Paramedic/EMT or Dual Paramedic

[Bieber]

Hi everyone.

So, I'm curious. Throughout my internship, which is coming to an end soon, I've worked with my preceptor and his partner who are both paramedics in a large service that runs dual paramedic trucks. They do hire EMTs part time if you're in paramedic school (I work part time for them as well, sort of) and are about to hire several EMTs full time. But so far, my only interaction with a BLS crew has been during an ALS intercept for a BLS only truck coming in from the next county over.

I've never worked with an EMT before in an ALS capacity, and pretty much all of my exposure has been in a dual paramedic setting, so I'm curious as to what kind of staffing your services maintain, and your own experiences working on paramedic/EMT and dual paramedic trucks. What are the benefits/cons to each model? Do you have a preference?

[Richard B the EMT]

FDNY EMS uses dual Paramedic teams, and dual EMT teams, for, respectively, ALS and BLS. The union prefers having 2 Paramedics, as having them provides a built in backup of knowledge, and skill. I have witnessed this many times, where one Paramedic is having a bad day and is unable to establish a line, and the partner gets it on try #1.

If the Paramedics go with the patient in the back of the BLS ambulance, at least in my system, the EMTs assist to the best of ability, and scope of practice. In the cases where both Paramedics need to ride in with the patient, the EMT assigned as "shotgun" becomes the driver of the Paramedic's ambulance, as the assigned driver/EMT in the BLS ambulance maintains such status, as both go to the appropriate ER.

We, in our union local, joke that it's a Pair-A-Medics.

On a side note, sometimes due to personnel having to leave in the middle of a tour for personal illness or family emergency, they will team up an EMT with a Paramedic, to keep a unit in service. The unit is considered a BLS unit, even if the EMT is then aboard the vehicle usually equipped for ALS, and the Paramedic assumes an EMT role. If the combined team has a dual training level call, as in both a BLS and ALS unit responding, the Paramedic is then allowed to use their ALS skills while with the full ALS team and equipment.

There have come times that the department agrees with 2 Paramedic teams, and times they bring up single Parqamedic units, or so-called "Mensa Medics" in contract negotiation times. So far, dual Paramedic teams have won out.

That's how the FDNY EMS Command does it, but this may not be the procedures and/or protocols of other agencies around the country, or the world. I'd check with your supervisors and medical director to find out what is expected of you in these circumstances.

Edited November 10, 2010 by Richard B the EMT

[uglyEMT]

Here in NJ its all BLS rigs with ALS being hospital based trucks (non transporting) that do intercepts. When ALS stays onboard with us EMTs turn into assistants. We will hang the bag, open packaging, hold things that sort of thing. If it was a code we will be bagging as the ALS uses their LP12 and manually difibs. Trauma calls ALS does their thing we do ours. We will be splinting, tabing bleed controling ect while they get intubations, meds, IVs done.

I like doing the trauma calls with them because its the one time we all work together vs a parent child relationship when we sit on our hands while ALS does everything.

Hope this helps

[Bieber]

That's very interesting, Richard. So, when there's just one paramedic on the truck they're only allowed to function at a BLS level even if they have all of the ALS equipment available to them on the truck? Is there any particular reason why that is?

UglyEMT, correct me if I'm wrong, but it almost sounds like you've been rubbed the wrong way by ALS on those medical calls. Is that true? How much experience do YOU get in the back of the truck as the sole provider for medical calls?

I've perhaps been spoiled by working in a system where there are always two paramedics available, and though I plan to work part-time at this same service after I get my yellow patch, I also plan on working part-time for a rural service that currently only has one paramedic and a couple of EMT-I's and a bunch of EMT's as well. There are a couple of people from my class that will be working there in an ALS capacity as well, so the service is about to have quite a few more (brand new) paramedics available to them, which may or may not be a good thing.

In my limited experience, I've found dual-paramedic trucks to be very fortunate and something I kind of like the idea of, especially with me about to be a brand-spanking new paramedic myself. On the other hand, I'm intrigued by paramedic/EMT trucks because of the inherent challenge in being the only ALS provider available. I don't know how your services are or how you guys run your calls, but I very rarely make a patient code green (code I by most of the country's standards?). The way my protocols read, I'm free to make them a yellow if I think they require paramedic evaluation, and I can pretty easily justify making any patient a yellow (code II?) and in fact do make most of them a yellow unless I can be certain of what's going on with them today and don't have any suspicion of their conditioning worsening. At the service where I'm doing my internship, I've gotten on average between five and ten calls per day, and out of them I've probably only made a dozen or so code green. In my system, all yellows get a monitor and IV, and it's rare that I don't at least have a look at their heart (which automatically makes them a yellow if I put them on the monitor).

Unfortunately, I never worked as an EMT before going to paramedic school (which has come back to make my internship much more difficult than it could have been), and I'm a big fan of working as an EMT before going to paramedic school because seeing the people in my class who did have that experience versus myself, I can see where they've got a leg up on me. At the same time, it also means I'm very ALS oriented in the sense that I'm all about seeing what their heart's doing and having IV access, though I tend to be conservative in my treatments themselves. So for me, it's easy to justify myself and say "I want to put them on the monitor and I want to have IV access, though I don't plan on giving them any meds or fluids unless something changes", but on the other hand, I have gotten almost no exposure to working with an EMT and the dynamics inherent in that kind of system.

[uglyEMT]

Beiber. No all my experiences with ALS have been good ones. But as you just stated being your ALS oriented you want monitor and IV which means BLS is out of the loop in my system. So I would just be in the back staring at the patient not really doing anything.

If I dont have ALS on board I am the provider. I will do the vitals, take lung sounds, check pupils, listen to bowel sounds, ect. I get alot of experience as most of our calls are 30 minute travel times to the ED. Plus I get to have interaction with the patient, talk BS that sort of thing.

Now with ALS on board the vitals are done by the LP12, the medic takes the lung sounds and has all the interaction. Thats what they do, its their job. They are the higher medical authority on the rig at that point.

I learn alot by watching and listening to what is said and reactions that are got. I dont mind being with ALS I just wish in my system we could do more then sit there.

Remeber that if your on a BLS rig at anytime Beiber. You may make some EMTs put off if its all about you you you in the back. Look at it this way, picture being in the back of your rig day in and day out and every once in awhile some hot shot gets back there and takes over like its all his and pushes you to the side. How would you feel.

[Bieber]

Beiber. No all my experiences with ALS have been good ones. But as you just stated being your ALS oriented you want monitor and IV which means BLS is out of the loop in my system. So I would just be in the back staring at the patient not really doing anything.

If I dont have ALS on board I am the provider. I will do the vitals, take lung sounds, check pupils, listen to bowel sounds, ect. I get alot of experience as most of our calls are 30 minute travel times to the ED. Plus I get to have interaction with the patient, talk BS that sort of thing.

Now with ALS on board the vitals are done by the LP12, the medic takes the lung sounds and has all the interaction. Thats what they do, its their job. They are the higher medical authority on the rig at that point.

I learn alot by watching and listening to what is said and reactions that are got. I dont mind being with ALS I just wish in my system we could do more then sit there.

Remeber that if your on a BLS rig at anytime Beiber. You may make some EMTs put off if its all about you you you in the back. Look at it this way, picture being in the back of your rig day in and day out and every once in awhile some hot shot gets back there and takes over like its all his and pushes you to the side. How would you feel.

That's a good point, UglyEMT. Thanks, I'll try to remember that if I get the chance to work on a paramedic/EMT truck.

So let me ask you another question, do you like your system the way it is? Or do you wish it were different? Instead of ALS intercepts would you prefer if your service just staffed paramedic/EMT trucks? When you guys have an ALS intercept, are the paramedics able to bring all of the equipment they need into your truck, or are there things that they have to leave behind do to space/moving issues?

The one ALS intercept I've done was for a chest pain call coming in on a BLS truck with an EMT-B and I in the back with a first responder driver. We brought our box, monitor, and narc box and rode with them into the hospital while my preceptor's partner followed in our truck. I was really impressed with the EMTs and their care, and I'm a little sad to say I haven't gotten to experience more calls like that during my internship.

[uglyEMT]

I like the system I am in. If we need ALS we get ALS but most of the calls can be run by just BLS so it gives me great experience.

When we have intercepts ALS they bring everything in they need, I have yet to see us leave stuff in their truck. We even have room for CPAP equipment to be secured down. FYI our ALS trucks are just Chevy Suburbans with just enough room for two medics LOL

Yes one of them drives their rig and follows close behind. If we need both back in my rig, rare but happens, the EMT will get out of the rig and drive their truck.

I guess it comes down to your area, what works for my area may not work somewhere else.

[tcripp]

I've never worked with an EMT before in an ALS capacity, and pretty much all of my exposure has been in a dual paramedic setting, so I'm curious as to what kind of staffing your services maintain, and your own experiences working on paramedic/EMT and dual paramedic trucks. What are the benefits/cons to each model? Do you have a preference?

When I was in school, all of my ride outs were with a dual paramedic truck. As graduation neared, I could see my self working for one of the local services because of the comfort zone with this type of arrangement; I would always have someone with whom I could confer...especially in the beginning.

However, I found employment with a 911 service that is 1.5 hours and 2 counties away...but this is the paramedic/EMT truck. At first, I was hesitant, but I've actually found that I really like the experience. Because I now work for a rural area, we have much more aggressive protocols than I would have had by staying in my own back yard. With this crew orientation, I am also getting more experience since 98% of the patients are mine. I feel as if I've progressed so much further/faster in this set up.

Don't discount it as an option. And, know, that your crew/command/medical director are just a radio away...so you never really lose that comfort zone.

Hope that helps.

Toni

[Richard B the EMT]

That's very interesting, Richard. So, when there's just one paramedic on the truck they're only allowed to function at a BLS level even if they have all of the ALS equipment available to them on the truck? Is there any particular reason why that is?

I admit to not knowing why the policy exists, but I will follow policy until I am told it's been changed. Then I'll follow the new policy. I am in a position that I follow, but don't assist in the creation or, policies.

I should mention that sometimes the Paramedics will have one, instead of both members of the team, ride with the patient, with the "shotgun" EMT, no matter if the transport is being done in the ALS or BLS unit. In this instance, the Paramedic assigned as "wheelman" stays driving the ALS rig.

[ERDoc]

You may make some EMTs put off if its all about you you you in the back. Look at it this way, picture being in the back of your rig day in and day out and every once in awhile some hot shot gets back there and takes over like its all his and pushes you to the side. How would you feel.

I don't have much of an opinion on either setup but I just had to make a comment here. No offense Ugly, but it should never be about the EMT or the Medic. It should be about the patient. If your pt needs ALS level care then you should happily step aside and let the pt get the care he/she needs. There is plenty of stuff you could do while the medic is doing the IV/meds. Monitors can be horribly inaccurate with VS. It's always a good idea to get a baseline set of vitals done by a competent human (ie the EMT). You might catch something that would otherwise be missed due to the monitor.