Staff Systems with More EMTs and Fewer Paramedics

[triemal04]

I really hope that you actually treated both those patients or that they had an event during your transport that required an intervention...otherwise your arguement falls flat on it's face. Can you clarify that please?

 

[RocketMedic]

Linuss, you also bring up an excellent point- an EMT is ill-suited to ride even a pony, much less a zebra. They are best for sheep.

 

[RocketMedic]

Well, Triemal, a paramedic is the difference between "bs old lady with bags packed" and "rapid access to definitive care with ED staff alerted to real danger", so yes, I'd say it made an impact.

 

[NomadicMedic]

So, this comes back to the "not everyone needs a paramedic, but everyone deserves a paramedic"

 

[46Young]

I've worked in hospital based third service controlled by the FD (NYC), municipal Third Service (Charleston County SC), and now in a dual role fire based system. I will always be partial to a tiered system, where here are two medics on the ambulance, and that ALS ambulance only gets dispatched to ALS call types, such as arrests, diff breathers, unconscious, cardiac conditions, etc. They should not be running sick calls, falls, most MVC's, EDP's, and drunks that are conscious. In this type of system the medics will rapidly become proficient. The problem is, much of the country prefers the medic/EMT txp unit, where they are subject to any type of call. I feel bad for the medic students that I mentor, because at least 80% of our patients are non-acute, and not challenging for us in the least.

Since the preference has gone away from running a tiered system, and I'm subject to working in an all-ALS (medic/EMT ambulance) fleet, I prefer to have ALS suppression units run first response. Does ALS first response affect patient outcomes? Maybe a little. While waiting for the txp unit I've treated Anaphylaxis several times, and ran a few codes for a few minutes, probably less than ten, but that's not typical. What I value from this system is that when an engine or ladder company is on-scene with me, I now have six people to do the work rather than two. If you train with the crews that you typically run with, pt. care with 5-6 people on-scene can be smooth and efficient, rather than chaotic with people stepping all over each other.

The value is that diagnostics/treatments, and movement to the ambulance, typically occurs 10-15 minutes quicker than if it were just my partner and I on-scene. If I need the suppression medic, I can take them for a ride with no issues. For reference, my on-scene times for a patient that requires monitor/IV/non-ambulatory typically run 15-20 minutes before I leave for the hospital. When I worked in NYC, any pt. requiring ALS kept us on-scene upwards of 30 minutes in many cases. The suppression crew saves me an average of 10-15 minutes for ALS patients, and likely 5-10 minutes on more non-acute patients. If I run the typical 5-6 transports, that's a savings of over an hour a day of in-service time. In a large system, that's equivalent to having an extra ambulance on the road (or several). In addition, the lifting is spread out, and as the txp medic, it's nice to have all your diagnostics and typically a line done without you having to touch the patient, which is nice at 0230 in the morning when you're burnt. These benefits are cost-neutral with the exception of fuel, medic pay, and ALS equipment on the suppression piece. The engine would have otherwise been idle in the majority of cases.

ALS first response suppression units may not have much of an effect on pt. outcomes, but it does make the on-scene to txp process much quicker, and spreads the work around, using resources that would likely have been idle otherwise.

 

[Shishkabob]

I really hope that you actually treated both those patients or that they had an event during your transport that required an intervention...otherwise your arguement falls flat on it's face. Can you clarify that please?

I shouldn't have to explain basic treatment modalities of hyperkalemia or vtach in the pre-hospital setting. Each was treated as appropriate for the given circumstance.

Anyhow, sometimes it's realizing that it's best to not do anything.

 

[triemal04]

I shouldn't have to explain basic treatment modalities of hyperkalemia or vtach in the pre-hospital setting. Each was treated as appropriate for the given circumstance.

Anyhow, sometimes it's realizing that it's best to not do anything.

I don't want you to explain what treatements were needed, just IF any treatements were given. The reason I bring this up is because, if nothing was done and no adverse events occured, it becomes harder to say that having a paramedic treat those 2 patients was truly needed. Unless you are completely confident that those things would have been missed and/or had a severe delay in discovery at the hospital...did the presence of a paramedic instead of an EMT matter?

(I don't mean to say that early recognition of a problem without treatement is worthless; it's very valuable and can help to get the hospital keyed into what's going on quicker. But there are times when it's given to much value.)

 

[triemal04]

46young-

But how much of that making things easier comes soley from having more help on scene, not from having more paramedics on scene? With a single patient, 2 paramedics are more than enough to take care of all interventions and treatements in a quick, efficient manner; the EMT's (if well trained) can be used to assist, and if needed and with a little prompting, get at least the initial info that's needed from any family or bystanders that are present. Believe me, I'm all for having extra hands to help out, but I don't see any reason for the extra help to be anything more than EMT's.

 

[medicsb]

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.

Well, thank god you're not. Too bad you can't let BLS take them in while you make yourself available (or better yet not even get dispatched in the first place). Your anecdote is of an out-lier. You had some hunch and caught something. It's an interesting case for sure and I assume there was more to the story and physical exam other than him saying he cant move his legs when he indeed could move his legs.

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?

Take them to the hospital? I see plenty of people with some degree of dehydration pretty frequently and even after the fact I don't think the majority of them would need a paramedic or an ambulance. Even the more severe dehydration patients will do just fine with a smooth ride to the hospital. A line and fluids is fine and all, but it is not absolutely necessary unless there is altered mentation, shock, or some other sort of identifiable end organ damage that warrants immediate attention. Plenty of these patients show up in the waiting room and wait hours with little problem.

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

So? The basic unit calls for a medic while they institute the most proven of all interventions - CPR and AED - while medics are enroute.

Paramedic for all ensures a Paramedic is always available if needed, instead of an unnecessary, avoidable, delay.

First off does a 10-15 minute delay really matter when BLS has an AED and an epipen? Consider that in many places and EMT can give albuterol or initiate CPAP, a paramedic is needed immediately even less. A paramedic for all also ensures either burnout in super high-volume systems, or it ensures lack of sufficient experience with critical patients, both of which will lead to poorer outcomes.

 

[RocketMedic]

Why do you assume EMT will be any less burned out? They are simply easier to replace.

 

[Tigger]

So, this comes back to the "not everyone needs a paramedic, but everyone deserves a paramedic"

Perhaps not a paramedic but certainly more than the assessment that a 150 hour technician can provide.

Sometimes it's patently obvious that this in fact not necessary, but how do you know that until you get to the patient. It's not anyone is ever surprised by a bs sounding call being a legit patient.

 

[Shishkabob]

The thing is, as EMS transitions from emergency medicine to a "Mobile Healthcare" perspective, Paramedics become more of a necessity, and there's less and less space for EMTs. If all you want EMS to do is drive people to the hospital, sweet, get all the EMTs you want. Minimal treatment, minimal diagnostic abilities, minimal ability to divert to more appropriate facilities will be available. But if you want EMS to transition in to the role we were thrust in to long ago, with less acute medicine and more generalized healthcare, than a Paramedic is a necessity.

 

[NomadicMedic]

I used to feel that every patient should be seen by a paramedic, but years of running to poorly coded "emergencies" has changed my mind. What we really need is better pre dispatch screening, an alternative nurse line, the ability to triage non emergent cases to a simple transportation unit and fewer paramedics in fly cars that can respond to truly emergent calls and treat if needed.

It'll never happen, due to politics, health care costs and the litegious society we live in... but it's a lovely thought.

 

[RocketMedic]

Disagree, DEmedic. You and I both know that system would be exploited shamelessly for maximum profit and minimum care if it's widened.

 

[DrParasite]

outside of for pain control, what calls require a paramedic for treatment? In many systems, EMTs are giving albuterol, benedryl, Epi 1:1000, aspirin, oral glucose, and able to defib using an AED.

Any unconscious person (for all causes), reported cardiac problems, reported respiratory problems, what else NEEDs a medic?ma

And while i'm sure you can name several, how many call would be dispatched as ALS calls? last time I looked at the Priority dispatch criteria (which can be found here: http://wiki.radioreference.com/index.php/Medical_Priority_Dispatch_System) the majority of calls would still fall in the A & B sections, with only C, D & E being ALS dispatch criteria.

The thing is, as EMS transitions from emergency medicine to a "Mobile Healthcare" perspective, Paramedics become more of a necessity, and there's less and less space for EMTs. If all you want EMS to do is drive people to the hospital, sweet, get all the EMTs you want. Minimal treatment, minimal diagnostic abilities, minimal ability to divert to more appropriate facilities will be available. But if you want EMS to transition in to the role we were thrust in to long ago, with less acute medicine and more generalized healthcare, than a Paramedic is a necessity.

I agree with Linus (I think). If you are looking at mobile healthcare, where paramedics are tracking patient conditions, performing non-emergency assessments for prescheduled appointments, alternative destinations/not everyone needs to go to the ER, more interventions outside of the ER and more treat and release situations, than I would agree, paramedics are much more of a necessity.

But the majority of EMS calls can be handled with two EMTs and a comfy ride to the ER, with no increase in mortality. If you have the paramedics available in a chase car for those calls that require ALS interventions, and ensure they only see sick patients you will get a better caliber medic.

I do think, however, that the 150 hours of didactic education is enough for EMTs. What I think is missing is a clinical component of 120 hours, where the EMT student is evaluated by a paramedic or experienced EMT to judge if the EMT has the clinical abilities to assess patients, determine sick vs not sick, and demonstrate competence in BLS interventions and documentations. And if they aren't able to, they don't become EMTs.

 

[Carlos Danger]

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.

Everyone has (or certainly has at least heard) stories about "that one time" that "it was a really good thing" we put the patient on the monitor / requested ALS / used the KED, etc.

Some of them are undoubtedly true, but many of them end up exaggerated either for effect or because over time, we tend to remember things as being a bigger deal than they were. Not saying that's the case with this particular story; just saying that it's a common phenomenon. It's one of the reasons why anecdotes are poor justification for sweeping policy or protocol changes.

I think we often exaggerate the ability of paramedics to detect and treat these more obscure or complex medical problems. Of course we can do more than EMT's, but we are still severely limited in our diagnostic and management ability, due to the narrow scope of our education, our lack of diagnostic equipment, our small formulary (who carries potassium?), and the limitations that are inherent in working out of a metal box on wheels.

Even when we are able to find and treat something like this, it often doesn't change outcomes, as compared to just waiting until the patient is in the ED.

I'm not arguing against the paramedic-on-every-call system design, I'm just saying that I don't think examples such as this support it very well.

 

[Tigger]

But the majority of EMS calls can be handled with two EMTs and a comfy ride to the ER, with no increase in mortality. If you have the paramedics available in a chase car for those calls that require ALS interventions, and ensure they only see sick patients you will get a better caliber medic.

Measuring interventions based only on mortality is not a very good indicator of service provided.

Sometimes a comfy ride to the ED requires pharmacological intervention, and we should be willing to provide that, not ignoring patient's symptoms.

 

[Altered Mental Status]

This may just be because I'm a Navy gal but I believe in roles and SOPs. I also believe in drills to stay sharp and I wonder why we don't do more of that.

EMTs are not "ambulance drivers." We can't lose sight of that. There's a reason the standard is not to have an EMR driving the box with a provider in the back and it's because we need another able-and-educated care provider doing more than just collecting insurance cards and cleaning the stretcher.

I personally agree with Tigger's assessment that every pt deserves care and transport by a team that can handle the full scope. In my mind, the ideal set-up is one-medic-one-EMT per unit. There's a care "caste system" onboard the rig, just like there would be at the hospital with both members of the care team having active roles in care for the pt and everyone knowing their roles.

Skills dilution can be avoided with regular drills and more lab time at refresher because honestly? Even if we could find the most ideal dynamic/combination, there are going to be gaps and we owe it to the patient to eliminate those--to not default skill/competence to be driven by random factors like "what symptoms showed up in the truck over the course of this particular year." I don't think the addition of drill time and lab time needs to be a huge inconvenience to an already-taxed staff of providers. There are ways to incorporate these into the existing system with little added invasion. Additionally, I think the EMT/Medic team dynamic encourages mentorship and growth as well as better EMTs. There are career-EMTs who don't WANT to be Paramedics but who know their job AND my job well enough to be exactly where they're needed down to muscle-memory movements all the time. That's amazing and it doesn't happen when those EMTs are on BLS trucks.

We're slowly but surely moving towards a system where perhaps someday, providers will do house calls. We'll be paid for non-transport care or transport to non-ED facilities. Skills dilution be damned. That transition is likely to happen much more easily when an ALS team is the standard. It's not our job to worry about the billing aspect of that. It's our job to get into the habit of providing only and all of the necessary interventions to Tx the pt in front of us.

Just my $0.02.

 

[RocketMedic]

Surprisingly insightful, AMS.

Yesterday, I took an IFT run. Hour-long routine transfer for appendicitis. Totally stable. Sure, I could have turfed it to my partner and it could have been a BLS call, but when the ED's meds wore off and pain returned, the patient was certainly glad to have a paramedic with him. That's the difference between paramedics and basics. I can do things that actually help outside of first aid.

 

[46Young]

This may just be because I'm a Navy gal but I believe in roles and SOPs. I also believe in drills to stay sharp and I wonder why we don't do more of that.

EMTs are not "ambulance drivers." We can't lose sight of that. There's a reason the standard is not to have an EMR driving the box with a provider in the back and it's because we need another able-and-educated care provider doing more than just collecting insurance cards and cleaning the stretcher.

I personally agree with Tigger's assessment that every pt deserves care and transport by a team that can handle the full scope. In my mind, the ideal set-up is one-medic-one-EMT per unit. There's a care "caste system" onboard the rig, just like there would be at the hospital with both members of the care team having active roles in care for the pt and everyone knowing their roles.

Skills dilution can be avoided with regular drills and more lab time at refresher because honestly? Even if we could find the most ideal dynamic/combination, there are going to be gaps and we owe it to the patient to eliminate those--to not default skill/competence to be driven by random factors like "what symptoms showed up in the truck over the course of this particular year." I don't think the addition of drill time and lab time needs to be a huge inconvenience to an already-taxed staff of providers. There are ways to incorporate these into the existing system with little added invasion. Additionally, I think the EMT/Medic team dynamic encourages mentorship and growth as well as better EMTs. There are career-EMTs who don't WANT to be Paramedics but who know their job AND my job well enough to be exactly where they're needed down to muscle-memory movements all the time. That's amazing and it doesn't happen when those EMTs are on BLS trucks.

We're slowly but surely moving towards a system where perhaps someday, providers will do house calls. We'll be paid for non-transport care or transport to non-ED facilities. Skills dilution be damned. That transition is likely to happen much more easily when an ALS team is the standard. It's not our job to worry about the billing aspect of that. It's our job to get into the habit of providing only and all of the necessary interventions to Tx the pt in front of us.

Just my $0.02.

Your viewpoints are valid. However, I've worked in a tiered system, an all-ALS third service system, and my current fire based all-ALS system. In the tiered NYC system BLS were dispatched to ALS calls if the medics had an ETA of more than ten minutes, or if the medics needed extra hands. The BLS learned their craft well as a result, as they were responsible for pt. care for 5-10 minutes before medics arrive. They would also learn to take the BLS abd. pain or sick call and recognize that they need ALS occasionally, based on presentation and Hx. You can't learn that in a lab. As a medic, I ran at least three patients in grave condition every day, usually more - arrest, cardiac rhythm disturbance, MI, critical asthma or COPD, APE, unconscious, "real" calls. In the other two all-ALS systems, I would be lucky to get one day's worth of NYC real ALS patients in three weeks to a month, depending on the area.

In NYC, we developed a good flow with our skills - the questions and assessment were smooth, inclusive, and polished, my hands worked real quickly with IV's, drawing up meds, dropping a tube, various types of lung sounds on a frequent basis, things like that. You can't reproduce that effectively in a lab environment, especially the lung sounds and the tube, and we do have Sim Man at our training center. It's not the same as a real person. Now, since critical patients are few and far between, the assessment and skills become more goofy and less polished, the flow is gone, and things like drawing meds and airway management become more clumsy. Meanwhile, the BLS are not able to think for themselves, past doing their usual vitals or obvious needed intervention. Many know what to do, but always need to ask a medic if it's acceptable, instead of acting autonomously, as they would be on a BLS unit.

I do understand that how we train is how we function in the field, but the lab only helps to an extent. Running BLS 90% of the time, or doing VOMIT most of the time (Vitals, O2, Monitor, IV, Txp), flattens out the learning/experience curve significantly. No one's learning much by taking vitals and and ECG on mostly stable patients day in and day out.