Saturday, August 15

"It does nothing for the patient"

Listening to the EMS Garage podcast (Episode 45) discussing the Los Angeles County cuts to service, the conversation turned to the reason to have Paramedics on the fire engines.
The panel spoke of various reasons for the cutbacks, then took an interesting turn when the commentators had this exchange:

"They (Los Angeles) have Paramedics on their engines."
"Why? Why would you do that? ...There is no benefit. Why is there tiered response to medical calls?"
"They do it to support their staffing"
"It does nothing for the patient."

This initially get me hot under the collar. I'm sure if asked to clarify their conversation there would be more explanation. At least I hope so.

Why is there a tiered response to medical calls? Why is there a tiered response to fire calls? Or to police emergencies? Why do we combine the abilities of different resources to aid as many as possible?

I am not for all ALS fire resources. Let me get that out now, before some of the single role folks start fuming. This debate has been going on for a long time, time to get it out here in the open and discuss it on it's merits.

If you support public access defibrillation then you recognize the need for early intervention in cardiac cases. Get a trained set of eyes with a med kit in there ASAP. If the system in place has Paramedics arriving with or before Fire ALS resources, then I call into question the need for Fire Based ALS in that community. Then again, what happens when all the ambulances are busy? Who will administer that epinephrine to the kid who got stung? Who will cardiovert the woman on the bus? There are so many ifs, that having an insurance policy is not a bad idea. Could these be handled by supervisors already in place by the EMS provider?

I believe in a scaled response model, be it tiered or provided by a single service, but I reject the idea that my responding and treating patients from the fire engine is doing "nothing for the patient."

Countless times I have initiated ALS care still waiting for an ambulance to arrive on scene.

Countless times I have been dispatched to BLS scenes miscoded by dispatch or exaggerated by the caller. As a trained Paramedic I can advise dispatch to slow down or reassign the ambulance to better the system's ability to respond to legitimate emergencies.

In many communities it seems the answer to keeping the fire department in business has been to throw a patch and a monitor on a truck and claim they "save lives." I've heard it said that the Fire Service is a budget looking for a mission and EMS is a mission looking for a budget. I like to think both are necessary, but no necessarily together in their missions. Some communities have strong private agencies who provide training and support for their crews, others not so much. In that case, it falls on the municipality to provide the ALS care. If that means putting competent Paramedics on a fire engine that is already responding, then so be it.

Too many cooks can spoil the soup. But when time can make a difference between an asthma attack and a resuscitation, I choose the early recognition and adequate treatment.

We're all on the same team here, folks. Sure I'm a Firefighter/Paramedic instead of a Paramedic, but I try hard to keep up on both skills. That doesn't make me any less of a care giver. I'm not slacking on my 12-lead skills because I had a tower ladder drill this morning, it just means that I can provide a service in a time of need as well as being available for a less common emergency (Fire.) I am very interested in learning more about breaking the Paramedic off of the fire crew for certain calls, whether that be in an APP model like Wakefield or a FRU model like the UK. Again, location specific based on community, topography and resources available.

I had to laugh when I listened to the next installment of the podcast, Episode 46, with the discussion of police officers with AEDs being a good idea because they can respond so quickly.

One or the other. Either an early intervention is good, or it is not. Why stop at AEDs? Why not encourage Paramedics to cross train as Police Officers? Because every police officer that responds to a medical call is taken off the streets from being a law enforcement resource.

Every bell I get to a medical takes my suppression unit out of it's pre-determined roll as well.

A perfect example of a tiered response happened at my suburban home last year. You can get the full story HERE, but the first responder on the scene was a police officer in a car who happened to be a licensed Paramedic, but not for his agency. Then the ALS engine arrived and began treatment, still no ambulance to be heard. When the major carrier rig did arrive, they were the professionals I expected and did a great job. Why not get a trained set of eyes on the scene as soon as possible?

The response mandates are backwards in my mind as well. We have to respond to BLS calls in 5 minutes, but ALS in 9? Think about that. We're required to be faster for the folks who don't need us as much? That is based on the BLS before ALS model which , unfortunately, is the cheapest way to provide EMS. Get an EMT on scene and hope a medic can respond. I hear on the radio all day long "Engine 99, do you need an ambulance code 2 or code 3? - Code 3" then the ambulance later clears on a refusal or a no merit.

I say dump that thinking right now. We need to break the mold of BLS first with an ALS chaser. Flip that model. Get ALS in the door first, then BLS can augment at ALS discretion.

There I go dreaming again, right? The privates think the FD is taking all the money and slacking on treatment and the FD thinks the privates are a bunch of folks who couldn't pass the firefighter test. Let's move past that. There are those on each side looking to go to the other side, always will be.

CK over at Life Under the Lights speaks of lifting the bar in EMS education so that the first person in the door in an emergency has the training and capabilities of modern day paramedics. Then CK would like to get the current Paramedic skills and training lifted towards the PA level. I was hesitant to get on board with that thinking at first, but if the only thing holding us from that reality is money, let's do it.

But that isn't our problem in EMS is it? Our problem is the folks passing through. Too often we are seen as a way point onto other careers. This was also a topic of discussion on the EMS Garage and I'm glad there are others that feel the way I do about it. So few reach the level of Paramedic and say "This is where I want to be" so they have no stake in making the system better. they're on the way to RN or PA or whatever and are looking to get an adrenaline fix.

The point of this rant is that I take personal offense to the comments on the podcast that I have no effect on patient care when arriving on the scene in a big red truck instead of a big red ambulance. The commentators meant no personal offense, I know that, but I would like to remind them they have a very large audience who is looking for role models and leaders for the next 20 years of EMS. All care givers need to work together to find what works best in their communities and strive to make it so.

Am I obsolete in the Firefighter/Paramedic role? Maybe. But currently, the model making the most difference is a tiered response from a public/private partnership.


AdCy said...

Hey HM. Your post made me think...
The only response system I know is where I have worked. I haven't taken the time to research other response systems. All I can do is offer my two cents.
I am a firefighter/paramedic. I am primarily assigned to an ALS MICU, mostly because not many of the ff's are paramedics. We have ALS engines, that respond with us to all calls. (The engine has to be staffed with one ff/pm at all times). If I need someone in the back of the MICU for transport to the hospital, I have every right to pull of that medic. the engine will only run with two ff's until I get done at the hospital. If I need two other people in the back with me, say for a full arrest, I have the fight to pull two people off the engine, and the engine will be out of service until I am done with them. It works out well for us.
In a previous system, we had a BLS rig. The BLS rig chased us in our ALS MICU, like you were commenting on. Occasionally they beat us to calls, but not often. It was wonderful knowing that rig was coming to back us up. Not to mention, they were some of the best trained EMT's I ever had the pleasure of working with. (we worked in a ghetto). When they did beat us in on a call, they would give us updates, let us know what we were walking into. Our dispatch center was sub-par.
Of both, I did like having the BLS rig much better. In my current system, however, my FD does have the option of pulling me off the MICU to fight fires. Give or take, whatever works best for the FD.

Greg Friese said...

Thanks for the interesting and thoughtful post. As a podcaster I often think of the size and diversity of the audience and do my best to think before speaking and choose my words carefully.

Anyway, the point in your post that I think is most interesting to me and one that I am just beginning to ponder is it the responsibility of EMS (regardless of the service model) to be ready for anything/everything because of poor call placement and/or no use of emergency medical dispatching.

Yesterday I attended a conference presentation about reducing use of red lights and sirens. The primary push back to reducing red lights and sirens was around the theme "we can't/don't trust our dispatchers to correctly identify the type and severity of emergency." So yes one solution is bring everything to every call as fast as possible. Another solution is to improve call taking.

Like I said I am just beginning to ponder this question. What are your thoughts?

The Happy Medic said...

Greg, thanks for commenting and double thanks for understanding my tone.
As to limiting the lights and sirens response to reported emergencies, I'm all for a scaled response which sends an advanced resource who can advise on other resources as needed. A good example of this is a suggested MVA policy. The closest resource (in this case an engine) responds lights and sirens, while the ambulance is no lights, no sirens until advised otherwise.

Of course the true answer is properly trained call takers and dispatchers so resources can be allocated appropriately. Interesting sometimes how my screen says "The problem is: Sick" but the call is coded by the computer as a 26A1 (minor, other) but has a call type of Severe Respiratory Distress because the caller simply said the word asthma.
Which do I believe?

I think for the time being, responsible driving techniques and erring on the side of caution is the best course of action. I saw your search for a no code three system on twitter, I know of none.

Looking forward to episode 47, HM

John said...


I too am a FF/PM. My dept went ALS after years of watching poor medical care by the local ambulance co. They have long response times, a revolving door of employees, and a few longtime medics who are there because they can't get hired anywhere else. We bit the bullet to provide better service, and since that bar is so low, we have. I understand the concerns about spreading the skills thin, we have 2-3 medics on every 3 man engine, and you can tell who wants to be a medic and who doesn't. Some get good at hands on skills, others are clipboardists, and some are willing to lift and offer ideas, but afraid to try an IV. That said, I'd rather have my brothers working on me than the fly by night ambulance folks here.

There is an answer, but I don't think the taxpaying public knows what they want or need, and whatever it is, they don't want to pay for it anyway. Fire/EMS is, IMO, the best way to maintain the necessary manpower to fight fires and respond to disasters when we have to, while providing adequate to great EMS. While I sympathize with the concept of a third service/public health model, I don't believe the taxpayers are willing to support a separate but adequate EMS and Fire service.

I wish you luck, and support your efforts.


TOTWTYTR said...

I have to agree with the title here. In fact, I'd say that having medics on engine companies probably hurts more than it helps. There are too many medics and not enough calls where their ALS skills are needed.

You ask "Who will defibrillate?" and "Who will give Epi?".

The answer doesn't have to be paramedics. Many cities, Boston and Seattle come to mind, have active Public Access Defibrillation programs. First responders have AEDs and can use them. In some systems BLS personnel can give Epi Pens, Albuterol, Aspirin, Glucose Paste, and Narcan. In other words they can do the things that medics do while the medics are responding.

The medics, on the other hand, see more sick people per medic than do all ALS systems. I don't know about you, but so far this year I've had about half a dozen intubations. Other systems have 0.3 intubations per medic per year. So, they intubate one patient each three years. Is it any wonder why some fire based systems have dismal intubation success rates?

The Happy Medic said...

Thanks for your comments. I have to disagree with the skills retention argument. Just because a medic sees more patients doesn't make them better. If that was the case, my system would have remarkable stats since we have one of the busiest systems around.
I have had 3 intubations so far this year, all on the engine. If anything, in an all ALS system it is the ambulance medic who arrives after care has been initiated who lacks the skills.

It all goes back to those who want to be there and make a difference will maintain their skills. Those who were forced in, as you say, will always grab the drug bag instead of the airway kit.

It can be near impossible to merge a system, as you said, but if it had been done with a mutual respect (easy on the giggling everyone) it could have worked.

Thanks again,

Chris said...

I would suggest that if the ambulance is arriving after the fire truck, there aren't enough ambulances.

If sounds to me like appliance-based ALS is a result of inadequacies in the ambulance cover. I wouldn't say that "It does nothing for the patient", rather "it should do nothing for the patient".

It appears that the problem is the large number of resources required to deal with a fire, and the speed with which a fire can spread. This leads to a need for a large number of firefighters and appliances located in such a way as to be able to get to any location quickly, just in case.

The public don't like paying for people "just in case", so the FD have started doing medical response to justify their budget. The problem (IMHO) is that this has then led to a reduction in dedicated ambulance resources.

To me, it's a great idea to have an EMT on fire appliances, and if they can be used as firtst resaponders, then great, but if the FD are regularly beating EMS to the scene, there are too few EMS. If there were adequate EMS resources (as in an ideal world), the FF/EMT would not be required to be an EMT-P, but an Intermediate or Basic would be perfectly adequate.

Having said that, there is also a place for a small number of FF/P's who can be used in inner cordon situations unsuited for non-fire trained personnel.

All this from an Englishman, based on how I understand your system to work. What do you reckon?

(PS, could you at some point do a post on the fire side of your work - how it works, the difference between an Engine, Squad, Truck etc...?)

medic999 said...

You should submit this post as a comment on the EMS Garage site HM.

Its a fascinating discussion!

brendan said...

Chris beat me to most of what I was going to say. HM, you see a long ambulance response as requiring an ALS engine nearby. We see a long ambulance response as... requiring more ambulances.

. Just because a medic sees more patients doesn't make them better. If that was the case, my system would have remarkable stats since we have one of the busiest systems around.

It's not about seeing MORE patients. It's seeing MORE SICK patients. Boston and Seattle have low paramedic numbers, and only respond to priority calls or as requested by BLS. As a result, some of them are intubating multiple patients per shift. 3 tubes in 8 months is better than some systems, but in Seattle or Boston it means you'll probably need to be in the OR before the end of the year to make your minimum number.

Hence why their tube success rates are above 97% and unrecognized esophageal intubations below 1%, while most all-ALS fire-based systems can't get above 70-80%, if that. Cardiac arrest save rates are also completely out of whack between all-ALS and tiered. Do you think that's just dumb luck?

brendan said...

Almost forgot. All-ALS systems have no science to support their model. What studies there are point in the other direction, from what I have read.

Let's also not forget that in cases of fire first response with a private ambulance response, almost without exception the ambulance dispatch is notified after the fire apparatus have been notified of the call- often by design. Hard to beat the throw when the first baseman already has the ball.

The Happy Medic said...

Great comments. As far as fire getting the call first, where I am we all get the call at the same time, it goes over the air to both fire and private cars at the same time.
I agree that the standard is quality over quantity, I have had shifts without touching the monitor, both on the engine and the ambulance.

More ambulances is not the answer, however, I believe better call screening is the solution. Just as adding more tow trucks to a bad intersection makes less sense than fixing the intersection.

I wait for ambulances because most of them are on BS runs we were not able to refuse.

I get no more "experience" watching a patient for 10 minutes than I did getting in the door first, assessing and beginning treatment for 10 minutes.

Each system needs to adapt to it's resources and scenario. Our system tried a BLS tier years ago but staffed it with folks who didn't want to be there, no wonder it failed. Some of these folks still scratch their heads at the idea of a Medic and an EMT on a transport unit.

True, most fire based ET rates are not stellar, most sub par, including my own, but I think the problem is less exposure and more a training issue.

As you said, I would find myself in the OR with only 3 tubes in 8 months, yet I went my first 2 years as a field medic with only 1. Yet I maintained my skills through training.

If the "Less medics means better medics" rule applies, let's drop to one paramedic in a car, jumping from call to call, performing every skill 100%. Of course that is unrealistic. If there are 3 medics on the scene of a tube, true only 1 gets it, but all three are doing something in their scope. I get the tube, but not the IV, now my IV skills suck.

I am against piling a patch and a monitor onto anything painted red and rolling it out to "maintain response times" and calling it an ALS service. It might be ALS, but it is no service.

Great comments, all. Thank you for a great discussion on a hot topic.


Ckemtp said...

Happy, I jumped into this on my own blog just a bit ago. We agree on a lot of things but... well, since I'm late just read a lot of the comments you got on this.

I work in a much less busy system than you do and I'm almost on my tenth tube for the year so far (I think, maybe more, I lost count)

I respect EMS based EMS. Patient focused EMS. If the Fire-Based model could truly prove that they were in it for the advancement of the best care for every patient, I would support them. Can they?

Anonymous said...

"If the Fire-Based model could truly prove that they were in it for the advancement of the best care for every patient, I would support them. Can they?"

In Seattle, yes. Check the response times. Check the cardiac arrest save rates. Check the intubation success rates. Check the number of Seattle Fire Fighters who compete to get into the Medic program. Check the repeated municipal services ratings by the citizens- #1 and #2 for EMS & Fire respectively (both provided by Seattle Fire).

Here is what works for our citizens: Tiered EMS response based upon dispatcher interviews, using Criteria Based Dispatching protocols; EMT Firefighters on Aid Cars/Engines/Ladders who expect to provide great BLS service and support great ALS service; low per capita number of Medic Units (with Medics having 2000 hours of training); strong medical oversight with an active Medical Director.

LtFD Seattle