Medical response law draws criticism

[CBEMT]

I'll be away from teh internets on vacation for a few days, figured I'd give you all something to chew on while I'm gone....

State lawmakers have quietly passed a new law that allows municipalities and private ambulance companies to cut by half the number of paramedics who serve in advanced life support ambulances.

While some officials said the new law mirrors similar rules in nearly every other state, the policy has angered paramedics and EMTs, who say it puts millions of state residents at risk.

“People are going to die because of this law,’’ said Robert B. McCarthy, president of the Professional Fire Fighters of Massachusetts, who served as a firefighter in Watertown for 34 years and as an EMT for much of that time. “You’re reducing the quality of care in half of advanced life support. I’m really saddened by this and can’t believe this was inserted in the legislation without even a hearing.’’

The amendment to the Municipal Relief Act, which was signed into law by Governor Deval Patrick, allows towns and private companies to staff critical-care ambulances with as few as one paramedic and one emergency medical technician, rather than the previously required two paramedics, who have more training, can administer drugs, and provide other potentially life-saving treatment that EMTs cannot.

McCarthy and other critics of the law argue that it was pushed by lobbyists for ambulance companies, who stand to earn more money from insurance companies by increasing the number of advanced life support ambulances that respond to calls. Those ambulances can charge higher rates.

But officials from the Massachusetts Ambulance Association, which represents the majority of the state’s private ambulance companies, said nearly every other state in the nation has similar policies. Officials at the state Department of Public Health also pointed out that 146 of 180 ambulance services in the state already operate under a waiver that allows them to operate advanced life support ambulances with one paramedic and one EMT.

http://www.boston.com/news/local/massachusetts/articles/2010/08/08/paramedics_say_new_mass_ambulance_staffing_law_can_cost_lives/

[uglyEMT]

At least in wasn't NJ doing this or we would really be the worst state. Sorry Mass you got screwed on this one.

[fiznat]

I don't feel like an ALS ambulance needs to have two paramedics. Sure, there are situations where extra ALS hands help, but to say "people are going to die" because of this decision is ridiculous hyperbole. I feel like riding with an EMT has made me a stronger paramedic, and I know that if I ever need more ALS help (which is extremely rare) I can simply pick up the radio and ask for it. In a time where everyone is looking to cut costs, I really can't fault this urge to reduce redundancy and get in line with the national standard.

[Chief1C]

Only a few times in more than a decade have I seen two paramedics in the same ambulance, and they both arrived separately. Usually really bad calls, and the other truck was called for the supplies, not the staffing.

[rock_shoes]

I don't feel like an ALS ambulance needs to have two paramedics. Sure, there are situations where extra ALS hands help, but to say "people are going to die" because of this decision is ridiculous hyperbole. I feel like riding with an EMT has made me a stronger paramedic, and I know that if I ever need more ALS help (which is extremely rare) I can simply pick up the radio and ask for it. In a time where everyone is looking to cut costs, I really can't fault this urge to reduce redundancy and get in line with the national standard.

Having seen both ALS paired and ALS de-paired responses first hand, my own anecdotal observation is that paired ALS responses improve both patient outcomes and the overall quality of ALS care. I don't know how to describe it exactly but, for lack of a better analogy, the "Vulcan mind meld" that happens between two long term paired ALS providers can be absolutely awe inspiring. One partner knows exactly what the other needs and wants without a word having to be said between the two. If the attendant misses something his partner need only give a passing wink for the attendant to clue in.

In addition these partners are able to discuss their calls as equals. What could we have done differently? Could changing practice have affected a patient’s outcome?

Bear in mind I'm saying this as someone who would also consider targeted use of single responder ALS units.

[JPINFV]

I like the concept of dual paramedic ALS units for the same reason that Rock said. More higher trained eyes looking out for the patient and catching oversights and mistakes. If one provider can't, the other can give it a shot. The ability to bounce ideas off one another. These are things not possible for a paramedic/EMT unit. There's a reason why EDs aren't staffed with a handful more physicians than there currently all and a bunch of ED techs.

Saying this, though, it's hard to argue that "ZOMG lives are at risk" in a state where only one or two regions require dual paramedic and the majority of the companies running IFT calls already have a wavier from that requirement for non-emergency calls. If Massachusetts wants to pull the "lives are at risk" card, why are they already permitting the majority of ambulance companies to operate in the EMT/paramedic setup?

Edited August 15, 2010 by JPINFV

[fiznat]

One partner knows exactly what the other needs and wants without a word having to be said between the two. If the attendant misses something his partner need only give a passing wink for the attendant to clue in.

What you are describing is a good working relationship between partners. I would argue that this relationship occurs just as often (if not more so) between a paramedic and an EMT. That has been my experience, and I can tell you that my EMT's "passing wink" has saved my ass more times than I care to count.

I would also submit that a 2nd paramedic on the truck is only useful for the time that is spent on-scene. The rest of the time, he/she is driving and removed from patient care. I would imagine that those (few) ultra critical calls where an additional paramedic might be of some real help, would also be those same calls that a provider would want to spend as little time on scene as possible.

In addition these partners are able to discuss their calls as equals. What could we have done differently? Could changing practice have affected a patient’s outcome?

I have these kinds of conversations with my EMT partners all the time. I think it is absolutely essential that we do, and I never really consider those conversations "unequal" in any way. Usually the things we seek to improve on calls are non-medical things anyways (how we moved a patient, how we managed a psych, how quickly or slowly we moved, the order in which we got our tasks done, the resources we called/didnt call, etc). If I want to seek advice about a particular ALS decision, there are plenty of paramedics to ask, and I don't think it is ever really essential that a person have "been there" in order to give advice or an opinion.

[thrutheashes]

I read an article here awhile back, I believe it may have been in Jems. Any way the article shed light on why a paramedic/emt crew is BETTER for pt care than a duel paranedic crew. Quite simply, it is a matter of roles. EMT strength is in the BLS call. The assessments. The silly little things like ABC's etc. Whereas paramedic strength is in the ALS calls, performing the invasive procedures, pushing the medications. The article pointed out that paramedics spend so much time learning all the new sklls, that the in a lot of cases BLS skills are lost. I'll see if I can find a link to that article and post it here later. All I know, though, is that what it said made sense. The cost savings are an added bonus, but in my opinion not the only benifit to a medic/emt car.

edited to add link:

http://www.jems.com/article/patient-care/back-basics-lost-art-bls-care

Edited August 16, 2010 by thrutheashes

[JPINFV]

I read an article here awhile back, I believe it may have been in Jems. Any way the article shed light on why a paramedic/emt crew is BETTER for pt care than a duel paranedic crew. Quite simply, it is a matter of roles. EMT strength is in the BLS call. The assessments. The silly little things like ABC's etc. Whereas paramedic strength is in the ALS calls, performing the invasive procedures, pushing the medications. The article pointed out that paramedics spend so much time learning all the new sklls, that the in a lot of cases BLS skills are lost. I'll see if I can find a link to that article and post it here later. All I know, though, is that what it said made sense. The cost savings are an added bonus, but in my opinion not the only benifit to a medic/emt car.

edited to add link:

http://www.jems.com/article/patient-care/back-basics-lost-art-bls-care

I don't agree with that article, mostly because an acceptable correlation is that an ER tech is as valuable than a physician or nurse solely because the ER tech can concentrate on "BLS." "BLS" (I use quotes because anyone failing "BLS" is failing at patient care) isn't "lost" because a provider has more than 120 hours of training and a pharmaceutical tool bag that goes past supplemental oxygen.

[Richard B the EMT]

What works in one geographic area might not work in another.

FDNY EMS Command runs roughly 3 BLS (EMT) crews for each ALS (Paramedic) crew. My station is a 2/1 ratio.

I admit a bit of confusion. In the past, Local 2507 (EMTs Paramedics and Inspectors of the FDNY) of District Council 37, American Federation of State County and Municipal Employees (AFSCME), fought single Paramedic Ambulances, in part, joking about a Pair-A-Medics, but saying the care was better with 2 on board the ambulance. Nowadays, in an effort to preserve jobs, they might go one Paramedic/one EMT ambulances. The single Paramedic concept is known as "Mensa-Medic", kind of named in honor of that society of geniuses.