So I'd say 4 paramedics would be ideal for the way we roll. 1 to be the team lead, 1 for the intubation/airway management, 1 to mind the monitor, and one to get the IV/IO and push the drugs. This way every one of those roles is filled by someone who is trained and legally able to carry out what needs to be done in their assignment. So the other two guys will be the chest compressors, at least until its time to move to the autopulse/lucas. Sure, it's overkill that the chest pushers are paramedics? Sure, I suppose, but is it enough to get up in arms about over saturation? Nah.
This is going to be a long post.
@FiremanMike I am not trying to start a fight. I respect you, your knowledge, and what you do for your agency. After the first paragraph this is really just going to turn into a repressed rant that's been building for months, please know that it isn't directed at you so much as an example of what some of us deal with.
I'm going to use the above to maybe illustrate a point. Here (and legally I might add), I can have an EMT drill the IO/start an IV and push the drugs I request. I can have an EMT manage the airway until I am at a point (if there is one) that I want to intubate. I can have an EMT show me the monitor and then charge and deliver a shock. These are all money skills. They were things I was very comfortable with before I set foot in paramedic school. The reason? That's how our system operates. That is my experience, it is no doubt different than yours. Your place sounds like it has its crap together when it comes to EMS. I have no doubt there are many fire departments that do as well. But you cannot keep citing your own agency as proof that not all fire agencies provide bad EMS. We get it, it's not 100%. But do you really suppose it's a coincidence that so many here have had watched a lower level of EMS be provided than by that of their own, co-responding service?
As alluded to, prehospital care in my area of Colorado is not like SoCal or the other much maligned areas of fire based EMS. The system is pretty well done and the guidelines actually change when practice does. Significant money, time, and resources are put into EMS by all parties in the system and it shows. But still, the care provided by the fire departments throughout the system is often below that of the single role providers.
Since you have shared your experiences, I will share mine. CSFD sends most of their paramedic students to a less than awesome program in Denver only because it is accelerated (I was fortunate to go to my program the year they sent their guys to the local program, truly have some lifelong friends (and good medics) from it). They then have a joke of an FTO period before they are released as a medic. Fortunately they're usually the only medic on their piece. Compare this to AMR, who will only pay for medic school if you went to the local (and better credentialed) program and pass an extensive FTO process that had well defined standards and FTOs who received additional training for their role to include EMS Instructor certifications. AMR now runs their own paramedic program, I hope the same initial educational standards are met but I have no reason to think they would not be.
In addition to the usual CE, there are several mandatory training events (usually regarding guideline updates) that all system paramedics must participate in. CSFD pulls companies out of service to do theirs, AMR employees must come in on their days off. Yet still, who is responsible for the vast majority of public M&M write ups that are published each month? You guessed it. Nevermind the fact that the per provider their medical division is three times as large. Or that they routinely get placed out of service to get education time from a well trained and equipped division. Lessons just aren't taken to heart, likely because their is no internal pressure to practice good medicine. Their is no self policing. At AMR, if I make a mistake, my peers will make sure I have the education to ensure it does not occur again. It'll still get to clinical education, but at that point it's likely water under the bridge. If you keep making mistakes, you'll get demoted to a transfer ambulance, and then you'll be terminated. CSFD? They'll promote you to lieutenant and remind you that officers needs not maintain their medic. Recently I ran a call in which a BLS truck company had administered several ALS medications prior to my arrival. They then proceeded to argue with me (the only medic on scene) about how their treatment path (dex) was more appropriate than mine (IM epi) for the about to arrest status asthma patient. There was no formal discipline aside from their medical supervisor lieutenant sitting them down and telling them not to do that again. If a BLS crew at AMR did that, they would be immediately terminated. Why is this difference acceptable? Why are they unwilling to maintain high standards? I mean you know it's bad when a medical division captain comes to your new hire AMR orientation and tells you that you are going to have to be on your game because his guys are not.
There are more than a handful of good fire medics. But watching them get belittled on scene by their (mostly EMT/FF) peers for being "too smart" is awful to watch. How do you think those guys feel about delivering in-station medical training to the rest of their crew? I interned at their busiest station for a change of pace. My preceptor made an effort to run scenarios with me everyday using their training equipment. Everyday someone had a less than encouraging comment for us. I could give two about the actual comments, it's the attitude that is worrisome. I think I spent as much time doing EMS training as I did learning to force doors there. There is not just no institutional want to be really good at EMS, like there is the want to be really good at forcible entry or smoothly deploying a department lay. While the majority of the line staff are "only" EMTs, the majority of their calls are "only" medicals.
And AMR is just a part time job. 36 hours a month maybe. But after four years, I haven't seen a lot of change. Meanwhile, at my full time job we were the only paramedics in the service area until a few years ago. The one paid fire district we cover decided they wanted a medic on each shift of four. Mind you they average being on scene without us for less than four minutes, but still, those four minutes multiplied by their yearly 6-700 medical runs equalled a lot of total minutes and boom, an ALS program was funded. One of their medics had worked part time on ambulance running 1500 total calls a year prior to this. The other two have no prior experience. None of them are willing to go get it. None of them will ever get the experience they need with that call volume and they certainly don't have the education to make up for it. Again, there just isn't an institutional want. Meanwhile, my employer all but mandated that I maintain employment as a part time medic for AMR (we only run 25-700 a year) and had me attend every single call out of the busy station for year. While awful, I sure learned. Vastly different agencies, but somehow the EMS only agency maintains and enforces the high standards while fire does not.
I am sure I sound a bit salty and certainly biased. But here's a twist, I also work part time as an FF/Medic. It's a little district with one cross staffed ambulance, but I kinda dig it honestly. The FFs treat the medic well and participate in our daily trainings. They take pride in their part of running the ambulance. I know first hand that it's possible to run a solid FD EMS service because I work with one. I think they are an anomaly, and I am happy to be here. But at the end of the day, given the choice between a fire and and a medical, you know what they'd rather be doing, whether it's real or training.
And I don't sit at home and type these sorts of things and leave it at that. All of my jobs involve running relatively often with small FDs that provide some EMS. Most of them don't do much better than an average job. I figure you can't complain about that unless you try to change it. So I started teaching for one of medical direction hospitals. I do monthly CE training and get the opportunity to dispel myths and encourage these places to embrace and take pride in EMS. I don't think I'm personally having much of an effect, but I am trying to be a part of the solution. I don't want to watch a good system be brought down by low standards pressed forth by fire departments.
TLDR; Locally, throughout the whole large system, the fire departments simply lack any pride in doing EMS well.
