EMS Crewing Levels 1, 2, 3.....?

[Melbourne MICA]

Posts in another thread have brought up the issue of mixed and solo ALS crewing versus models with 2 person BLS and ALS crews.

Mixed crewing here has been viewed with much scepticism by staff and was tried in 1998 with very poor results. The main issues that have arisen revolve around the standards of the staff involved and how these are guaranteed and also the role play. Does a Paramedic need just another pair of hands or does he/she need another ALS brain along side as well.

The complexities grow further when you start talking about responding solo Paramedics in sedans with an attending stretcher BLS resource.

Any thoughts?

MM

 

[triemal04]

2 Paramedics on an ambulance. While not every call needs both, there are enough times when having another skilled set of hands, and more importantly another skilled brain immediately available helps. Having someone there with equal or better education is definitely a bonus on the more in-depth calls, and, in busy systems, will help with the workload since both can rotate calls.

Of course, the argument for a paramedic working with a basic can be made, and may be made more often if the current economic situation continues. Not every pt need's a paramedic, and a lot will be perfectly fine with someone with less education treating them. For my money though, it's still 2 medic's.

I guess in a perfect world I'd rather it was 2 paramedics and 1 basic on every ambulance...though that probably won't happen. But, it would allow for a better division of labor, appropriate treatment for each pt, and having an extra set of hands available all the time would make many calls run smoother.

 

[Hastings]

Not directly related to the question, but the title of the thread reminded me of the system the company I work for does things.

Level 1 is Basic
Level 2 is New Medic
Level 3 is Experienced Medic.

And a truck has to equal 4 or more.

Which means a 3 and a 1, two 2's, 2 and 3, or 3 and 3.

No 1 and 1 or 2 and 1.




Great system, in my opinion.

 

[TransportJockey]

Our system in ABQ is as follows:
Dual Response FD/Private. Private service usually is a Medic/Basic or Medic Intermediate. Depends on the FD responding, city fire is dual medic, county fire is mixed sometimes and sometimes dual medic.

 

[Melbourne MICA]

Variety is the spice of life - or is it?

But do ambos feel the systems they are working in are effective in real terms for the pts and which would they like to see given all the considerations?

It's amazing there are so many models but none is viewed as the benchmark irrespective of region size, population catchment etc. We treat one pt at a time no matter where you are so is it a matter of the crew mix or how you use your resources? (eg in Melbourne there are just 16 MICA units for 3.5 million).

MM

 

[Melclin]

Warning: Impending Rant Detected

We're getting some mixed messages from lecturers and scuttle but at uni.

The 16 MICA units, is that a total including single responders, or is it 16 MICA vans added too by singles?

Having some MICA (intensive care paramedics) singles or BLS/ALS combinations seems a good idea if you're going to be adding to the present compliment.

The area covered by MICA 6 for example is ridiculously large. Some people in genuinely metro areas are at least 15 mins away from Intensive Care Ambulance service, doesn't matter how fast you drive. So their plan to split it to two single responders and split the area in half seems reasonable from my point of view, but of course I'm notable hamstrung by very little experience. It seems it would be better to have two full Intensive Care Ambulances, but if u can't afford it, or can't staff it, splitting the difference seems a reasonable compromise. Better than not having anything.

Regarding procedures and two-ALS-brains-better than one thing, I think most people would rather have only one Intensive Care Paramedic arrive when they are alive (esp if there's a normal ambulance crew there already that can assist), rather than two arriving when they're dead. Spreading your eggs into different baskets, so to speak. If they aren't being backed up by a road crew, then that's a different story, but singles being left without backup for significant periods of time can't be that common can it? And if it is its an administrative problem with organizing backup, not necessarily a problem with the single responder system.

I'm really just playing devils advocate here. I understand a lot of paramedics are unhappy about it, and I understand why, I don't like it either, but it seems like a necessary compromise if their are staff or budget restrictions.

Personally, I think ALS/BLS combinations in metro areas would be a great idea but I asked one medic about it and he said it was rubbish. Seems to me that it solves the transport and not-enough-hands problems of the singles, while spreading the Intensive Care Service further. Someone said that you get screw ups in drug dossages because there's no one to back up the Intensive Care Paramedic's calculations. Seems to me that it should be the responsibility of the BLS backup to have a basic understanding of the Intensive Care drugs and treatments. I was at an arrest once where the Intensive Care single just told the BLS guy to give the man atropine, and he drew it and shot it, no troubles. All road crews should be able to back up ICPs that way. I'm only in my second year of uni, and I already have an understanding of the ICP drugs and some of their dossages, because I make an effort to understand my future craft. I've read up on chest tubes and seen one go in, so I couldn't do one, but I could probably remind you to drink some coffee if you were about to stick it through someones head.

(You've got me on a rant now because I'm passionate about Paramedic professionalism. We're hearing so much about it at the moment but it has to be earned, not demanded [I've heard some shocking stories lately of piss poor medical theory and clinical approaches from BLS crews harming and even killing pts]. I reckon the first part of that is having the book learnin of a professionalB)). I'd love to hear from anyone on this, but people from Melb specifically would be good (esp MICA blokes, you guys will probably demolish me, but if I'm wrong I'm happy to hear why. I am a student after all and I'm pretty keen on learning as you might have noticed:blush.

I'd love to here from a British medic if there are any on here too. I understand they've had singles for quite a while, and I've heard a few horror stories about people dying without transport and so on.

 

[Melbourne MICA]

It's a long story

I've got a shift in the morning so I can't stop right now to give you a detailed response but will when I get home.

One little thing - MICA 6 is being converted to one single responder not 2. Does that change anything in your mind?

Another. More than 50% of all the roadies now working are students most DAPs or GAPs straight out of uni? Does that chnage anything in your mind.

One last thing. Many many times, MICA units are sent to backup SRU's because there are no road cars available. ie to transport only.

Thats now.

What happens when there are the planned 20 or so single responder units next year all needing cars to help with the transport side of things let alone to assist with sick pts in road trucks that are not set up to do such work. OH&S issues, no spares or gear MICA units carry etc?

Theres' only three SRU's currently - 300, 301, 302. Not counting CSO's who don't do many primary responses anyway.

More tommrrow. Some things to ponder.

MM

PS I bet non-one from the service or from the uni explained why they are so short of MICA staff in the last 3-4 years.

 

[HotelCo]

I'd like to have another Paramedic with me. It's always nice to have a second set of eyes to make sure everything is going well. (especially when it's late at night and you're dog tired)

 

[Melbourne MICA]

We're getting some mixed messages from lecturers and scuttle but at uni.The 16 MICA units, is that a total including single responders, or is it 16 MICA vans added too by singles?

The Labor Government wanted 16 MICA units. (17 actually). These were election comminttents. There have been 3 SRUS's for about ten years only in the city.

Having some MICA (intensive care paramedics) singles or BLS/ALS combinations seems a good idea if you're going to be adding to the present compliment.

The area covered by MICA 6 for example is ridiculously large. Some people in genuinely metro areas are at least 15 mins away from Intensive Care Ambulance service, doesn't matter how fast you drive. So their plan to split it to two single responders and split the area in half seems reasonable from my point of view, but of course I'm notable hamstrung by very little experience. It seems it would be better to have two full Intensive Care Ambulances,

Now you got the last bit right. The reasons are many and various.

There are no studies anywhere in the world supportive of a single responder system. Our two tier, two man MICA/ALS system, however has produced worlds best practice for years.

The funny thing is when anybody looks at this issue they always think of it in clinical terms - like you would expect ambos to think. Also in terms of budgets and affordablity.

But why don't we ever think politically or in human terms about decision making? Labor wanted 17 MICA units - reaching most of the main electorates. They have never been able to staff 17 - thats Rowville - no troops. Now by Feb 2008 we were 48 MICA staff in arrears. Why because they left - not retired - fed up up with MICA working conditions, dispatching, meal breaks, treatment on issues like long service leave, rosters, pay - do you know that up unitl about 2000 MICA officers were payed just $1.70/hr more than their ALS counterparts? And by 2006 An ALS CI, working a peak period unit with one night shift earned just $70 less than say someone like me - a MICA CI, 15yrs on MICA. Getting the picture?

but if u can't afford it, or can't staff it, splitting the difference seems a reasonable compromise. Better than not having anything.

We have a 1/4billion dollar budget - AV spent $6.6million just setting up VACIS - do you think a few extra MICA units will cause budget woes?
And where is responsibility for the poor staffing levels? There are many industrial and OH&S issues with single responding beyond anything clinical. Safety at scenes, psychological welfare issues caused by prolonged isolation working in a stressful non-predictable occupational situation etc. Plenty more

Regarding procedures and two-ALS-brains-better than one thing, I think most people would rather have only one Intensive Care Paramedic arrive when they are alive (esp if there's a normal ambulance crew there already that can assist), rather than two arriving when they're dead. Spreading your eggs into different baskets, so to speak.

The public has no idea what ambos are when they walk thru the door - it's just the blue uniform they want to see when the proverbial is hitting the fan. Beyond two brains what about two pairs of hands? I defy anyone to do 2 manual tasks at the same time - delegate you say now a) you can't always do that when you are first there and no road car will arrive for say ten munites and B) if its roadies we are talking about would you let a pair of roadies with no experience, never done an arrest, never drawn up a drug etc being the backup for a single MICA officer under the pump at your relatives medical drama? And besides ETT and IV sides of things are musts - you have to get them right otherwise you are going nowhere fast with your pt. Do you see where this is all going? Substandard clinical practice - its like a Woolies homenbrand version of MICA/ALS care.

If they aren't being backed up by a road crew, then that's a different story, but singles being left without backup for significant periods of time can't be that common can it? And if it is its an administrative problem with organizing backup, not necessarily a problem with the single responder system.

Realistically this is the nub of the problem. AV cannot resource now let alone when such a massive SRU restructure is put in place. Workload is going up 7%/annum. The road cars now are being pushed to the limit. Crews don't get meals often till 3 or 4 in the morning on a night shift - some not at all. When AV has to find backups for all the cases that get overdespathced and to the sick pts they will be overwhelmed and pts will suffer for it. They are overwhlemed now. Even if they send two MICA SRU's to a sick pt- great clinical care you say, they are going nowhere without a trasnport truck are they?

The whole system is dependent rather then independent. When you are talking about an organisation whose whole role is based on a risk averse principle to guarantee pt care this model makes no sense whatsoever. But it does if you don't care and are setting up an entirely different labor force structure to meet different priorities than an ethical responsibility to provide quality pt care. More on that in my next post later on. Have to go to work now.

Cheers

MM

 

[emtjack02]

Here I am on a volunteer 911 ambulance. We typically run driver/basic/medic. Now sometimes a basic will take the driver spot. Or a medic will take the driver spot or basic spot. Some/most of our basics have a lot to be desired or maybe it's a lack of direction by myself. Anyways most the time basic/medic is enough for me. But there are definitely those calls that having two medics would be nice.

 

[Aliakey]

Our system in a mid-sized city recently changed from:
A dual-paramedic staffed ambulance with experienced paramedic first responders in pickups

to...

A Basic EMT/Paramedic staffed ambulance on half of the available ambulances, but with the first responders all remaining as experienced paramedics.

I am a paramedic on one of the "mixed" ambulances. I would not trade my EMT partner for all of the Aztec gold in the world, but have to admit, there's times when that one train-wreck of a patient will really make you work double-time. Flash pulmonary edema comes to mind. Our first responder units are only a radio call away, but the average response time can be five minutes for them to arrive on scene. However, there is plenty to keep my EMT partner busy even with the critical patients.

Quite literally, there are not enough good paramedics to staff this growing 9-1-1 service. Not for a lack of students, as we have a community college in this area that churns out EMS students. But, about 60% cannot pass the NREMT exam... and even in light of that dismal number, I'm a supporter of this tough exam compared to what this state used to put out that it called a "test".

So, with a lack of qualified personnel and of course, budgets in mind, they just started hiring EMTs and EMT-Intermediates last year.

It's a workable solution. I have yet to have that one critical patient go even more sour because my partner is an EMT. He's damn good at his job, and I can trust him to have everything ready to make my life easier.

The real concern about the mixed truck situation in my mind is this: Whether your partner is an EMT or a Paramedic, can you really trust him or her with half of your patient care? There are paramedics in this service I would never want to work with because of their dead-set opinions on patient care, never willing to learn the evolving knowledge in medicine and EMS. Yet here I have an EMT partner I would trust my own life with. There's a lot of BLS work in taking care of even a critical patient; it's not all paramedic-only.

Just my two cents worth.

 

[Melbourne MICA]

I'm really just playing devils advocate here. I understand a lot of paramedics are unhappy about it, and I understand why, I don't like it either, but it seems like a necessary compromise if their are staff or budget restrictions

.

For the most part there have never been significant budget restrictions on the ambulance service. They have to provide a budget forecast and OPS plan of course but such is the sensitivity of the public to ambulance response times and clinical failures resulting in someone losing a child for example, that the government will do anything to stave off adverse publicity. As a result response times have now become such an obsession with AV, any government in Victoria or overseas for that matter that all other priorities have taken second fiddle to response times. And even on this count MAS/RAV now AV have failed miserably.

The respone time despatching target for the 50th percentile Signal one response time in 2005 was 9 minutes, ie we have to get to at least 50% of sick pts in under 9 mins. This is the international benchmark and is related to the chain of survival for cardiac arrest pt concept - you have probably already studied this. The 90th percentile was 13 mins in 2005.

In 2009 our 90th percentile stands at 16.5minutes -after each yeasr the government has said AV can raise it. We haven't met our KPI - key performance indicator - thats the principle measure of AV's perfomance by government - in over 5 years if ever. And the times are blowing out even further.

Despite the spin in the media, AV can't meet recruiting numbers, especially on MICA, as the workload continues to spiral out of control - up 7%/annum.
Staff are so overworked, and have been for many years now, that sick leave rates are through the roof. Add to this a new dimension which is young student recruits. It is a generlisation I concede but it is becoming clear that 19-21yr old students and graduates have their own take on their social life. Most are single and when asked to work night shifts, particulalry on weekends have discovered all you need to do is call in sick, get a stat dec - end of story, Friday, Saturday, Sunday nights doing what young people do - socialising. AV moved training and education to a uni model so they wouldn't have to pay for it. But they clearly didn't factor in the sociological impact of very young recruits.

Some students have already used up all their sick leave engaging in this expected behaviour and even go sick without pay to accomodate their weekend activities.

This is not an old married man's jealous take on the situation. It is happening now - every weekend. Dropped shifts at ALS and MICA units - yes the oldies are doing it too as much because they are fed up, disillusioned or burned out - 3,4,5,6,7 units closed and unstaffed because their is no-one who wants to work them. And their is a limit to how much overtime the married family staff are prepred to take on.

Lastly on this area - such is the madness to recruit that AV and government have dropped the bar on student standards to such a degree (but don't care) that one particular student group recently, as an example was 85% performance managed. What that means is that 85% of the students in that group were so bad - at the point of being told to pack their bags - unemployable - they couldn't put the class through.

AV told the government this, AV were quizzed about a shortfall in recruit numbers if they did and prompty told to pass them through anyway. Such is the obsession with bums on seats and response times as I stated earlier. Add to this dilemna of the Clinical instructor situation and the much rumoured story that even students with grades of 40% are being passed through and the fact that students get what - 12 days of on road training? - in 3yrs and you can see why the "ALS" backup cars for the 20 or more MICA SRU's to be implemented is a disaster waiting to happen let alone the resourcing problems, especially on weekends, I mentioned.

Personally, I think ALS/BLS combinations in metro areas would be a great idea but I asked one medic about it and he said it was rubbish. Seems to me that it solves the transport and not-enough-hands problems of the singles, while spreading the Intensive Care Service further. Someone said that you get screw ups in drug dossages because there's no one to back up the Intensive Care Paramedic's calculations. Seems to me that it should be the responsibility of the BLS backup to have a basic understanding of the Intensive Care drugs and treatments.

AV tried "PRU"S - that's one MICA one ALS officer back in 1998. They haven't been employed since. Some of the points you mentioned above were in fact part of the problem. Also many roadies at the time didn't like the idea of being second fiddle all the time to a MICA person, having to do all the usual basic crappy road jobs as well as treat and transport sick pts. It was also seen as another attempt to spread the MICA butter further on more pieces of toast without guarateeing any clinical benefits for pts. Most staff, especially the MICA guys read between the lines and bitterley opposed the idea. It fell flat anyway by itself. Like the SRU"S by the way, there are no reputable studies whatsoever on the validity or clincial performance of PRU's over dual crewing models.

I was at an arrest once where the Intensive Care single just told the BLS guy to give the man atropine, and he drew it and shot it, no troubles. All road crews should be able to back up ICPs that way. I'm only in my second year of uni, and I already have an understanding of the ICP drugs and some of their dossages, because I make an effort to understand my future craft. I've read up on chest tubes and seen one go in, so I couldn't do one, but I could probably remind you to drink some coffee if you were about to stick it through someones head.

I take your point and commend your enthusiasm but many issues surrounding the capabilities of ALS operators have rested on this misconception. What the MICA experience has revealed is that it is not enough to just learn about skills or drugs. It is also not enough to learn the A&P.

Pre-hospital is unique in its emphasis, brought about by necessity and through time and experience, on field craft -hands on practical evaluation in real time , on real pts, troubleshooting problems, adpating the knowledge base to the changing dynamic of clinical situations that can turn on a dime and problem solving and decison making under extraordianry pressure with none of the resource or environmental luxuries available in the casualty department. There is also the issue of practice and experience. Has the workload has incresed and the number of units likewise so too has the experience base been diluted to gain exposure to the multitude of clincial situations. Add to this the mentality amongst some, not all, ALS operators that if MICA is coming they need to do little other than the basics as MICA will do it for them. This despite "ALS" training and guidelines.

(You've got me on a rant now because I'm passionate about Paramedic professionalism. We're hearing so much about it at the moment but it has to be earned, not demanded [I've heard some shocking stories lately of piss poor medical theory and clinical approaches from BLS crews harming and even killing pts]. I reckon the first part of that is having the book learnin of a professionalB)). I'd love to hear from anyone on this, but people from Melb specifically would be good (esp MICA blokes, you guys will probably demolish me, but if I'm wrong I'm happy to hear why. I am a student after all and I'm pretty keen on learning as you might have noticed:blush.

Self critical reflection is an admirable trait so never be embarassed by it. There is much to learn and much to practice. Don't let my depressing take on the situation deter you from excelling. However, take away an appreciation that all is not as it seems.

There are political, bureaucratic, organisational, OH&S, industrial, cultural and behavioural forces at work in ambulance and always have been. Students need to ask about the reality of the situation from ambos themselves, not those with vested interests. Unfortuantely as employers, industries and governments change the underlying basis of their labor force policies we are often the ones who suffer. People need to eat, need to rest, should be apid on merit and should be avaialed with all the tools necessary to perform their primary role to the highest standard.

The way I see it AV and the government have a different take on this concept.

 

[Melclin]

"Capabilities of ALS operators have rested on this misconception. What the MICA experience has revealed is that it is not enough to just learn about skills or drugs. It is also not enough to learn the A&P."

Yeah, I totally agree. I have a now ex friend, who is a biologist, who used to look down on me because he'd see my course work and a couple of dot points about drug side affects or something and have a go at me for doing a soft course, completely missing the complexities of real world application of the skills, thinking that that was all there was to know. I think a lot of other people doing my degree (I don't want to spread aspersions, they're almost universally lovely people) don't really get the differences between the two which I'll touch on in a moment. I do get that there's a difference and I'm not at all saying, reading the CWI twice means u can do the thing. I had just heard a paramedic say that a MICA paramedic had once killed someone by making the wrong drug calculation because she was tired and the ALS medic couldn't back up the calculation. It just seemed to me that u could, as the ALS assitant, just spend 5 mins wrote learning a few dosages and, while you're not going to understand the subtlties of the practice, if you're MICA partner is about to poor sux down a persons throat with a shovel, cos he's so deliriously tired (which I understand is essentially what happened in that case I mentioned) then the ALS partner could stop that. That's just what I was getting at. But I take you point.

I think as far as policy goes, it seems from the outside, that what they're doing would work. Even with a bit of knowledge about the system. As usual though, their lack of consultation of the people on the ground has caused problems. "There are political, bureaucratic, organisational, OH&S, industrial, cultural and behavioural forces at work in ambulance and always have been. Students need to ask about the reality of the situation from ambos themselves, not those with vested interests." Hence my dialogue with people like you. The amount of bull:censored::censored::censored::censored: they feed us at uni about the ambulance service, the realities of working and about the application of clinical skills is obvious to some of us, so sorting through whats crap and what good is a difficult process. I could sit here and write you an essay on the reasons why our curriculum is bull:censored::censored::censored::censored:.

I'm not shocked to hear so many grad paramedics are poor, I am shocked though to see that they got passed through. The degree is getting better, but it still has some fundamental problems. I don't disagree with recruiting young people, nor having the course as a degree course. My problem is that they have just said, 'oh so we're making a degree, what do degrees have,...lectures...tutes...essays...okay lets have them" Without thinking that these things, in the same form as they take in other degrees, might be inappropriate for teaching paramedics. Medicine degrees take on quite different forms to other degrees. Science (which I started first) has extensive labs for every subject. Yet even for the particularly practical subjects (concepts of clinical practice, or A&P labs) we barely have any time to really practice the skills. We also have almost no 'class time' in which we could sit and work on intellectual problems like ECG interpretation with a teacher and ask questions when we come up against a problem or have a question. An academic degree is focused on weeding people out onto a spectrum between people who wanna learn and people who don't, and they are marked accordingly. Our degree should be focussed on training everyone up to the same level. So far all that has happened as far as that is that they make the course work pitifully easy so no one fails (which sounds similar to the problem you were having). When someone argues that point, all they do is make exams with tricky multiple choice questions that bear little resemblance to real life knowledge or application, just like the academic degree. Also you only need to know 50% of the course material to pass. Maybe I don't turn up the the lectures on shock, AMI, giving set calculations. I can still pass the exam with an alright mark of maybe 65-70% and go out on the road not even knowing what shock is let alone how to deal with it. Anyway, sorry, I get really angry at uni.

"12 days of on road training? - in 3yrs" The ammount of clinical experience in undergrad is improving. The buzz word at the moment is "education-not training" but we clearly need both, as I was saying above. I asked the director of the Queensland Ambulance Service about the risk of "overdoing the education at the expense or training in real world clinical applications" and he gave me the most convoluted politicians answer I've ever heard from a person, but I didn't have the guts to call him out on it in front of every pre-hospital luminary in Australia (this was at a conference on professionalism). I'm still not sure that he actually spent that 5 mins saying anything at all, which was odd because up until then he'd been a straight shooter. My degree has about 13 weeks of clinical experience. Although what this actually involves may differ greatly from student to student, depending on how nice your paramedics are, and what cases you get. I have uncanny luck. Three separate medics have had a go at me for being a case magnet. But I also make use of my time by asking questions, using the gear in the down time and making the most of cases with nothing in them (helping granny up off the floor is a good time to practice reassuring and building rapore with patients I reckon, its a good one for us undergrads). I'm sure some of my paramedics get sick of my enthusiasm and questions, but that's their problem, I need to learn. Other students have gone on three of four shifts and not had a single case, or did one grazed knee, and then sit there and watch TV the whole time with a monitor, oxysaver and drug bag sitting there ready for practicing on (I don't get that. They just don't seem to care about learning their craft). My aunt is a grad paramedic in SA and in 2 years on the road has never seen a trauma arrest like the one I did in my 5 shift of placements. It's a lottery, but you also have to make an effort.

Mostly, we need more placements, but its a nightmare trying to get uni admin to get off their arses and organise them for us. But we can hardly just walk up to an ambulance station, in our gherkin uniform, and say hey can I ride along today, I'm a student and I need more experience (although I've considered it:wacko.

"you can see why the "ALS" backup cars for the 20 or more MICA SRU's to be implemented is a disaster waiting to happen let alone the resourcing problems, especially on weekends, I mentioned." --Good god its a sorry state of affairs. I get what you mean about the ALS back up. And I'm shocked but also not entirely suprised at the younger medics doing all that business.

"Add to this the mentality amongst some, not all, ALS operators that if MICA is coming they need to do little other than the basics as MICA will do it for them" -- To be clear, I agree that the ALS operators are largely not capable of doing what I was saying. I've heard some terrible stories lately about ALS ineptitude (The worst being a case where ALS response to an elderly diabetic having had a seizure, they gave the Glucose paste and Glucagon IM, no response, called MICA, 30 mins after the seizure, when MICA arrives just as they're putting a monitor on-asystole. They didn't even think to check the womans pulse or even breathing while waiting for the glucose or before it, she'd been in cardiac arrest all that time and they just say there waiting for some sugar to work). I was saying that they should be. That its their responsibility to be able to back MICA up, that its not necessarily the fault of a SRU system. That maybe its okay to SRU. maybe the problem is that to many ALS medics aren't up to scratch. I suppose I was saying that the fault may not lie in the theory of a SRU system. But I take your point. Even if the SRU system works in theory, you can't force the issue if it doesn't work in practice.

Thanks for explaining it all in such detail and with such patience. It really is helpful to have paramedics who will teach rather than scorn.

 

[Melbourne MICA]

To Mecklin

I appreciate your insights from the students perspective. Attitudes and opinions can become fixated especially when you get a bit older thus an open mind becomes an elusive quantity.

There are many truths to be uncovered and discovered and ambulance is as good a place as any to do so. I hope you come to recognise as it seems you already have that whilst not all of them meet expectations in the real world there still remains enough to keep us interested in the journey ahead.

Enjoy your studies - And challenge everything.

MM

 

[Melbourne MICA]

Mixed crewing

Our system in a mid-sized city recently changed from:
A dual-paramedic staffed ambulance with experienced paramedic first responders in pickups

to...

A Basic EMT/Paramedic staffed ambulance on half of the available ambulances, but with the first responders all remaining as experienced paramedics.

So your setup has gone from two EMT-P's ambulance crewing + single responder ALS to half the 2 man Paramedic crews losing their Paramedic. Does that sound right? Unfortunately our terminologies differ.

I am a paramedic on one of the "mixed" ambulances. I would not trade my EMT partner for all of the Aztec gold in the world, but have to admit, there's times when that one train-wreck of a patient will really make you work double-time. Flash pulmonary edema comes to mind. Our first responder units are only a radio call away, but the average response time can be five minutes for them to arrive on scene. However, there is plenty to keep my EMT partner busy even with the critical patients.

Quite literally, there are not enough good paramedics to staff this growing 9-1-1 service. Not for a lack of students, as we have a community college in this area that churns out EMS students. But, about 60% cannot pass the NREMT exam... and even in light of that dismal number, I'm a supporter of this tough exam compared to what this state used to put out that it called a "test".

So, with a lack of qualified personnel and of course, budgets in mind, they just started hiring EMTs and EMT-Intermediates last year.

It's a workable solution. I have yet to have that one critical patient go even more sour because my partner is an EMT. He's damn good at his job, and I can trust him to have everything ready to make my life easier.

The real concern about the mixed truck situation in my mind is this: Whether your partner is an EMT or a Paramedic, can you really trust him or her with half of your patient care? There are paramedics in this service I would never want to work with because of their dead-set opinions on patient care, never willing to learn the evolving knowledge in medicine and EMS. Yet here I have an EMT partner I would trust my own life with. There's a lot of BLS work in taking care of even a critical patient; it's not all paramedic-only.

Just my two cents worth.

All of this sounds very familiar. Personally I think EMS everywhere is struggling to find the right balance but I've always believed the basic starting point is to look at what's working well.

Our two tier system with 2man MICA Paramedic teams ( Use the term deliberately) and 2 man "ALS" teams (roughly equivalent to EMT-I's I think) has produced worlds best practice in a number of areas. And our vehicles are a key component. I see them as a work platform - our office. They are not just a transport medium. Detach Paramedic teams from their work platform, (put them in sedans eg) and they become something much less in my opinion.

Now our bosses want to unravel a proven system to introduce an untried model. 24 MICA SRU's!!!. I really don't think our superiors have the vaguest idea of the shambles they are going to create. Tragically, none of us will ever really suffer - only our pts do.

MM

 

[Melclin]

Tragically, none of us will ever really suffer - only our pts do.

We're just as likely to become patients as anybody else. In fact, given some of the inherent dangers of the job, maybe more so.

Perhaps management/politicians should start thinking, if I were having an AMI, what level of care would I want. An SRU and with a poorly trained grad paramedic team backing them up, all of whom are tired from being overworked? Probably not :blush:

 

[Melbourne MICA]

Ditto

Absolutely.

I have a pet theory - it's called my Lemming principle.

It revolves around the idea of people filtering the information they don't want to, care about or are interested to hear. They don't join the dots and see that everything is linked. They endlessly complain about what they don't get but will do nothing to help themselves, help others or inter-relate to the universe or the world around them. They are "self" aware - literally - and that's it - self.

So when the bombs start dropping on their house they don't even know what hit them because they are lemmings - they just marched along with all the others who were just "self" aware. They weren't interested in politics or foreign policy or economics or environmental issues or the bus about to hit them whilst they were busy listening to the Ipod and on the mobile talking about - BS***

And because they hadn't stopped to take note that 1700 is a really busy time because there are a thousand businesses and people with cars and on buses going home and that particular stretch of road - if they had looked and taken in the data - was completely blind where they were stepping off the curb.

The principle applies to us as ambos and to politicians who can't see beyond the next election or dismal budget forecast.

Listen to everything, watch everything, be aware of everything - process the data. Don't be a lemming.

Well it's a pet theory anyway.

MM

 

[Melbourne MICA]

ignore th first bit

Absolutely.

I have a pet theory - it's called my Lemming principle.

It revolves around the idea of people filtering the information they don't want to, care about or are interested to hear. They don't join the dots and see that everything is linked. They endlessly complain about what they don't get but will do nothing to help themselves, help others or inter-relate to the universe or the world around them. They are "self" aware - literally - and that's it - self.

So when the bombs start dropping on their house they don't even know what hit them because they are lemmings - they just marched along with all the others who were just "self" aware. They weren't interested in politics or foreign policy or economics or environmental issues or the bus about to hit them whilst they were busy listening to the Ipod and on the mobile talking about - BS***

And the bombs hit because they didn't listen to the loud mouth whiner who said: these neighbours are dangerous - you had better move.

Why should they worry - after all, the neighbours were the ones making the Ipods and mobiles.

The principle applies to us as ambos as much as anyone else - we are no different.

Listen to everything, watch everything, be aware of everything - process the data.

Don't be a lemming.

Well it's a pet theory anyway.

MM

 

[Melclin]

And because they hadn't stopped to take note that 1700 is a really busy time because there are a thousand businesses and people with cars and on buses going home and that particular stretch of road - if they had looked and taken in the data - was completely blind where they were stepping off the curb.

Oddly specific. Based on a true story perhaps? After a few years on a MICA van, I would imagine so.


Any how, not that anybody probably cares about my pretentious musings but.... Sounds like what you're getting at is one of the inherent problems (I feel) of people assuming a priori knowledge: thinking they can know things from just thinking instead of experiencing, then sitting their comfortable in the knowledge that they are right and content not to probe the word around them...up until the moment when, as u say, the bombs drop. Enter constructivism to save us with its sensibility. The idea that things are subjective and that while there might not be a single universal truth to things, we can learn about our reality and create useful 'truths' like "morphine goes in->pain goes away" from constant critical examination of the world around us and positive action to make change based on that examination. The 'doing something about it' part.

I'm probably making a mess of the philosophies, but you get my point. Piaget, Fleck and Glasersfeld beat you to the punch but, I say take the credit on account of them having stupid names. B)

My power-nerd rant up there is my way of saying I agree with you. As you can see, people's pervasive stupidity, and their consistent pattern of doing "have-their-cake-and-eat-it-too" type things (like voting for the guy who gives you a twenty dollar tax cut, and then complaining that the hospitals are full, their aren't enough police and the roads are falling apart) are familiar topics of thought for me (and conversation...if anyone will listen).

Except the bit about the Ipods. They're awesome. If you take my Ipod, I'll take your face h34r:

 

[carpentw]

At the system I currently work at we staff one Firefighter/EMT-P and one Firefighter/EMT-I on every ambulance. A small private ambulance staffed usually with EMT-Basics and some EMT-Intermediates handle all the hospital to hospital, discharges, etc... Every 911 call for service gets a "paramedic level unit," but generally the EMT-I and EMT-P switch off on every call. I don't know about Victoria MICAs, but EMT-Is here fall a little below ASNSW ICP.

I have worked for other services which staff two EMT-Is on each ambulance and are dispatched with a single regional EMT-P on certain calls. The problem I have seen with this model stems from dispatch. ie Dispatched to "a man exp difficulty moving" arrived on scene and he was having trouble moving bc he was coded. Or Dispatched to a "man having chest pain" he was having chest pain because he had been shot in the chest. Every call has the potential to go south, so why doesn't every call get a MICA medic? Is it theoretically possible to put a MICA medic on every truck partnered with an ALS provider so you could just switch calls? Also, if there is such a shortage of medics, how come Victoria doesn't recruit from overseas like Queensland has been doing?