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Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Too Many Medics?

Tue, 01 Sep 2009 23:41:13 -0400 by

Also posted over at Paramedicine 101. Go check out the rest of what is there.

In some of the posts on the recent intubation study,[1] this question keeps coming up: What is the right number of paramedics to provide the best care to patients?

There was an article that covered this.[2] Here is the chart from the article.

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RESULTS FROM FIVE CITIES
The study examined cardiac-arrest survival in five
unnamed cities. The findings include:

City with best outcome City with worst outcome
Cases of sudden cardiac arrest per paramedic each year 4.7 1.6
Length of time paramedics arrive after first responders 4 minutes 1 minute
Survival rate 27% 4%

Source: Researchers at Ohio State University in Columbus

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This does not mean that medics should not be sent at all. Rather, it strongly suggests, that in our desire for a quick ALS response for cardiac arrest, we may be making things, not just a little bit worse, but a lot worse.

These numbers agree with what I have been stating about ALS getting in the way of BLS during cardiac arrest treatments (CPR). The numbers do not prove what I have been stating, but they seem to be giving a very strong hint.

The places with fast ALS responses are able to respond quickly because they have a lot more medics. In other words, they have dramatically reduced the amount of experience per medic.

Why?

To make everybody feel good, even though it appears to be killing people.

Almost a 7 times higher survival rate in the cities with fewer medics.

Feel good?

More medics means that more people are medics, and can feel good about being medics.

More medics means that more people are having medics respond to treat them, and can feel good about receiving care from medics.

This is just to make people feel good. Then, why not make everyone a medic? The response time would be immediate, unless maybe you fall in the woods, and there is nobody else there to hear you fall. In which case the philosophical question is, If a patient falls in the woods and there is nobody there to call 911, is there a response time? Not, Does the patient make a sound? And, since the patient is a medic, there is already a medic on scene, so there is no worry about response time.

Do the response time rules state that the responding medic has to be alive?

Probably not.

We could have all of the patients in nursing homes become paramedics. Talk about cross-training leading to improved response times!

Too many medics = too many failed resuscitations.

Too much of a good thing can be a bad thing.

Footnotes:

^ 1 Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93.
PMID: 19608824 [PubMed – indexed for MEDLINE]

PubMed states that the full text article is free at the journal site, but it is not

^ 2 Fewer paramedics means more lives saved
Updated 5/21/2006 8:58 PM ET
USA Today
By Robert Davis
Article

The chart is from this article.

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Filed Under: Cross-training, Heresy, Medic X, Paramedicine 101 Tagged With: , , ,

Fla. EMS director pulls certification of 25 paramedics

Thu, 27 Aug 2009 07:18:14 -0400 by
It seems that there is a bit of a squabble going on down in Florida.

Twenty-five North Naples firefighters are no longer allowed to work as paramedics because they haven’t met training requirements set by Collier County Medical Director Dr. Bob Tober.

North Naples Fire Chief Orly Stolts said the move puts good medics out of commission and endangers residents.[1]

A fire chief opposed to training? WTF?

Oh, it’s EMS training that he is opposed to. That explains it. The chief thought that he would be able to force the medical director to sign off on the ex-medics, just because the chief was going to huff and puff and sputter and grimace and cry like a little baby.

“What he’s done is minimized the fire department’s ability to save lives,” Stolts said of Tober. “We’re going to have to stand there and wait to give life-saving medication until an ambulance arrives at the scene. That puts our guys in a pretty hard spot.”[1]

Well, he is the chief. He should know.

He is a fire chief. His highest ranking medical person is telling him just the opposite of what he wants to hear. He just really, really, really doesn’t want to hear this.

“We’re going to have to stand there and wait to give life-saving medication until an ambulance arrives at the scene.”

If he truly believes that, then maybe he should have acted as a Chief and made sure that his people had the required training. This is all the fault of Chief Numbskull.

This is a wonderful example of a blithering idiot.

Stolts said arranging to have his firefighters pulled from an engine once a month causes significant scheduling and overtime difficulties.[1]

In other words, Chief Stolts is completely responsible for this. He chose not to follow the medical training rules. I wonder if he does that with fire training rules.

Maybe he is cross-trained and incompetent at both fire and EMS.

Maybe. We know he has one area of incompetence fully covered.

Footnotes:

^ 1 Fla. EMS director pulls certification of 25 paramedics
By Ryan Mills
The Naples Daily News
August 26, 2009
EMS1.com
Article

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Filed Under: Cross-training, Fraud, Heresy, Medic X Tagged With: , ,

Maryland Helicopter EMS Panel Supports Fewer Medevac Flights

Wed, 26 Nov 2008 21:07:13 -0500 by
Apparently I misjudged the independence of the panel that met briefly to review the way the Maryland flight program is operated. I apologize. Perhaps I misjudged those in charge of things in Maryland (Dr. Bass and Dr. Scalea), as well. I hope to be writing more apologies as the panel’s recommendations are implemented.

Maryland’s emergency medical helicopters could fly fewer accident victims to hospitals without reducing survival or affecting quality of care for patients, a panel of experts told state officials yesterday.[1]

This is certainly not news to anyone with a broader experience of EMS than just MIEMSS (Maryland Institute for Emergency Medical Services Systems) and/or Shock Trauma (R Adams Cowley Shock Trauma Center – University of Maryland Medical). Dr. Bass is the CEO of MIEMSS and Dr. Scalea is the trauma surgeon in charge of Shock Trauma.

Shock Trauma brought us the concept of the trauma center. It is named after Dr. R Adams Cowley. Dr. Cowley is the marketing mind behind the Golden Hour. I refer to it as the Bogus Hour, because it is not based on anything other than a desire to sell.[2]

Sell the trauma center concept.

Sell the HEMS (Helicopter EMS) concept.

Sell the R Adams Cowley concept.

If there had been some research behind the Golden Hour, I would not be referring to it as the Bogus Hour. If there were some response to the evolving research, by those running the trauma franchise, many others would not be so critical of the Maryland way of Fly everyone and let Shock Trauma sort them out.

Late addition (11/27/08) – ParaCynic has a great post on the Golden Hour from a different perspective. Go read City Slickers 2: The Legend of Cowley’s Gold.

“We felt there are too many helicopters – not just in Maryland but in the Washington-Baltimore-Philadelphia corridor,” said Dr. Bryan Bledsoe, a professor at the University of Nevada School of Medicine. “That said, there’s no clear definition of what is a correct number.”[3]

“A level of overtriage is occurring that exceeds that of comparable systems,” said panel chair Dr. Robert C. MacKersie, director of trauma services at San Francisco General Hospital. “There is a high likelihood that opportunities exist for reduction in Maryland’s (helicopter) transport of trauma patients without compromising patient outcomes or the quality of care.”

But what were the actual recommendations?

•Reconsider whether Maryland needs 12 helicopters and eight bases. Several members called the fleet excessive.[4]

That would seem to be obvious. If the flights are down by more than half, the state should not need anywhere near as many helicopters. It is a small state.

•Adopt national accreditation guidelines mandating two health care providers on each flight, instead of the single paramedic used now.[4]

Absolutely. How has MSP (Maryland State Police) been able to convince people otherwise? Take a medic off the job of paramedic for a year, so that the medic can work just as a trooper. Then return this trooper to patient care and retrain the trooper as a trooper/medic. And the punch line is that this extra training as a trooper means that the trooper/medic is supposed to be better than the nurse and paramedic crews on all of the other helicopters in the region. Apparently the trauma specialists did not get the joke.

•Monitor recent changes in triage to see if they continue to reduce the number of patients flown. Fewer patients can probably fly without affecting outcome.[4]

If you believed the scare stories that have been coming from a lot of people supporting the status quo, you should have bought up all of the body bags that you could. Shockingly, there has not been a sudden increase in the need for body bags, although flights are down by almost two thirds. Are injuries down, too?

It is beginning to look as if the only need for body bags was for the crew members and patient in the recent crash. If the patients had been driven to the hospital, the pilot, trooper/medic, local EMT, and the patient who died, all would probably be alive and well.

The surviving patient would not have had a lower leg amputation, a couple of months in the ICU, and prolonged rehab. How is it that this patient is too badly injured to be transported by ambulance, yet survives a helicopter crash, is lying on the ground, in the rain, in the woods, and without care for almost 2 hours until rescue crews find the wreckage and her, and she survives an ambulance ride to the hospital?

Those are not signs of a seriously injured patient. At least she does not appear to have been seriously injured before entering the helicopter.

•Comply with the same FAA standards as commercial helicopters.[4]

MSP has been claiming that they need to protect the patients in Maryland from the big bad commercial helicopter services. After all, they will charge you money for the flight, while MSP will tell you there is a free lunch. Free. Free. Free.

Why is it that they are not operating at even close to the standards of the private helicopters in the area?

Only one person to provide patient care. Yes, they can take somebody from the scene. Of course, the personnel they take from the scene are the lowly ground providers, that they have been telling us patients need to be rescued from. I suspect that plenty of ambulances in the area have better staffing in the patient compartment than the helicopters do.

How have they been able to get away with such shortcuts?

How have they been able to convince people that they were setting the standards for the rest of the country to copy?

And the panel called for something of a cultural shift, saying Maryland’s trauma and helicopter system is overly focused on speed and not enough with quality and appropriateness of care before patients reach a hospital.[4]

Gosh. If only we were to focus on providing high quality EMS, things might be a lot better. As The Erstwhile Medic has stated, instead of worrying about spending the hundreds of millions of dollars on the flight program, maybe we should spend some money on better educating the ground providers.

Dr. Robert R. Bass, executive director of the Maryland Institute for Emergency Medical Services Systems, said he expects the system’s board members, who will formally receive the report in several weeks, to give the findings strong consideration.

Only strong consideration?

Maybe I am naive, but I don’t think the people of Maryland are going to continue to buy what he’s selling. Low standards. High cost in money. High cost in lives.

The MSP troopers deserve better.

The people of Maryland deserve better.

“We do think we’re a model for other systems, and we want to continue to be a model,” Bass said.

Perhaps he means a model of how not to operate a flight program.

Footnotes:

[1] Panel supports fewer medevac flights
By Robert Little
November 26, 2008
Baltimore Sun
Article

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[2] The golden hour: scientific fact or medical “urban legend”?
Lerner EB, Moscati RM.
Acad Emerg Med. 2001 Jul;8(7):758-60. Review.
PMID: 11435197 [PubMed – indexed for MEDLINE]

Link to Free Full Text Download in PDF format from Academic Emergency Medicine

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[3] Panel: Md. flies too many medevac helicopters
By BEN NUCKOLS, AP
Nov 25, 2008 5:42 PM (1 day ago)
examiner.com
Article

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[4] Panel supports fewer medevac flights This is the same as footnote [1]
By Robert LittleNovember 26, 2008
Baltimore Sun
Article

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Filed Under: Ethics, Fraud, Golden Hour, Helicopters, Heresy Tagged With: , , , ,

Another One Walks Away

Sun, 02 Nov 2008 18:22:32 -0500 by
Dr. Bryan Bledsoe[1] wrote an article for JEMS magazine called Another One Walks Away.[2] Copying the title was not imaginative, but I suspect that will be the least of the complaints about this post. This is an article that has generated a lot of comments at JEMS.com.
The article is about a medic, who left the profession club. EMS might be a bit better off if it weren’t viewed as just a simple task of transporting people, following protocols, and maintaining, or almost maintaining, low standards. 
If that were the case:
Maybe EMS would not be put in the hands of people who have a full time job in another field, but since they live in a rural environment feel they are qualified to provide medical care – As long as we keep the medical standards LOW.
Maybe EMS would not be put in the hands of people who are trained to fight fires, but due to the flashing lights and the woo woos feel they are qualified to provide medical care – As long as we keep the medical standards LOW.
Maybe it would not be put in the hands of nurses, but since they have a college degree feel they understand EMS better than those in EMS – As long as we keep the medical standards LOW.
Maybe EMS would not be put in the hands of people who are trained to be police, but since the state wants to maintain a monopoly on HEMS, feel that having a medic take a year off from EMS to work as a state trooper makes the medic better qualified to provide medical care than ground EMS providers – As long as we keep the medical standards LOW.
Maybe medical oversight would not be put in the hands of people who do not pay attention to what the medics actually do, but since they require a phone call for permission to do anything dangerous, they feel they are qualified to provide medical oversight – As long as we keep the medical standards LOW.
Maybe EMS would not be put in the hands of people who think that the purpose of a uniform is to blind you with a bunch of flare or some other appearance fetish, but since they have no clue about medical care, they think the uniform is important – As long as we keep the medical standards LOW.

Maybe EMS would not be put in the hands of people who are more concerned about the availabilty of ambulances, than the care provided by those in the ambulances – As long as we keep the medical standards LOW.

Maybe EMS research would not be put in the hands of people who think that the way to control for a variable is to make the same mistake as many times as possible – As long as we keep the medical standards LOW.
If I have missed anybody, I apologize, but I am working with low standards, here.
I do not mean to include all volunteer departments, all fire departments, all nurses, all police, all medical directors, all Liberace wanna be’s, all EMS researchers, . . . in my criticism. Part of the problem is that there are few who provide excellent EMS. Cross-training convinces people that EMS only requires part time attention.
I know people who provide excellent medical care and also do a good job in another field. Emergency services attracts the ADD personality. Some are good at several skills. Some are only good at making messes. Most are somewhere in between. Being an adult means having to make choices. Do I want to be a fire fighter, police officer, doctor, nurse, paramedic, . . . As a grown up, I need to choose.
Why should we eliminate people from a field, because the do not have a desire, or the aptitude, to be cross-trained in an unrelated field as a requirement of the job? Is our quality problem that everyone is too good? Absolutely not. We need to trying to recruit the best at EMS – not EMS and whatever the town council has chosen from a grab bag of jobs they, in their ignorance, think are related.
Cross-training only encourages the bean counters to devalue everyone. Look at triage nurses. They are required to provide all sorts of social screening and are having more added to their job requirements.[3] This is idiotic, but that’s what you get when you convince people that cross-training is a good idea. 
When we get serious about eliminating the lowest common denominators, we will need to eliminate this trend toward cross-training. In order to accept cross-trained providers, you have to accept that the LCD (Lowest Common Denominator) will drop even lower. Training people in unrelated fields will never result in higher standards in either field.
If there is a fire, I want those responding to be fire fighters – not paramedics cross-trained as fire fighters.
If I need the police, I want those responding to be police officers – not paramedics cross-trained as police officers.
If I need to be triaged in the ED, I want to be triaged by a nurse – not a social worker cross-trained as a nurse.
Maybe what we need is for anyone in EMS, who can get a real job (that includes fire fighter), to get one. Maybe we should leave EMS to those with only the ability to understand Would you like fries with that? 
On the other hand, maybe a job in EMS is one of the safest if there is a recession. It might even be better than having a real job.
Footnotes:
^ 2 Another One Walks Away

By Dr. Bryan Bledsoe
JEMS.com

^ 3 Here is the post I wrote about proposed changes in the duties of triage nurses.
Filed Under: Cross-training, Ethics, Heresy, Management Tagged With: ,