Staff Systems with More EMTs and Fewer Paramedics

[Tigger]

This article generated a lot of activity on a facebook page that I occasionally find myself on. Please do us all a solid and be better than them and read the article before you comment.

The crux of the article:

We don't need Roy and Johnny on steroids, we need them just the way we first met them: well-trained, frequently seeing the worst patients and strategically employed.

http://www.jems.com/articles/print/...tems-with-more-emts-and-fewer-paramedics.html

I agree that there are way too many paramedics in most systems. I work (part time) in a system where every fire apparatus responds with at least one paramedic (usually two) with the balance of the crew being EMTs. The ambulance responds with one paramedic and one EMT. Very rarely do I think this benefits patient care and its well proven that it certainly increases skill dilution, making all of the paramedics less effective providers. ALS first response has never been proven to increase patient outcomes either.

I don't agree with the author's final comment that is highlighted above. I am very firmly of the thought that every patient deserves the opportunity to be assessed immediately by a paramedic. There is nowhere else in the developed world that routinely places a provider with less than 200 hours of education as the primary caregiver. It's just not enough education, and our patients deserve better than that.

I have many more thoughts on this issue, but first, what say you?

 

[NomadicMedic]

Agree. Put paramedics on chase trucks and have them respond to meet (or beat) the ambulance at the scene. If not needed, they leave. Most calls need an ambulance, fewer need a paramedic.

 

[Tigger]

In your previous system, were paramedics dispatched to every call? Do you think that the EMTs in that system were able to accurately determine what calls would and would not benefit from a paramedic?

When I worked on a BLS truck in Boston, many of my coworkers had no idea when to call for medics and when not to. Clear and obvious stroke? Boogie to the hospital, no sense in waiting for ALS when we could just be at the hospital. Yet many of them thought that every stroke needed an IV prior to arrival. Ugh. Meanwhile you have grandma who is altered, hypotensive, and tachycardic. Nah we'll just BLS that in, she's old so she probably is always a little out of it. More ugh.

My thing is that while few calls truly need a paramedic, many patients can still benefit from one. Sure, no one died from pain or vomiting. But if we can treat it, shouldn't we?

 

[PotatoMedic]

I will say it is education dependent. I went to king county's EMT school, and I can say they really taught us sick/not sick well since king county relies heavily on EMT triage for medic evals. So yes. I do think emt's can be taught when to and when not to call for als. Does that run a risk of missing patients or giving a stable pt a medic? Yes. But if you want less medics that is a risk you will have to take.

 

[NomadicMedic]

Pre screening and PMD goes a long way. In my previous,system medics only went on Charlie, delta and echo calls. Most BLS was pretty medic dependant though. The ability to triage to BLS after an evaluation is where the real value lies.

 

[chaz90]

Ahh. Now here's a topic to which I can relate!

We are not dispatched to every call. We are dispatched on all Charlie, Delta, and Echo responses automatically, with dispatcher discretion to add ALS for Omegas, Alphas, and Bravos. BLS can obviously request or cancel us on any call they desire.

The PMD system has some known issues, but I don't fault it for at least trying to prioritize and tier response plans. BLS varies in what they do and do not transport prior to arrival of ALS. The system as a whole pretty much expects them to request medics for any CVA unless the hospital is closer than the medics. I have no problem assessing these stroke patients at what I imagine is a slightly more thorough level than some of our EMTs and getting an IV and labs before arrival at the ED, but our local BLS (especially the departments closest to all three hospitals) are more than happy to cancel medics based on proximity and transport alone for any call.

I do have a problem with some of the patients we are cancelled on due to "proximity" or simply never dispatched. I strongly believe many of our respiratory patients can benefit from stabilization and treatment prior to arrival at the ED and any movement at all in some cases even if the hospital is 2 minutes away. I despise getting requested for pain control that is worsened on movement only to have BLS move them and make us intercept them somewhere. I wish we had the means to make sure they wait on scene as these isolated ortho injuries aren't time sensitive and could certainly benefit from medication prior to movement. I've also intercepted a couple unconscious diabetics who I was forced to treat in an ambulance rather than wake them up gently on scene and happily make them a PB&J as they sign the refusal paperwork. Don't even get me started on intercepting cardiac arrests with CPR in progress because BLS just wanted to load and go to the hospital like it's 1950. I think these scene management problems could be mitigated by having the paramedic on scene of the transport unit so the BLS personnel staffing the ambulance don't panic when they run out of things to do/talk about and just load the patient into the ambulance and drive as they revert to what they know.

I think some of these finer points of the treatment side of EMS that doesn't involve immediate emergent transport to the hospital is lost on a few of the local BLS providers. Basically, I don't think the local BLS community as a whole understands when paramedics can help and when we have our hands tied. In some ways, we as ALS don't even present a unified front. There's constant variation between what individuals do prior to transport and based on hospital distance, so in some ways it's unfair to blame BLS for not understanding what I prefer as an individual.

I do believe we're making some slow progress, particularly with the good paid BLS crews that we interact with on a daily basis. I explain why we do the things we do with these providers, and the ones who are receptive to learning are improving. Our biggest hindrance in getting BLS crews to recognize when and when not to call for paramedics is the low volume departments and/or the old volunteers that only come take calls every few weeks or months.

In spite of these issues, I remain a big fan of our tiered, dual response system. I love not getting tied up in clearly BLS calls that simply need a ride to the hospital, and I think the ability to release a patient to the care of BLS after an ALS assessment is invaluable. I see a much higher average acuity of patients in this way, I manage more critical patients for longer periods of time than most of my ambulance bound fellows, it lets us work with a paramedic partner yet still keep our district covered with an ALS resource when one of us transports a patient, and it slows burnout from the continual grind of BLS patients that don't need us. I run enough calls to avoid boredom (well, sometimes) but have enough downtime to avoid burnout, which is perfect. One of the biggest problems with this? You can't bill for an ALS transport when the paramedic didn't transport.

 

[chaz90]

TLDR? See DEmedic's post.

 

[Tigger]

Pre screening and PMD goes a long way. In my previous,system medics only went on Charlie, delta and echo calls. Most BLS was pretty medic dependant though. The ability to triage to BLS after an evaluation is where the real value lies.

Absolutely. There is no reason why a paramedic needs to accompany every patient to the hospital.

I guess I just wonder how many "missed opportunities" there are for better care if a paramedic responds to all calls. We are all well aware of EMD and its downfalls, to include both overtriage (I breathed dust and now I'm coughing equals delta level respiratory) and the other end with many alpha level illness calls being legitimately ill people. I have no idea if ALS response to everything would measurably improve outcomes, alas I am just rambling here.

I like our Paramedic/Basic ambulances. Everyone gets the opportunity to be assessed by someone with legitimate education. Tiered systems have always seemed backwards to me in that you are trusting the least educated provider to understand when someone with more education is needed. The flip works much better, I trust that a paramedic has the knowledge to know a BLS transport is appropriate.

 

[RocketMedic]

Would ED tr7age work if it was run by the cafeteria line cook?

 

[Handsome Robb]

This is a system specific question towards @chaz90 and @DEmedic . Are ALS units dispatched to all MVAs (or TCs, whatever the local area calls them) or only specific ones? Ours tend to vary in dispatch code between Bravo and Charlie.

I think that skill degradation is an issue but I also think that there are ways to afford our patients all an ALS assessment. Now whether it's cost effective or not is a completely different story. We run I/P staffing and rarely P/P. Only one of three of our FDs is ALS currently. The I/P ambulance staffing allows every patient to have a Paramedic on scene at any call in the County however we are allowed to triage down to our ILS partners.

 

[chaz90]

This is a system specific question towards @chaz90 and @DEmedic . Are ALS units dispatched to all MVAs (or TCs, whatever the local area calls them) or only specific ones? Ours tend to vary in dispatch code between Bravo and Charlie.

Nope. We only go on Delta level MVAs from dispatch. These are only the high mechanism accidents (rollover, ejection, head on, involving a motorcycle), reported entrapment, or patients reported unconscious. We're also dispatched if it's coded out as an MCI.

We don't have Charlie level MVAs. Everything is either a 29B or 29D.

 

[Carlos Danger]

I can see it both ways.

First, I've always thought a system like what Chaz and DE describe is the ideal system design. Common sense (and the literature, in most cases) dictates that EMT's can handle most EMS calls perfectly adequately. Research also shows that more paramedics = skills dilution. Why spend more money than we need to on a bunch of paramedics and multiple sets of ALS equipment, when relying mostly on BLS ambulances and staffing just a handful of paramedics per system on QRV's seems to work well?

On the other hand, some say just the opposite: that ideally, EMT's have little or no place in an ALS 911 response system. Why not have a paramedic - or two - on every 911 ambulance? What's the downside? Not talking about sending an engine with 4 paramedics on it to everything so that you end up with 5 or 6 paramedics to every call; just the one or two on the ambulance. It isn't like a paramedic is some super-expensive, highly specialized, scarce resource that must only be summoned from the ivory tower when things are really, really bad. Under-triage or lack of availability of ALS when needed is a real risk in the first system design, but it becomes a non-issue in the paramedic-only one. Skills dilution can and should be mitigated by better initial and ongoing training, not by limiting an important public-safety resource.

I think you can make a good argument for either approach. Personally, if I were to work full-time as a ground paramedic again, I would undoubtedly want to be in a system that uses the first design. But if I'm being completely honest, that's mostly because I think it would just be a more fun system to work in and I'd have to deal with fewer BLS calls.....it's not necessarily because I think it's an inherently better design.

 

[Shishkabob]

I used to think the same way, but as experience and education have continued I now think having a medic on most trucks, if feasible, is reasonable. Yes, Paramedics are meant for the actual life threats, but there's something to be said for pain relief, nausea relief, and catching the odd zebra. Keep some BLS trucks for the extremely obviously stupid "I want a flu shot" calls (if you can't outright refuse transport).

Shoot, last year I had a psych call where the patient was convinced they had been cursed because they couldn't walk. History of paranoid schizophrenia, reflexes intact, hell I saw them move their legs! On a hunch I threw on an EKG and saw... sine waves. Hello K+ of >9.3. What about the old lady with diarrhea for a week? Oh hey look, runs of v-tach with a K+ of less than 2. An EMT, with their current levels of education, would not have caught those, nor have understood the idea behind catching them.


Now I am of the idea that a medic should be on most trucks, but have specialized Paramedics (Advanced Practice Paramedics, Critical Care Paramedics, etc) on fly cars sent to back up units on the more serious calls (arrests, major trauma, etc). This way those medics see more of the critical people more often and thus have more experience with them and are able to help the truck by being yet another experienced Paramedic with maybe a bit more skills / drugs at their disposal.

 

[RedAirplane]

I heard a Podcast about a new EMS model with community paramedics making house calls. The BLS trucks would run 911 with a slightly expanded scope and if ALS was truly needed (CP, arrest, major trauma, etc) then one of the paramedics would divert from a house call to intercept the ambulance on-scene or enroute.

At first I thought this was weird, but the more I think about it, the more it makes sense. Of course, I can't imagine community paramedics intubating their house victims often, so I'm not sure how to address that aspect of the article.

 

[medicsb]

I used to think the same way, but as experience and education have continued I now think having a medic on most trucks, if feasible, is reasonable. Yes, Paramedics are meant for the actual life threats, but there's something to be said for pain relief, nausea relief, and catching the odd zebra. Keep some BLS trucks for the extremely obviously stupid "I want a flu shot" calls (if you can't outright refuse transport).

Shoot, last year I had a psych call where the patient was convinced they had been cursed because they couldn't walk. History of paranoid schizophrenia, reflexes intact, hell I saw them move their legs! On a hunch I threw on an EKG and saw... sine waves. Hello K+ of >9.3. What about the old lady with diarrhea for a week? Oh hey look, runs of v-tach with a K+ of less than 2. An EMT, with their current levels of education, would not have caught those, nor have understood the idea behind catching them.


Now I am of the idea that a medic should be on most trucks, but have specialized Paramedics (Advanced Practice Paramedics, Critical Care Paramedics, etc) on fly cars sent to back up units on the more serious calls (arrests, major trauma, etc). This way those medics see more of the critical people more often and thus have more experience with them and are able to help the truck by being yet another experienced Paramedic with maybe a bit more skills / drugs at their disposal.

Ermagerd! Get a 12 lead for every psych patients... because they might have hyperK!? (>9.3 is not compatible with life... either that was a lab error or someone needs to write the case up for publication.)

At this point, out of nearly 1000 patients that I've seen in the past 9 months (many whom I've measured BMPs/chem-7s on), I have maybe heard aof 1 o 2 w/ a K <2. And the ones close to 2 were not little old ladies with diarrhea (one was a young DKA pt. who continued to drop her K despite multiple repletions that required an IJ so we could run K in as fast as possible). Sure, it can and does occur, but not with any regularity to justify a paramedic be sent to every person with diarrhea. If BLS arrives and notes the patient to have an irregular HR or episodes where the pt. gets very tachycardic, then sure, call for ALS. But these "what if" scenarios play more to ones emotion than logic.

Ultimately, I think the answer to the over-arching problem is to better train the primary responders, whether the EMTs, or upgrading to AEMTs, but paramedic-for-all is silly and wasteful.

 

[Tigger]

I lived in New Zealand for six months and spent some time studying their EMS system while I was there for my thesis. Their base paramedic has a scope somewhere between an AEMT and I99, and it's a three year degree. If that's what we can have for a base level provider, I am all for tiered systems. But to think that someone with a 150 hours of training and limited diagnostic tools can determine who legitimately needs further care seems silly to me.

 

[medicsb]

I lived in New Zealand for six months and spent some time studying their EMS system while I was there for my thesis. Their base paramedic has a scope somewhere between an AEMT and I99, and it's a three year degree. If that's what we can have for a base level provider, I am all for tiered systems. But to think that someone with a 150 hours of training and limited diagnostic tools can determine who legitimately needs further care seems silly to me.

I do agree that 150 hours is too little for EMT, but I do not think it takes 3 years of schooling (or even 1) to differentiate between need or no need for a paramedic.

 

[Tigger]

To add to that, most NZ paramedics are more than capable of managing most calls themselves. Their scope is less than that of US paramedics, but includes the more high frequency assessments and treatments.

 

[Aprz]

I do agree that 150 hours is too little for EMT, but I do not think it takes 3 years of schooling (or even 1) to differentiate between need or no need for a paramedic.

The three years of training is not only to differentiate between the need for a paramedic (in New Zealand, an intensive care paramedic (ICP)) or not. They are better trained and equipped to assess and treat everyday calls compared to US EMTs.

 

[Shishkabob]

Ermagerd! Get a 12 lead for every psych patients... because they might have hyperK!?

Not the point, not the intention, not what I said. In fact I can count the number of times I've done 12leads on psych patients that haven't overdosed on 1 finger.

(>9.3 is not compatible with life... either that was a lab error or someone needs to write the case up for publication.

Confirmed multiple times via i-stat and actual lab data. But what do I know, I was just there.

Shoot a quick 3 second Google revealed someone with a 14.0. (http://acutecaretesting.org/en/jour...record_breaking_serum_potassium_concentration)

Or heck, studentdoctor has a thread on it, with quite a few above the 10 range (sure, anecdotal) (http://forums.studentdoctor.net/threads/whats-the-highest-k-youve-seen.347703/)

You're right... it's not compatible with life, except for when it is.

Sure, it can and does occur

Than why are you incredulously questioning it? But that wasn't the point anyhow; what's an EMT going to do for someone who's dehydrated after several days of diarrhea?

Some people get trauma. Some people get strokes. I get odd-as-hell cardiac calls.

But these "what if" scenarios play more to ones emotion than logic.

Logic also says a low priority sick person should never be a cardiac arrest, but alas.

but paramedic-for-all is silly and wasteful.

Disagree. All Paramedics (that FDs love to do) is wasteful and potentially dangerous; Paramedic for all ensures a Paramedic is always available if needed, instead of an unnecessary, avoidable, delay.


It's oft said when you hear hoof beats, think horse and not zebra. When I hear hoof beats I think horse but look for a zebra.