Administration and Leadership, Columns

Staff Systems with More EMTs and Fewer Paramedics

Issue 4 and Volume 40.

When Jim Page spoke about his involvement with the Los Angeles County Fire Department (LACFD) in the early ’70s, he was proud to point out there were only a few paramedics, each of which was highly trained to respond to high-priority calls (in the now-famous Squad 51-type vehicles) with LACFD firefighters trained at the EMT level. This was also the way the system was shown on the TV series Emergency!, where he served as one of the technical advisors.

This model—the same as the predominantly fire-based models in King County, Wash.; Columbus, Ohio; Seattle; Miami; Jacksonville, Fla. and Los Angeles; as well as in large third-service models in New York City, Pittsburgh and several other areas of the country—didn’t have paramedics on every engine. A limited number of strategically placed ALS units were sent to high-priority calls with fire first responders, who were well-trained in BLS procedures and orientated to assist the paramedics.

In these systems, the EMTs would arrive on scene rapidly for Charlie or Delta calls, start CPR and other essential BLS airway and hemorrhage control procedures, begin patient assessment and stabilization, and then assist the paramedic crews on their arrival.

Their forward-thinking and highly motivated medical directors found that deploying fewer paramedics to answer a very high volume of serious and critical cases each shift resulted in better cardiac arrest resuscitations and other clinical outcomes. In most of these early systems, paramedics were looked upon as some of the most clinically skilled and knowledgeable field clinicians in the country. If you look at the data and history of these systems, you’ll find this model is still one of the most efficient and cost-effective models in the world.

Former USA Today acclaimed reporter Robert Davis reported in his famous three-part series on America’s busiest EMS systems that Seattle Fire Department’s Medic One system and Boston’s third-service ALS system—both deploying just a few paramedic units, multiple BLS ambulance units and BLS fire first responders—had the highest survival-to- neurologically-intact cardiac arrest patients.

So what happened? Fire departments, EMS managers and politicians became enamored with Johnny and Roy and wanted ALS in their communities. Paramedics were new and exciting and, in a competitive sense, agencies and their city officials didn’t want their neighboring EMS systems to have ALS before them. They also incorrectly thought that the more paramedics and ALS units they had, the better the care and results.

Systems soon adopted a philosophy of placing paramedics on all ambulances and, worse yet, on all engine companies so ALS could arrive and stop the fictional seven-minute-59- second time-to-care clock. Neither concept had any clinical research to back up the approach.

In addition, many fire-based systems saw the addition of a paramedic on every engine as not just a good thing, but a way to enhance their value. What they—and often their city officials and medical directors—failed to realize was they were severely diluting call volume and, consequently, the important skill volume of their new mass force of paramedics. This in turn diminished the assessment skills and clinical prowess of their paramedics.

We bypass hospitals to go to trauma centers because it’s proven that specialized trauma surgeons who see a high volume of critical trauma patients have better resuscitation results than general surgeons who don’t routinely treat trauma patients. We no longer take ST elevation myocardial infarctions and strokes to just any hospital; we go to specialized resuscitation centers. And most people wouldn’t want their loved one’s spleen or cancerous tumor removed by a physician who only does the procedure once a year.

So why do we continue to overstaff with paramedics, often 35–45 engines per shift in many major metropolitan centers, where some paramedics only intubate and fully manage some patient categories once a year?

Fire chiefs need to take a close look at their budgets, specifically the overtime and associated costs to staff and maintain a paramedic on every engine each shift. Examine the cost for continuous training and recertification, and the cost to equip, maintain and re-equip engines with $50,000 of ALS equipment that’s seldom used throughout a call. Then, compare those costs to Pittsburgh, Seattle, Boston and New York City where the BLS/ALS model has worked efficiently (and cost effectively) for decades.

They need to use these systems as examples of new ways to deploy your resources. For example, the Tulsa Fire Department and San Diego Fire Rescue have begun to redeploy and reposition firefighter paramedics in smaller, more cost-effective mini pumper squads, which places ALS care in very hard-to-reach districts.

And my challenge to medical directors is to look at the data for ALS care rendered by first responder paramedics (12-leads run, IVs started, intubations performed and medications administered), before the arrival of designated ALS units or ambulances. The data will prove my point: More isn’t always better.

We don’t need Roy and Johnny on steroids, we need them just the way we first met them: well-trained, frequently seeing the worst patients and strategically employed.