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

[frogtat2]

Well, here's how we do things in my area. I live in Northern Wyoming. Our ambulance area is frontier/rural. The closest Trauma center is 90 minutes away. We don't have paramedics at all on my service. We have 3 rigs. We run a 3 man crew, with at least one EMT-I. Our crew has 28 members, 8 of which just finished EMT-B class. Of the remaining 20, we have 7 EMT-I's.

It's not perfect, but it's what we have to work with and we do our best.

 

[Melbourne MICA]

A Paramedic on every truck

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?

Agreed, dispatching is major headache and no less so here. We've got around the problem partially by having a MICA Paramedic "clinician" in the control room who vets calls coming in. He can downgrade the case or upgrade it. He can also look at odd sounding cases and dispatch a MICA unit if he smells something brewing. It has worked pretty well in tidying up MICA dispatch. It makes a mockery of how good the old AMPDS system is supposed to be.

The idea here was always a two tiered approach. Every case will get a normal road unit (as I have said they are roughly equivalent to EMT-I's, maybe even better than that) as a bare minimum. MICA units are supposed to be dispatched to the sickest pts.

We have 16 MICA units and a few single responder MICA units in sedans. That's changing next year to mostly single responders but that's another story.

The system has worked very effectively because the average ambo is skilled and educated above most models in the US eg and the MICA units are a big step above that again. So even moderately sick pts can get a fair bit of care above and beyond the bare minimum EMT-B level with the MICa units carrying the bag on the very sick pts.

Things are changing, (not for the better) as workload and response times grow and our bosses are getting far too pragmatic about standards, ages of students, minimum recruitment levels etc.

You really don't need a MICA Paramedic at every case as despite it's flaws the AMPDS system plus PROQA which is how our docs have modified the categories of calls as to the level of despatching required plus the clinician has been a big help. When it works MICA goes only to the sickest pts + or - a normal road car. Two sets of hands and two crews with above average skill sets makes life a lot easier as well at most cases. So MICA here is really like (supposed to be like) a kind of special forces unit.

All MICA would be overkill for a number of reasons not the least of which is getting hands on experience in sick pts on a regular basis - ie leading to dilution of skills.

As for importing "MICA" Paramedics - well OS systems are so different to transition imports would be a big headache. When our service isn't killing of MICA troops through neglect or discouraging roadies to step to MICA through a lack of incentive we haev kept our numbers up.

As for "mixed crewing" ie one -P and one -B eg; we tried it ten years ago - big mistake. They spent more time going to low level cases, attracted crappy staff and all the MICA guys saw it as a step away from the way MICA should be used - special forces stuff etc. The service used the units as just another rig for despatching to keep response times down. Two tier only works when the MICA units are letp as the second tier. Once you go to the clsoest car approach or abandon dual response (two tier) due to wrokload the MICA system is totally invalidated.

Not to brag but at least in Australia, the Melb MICA troops are the benchmark for ALS Paramedics in Australia and have a pretty good rep OS as well.

But who knows what the future holds - when we go majority MICA single responders I see the end of MICA as an effective second tier happening real fast.

MM

 

[Melbourne MICA]

Doing one's best

Well, here's how we do things in my area. I live in Northern Wyoming. Our ambulance area is frontier/rural. The closest Trauma center is 90 minutes away. We don't have paramedics at all on my service. We have 3 rigs. We run a 3 man crew, with at least one EMT-I. Our crew has 28 members, 8 of which just finished EMT-B class. Of the remaining 20, we have 7 EMT-I's.

It's not perfect, but it's what we have to work with and we do our best.

Is it privately run or county funded and staffed? How many calls do you do /mth eg? I guess you have chopper transport options for backup when needed?

If not why wouldn't/haven't the medical directors of your operation sought a higher basic level of staffing say all EMT-I's given time to ED door?

Sounds like if you are stuck with a sick pt and aren't allowed/trained to do much you will run out of things to do pretty fast and that can't be good for sick pts.

I take my hat off too you however - it's a whole different ball game when you have an hour plus transport time to the nearest ED - Takes a special kind of ambo I think. Despite the limts imposed upon you I suspect you guys are held in pretty high esteem by your local community. Which is how large by the way?

MM

 

[Afflixion]

When I was working in El Paso the company I worked for only had about 8 full time medics, so most of the trucks that ran we're EMT-B / EMT-I pairs. I thoroughly enjoyed working with experienced I's (at this time I had just obtained my medic) They helped me out a lot when I second guessed my self. Now when working in Tucson we ran double medics and personally I didn't care for it... it may have just been my partner but we bumped heads a lot and always had different treatment plans. I like both ways if you don't have two stubborn medics I'm sure it would be great but I also did not mind working with an I one bit.

 

[smurfe]

I work for a dual paramedic staffed metro municipal service. We are dual paramedics solely due to the call volume to unit ratio. We rotate calls so you don't get burnt out. Even on serious calls we rarely ride together in the back and will take a BLS firefighter to ride. This boils down to the service doesn't want non-employee's driving the units except in dire situations such as we have 2 or more critical patients to transport. We don't call out extra units to calls unless we can't fit them all in our truck and just handle up on what we have. I have worked for services that were paramedic/Basic staffed and had little issue with that. I only had a couple worthless partners who only wanted to drive the truck and drive it fast and were no help on calls. Overall, I had some great basic partners who could tell me what condition the patient had by preforming an excellent BLS assessment which every paramedic should do to diagnose the patients issue.

 

[Melclin]

http://www.paramedic-resource-centre.com/overseas/australia1.htm

British medics perspective having come to work as an ICP in SA. Its longish but the main point is that the author feels that its the autonomy and extensive general medical knowledge that separates a lot of the the Australian second tear paramedics (MICA, ICP) and Australian paramedics in general from many others. I'm beginning to think from getting to know the American system a little more that a lack of autonomy permeates every aspect of their practice, even the mindset of those medics that do have actual authority. I'm not saying its an inherently bad thing but its just I'd not given the issue of autonomy as much thought until now, or at least not prescribed it as much importance as I'm beginning to think it deserves.

Melb, I'm not sure if there's much to be gained from trying to compare American EMT-Ps to MICA and asking them how they feel about working alone. Not that Ps are necessarily worse or anything, it just seems like the systems, the people and the ethos are too fundamentally different.

P.S. I also asked some of my lecs at uni about research into single responder systems, and did a literature search myself, and it would seem that there is a grand total of NO research into the efficacy of SRUs. Disheartening.

 

[carpentw]

Personally, having worked for the American EMS system for several years, I can tell you that the amount of autonomy given to the various levels of providers varies quite largely from service to service. I work for two different service and one allows RSI's and several other extremely invasive techniques and the paramedics are given a large latitude regarding protocols. The other service I work for is very strict and doesn't even carry midazolam in the field.

 

[Melclin]

Personally, having worked for the American EMS system for several years, I can tell you that the amount of autonomy given to the various levels of providers varies quite largely from service to service. I work for two different service and one allows RSI's and several other extremely invasive techniques and the paramedics are given a large latitude regarding protocols. The other service I work for is very strict and doesn't even carry midazolam in the field.

I wasn't so much talking about specific protocols or guidelines. More about a less tangible underlying culture or ethos or something. I'm talking more about a mindset that might be instilled from the very beginning of being student that permeates throughout an entire career regardless of what procedures and drugs a person might be allowed to use later down that track. I thinking more about some kind of fundamental difference in the systems and the ideas they're built on, not to mention the type of people who get involved in them. I know I'm being vague. I'd like to reiterate (just in case :blush:, I know how things can kick off on this board) that I'm not making any value judgments or anything, its just an observation of differences that's come to my attention in the past few days, nothing solid. I've just been learning more about American EMS and the reading the histories, and the more I do, the more foreign it looks to me.

 

[Melbourne MICA]

http://www.paramedic-resource-centre.com/overseas/australia1.htm

Melb, I'm not sure if there's much to be gained from trying to compare American EMT-Ps to MICA and asking them how they feel about working alone. Not that Ps are necessarily worse or anything, it just seems like the systems, the people and the ethos are too fundamentally different.

P.S. I also asked some of my lecs at uni about research into single responder systems, and did a literature search myself, and it would seem that there is a grand total of NO research into the efficacy of SRUs. Disheartening.

You're right about the research (or lack thereof) into SRU's. And it is disheartening - worse than that actually, it's negligent.

My questions about single responding are loaded - it's a barrow I've been pushing for a long time. I've been waging an unrelenting campaign about the moves to slice and dice the MICA team system into single responder pieces that will take MICA into irrelevency.

MICA effectiveness is dependent on it being a second tier. A "team" approach and a mobile and upgradeable workplace (our trucks) are indespensible components of its success as well. There is also the value of the independent thinker concept on top of that as you mentioned.

On much being gained by comparison of MICA +/- SRU's with US EMT-P's - I disagree. Boston for example runs a two tier ALS/ICP system much like ours and with similar successes in ETT/RSI etc. The Paras on the forum here have been very forward with information and as one of the posters in this thread said whilst there is much variation in systems/models there are many comparative services/jursdictions.

In the absence of any peer reviewed literature/studies etc on single responder efficacy, the guys here have been great in providing at least an anecdotal perspective backed up with a lot of useful facts and figures.

Many services are deploying single responders around the world (have been for some time). The absence of the willingness (of services and governments) to engage evidence based examination of the functuining and effectiveness
of these systems smells to high heaven of the real impertives underlying these models - and they aint anything to do with better pt care or appropriate working systems than guarantee staff conditions, work contentment, self worth, futher development of EMS etc.

MM