Paramedic/EMT or Dual Paramedic

[emtannie]

Good thread, Bieber, and you will get a lot of opinions on this one, I think…

I noted one thing that I wanted to comment on, before I get to my reply to your original post.

….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).

In our service, a patient isn’t coded yellow unless they are decreased level of consciousness and/or are deteriorating regardless of our interventions. I can see where you could make the majority of your patients yellow under your criteria system. I would like to encourage you to trust your instincts. Don’t make a patient a code yellow just because you can.. trust your knowledge and that of your partner.

I have worked on a BLS service for years, and I should explain that our EMT’s are a little different than yours. What you call EMT-B’s, we call EMR’s (Emergency Medical Responders) . Our EMT’s are more like your EMT-I’s, and can start IV’s, give come meds, and cardiac monitor patients.

I also work on an ALS service, where I am paired with a medic (I am currently in medic school). Although paired with a medic, we alternate who attends on calls, so that I gain experience, and the medic can step in if needed. Since a lot of calls are BLS anyways, this gives the EMT experience, and they can maintain their skills, and learn from the ALS partner. We do have some dual medic cars. These are cars where one is an experienced medic and the other is a relatively new medic. This allows the new medic to work with someone more seasoned, until they feel comfortable being the senior person on a car with an EMT, rather than throwing them into a senior role as soon as they have completed their medic training. This seems to work well, as the new medics gain experience and the confidence before moving to a car with an EMT. As the ALS service is a city service, in the event of a delta level call, we do have a shift supervisor medic who responds to those calls as well, so that you have 2 medics on the most serious calls. The BLS service I work for is rural, and the closest ALS service is an hour away by ground, or 30 minutes by air, so we have to be able to handle the situation on our own for quite a while before getting ALS assistance. Scary? Sometimes, but great experience, and it certainly weeds out those who don’t have confidence in their abilities.

Bieber, you are a joy to have in these forums – your posts and questions are well thought out, and your interest in learning more is a good push for the rest of us. Thank you for joining this site!

[Lone Star]

In my experience I've been in BLS/BLS trucks, BLS/ILS trucks, BLS/ALS trucks and have been a 'third rider' in ALS/ILS trucks here in GA.

I realize that not every patient is going to be needing ILS/ALS interventions, (like the IFT's), and that works great. Aternatively, there are scenarios where the dual BLS truck is in 'over it's head' as soon as they roll up on scene.

I have to admit that I like the set-up here in GA with one exception....

In GA, you're very likely going to be passed over for employment if you are only BLS certified/licensed. It's a well known fact that the IFT is the 'bread and butter' of any private carrier. Most of the IFTs only need BLS interventions/monitoring.

The EMT-B is a healthcare provider in his/her own right, and shouldn't be passed over for employment simply based on the fact that they're 'only BLS', nor should they be relegated to only being the 'wheelman'.

I know I've rallied on about how BLS shouldn't be removed from the 9-1-1 calls, but as I've progressed up the food chain my opinion has changed slightly.

I still believe that BLS has a place in EMS and is more than a 'go-fer' and 'wheel man' for ILS and ALS.

If you're going to put the BLS personnel into the 9-1-1 system, then pair them with a higher license level. If you're going to be doing IFTs, then put the Basics there, but don't just 'eliminate them' simply because they're BLS.

As far as working a 'mixed truck', it's been my experience that the attending EMT (regardless of license level) is what determines the unit designation. For example truck #711 is a combination of BLS/ALS. If the EMT-B is attending then they are called Bravo 711, if the Medic is attending then they are Alpha 711. It's not a difficult concept to grasp, and it gives the dispatcher a 'heads up' when the unit radios in and upgrades the patient transport status. This way, the dispatcher won't have to question the driver over the air why they're suddenly transporting a 'cold call' hot...(yes, I've actually had that happen, and it's frustrating as hell!).

[medicgirl05]

I work for a rural service that runs either Paramedic/EMT or dual Paramedic depending on the staffing available. They both have pros and cons. We are at least 30 minutes from an ER so we seldom sit and play at the scene regardless if I am working with a paramedic or a basic. If the patient is not critical we can turn the patient down to the EMT. The problem with this is that EMT's don't get a whole lot of experience. However, thats what must be done to provide optimal patient care. If we have an extreme call-A code, or serious trauma, or multiple patients in the unit we can have a fireman drive us in. That provides the basic with a little experience.

[uglyEMT]

ER I totally agree. basic skills (not level here) are always important. I was just mentioning that sometimes when ALS gets onboard they dont want the EMT-B anywhere near "their" patient. Thats when I feel we get put off. I feel we have alot to offer the patient even in the paramedic / emt setting but their are some that feel once they are on the rig its their show. I was just letting Beiber know not to be "that" guy thats all.

BTW Thanls ERDoc for giving Basics the thumbs up as a vital part of the crew

[Fox800]

Working a service with both large urban/surban and rural areas in the same district, I'm starting to favor dual paramedic transport units in the larger rural (county) areas, and dual-EMT transport units in the urban/suburban areas backed up by dual-paramedic squads.

[DwayneEMTP]

Working a service with both large urban/surban and rural areas in the same district, I'm starting to favor dual paramedic transport units in the larger rural (county) areas, and dual-EMT transport units in the urban/suburban areas backed up by dual-paramedic squads.

I can see paramedic response backed up by a dual basic truck, but how do you justify it the other way around? It just makes no sense to me to have a basic assessment decide if a medic assessment is necessary..

Dwayne

[tniuqs]

I also work on an ALS service, where I am paired with a medic (I am currently in medic school). Although paired with a medic, we alternate who attends on calls, so that I gain experience, and the medic can step in if needed. Since a lot of calls are BLS anyways, this gives the EMT experience, and they can maintain their skills, and learn from the ALS partner. We do have some dual medic cars. These are cars where one is an experienced medic and the other is a relatively new medic. This allows the new medic to work with someone more seasoned, until they feel comfortable being the senior person on a car with an EMT, rather than throwing them into a senior role as soon as they have completed their medic training. This seems to work well, as the new medics gain experience and the confidence before moving to a car with an EMT. As the ALS service is a city service, in the event of a delta level call, we do have a shift supervisor medic who responds to those calls as well, so that you have 2 medics on the most serious calls. The BLS service I work for is rural, and the closest ALS service is an hour away by ground, or 30 minutes by air, so we have to be able to handle the situation on our own for quite a while before getting ALS assistance. Scary? Sometimes, but great experience, and it certainly weeds out those who don’t have confidence in their abilities.

Question emtannie:

1-When you are on a student car is it a 3 man/women ?

2-As student do you receive a stipend an honorarium or a wage ?

Good ideas in a perfect world, well accept in rural areas and I am of the opinion that ALS in anyway shape or form should be considered an essential level of care.

I will follow this thread as having worked in services both single medic alone in remote austere settings, urban and rural in dual level services and in tiered response systems on ground.

In Air Ambulance partnered alone a single Medic L.D.T. (ie international repats btw ill advised) and/or partnered with EMT or Paramedic or RN or RRT or ICU Teams.

No time to comment in depth presently .

cheers

[HERBIE1]

As evidenced by the responses, there are many models of EMS- orivate, fire based, hospital based, etc. The trend in many places seems to be to have an EMT and a medic on an ALS rig. In many areas, this is all they know. Budget constraints is probably the most common issue- 2 medics require more pay, training, etc, and in many rural places are not easy to find because if a person has been trained to the level of a paramedic, they often look for employment where the pay is better.

Our ALS rigs are 2 medics, our BLS rigs are 2 EMT's. There has been talk for years about making ALS rigs one EMT and one medic, but obviously that is seen as a reduction in the level of care and has been met with a lot of resistance. In most cases it simply does not matter- a single strong medic can handle the call even if it's ALS. BUT- in those cases where it's a complicated run, that 2nd medic can be vital. As the doc said, sometimes the EKG may be funky, the patient's problems may be confusing, and a 2nd opinion and pair of hands can be crucial. Doctors call in for 2nd opinions/ specialists all day long. Problem is, you never know when you may need that extra help.

Every area has their own standards- sometimes they are local, sometimes they are state statutes. You work under the constraints and regulations of your area and become accustomed to whatever your local norm happens to be. If you don't like the way things are, moving on is always a possibility.

Beiber- you sound like a bright person and are a credit to this profession. EMT or medic, I would love to work with someone like you who is so interested in advancing their knowledge. Keep asking these quality questions, keep looking for answers, and your patients will benefit from your attitude.

[Richard B the EMT]

It just makes no sense to me to have a basic assessment decide if a medic assessment is necessary..

Try thinking of it like this: We all know some "professional" callers to 9-1-1 know the buzzwords to get both a "faster" response, and/or an ALS response. The other side of the coin is the caller that doesn't have a clue, and the call-taker gets an incorrect idea of what's going on, and starts out a BLS response where an ALS response was actually needed. This is not the fault of the call taker. On arrival, most BLS crews can recognize when ALS is needed, and request them for on-scene meet-up, or intercept.

Hopefully, that can help you make sense of it.

[summerdawn]

The service I am employeed at we have a EMT Basic and Paramedic. The company does not allow two ALS providers on the same truck at the same time unless it is a transport with a critical patient then it is a two ALS providers and EMT. Its a money thing, the more money they save the more they like it.