City manager to decide on paramedic staffing in ambulances
AUSTIN – The fate of future staffing on Austin/Travis County ambulances now lies in the hands of the Austin city manager.
Austin/Travis County EMS leaders are proposing to get rid of one of the two paramedics currently working on ambulances and replacing them with a lesser trained emergency medical technician, or EMT.EMS brass says the plan is not about saving money but more about increasing the quality of service because they say it’s getting tougher to find paramedics. Critics disagree.
I must be a critic, because I disagree. Now, I know that many, if not most, EMS systems do their ALS staffing this way. Frankly, I’ve always thought it was sub optimal staffing. Sure, on many calls the second paramedic drives the ambulance to the hospital while the first paramedic treats the patient. Which is not to say that the first paramedic ONLY drives the ambulance. In my system both paramedics treat the patient up until transport starts. If the patient is stabilized before transport, which they usually are, the second paramedic drives and the BLS crew is released back to service. If, on the other hand as often happens, the patient remains unstable, both paramedics stay in back and an EMT drives to the hospital.
I’ve said this before and I’m sure I’ll say it again. It’s not difficult to find paramedics. It IS difficult to find paramedics who will work for the level of pay and benefits that most EMS systems offer. Add to that the work schedules, including weekends and holidays, working in all kind of weather, and the stress of EMS, and it’s often difficult to find and keep people who are willing to work in EMS.
>Chief of Staff for Austin/Travis County EMS James Shamard said this is a move which other major cities are adapting to all across the country.
“I think this from a clinical standpoint, this is the right next move for the community,” he said. “I think it’ll make a real big difference in our ability to provide quality care to that next level in our community.
How is reducing the number of advanced providers improving clinical staffing levels improving clinical care?
I have a better idea, how about a tiered system? A mix of ALS and BLS ambulances and a triage system that helps to determine which sort of ambulance is sent to a 9-1-1 call? Interestingly, Austin used to have that sort of system up until someone decided a couple of decades ago that staffing each and every ambulance with paramedics made sense. At the time that was seen as a way to stave off a fire department takeover of EMS since all fire fighters were required to be EMTs.
Which underscores even larger problems with EMS. It’s still not a trade, let alone a profession. It’s a skill set that many other trades and professions claim as their own.
We’re still fighting for EMS 1.0, but some days I think we’re heading back to EMS 0.5.
Speaking of fire departments, doing less with more, and back tracking,
Mayor requests more ambulances to ease concerns about LAFD
LOS ANGELES — Retooling the embattled Los Angeles Fire Department, Mayor Antonio Villaraigosa on Thursday appointed a new data director, recruited a veteran commissioner and requested six new ambulances to ease worries about emergency response times.
Villaraigosa appointed Jeff Godown as interim director of statistical analysis and review at the Los Angeles Fire Department.
Godown starts work on Monday in what the Mayor’s Office considers a temporary position, although a specific time frame for his work was not announced.The former interim chief of the San Francisco Police Department, Godown will analyze and verify LAFD’s statistical data, including emergency response times, Villaraigosa wrote in a letter to the City Council.
Let me turn on the politician/bureaucrat translator here and explain what this says,
The Mayor has serious concerns about the veracity of the response time statistics submitted by the LAFD. He also seems to have concerns about the ability of Chief Cummings and so is bringing in someone who is used to dealing with BS to help oversee the chief. Oh, and he wants more ambulances or rather he wants to restore ambulance previously cut “with out effecting service levels”. Which means that despite what the LAFD chief has been saying, cutting ambulances was a bad idea. I don’t know if six ambulances will make that much difference in a city as large as LA, but it certainly can’t hurt.
To paraphrase Chief Justice Roberts in the Ricci case, “The best way to deal with a shortage of ambulances is to provide more ambulances.” The answer to a shortage of ambulances is not to provide more fire trucks just as the answer to a shortage of electricians is not to send plumbers.
“In the last few weeks, the LAFD has endeavored to provide more accurate information about its response times, but unfortunately this has raised more questions than answers. Instead of the needed clarity, there has been confusion.”
As my lawyer/paramedic friend might ask, “You’ve changed your testimony. Tell me, were you lying then or are you lying now?” Of course it’s entirely possible that they were lying both times.
It amazes me that systems think they can just do what their neighbor is doing because EMS is EMS. Parts is parts. we have a successful PM and EMT split system because the other medic arrives first most of the time and is already built into the system. If we didn’t have that, I’d be required by state law to double medic staff my rigs, and my patients would suffer for it without a quicker response (without outcome data I can only judge us by response times…for now)
However, Roberts was wrong about “The best way to deal with a shortage of ambulances is to provide more ambulances.” The best way to deal with a shortage of ambulances is discover what changed to require you to need more. In most cases it’s an increase in non acute calls we can’t retriage, I think you’d agree on that.
The answer to accidents is not more tow trucks and the answer to a skewed response metric is not buying ambulances, it is fixing the skew. You better believe as soon as this story broke I gathered our metrics and locked them even tighter.
Thanks for posting,
HM
Roberts didn’t talk about ambulances. Speaking about Ricci v DeStefano, which was a New Haven FD affirmative action case, Roberts said, “The best way to end descrimination on the basis of race is to stop descriminating on the basis of race.” Hence my paraphrasing.
That aside, your analogy doesn’t hold up. The tow truck operators are not the cause of the accidents, but to a very large extent we in EMS and the politicians that we ultimately work for are responsible for a lot of the non emergency responses that we have to go to. Remember “If YOU think you have an emergency, don’t hesitate to call 9-1-1?” We spent much of the 1980s and 1990s begging people to call EMS for just about anything and everything. Politicians did the same thing, using us to garner favor and votes. Well, we succeeded all to well, now people call us for totally non emergent problems. And of course now we’re complaining about it.
All ALS systems are going to prove to be too expensive in the futured given that anywhere from 75-90% of all EMS calls are purely BLS. I know the west coast favors paramedics on every ambulance but from a skill retention and cost stand point, it’s not very good. Having fire fighter/paramedics on every piece of apparatus is probably even worse, especially since there is no evidence that doing so reduces mortality or mobidity.
Hiding data never works, especially in the public sector. I’d not be surprised to read that Chief Cummings has retired in the near future.
Finally, and I think you’ll agree, response times are a political, not clinical issue. Except for a very few instances, a five, nine, or 15 minute response time doesn’t matter. Cardiac arrest? Sure. Airway obstruction? Definitely. Asthma flare? Maybe, but likely not. Trauma? That depends, doesn’t it? In my experience patients are either dead, going to die, or going to survive, all without rapid intervention changing a thing.
I know we like to fancy ourselves lifesavers, but the truth is most of the time we aren’t.
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My local agency has used the paramedic-and-a-basic model for a long time. (Sometimes the -B is actually a -I, which is a NY thing that lets you do IVs and a few other things but doesn’t really add much beyond that.) There’s also at least one and usually two ‘medics floating around in fly cars when a call either sounds like it has potential to go south or does so unexpectedly.
Does it affect patient care? Perhaps. I can see where having a second -P to bounce things off or to catch signs and symptoms the first missed makes sense. I can also see where it is the EMS equivalent of sending two engines and a truck on an automatic fire alarm: improper application of resources.
I don’t have a dog in the fight, but I am paying attention…
Granted, as I pointed out, in most cases the second paramedic is not necessary, but is of course good to have. It’s the small percentage of critical patients, including RSI patients, where the second medic is the difference. Having fewer medics systemwide is better for skill retention, at least it seems that way but I don’t know if anyone has actually studied it.
Either way, it seems that the biggest loser(s) will be the people who rely on the service.
It usually is.
Hmmm….As for the P/B staffing…I’m not a big fan either. I don’t doubt that there are places that have made this work with reasonable success, but it doubt it’s the panacea that ATCEMS thinks it will be.
With all things being equal, a tiered system would be the best option. That said, tiered systems are expensive, since you’re essentially running 2 ambulance services simultaneously. Again, clinically it may be the best option, but in our area, we couldn’t afford it. We receive 0 (zero) direct funding from the taxpayer base (and so many other programs are on the govt. teat that trying to get on would be suicide).
Of course, in our area, EMTs make a decent wage too…so it wouldn’t save us all that much money to go to all-medic to medic-EMT…so I don’t see that coming either.
As for LA…it may have been smarter to hire the statisticians first and then see how many ambulances you need. Then again, 6 very well may not be enough.
I worked in a system that was double-paramedic for a while. It was nice, having two paramedics, but I found that it also had the drawback of allowing a weaker medic to “coast” under the wings of a stronger medic.
I work in an EMT-Paramedic system now, and it seems to work really well. Except for that one time when two patients were actively seizing. At the same time. In the same room. On the same couch.
I only have so much Ativan, you know!
Weaker paramedics can only coast because management allows them to. Or their partners allow them to. In our quest to become a profession, we are undermined by lazy medical directors and go along to get along EMTs and paramedics who might mutter under their breaths, but don’t do anything when they see incompetents in our ranks.
What really bothers me about the Ricci case is this quote:
“Then, using the approved sources, IOS drafted a 100 question multiple-choice test written below a 10th-grade reading level.”
Wow. You don’t even need a high-school education to be promoted to a 1st or 2nd level supervisory position at NHFD? Glad I don’t live there.
“When all else fails, lower your standards.”
It’s all part of celebrating diversity. Once you decide to lower the standards to “help” one group, you have to lower them for everyone. Look at why the public schools are so bad and why the passing scores for the standardized tests need to be constantly “readjusted”.