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

- Rogue Medic

I ignore it when NJ calls me a Semi-Medic, but it hurts when you point it out

Dan response to Long Beach Fire Department considers single paramedic response system with misdirection –

I’m going to ignore the obvious arguments against single paramedic care and go right to the point.

It is embarrassing to try to make sense of these arguments.

Much better to claim that their logic is obvious, declare victory, and run off to a different topic before anyone realizes that the arguments are not valid.

If one medic doesn’t know what to do on ALS calls, the solution is not more medics.

I don’t know what to do.

I lack experience, because I drive on half of the ALS calls.

Two medics on a call dilute experience.

Three medics on a call dilute experience even more.

Four medics on a call . . . .

And so on, for five, six, and more medics that some services may send to treat one patient. We certainly are not Texas Rangers.

The solution is to remediate, or terminate, that medic.

More of the same experience divided by more medics is not more experience.

As I wrote –

Is there any evidence that a second medic improves patient care?

No.

If you have some evidence, please provide it.

As a New Jersey paramedic, I find it offensive to be referred to a “semi-medic”.

I have taught in NJ. I know a lot of NJ medics.

This is not a criticism of the competence of the medics.

This is a criticism of the way that NJ has decided that a single medic is not a medic in NJ.

If you disagree, grab some gear and respond to a call near where you are, while your partner remains with the original patient. See what happens. Or have things changed in New Jersey?

The semi-medic rule is not my rule. Don’t blame me for making you a semi-medic. Blame NJ OEMS (Office of EMS) or the legislature.

I do not have any objection to you treating a patient without another paramedic present. The semi-medic rule does not come from me.

 

Elsewhere, even in busy systems, even in systems with very progressive protocols, we manage with one medic per patient.
 


 
We can always call for assistance in the rare case that another medic might actually contribute something that might improve the outcome for the patient, but there is no evidence that more medics improve outcomes.

None.

New Jersey has some of the highest standards for selection and training in the country, from didactic to clinical rotations to field internship.

That is a lot of paperwork to be a semi-medic.

We have broad standing orders,

I was told that you do not have standing orders, only orders that may be completed prior to medical command contact.

I realize that this is a distinction without a difference, but I was severely chastised when I complimented someone in NJOEMS for finally approving standing orders. I was lucky to avoid being tarred and feathered for that politically incorrect statement.

including pain management, needle thoracostomy, and can perform rapid sequence induction and needle cricothyroidotomy.

The protocols are expanding. That is excellent.

Some day New Jersey may permit you to be a paramedic without another paramedic present.

I have a wide latitude in my clinical practice…and I do call it practice.

A practice that is prohibited, unless in the presence of another semi-medic?

I’m quite sure that if measured against other states and programs, NJ would measure up very well. I’m not sure why you chose to bash NJ, when stellar programs such as King County, Boston, Pittsburgh, and others do great patient care with a two-medic system.

NJ is a state, while King County is a county system, and Boston and Pittsburgh are city systems.

Do these systems prohibit splitting the crew to deal with second calls?

If you’d like to see just how “semi” medics work, let me know. I can get you a ride along.

I have worked in systems that use dual medic, medic/basic EMT, nurse/medic/basic EMT, and single medic on a fly car.

I don’t need a medic to hold my hand, because I am more likely to be holding the patient’s hand.

I don’t think you need a medic to hold your hand, either. New Jersey thinks you need another medic to be a full medic.

Go read Dr. One and Dr. Two by Happy Medic. He puts a slightly different perspective on this. 😉

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Comments

  1. I have only worked in single-medic systems. As in an EMT and a paramedic team. What does te patch on the arm of the guy driving have to do with how care is provided in the back?

    My regular partner, while “just an EMT” provides much better care than lots of paramedics I have seen.

  2. The best part about NJ is that even though 2 medics are required in order to be medic, a single first aider without an Enter card can respond solo to a scene and decide the semimedics aren’t needed, and only 1 EMT needs to be present to transport.

  3. Boston EMS may have dual medics, but they’re part of a tiered response system. When a medic unit is running a call in Boston, they are doing ALS stuff.

    That’s a different critter entirely than a dual medic truck running *all* calls, including the 70% or so that are BLS.

  4. Very good points here and well explained.

  5. I know I’m going out on a limb, but I’ll venture to say that NJ paramedics are the most experienced paramedics per capita in the entire US. Having worked in NJ for 5 years and having worked in PA, I’ll take the tiered, 2 medic set-up any day. I’ve worked on ambulances in SE PA (even for one of Noonan’s former employers) where medics are lucky to see 1 sick patient per week, while medics in NJ often see multiple sick patients per day. NJ is probably one of the least saturated states in the US (~17 per 100,000; there’s generally around 1500 current medics in NJ). Medics in NJ, despite almost no QA/QI of dispatchers, still tend to only see “ALS” patients. Medic units in NJ are probably some of the busiest per capita in the country (at peak hours there are around 120 medic units state wide – ~1 per 73,000 people on average). Fewer medics and busier medics = more experience per medic. While the medics could get more procedural experience by dropping down to 1 medic per unit, there is a certain benefit to having another medic. You both get patient management experience and more contact with pathologies, you can learn from your partner (great when you’re right out of school), you can bounce ideas off each other when there are questions about what to do, and you can stream-line scene time by one medic getting the HPIx and the other performing the physical exam (and/or initiating certain interventions), among others. In medicine, there are few circumstances where one person is responsible for the H&P and initiating treatments by themselves. Nurses and physicians frequently rely on help from other nurses and physicians for procedures and for input. Believe it or not, but some physicians, even outside of formal consults, will request advice or input from other physicians. I do not think NJ is perfect and I do think medics should be allowed to split up, similar to Delaware. (Fortunately, in some circumstances it is possible for NJ medics to split.) Anyhow, you should try actually try working in NJ instead of just talking to medics from there. There’s a lot of bad, but there is a lot of good. Until their is more (or any) evidence of benefit from ALS, EMS systems should limit the number of medics practicing. If nothing else, NJ has at least done that.

    • Just about everything you said could be performed by a medic with an EMT. While the medic is doing a physical exam, the EMT can be getting the H&P, An EMT can be providing BLS interventions while the medic provides ALS intervention, (and remember, very few of our ALS interventions have been proven to affect long term outcomes), EMTs, who have less training also benefit educationally by working with a medic (anecdotally, the best EMTs I’ve worked with were the ones I worked with in single medic systems). In double medic systems, I often see senior medics take on the roll of driver, and they limit themselves in how much actual patient care they provide. I would love to see studies comparing the proficiency of both EMTs and medics who work in single medic systems versus multimedic systems.

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