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

- Rogue Medic

Long Beach Fire Department considers single paramedic response system

It is disappointing that it takes a budget crisis to get some EMS systems to improve the care that they provide, but that appears to be the case in Long Beach.

New medics should not be thrown to the wolves, but precepted for an extended period. A certification test is not an indication of readiness to work solo, but only readiness to be precepted. Oddly, some organizations use the ready to be precepted test as a criterion for higher pay. Others require passing this ready to be precepted test for recertification, although none of them seem to require that those completing the test be precepted again. If not for inconsistency, EMS might have no consistency at all.
 

The response-time improvement would occur by placing more paramedic units in the field, going from two paramedics on eight ambulances to one paramedic and one emergency medical technician on 11 units, according to LBFD Chief Mike DuRee.[1]

More ALS (Advanced Life Support, or paramedic) ambulances are the result. That must be bad.

Does a paramedic really need another paramedic to hold his hand?

Does anyone benefit from having their experience cut in half?

Why transport patients to specialty hospitals (Trauma, Children’s, Burns, OB/GYN, et cetera)? There certainly is no benefit to extra experience.

The myth of skill dilution can be expected to produce dire warnings, but no evidence. They are consistent and the evidence is not there.

I will look at only some of the evidence that skill deteriorates without use. There is too much to look at all of it.

Driving an ambulance with a critical patient in the back is not the same as taking care of that critical patient.
 

 

The difference between a basic EMT and a medic, in my opinion, is the ability to make patient care decisions without having to call a meeting.

I keep being told that I just need to lower my standards.

The epitome of this problem may be New Jersey, which only seems to want semi-medics – one is not considered to be a paramedic unless one semi-medic is with another semi-medic.

What should we call someone who cannot manage patients without another semi-medic?

Paramedic does not seem appropriate.

The change, which must get approval from the Los Angeles County Emergency Medical Services Agency, is being criticized by the firefighters union.

“We’re all for looking for innovative ways to deliver EMS, but the model that’s being discussed compromises patient care,” said Rex Pritchard, president of Long Beach Firefighters Local 372.[1]

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

No.

Rex Pritchard is only singing the union’s party line. since he is president of the union, this is no surprise.

Opponents of a “one-to-one” model – with one paramedic and one EMT – say two paramedics back up each other and can execute interconnected procedures, such as intubating a patient while beginning intravenous therapy, faster than a single paramedic.[1]

There is no evidence that this improves outcomes, but the way we do CPR was changed because of too much ALS interfering with what really works – continuous chest compressions and rapid defibrillation.

Also read Dr. One and Dr. Two by Happy Medic.

Footnotes:

[1] Long Beach Fire Department considers single paramedic response system
By Eric Bradley Staff Writer
Posted: 08/06/2012 08:44:17 PM PDT
Updated: 08/06/2012 09:01:52 PM PDT
Contra Costa Times
Article

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Comments

  1. I’m going to ignore the obvious arguments against single paramedic care and go right to the point. As a New Jersey paramedic, I find it offensive to be referred to a “semi-medic”. New Jersey has some of the highest standards for selection and training in the country, from didactic to clinical rotations to field internship. We have broad standing orders, including pain management, needle thoracostomy, and can perform rapid sequence induction and needle cricothyroidotomy. I have a wide latitude in my clinical practice…and I do call it practice. 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.
    If you’d like to see just how “semi” medics work, let me know. I can get you a ride along.

    • Dan,

      Actually, I’d rather bypass the gratuitous slam of NJ and address the point of the article. What are these “obvious arguments against single paramedic care” that you mention? Yes, there are calls where multiple medics will benefit; but what percentage of normal call volume are those? How does that 2nd medic help while driving, or does the need for the 2nd medic magically vanish once transport starts?

      Finally, addressing the article cited, how the hell is 11 EMTS-medic units worse than FEWER dual-medic units?

  2. Having worked in both double and single medic systems, I do like and see the benefit of the medic/emt model. One thing I do notice though is that the medic/emt model seems to have emts looking to the medic to take all calls. Trying to fit every patient into an ALS level call despite what the medic finds on assessment and how the patient presents. Making the emt a glorified drive who is medic dependent on even the basic of calls.

    I also wonder that in a high call volume area like some NJ areas, NYC etc. If a single medic response system would cause medics to burn out doing all the ALS calls. Not having that cushion of alternating calls and sharing the load. I mean even the basic ecg, IV calls can start to wear on a person if they are doing 8-12 of them a shift.

  3. I found this blog around the beginning of the year and have been a devout reader since. This has to be the biggest disagreement I’ve had with a subject you’ve posted.
    I’m not as eloquent and well organized a speaker as you, so please excuse the response if my thoughts seem jumbled. They make sense to me 🙂

    I live in Texas and have worked in a dual medic system as well as a medic/EMT system. More prevalent in the private EMS services here are the combo crews, whereas the dual medic crews are more prevalent in the fire-based services.
    The biggest advantage to the double medic system is having two sets of eyes, hands, brains, etc that are being utilized for ALS skills. No matter the experience or competence level of the medic, we’re going to have calls we have difficulties. We fall into “slumps” with skills; those days we just can’t get an IV, unable to secure an ETT, etc. I understand the majority of the time we won’t NEED the IV, and we can drop the Combi-Tube/LMA/King Airway in lieu of the intubation. However, it’s nice to have a second person able to perform IV access on a call in true need of IV only medications (SVT, stable V-TACH, hypoglycemia, etc). I agree with the statement about too much ALS getting in the way of pt care. But sometimes, the pt does need an ALS intervention and suffers from a delay in getting it.We’re not giving these pt’s good care by delaying treatment the additional 10-15 minutes transporting to the hospital.

    You’ve always said assessment was the best tool we have. That’s true. While most of the conditions needing intervention can be identified by an EMT, it benefits the pt to have two competent ALS providers taking part in the assessment, even if one is just bouncing ideas off the other. I know you may have a field day with that statement, but I believe the pt needs every available resource his condition warrants. Is it incompetence to admit you don’t know something and ask your partner for guidance? I feel it’s incompetent to know you’re in the wrong and keep proceeding without correcting it. We all make mistakes in our assessments and our skills. That doesn’t make you a “semi-medic”. However, you become a downright dangerous medic when you refuse to seek aid and carry on making your mistakes. I don’t believe it’s equivalent to having your hand held if you need to ask another ALS provider something regarding your pt care. Doctors do this all the time, the ER doctor will consult with a cardiologist, neurologist, surgeon, etc in a heartbeat when the pt condition exceeds his comfort zone.
    No matter how intelligent, well read, or overall “good” we are, each medic will encounter a call he is stumped on. Any medic that says he’s never been anxious, upset, scared, or lost on a call either just started or is lying.
    Is there proof having the second medic will help? No. But where one medic is having difficulty the other may very will have insight that proves vital to the pt care.

  4. You are not a experienced in-charge Paramedic until you have had a the very least , one year of full time experience. BUT with the economic problems we face today, It will not happen. Sad but true. In order to provide a proper FTO program that keeps Medics as attendants for at least a year. The budget would have to take away from somewhere else. Equipment, Raises! medications, benefits, reduction in basic EMT’s.

    I work in a state that has a huge amount of progressive services and we do not have a scope of practice. We have services that use pumps, vents have medications such as Levo, Dobutamine, Procanamide, Verapamil, Dilaudid, Demerol, Fentanyl, Ketamine, Rocuronium, all the benzos,Catopril, Nitro drips, Dilantin, and can preform procedures like Pericardiocentisis, Cook cath chest decompression, surgical airway, PAI, and you are held accountable if you do not treat your patient. Just enough is just enough to be unemployed.

    We also have services on the other end, services that carry basically nothing and medical direction that would prefer you did nothing.

    The difference between both types is education, yea blah blah blah. But it is true. The services that are receiving monthly education to a higher level are the ones that have the protocol and the experience. Not card classes. Card classes are great for your new Medics and of course your yearly recert requirements but they are outdated after the first year of release.

    How many still do not know oxygen kills? Yes it does cause worse muscle death in MI, it causes a drop in cardiac output ( great for a dying heart huh) it cause vaso constriction in the brain ( even worse for CVA) and we still give it to someone who has sats over 96……… this is not new science at all

    How many know the difference between analgesia, Anesthesia, sedation, paralyzation ? why do we give Vecuronium post intubation and nothing else? How inhumane and criminal.

    Why is the ONLY prehospital tool that tells how well a patient is ventilating not as mandatory as a blood pressure cuff. ETCO2 is vital sign just as or more important than any.

    Our industry is getting better. There is a huge shift towards education that has taken place over the last few years. And it will only make us more credible in the future. But we have a long way to go
    the list goes on and on. I am a huge advocate for EMS

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