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

- Rogue Medic

Allentown EMS will remain an all-paramedic squad

Another EMS agency looks at switching to paramedic/basic EMT crews, but passes up the opportunity to change to a level of service that would result in more experienced paramedics.

But Allentown Fire Chief Robert Scheirer, who in June was empowered by the city to make the final call, confirmed to city council tonight that EMTs will not be added.[1]

This is based on –

“I think we’re at an excellent level of service right now, and I don’t think we want to move backward,” Scheirer said. “I think an all-paramedic unit is far superior to one that also includes EMTs.”[1]

A lot of opinion, but no evidence.

The plan to switch to paramedic/basic EMT ambulances was a plan that was approved by the City Council in December.

Consider the history of this decision. Why did the leadership start departing from Allentown as if someone put a contract out on them?

But the overhaul was placed on hold after Van Allen abruptly resigned in December, and the future of the squad faced even further uncertainty after his successor also suddenly resigned in June.[1]

Now, the plan has been canceled.

Cause and effect? I don’t know.

Allentown EMS also needs to add an ambulance, but –

“We’re trying to figure out how to do it the least expensive way to the taxpayers,” he said.[1]

Is it economical to waste a paramedic as a driver for each patient who might benefit from paramedic level treatment?

While the second paramedic may come in handy on the rare call, too much paramedic treatment can be a huge problem.

Too much of what we do is not good for patients.

Too much of what we do is bad for patients.

Not enough paramedics understand the difference between good patient care and too much treatment.

Not enough medical directors understand the difference between good patient care and too much treatment.

How many patients will be better off because of faster aggressive paramedic treatment?

How many patients will be worse off because of faster aggressive paramedic treatment?

One defense of the more medics systems is to focus on being able to have faster protocol monkeys. Was this the alternative to giving the protocol monkeys amphetamines? Wouldn’t it be better to get rid of the protocol monkeys?

Another defense is that the medics have someone of equal decreased experience to bounce ideas off of. I’ll take the more experienced paramedic over the ones who can’t make a decision. I’ve seen what happens when we try to agree on where to go for food, and lives do not usually depend on those decisions.

The paramedics in Allentown do not appear to understand that more is a measurement of quantity, not a measurement of quality.

Watchful waiting is often, maybe even most often, more important than rushing through the protocol is essential to high quality EMS.

Footnotes:

[1] Allentown EMS will remain all-paramedic squad, no EMTs will be added
Published: Wednesday, August 15, 2012, 9:46 PM
Updated: Wednesday, August 15, 2012, 9:58 PM
By Colin McEvoy
The Express-Times
Article

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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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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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