Proper EMS Operations

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ItsTheBLS

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Hey all, first post here.

I've been a jolly-volly EMT for a year or so now in an organization which is as professional as I would imagine a volunteer organization gets (proper uniforms, 12 hour shifts w/ ~10 calls a night, correct documentation, etc.), however one primary problem I've noticed is organization with running an average call. When there are 3 EMT's on the truck things seem to be less organized than with two.

The paramedics in our area run on a 2 medic fly-car system. If the patient is stable, 1 medic will obtain all PT information while the other does patient care. This system seems highly effective. My question to you, EMT life..
How do you and your partner(s) run a scene? Who does what? Who writes the chart? Is it pre-planned? Thanks
 
I'll preface this by saying I rarely work with a three person crew and when I do the third is usually a new hire doing orientation time. In that case I just observe and let the new person get in there.

That said, with me whoever is attending in back writes the PCR, I cannot imagine that happening any other way. Given that, the attendant is "in charge" on scene regardless of who is most experienced. If I am attending I like to interview the patient and perform the actual physical assessment so I can document the results more easily. I'll direct my partner and driver to get vitals, patient medications, and a history from bystanders if available. If for some reason we do not have a piece of equipment, he will go retrieve it and I stay with the patient.

Any partner I work regularly with knows this routine, and if not we'll talk about it on the way in, "hey do you wanna get vitals and whatnot and I'll ask the questions?"

When I am driving, I'll do whatever the attendant asks though I still try and get them to give me a little game plan before we make patient contact so I know what to expect.
 
If I'm riding with another medic, we have to decide who's going to be the attendant on the first call. This brings the quintessential question "Do you want to drive or ride?" Bonus points for asking the question in unison as you walk toward the truck together. Double bonus points for the followup unison answer "I don't care, whatever you want."

After we decide who's going to drive or ride, we just do those jobs.

Job descriptions:

Driver drives. This means you get to chose the radio station, control the siren/lights, and fuel the truck when it's time (assuming there's no junior or probie type person to do it for you). Driver helps with patient care as needed until it's time to drive again, usually always gets first set of vitals. The driver is also responsible for putting the truck back in order at the hospital, and restocking as needed.

Attendant: Navigates to calls. Talks on the radio. Talks to the patient and family to obtain a history. Typically, the attendant is the ONLY person to talk to the patient, unless something comes up that must be addressed. Attendant does patient care, does all documentation, and is responsible for changing out drug box or restocking meds as needed.

Any additional people just lighten the load, get vitals, do whatever patient care needs to be done, fetch stretcher, carry bag, etc. The most documentation I want a third rider to do when it's my call is just the demographic information and the med list. Beyond that, I really like to do my own documentation.
 
ItsTheBLS said:
When there are 3 EMT's on the truck things seem to be less organized than with two.
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I love having 3 people on a crew. if you can't figure out how to operate with 3, than you are doing something wrong (and if you are in hudson county and operating on a crew of 3 and having issues, you are doing something wrong, since the standard is 2 and that can sometimes be not enough).

If i'm on a 3 person crew, the driver drives, the crew chief/person who sits up front and doesn't drive and has whatever title you have designated him to have handles all paperwork and asks related questions, while the attendant/person who sits in the back while enroute to the call handles the physical assessment. if any equipment is needed from the truck, either the attendant or the drive can go back and get it without interrupting the assessment.

Also keep in mind with a flycar medic, you have 2 medics + at least 2 BLS providers in an ambulance on every call.... 4 people total.

As the guy who has been the 3rd guy (and the 4th guy once when I was bored and jumped a call with my gf at the time), I can say I'd rather have too many hands than too few. on that call where I was the 4th guy, I was the last in the house, took my time, grabbed the stairchair and brought it in, so when the CC decided she needed a stairchair to get the patient out, like magic!! it was there. and then once it was set up, I set up the cot outside. and after that, I was holding up the wall to make sure it didn't move.

If Im on a 2 person crew, it's a little different. typically driver is responsible for getting the patient to the ambulance, and the CC is responsible for patient care. or the CC handles all paperwork and questions, while the driver does the assessment. it depends on how the crew operates, but the labor is divided among 2 people, instead of 3.

If you are finding it hard to work with 3 people, than you should work on your resource management and delegation of tasks. I'd always prefer to have the problem of too many people and someone has to hold up the wall instead of having too few.
 
I do it the same as abckidsmom, though who drives/provides depends on whether the call is BLS or ALS.

We have a third rider a decent amount of times, as I work at a combination department and we sometimes have a volunteer with us. The issue with 3 is that it requires more communication between the two attendants in the rear. I think it's important to have one of the two attendants "in charge" for a call, that way you don't have headbutting or duplication of tasks.
 
In my current system, it's a little goofy because it's fire based - the engine medic could be there before us, or my partner could be a type-A OCD control freak that outranks me. Usually if we get there first (when I'm lead), I'll let my partner (it they're ALS or if they know what questions to ask initially) and the engine medic if present to assess the pt and gather diagnostic info while I speak to family, obtain demographics/Hx/meds etc. When I'm done, I take report and then it's only me that speaks to the pt for the most part. In the ambulance, one of us will drop a line and/or give meds, and the other will do the monitor, a physical assessment, etc.

Whwn I worked in the NYC 911 system, we were dual BLS or dual medic. Just two of us unless it was an arrest, we had a greater than 10 min ETA, or we requested BLS for pt care. Typically, one person would assess the pt, the other would recored demos/meds, then jump in to do any necessary interventions. NYC is different from suburban VA in that we mostly treated in the residence in NY since the pt's were typically sicker than what passes for an ALS call here, and they were typically up several flights of stairs, deep inside some projects, and they might not make the trip down to the bus. In VA, it's typically a SFH with easy egress, so we can usually just get an assessment and then treat in the bus.

The difference between NYC and VA regarding pt care is that in NYC, you and your partner are more or less equal, and should have equal input in pt care. In VA, you have medic officers and medic firefighters, and some officers pull rank and do what they want, and just tell you to do a 12, drop a line and drive.
 
46Young said:
In my current system, it's a little goofy because it's fire based - the engine medic could be there before us, or my partner could be a type-A OCD control freak that outranks me. Usually if we get there first (when I'm lead), I'll let my partner (it they're ALS or if they know what questions to ask initially) and the engine medic if present to assess the pt and gather diagnostic info while I speak to family, obtain demographics/Hx/meds etc. When I'm done, I take report and then it's only me that speaks to the pt for the most part. In the ambulance, one of us will drop a line and/or give meds, and the other will do the monitor, a physical assessment, etc.

Whwn I worked in the NYC 911 system, we were dual BLS or dual medic. Just two of us unless it was an arrest, we had a greater than 10 min ETA, or we requested BLS for pt care. Typically, one person would assess the pt, the other would recored demos/meds, then jump in to do any necessary interventions. NYC is different from suburban VA in that we mostly treated in the residence in NY since the pt's were typically sicker than what passes for an ALS call here, and they were typically up several flights of stairs, deep inside some projects, and they might not make the trip down to the bus. In VA, it's typically a SFH with easy egress, so we can usually just get an assessment and then treat in the bus.

The difference between NYC and VA regarding pt care is that in NYC, you and your partner are more or less equal, and should have equal input in pt care. In VA, you have medic officers and medic firefighters, and some officers pull rank and do what they want, and just tell you to do a 12, drop a line and drive.
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Your system is quite different than the rest of VA, just saying. It's bizarre how they apply the strengths of 7-9 people to one sick person.
 
Thank you guys for outlining the problems I'm facing. What I'm starting to realize is there are obvious communication errors going on. There is little general organization. Also, the way our system is set up, the most experienced person is the driver.
 
abckidsmom said:
Your system is quite different than the rest of VA, just saying. It's bizarre how they apply the strengths of 7-9 people to one sick person.
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It's utter and total overkill, I agree. My medic partner and I in NYC could run laps around the standard ALS scene management in my dept in many cases. The only way things mibhg go quicker here is because one person does the monitor, another gets L/S while #3 geta a B/P while #4 gets a BGL while #5 gets the stair chair while # talks to the pt while #7 sets up the cot. It's makes for easy work, but it's unnecessary.

I would say that our "1 and 1" units are a blessing in that we don't have an officer to deal with, but now more often than not we get a disgruntled EMT driver that purposefully does a poor job of restock and equipment check because they don't get ALSs riding pay and are "stuck on the ambulance."

Probably three bad BLS partners for every good one in my estimation. (Probably 2:1 for ALS, to be fair).
 
A troika?

We rarely did in the ambulance, but the P-10 rescue wagon had three as a rule. The crew chief was in charge, the driver and rescueman did his bidding.
 
ok a rig where all people are of the same level (obviously on a Medic/Basic truck, the medic is going to be taking all ALS runs)

2 people:

Driver: Drives us to the scene, assists the in-charge (IC) while on the scene, drives us to the hospital, cleans the back of the truck, restocks supplies, drives us back to station (many people switch who drives back, but we have found that having the original driver drive back allows for the IC to finish paperwork etc). Back at station, driver finishes stocking, fuel if required. Switch!

IC: Navigates to the scene, operates the radio, siren, horn, rumbler, lights, etc., makes patient contact, provides patient care, gives radio report, fills out run sheet. Back at station, logs the run into the computer/run book. Switch!

3 people:

Now you just have an extra set of hands. The third man helps with patient care, restocking, cleaning, etc.

I don't understand how things get less organized with 3 people. He asks the IC if theres anything he needs to do for the IC. If not, he asks the driver if there is anything he needs to do for the driver. If not, he goes to the EMS room and gets a coke!
 
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