who can start IVs, operate the monitor, and knows the layout of the truck) in back with me and we're good to go.

I think having two paramedics in back is probably needed if you are trying to provide more than than typical ALS care. Running a vent, multiple infusions, maintaining sedation, and watching the monitor (etc) is something that I can do buy myself, but I don't feel particularly safe doing that. My EMT partner is not a huge amount of help in these situations. That's when having two medics shines. I don't much care who drives.
 

E tank

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I think highly of Paramedic + AEMT (or EMT with an IV cert in Colorado) ambulance as a 911 staffing model with some EMT/EMT ambulances in the system.

I think more highly of the AEMT/EMT ambulance system with Paramedics in fly cars.

I think poorly of Paramedics on fire engines as part of an EMS system.

I have a very difficult time understanding why the fly car/BLS model isn't in place in more metropolitan areas. Especially in smaller metro areas. And fire department politics isn't a reason, it's an excuse. If that is the excuse, it flies in the face of the public welfare and responsible stewardship of taxpayer's money.
 

KingCountyMedic

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If you can have two Medics working together this is always going to be best for the patient. Obviously on a sick patient (CPR, Trauma, etc.) one Paramedic can take care of the airway and the other Paramedic can gain access via IV, IO, or Central. I agree a single Medic on an engine company is not a great way to go, if that's all you have then that's all you have. The same for EMT with Paramedic, you work with what you have. On medical calls, especially the more complex medical calls it's very nice to have a dual medic unit. While one medic is working up the patient the second medic becomes the "detective" checking out history, reading charts if it's at a facility, interviewing friends or family or staff. I can get the story from the patient while my partner gets the rest of the story if there is one. No offense to EMT's but a Paramedic is going to be able to think about things and look for potential things on a medicine patient that an EMT probably would miss. We meet up and compare information and decide together on a treatment plan. At a car crash one medic can establish care while the other medic checks out the vehicle and pass along info about mechanism of injury etc. Also if there is a problem with the airway or access it's nice to have someone else there that can assist with airway and access. We do a lot of surgical airways and it's very nice to have two medics around for that procedure. I think this type of system works well when you have a ALS crew that works together all the time and have the same protocols or guidelines or whatever. I don't think it would work as well if you have a medics from multiple agencies on scene that don't work together as much. I came from a system that had private and fire medics running the call together and it usually was a cluster. Just my thoughts and opinions.
 

StCEMT

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I have a very difficult time understanding why the fly car/BLS model isn't in place in more metropolitan areas. Especially in smaller metro areas. And fire department politics isn't a reason, it's an excuse. If that is the excuse, it flies in the face of the public welfare and responsible stewardship of taxpayer's money.
I wish this is how we ran, or at least have the ability to let my basic partners tech calls.
 

BobBarker

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In LA County, you have to have 2 paramedics on each ALS ambulance if you run 911, that's the regulation. A minimum of 2 would respond to an ALS call where an ambulance is requested. You could have 1 paramedic on an assessment fire engine and the rest EMT Basics, but they are non-transport. Some cities even have ALS ambulances and a medic on the engine as well, so every unit is technically ALS.
 

Bullets

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I have always maintained that the NJ system AS DESIGNED is the best model. Regional, hospital based P/P units in fly cars with local B/B units. With each town or group of towns having their own BLS trucks, they can handle the vast majority of calls. Through good call taking, calls can be sorted ALS or BLS. If it is an ALS call then you get two paramedics. BLS can cancel medics, or medics can triage back to BLS. This allows the medics a higher probability of treating patients that require ALS skills and lessening the chance of them perishing. If the patient is serious (yellow) but not critical, one medic can treat with the help (or not) of the local EMT in the local ambulance. Stuff like stable chest pain, asthmas, single episode syncopes, ect. If the patient is in the crapper then you get both medics who can more efficiently do RSI, hang drips, bag, vent, CPAP, ect all the really fancy ALS skills. The EMTs then drive the ambulance and the ALS car.

In a typical shift i might have 3-4 treats, but those 3 treats are an RSI, a cardiac arrest and chest pain, maybe a trauma or a stroke. Im not mixing them with week old flu symptoms, leg pains, belly aches, toothaches, pysch transports, drunks.


Anything with these two authors on it is immediately suspect, especially #1
 

hometownmedic5

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99 times out of 100, one paramedic is sufficient. The trouble is, when and where that other call is going to happen is unable to be predicted and thats the one where you absolutely need that second medic and there isnt time for them to come from anywhere but the passenger seat.

Is P/P staffing worth that one percent(a figure that I cleanly and without any hint of authority made up out of thin air)? I don’t pay the bills, but it seems like a good idea to a large percentage of services, at least in my area. I don’t have a firm emotional stance on the matter myself. I work in a P/P system and I like having a paramedic partner. I don’t find myself in over my head too often, but when it happens, having a partner with at least theoretical parity is nice.
 

E tank

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I wish this is how we ran, or at least have the ability to let my basic partners tech calls.
Marin County, CA had something close back in the 80's. 2 fire medics in an ambulance and they'd call for a BLS ambulance once they determined the level of care. Southern Marin and Novato had (have?) 2 medics in a squad and a simultaneous bls ambulance dispatched. If it had to be fire, that would be the best of both worlds. I suppose a big problem for the private sector is having non transport capable vehicles which are just dead weight in terms of generating a bill.
 

Summit

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I suppose a big problem for the private sector is having non transport capable vehicles which are just dead weight in terms of generating a bill.
Yea... Paramedics are not so much more expensive than EMTs such that it's worth it to have say 25 EMT/EMT ambulances and 10 medics in fly cars vs just having 25 Paramedic/EMT ambulances.

Economics sadly make ALS fly cars + BLS ambulances work better for low volume large area systems.
 

NPO

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In LA County, you have to have 2 paramedics on each ALS ambulance if you run 911, that's the regulation. A minimum of 2 would respond to an ALS call where an ambulance is requested. You could have 1 paramedic on an assessment fire engine and the rest EMT Basics, but they are non-transport. Some cities even have ALS ambulances and a medic on the engine as well, so every unit is technically ALS.
What's crazy about that is if a private ALS/BLS ambulance runs across an ALS type situation either by still alarm or on an assigned call, they can't TECHNICALLY transport. They have to call the FD who has an "ALS" unit because they have 2 medics.

Been there, done that, got the write up.
 

BobBarker

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What's crazy about that is if a private ALS/BLS ambulance runs across an ALS type situation either by still alarm or on an assigned call, they can't TECHNICALLY transport. They have to call the FD who has an "ALS" unit because they have 2 medics.

Been there, done that, got the write up.
Correct, however in years past an IFT company can request a special waiver from LA County Department of Health to operate a 1 Medic/1 EMT IFT amabulance. I don't know if they would be considered ALS to transport if called upon by the fire department, but there was a process.
 

NPO

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Correct, however in years past an IFT company can request a special waiver from LA County Department of Health to operate a 1 Medic/1 EMT IFT amabulance. I don't know if they would be considered ALS to transport if called upon by the fire department, but there was a process.
It's called 1:1 training. It does not exempt them from the dual paramedic requirement for emergency calls.
 

Peak

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I think more important that how many medics are on scene/on the bus is that the medics are actually interested in providing medical care and good progressive medical direction. If you have two or three good experience medics who work well together then your outcomes are going to be better than one medic, but two or three incompetent medics who can't figure out who is lead is a setup for disaster.

There are some firemedics who are both interested in providing good medical care and want to work suppression. I loved the medical care but I still loathed being assigned on the bus, although that was the case for all of our firemedics. On critical calls we would take a second medic off of whatever unit they were on (once the buses were staffed we didn't care if additional medics were on the engines, rescue, or type 6s) and they would ride in but the daily assignment was almost always one firefighter/medic and one firefighter/EMT. We had progressive protocols and a great medical director, and in retrospect I still think our system worked great.

I dislike the idea of having medics on fire who don't have an interest in the medical care and only do it for the pay bonus, which honestly is the majority of fire based medics. I also think that if fire is going to have medics they should probably run their own ambulances, I'm sure it exists but I have yet to see a department who contracts out ambulances or has a 3rd service who has consistently good medics. I also think that fire departments don't need to have medics to be a good department or have good outcomes, both FDNY and Denver Fire are great examples.

As far as ambulance staffing I think that staffing needs to depend on call volume and acuity, but most systems are probably just fine with Paramedic/EMT or EMT/EMT with ALS fly cars. If the system can support it then having P/P ambulances are great, but most systems just don't need it and don't have the acuity to keep skills up.
 
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DrParasite

DrParasite

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In a typical shift i might have 3-4 treats, but those 3 treats are an RSI, a cardiac arrest and chest pain, maybe a trauma or a stroke. Im not mixing them with week old flu symptoms, leg pains, belly aches, toothaches, pysch transports, drunks.
disclaimer: Bullets works for the same system I used to work for at my first career EMS agency. So I do agree with his point of view on the system.

However, if you ALS everyone, the belly ache/sick person can get zofran, the week old flu symptoms is likely dehydrated and might benefit from some IV fluid, the psych patient can use haldol or versed or your calming drug of choice, and your drunks are just drunk. So you can ALS a lot of those simple patients, especially if they are there. Not that I wouldn't have any issue giving all of those patients a nice comfy ride to the hospital.....

Anything with these two authors on it is immediately suspect, especially #1
The first author I absolutely agree with. The entire purpose of the study was to make up for the poor salary, poor conditions, and poor management at their employer, as they are unable to keep medics, so this is their justification to convince the state to change the law to allow them to go from 2 paramedics on an ALS unit to 1 paramedic and 1 driver. The second author is very pro EMS, well known and respected, but does serve as the system medical director, so I think it's more author #1 with #2 with more credibility.

I prefer the two paramedics on an ALS call, especially involving a sick patient. But I think that EMTs should be competent enough to know sick vs not sick, and be able to determine when ALS is needed. Putting 2 medics on a "BLS" call is a waste of their education and capabilities, and having an all ALS EMS system (even if it's 1 medic and 1 EMT) will mean that paramedic will spend a ton of time (statistically, 80% of their calls) dealing with patient who don't need ALS interventions, so you end up with poor paramedics because they don't do it enough.

I've said it before, and will say it again, ALS on the engines is a waste of resources, and unless that paramedic has spent a few years working on an ambulance, I question their abilities and competencies. I'm sure there are exceptions, but I haven't seen many of them.

Agreed...And I'd argue that the majority of systems in the US are low volume large area.
What is the definition of a system that is low volume large area? I would argue that most of the urban EMS systems, and the systems that operate in city environments, would not meet that definition, however a lot of the rural areas (of which there are a lot in the US) definitely would
 

E tank

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What is the definition of a system that is low volume large area? I would argue that most of the urban EMS systems, and the systems that operate in city environments, would not meet that definition, however a lot of the rural areas (of which there are a lot in the US) definitely would

Haven't thought it through enough for a definition, per se, but a start would be a given population/square mile. Demographics play into it as well, but I can't offer any metrics. Could give a couple of examples, I guess. Boise, Idaho would be one. Maybe Spokane, Washington would be another. Salt Lake City. You see where I'm going. When I say low volume, I compare these to urban metro areas like the Bay Area, Chicago, Seattle, LA...
 
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