Airway & Respiratory, Cardiac & Resuscitation, Columns, Patient Care

Two-Medic vs. Medic-Plus-EMT Teams

Dear Mr. Werfel,

I saw you recently at a conference and you were advocating for two medics in an ambulance in an urban system. As a line officer in an urban system, I would have thought that you would support a team of a medic plus an EMT. I believe with the current shortage of EMS personnel, no other option is possible. Can you comment further and give me your rationale?

Sincerely,

JT

Dear JT,

I appreciate that you took the time to hear me speak at the conference and to write. However, I must take issue with a few of your contentions:

First, I don’t necessarily believe in a “shortage” of EMS personnel. I would ask: How many EMS providers do we need? Is it a ratio of X amount per 100,000 population? While we’re at it, how many paramedics and how many EMTs do we need? Should they be on fire trucks, ambulances or response vehicles? Fact is, nobody knows. Similar to the “nursing shortage,” I suspect no EMS shortage exists at all. Look in the state directories for people with nursing licenses. There’s no shortage of people with the requisite credentials to work in nursing; however, there is a shortage of people with the qualifications who are willing to work in nursing for the salaries offered. I suspect the same is true in EMS. As long as we keep publicly insisting that EMS is a vital part of the health care/public safety/homeland security infrastructure but continue to pay EMS practitioners less than fast food salaries, we’ll continue to have this “shortage.”

Secondly: I don’t necessarily support two medics working together in urban venues, or any other for that matter. Little to no research supports this position. The only research on this topic compared systems with three providers against a system with two providers. That research concluded the only difference was longer scene times for the two-person EMS crew.

Surely you can conclude that you increase the amount of medics available to respond to assignments, but no studies link more medics with higher survival rates from cardiac arrest. In fact, one school of thought suggests that the more paramedics you flood into an area, the less competent they are. This is due to the fact that you’re diluting the skills of these providers. For example: City A had 200 intubations this past year. This year, we double the amount of medics in that city. If the amount of intubations remains steady, each medic will use these skills half as much this year.

No scientific studies show that having more paramedics saves more lives. But it consistently appears to be what the public and most politicians want

There are positives and negatives in the two-medic vs. medic-plus- EMT responses:

Two medics:

Advantages:

  • Skill redundancy
  • Checks and balances
  • Medics can consult each other The “what do you think” factor
  • Scheduling may be easier in certain systems
  • Multiple ALS skills can be performed simultaneously
  • Learning from senior medics

Disadvantages:

  • Cost
  • Poor resource allocation
  • Skills become diluted
  • Leadership issues
  • Dominant/submissive issues

One Medic and One EMT:

Advantages:

  • Good resource allocation
  • Develop stronger EMTs and medics
  • It may be easier for supervisiors to fill vacant shifts without the requirements of two medics
  • Skills don’t become diluted

Disadvantages:

  • With only one medics, a lack of checks and balances
  • Possible care issues
  • On complex patients requiring multiple interventions, only one ALS skill can be performed at a time perhaps resulting in longer scene times.

I would submit that cities with the highest survival rates train firefighters and citizens to respond first with defibrillators and CPR, sending in a smaller, closely supervised corps of paramedics minutes later to give advanced care. Seattle, Boston and Tulsa represent cities with fewer paramedics. While I don’t wish to speak for them, they seem believe that a paramedic who rides a fire engine to every call doesn’t get enough practice providing skilled care because so few calls are real medical emergencies. These cities put a premium on having no more paramedics than their medical director can closely monitor.

The choice is yours; your mileage may vary

Best,

Paul