EMS and Ranking Structure

[Bieber]

Hi everyone.

So, for those of you who don't know, at my service we have a pretty rigid rank structure (stupid, but that's a debate for another time). Anyway, the gist of it is that every ambulance must have a lieutenant (2+ years FT, plus passing a test, interview, etc) or an acting lieutenant (paramedic in good standing, generally 18 mo FT exp.) on it. Because lieutenants and acting lieutenants must be paramedics, non-lieutenant paramedics ("techs") who cannot act as lieutenant also cannot work with part-timers or EMT's.

Lieutenants (and acting lieutenants) are technically in charge of everything that happens on the truck; principally with regards to operations issues (i.e. in charge of running incident command during an MCI or multi-patient incident, figuring out what to do if something breaks, if there's a crash, ensuring adequate supplies, etc, etc), but also technically with regards to patient care as well (i.e. if something is about to go wrong, it's the lieutenant's responsibility to prevent it; and if something DOES go wrong, it's the lieutenant's fault for not preventing it).

In theory, every truck in the service should have a lieutenant on it, and acting lieutenants should only be utilized when an LT is sick, on vacation, etc; in practice, we've had a moratorium on lieutenant promotions for almost a year (as we go through a ton of organizational changes) so we've ended up with a bunch of "dual tech" trucks with acting lieutenants running the show on them. Also, we've got so many people gone on any given shift (and numerous open positions), so people who can "act" are invariably shifted around to ensure adequate lieutenant/acting lieutenant coverage for all trucks.

Anyway, long story short, the Biebs' time has finally come, and I am finally cleared to "act" as a lieutenant. What this basically means that from now on I am cleared to work with part-time paramedics, paramedics with less seniority than me, and EMT's.

Being that my service is the way it is, I have never, ever worked with anyone other than a paramedic, nor have I ever worked with anyone with less seniority than me or a part-timer. Now that I can act, it means that my regular partner and I will be split up often so that they can use me to maintain adequate "lieutenant/acting lieutenant coverage". My partner is going to be acting captain (division supervisor; 2 per shift; ride around in Suburbans doing supervisory shit) this weekend and Friday and Saturday will be my first shifts acting. I'll be working with a part-time paramedic who was in the class after me, but looking ahead I'm also scheduled to work alongside an EMT next Tuesday (on a shift trade that I can now do, thanks to being cleared to act), and a couple more days (unknown who my partner will be yet) near the end of the month.

So! Your mission, should you choose to accept it, is to share your thoughts, experiences, opinions, etc with me with regards to serving as the lead paramedic (if your service has such a thing) OR working with an EMT on a paramedic/EMT truck and on EMS ranking structure in general.

First, tell me about your service. Are you let free to work with whoever in whatever capacity as soon as your paramedic cert is printed, or did you have to work alongside a senior paramedic initially? Who was your first partner? Medic? EMT? More or less experience than you? Do you have any sort of hierarchy on your trucks or are both crew members considered equal? What kind of system do you prefer? What is the certification level of your current partner?

Personally, while I think that as a new paramedic it's helpful and probably good to work with a more senior paramedic initially, I strongly disagree with the notion of having one paramedic in charge of another. I feel that patient care should be a team effort, and that establishing "ranks" (even if in practice they're not utilized--usually) is not particularly the best thing. Dwayne knows all about my frustrations of being overruled by another paramedic--even on my own calls--as well as my frustrations with wanting to be "thrown to the wolves" so that I could make my own mistakes and learn from them, without being stiffened by a senior paramedic who may simply have disagreed with my treatment plan (regardless of whether or not it was correct or simply not the way they would have done things).

But wait! Don't think I'm leaving the nurses, physicians and other healthcare practitioners out of this! I want to hear from you too! Tell us about the rank structure (if one exists) at your healthcare setting. Obviously an attending overrules an intern and a charge nurse overrules a nurse, but something tells me that you folks who actually work in that setting can elaborate on that a hell of a lot better than my meager simplification.

Anyway, sorry about turning this into a novel. Please, let's hear from you!

[Kiwiology]

Each station has a Team Manager

Groups of stations are in a District, each District has a Manager

Groups of Districts are in one of three regions, each Region has a Manager

Some stations (depending on how big they are) will have a Team Leader for each watch and they look after their watch for the Team Manager as he may be on e.g. blue watch and never see his people on e.g. red watch

Metropolitan Auckland has recently been split into three areas (central, south and west) following the district model used elsewhere and each area has a watch based Manager who is responsible for that area. This is a change from the previous Duty Operations Manager model where a watch neutral person covered Metro. Now each watch has somebody specific.

This structure is more about people performance and management than actual on-the-ground leadership. If a crew needs operational support the District Manager is their first port of call either on the ambo phone or in person.

The management structure was significantly changed in the early to mid 2000s here to remove a lot of crap and bullshit (unfortunately some of the culture that was inherent has not gone)

As far as graduates; they must be assigned to a senior Ambulance Officer for their transition to practice year (applies to both Paramedic and Intensive Care graduates) who may or may not be but most likely will be a Clinical Standards Officer. During this time you can not practice you qualifications associated scope of practice independently without supervision by somebody at that practice level or higher, you can work with somebody who is junior in clinical level to you but you must only use your authorised scope of practice. What this means is that Paramedic degree graduates can act independantly as a Technician and only use Paramedic level interventions or medicines when supervised by a Paramedic or higher so if they are required to work with a Technician then the vehicle will have two Technicians

Edited June 15, 2012 by Kiwiology

[Bieber]

Thanks for sharing that, Kiwi!

[WolfmanHarris]

Recently the EMS Chiefs of Canada (EMSCC) and under them the Association of Municipal EMS Services of Ontario (AMEMSO) adopted standardized titles and insignia for Paramedics and specifically management. As a result services have been slowly but surely moving from the mix of Directors/Managers/Chiefs/Grand Poomba's of before to a management structure like this:

-Chief

- Deputy Chief

- Commander

- Superintendent

Only our Superintendents currently work in a field supervision role. Each day has a Deputy Chief on call that is available for any big issues but they're off site outside business hours.

Within HQ we have two Deputy Chiefs assigned to Operations (one covering the busy south districts, the other the north district and Special Operations), one assigned to Performance and Development and one to Logistics.

For Commanders we have one assigned to Fleet and Facilities and one to Supply and Equipment.

For Superintendents we have one assigned to each district per platoon (12 total) plus acting Superintendents which are are nine month secondment from the road to fill in for vacations, sick time, etc. We have Superintendents assigned to Clincal and Community Programs, Performance and Quality Improvement, Scheduling and Deployment, Special Operations and The Office of the Chief.

Captains are a fairly new title and used to be called Lead Paramedics. They're so far only assigned to education and community programs but there's been some talk of seeing them take on non-management, field leadership roles.

As for crews on the road, there is no rank on a regular truck. Certainly and ACP may pull clinical rank if the call warrants their taking over, but it's a team effort and shouldn't come to that. For new hires, they spend their one month orientation and one month riding third as "Recruit Paramedics." They are fully qualified to practice but as part of their intake they are eased into full duties. After those two months though they can be partnered with any other medic. Frankly I'd like to see this expanded so that no one with under a year on the road can be partnered with someone else with under a year. But maybe that's due to the stupid mistakes I made in my first 12 months.

[Arctickat]

Recently the EMS Chiefs of Canada (EMSCC) and under them the Association of Municipal EMS Services of Ontario (AMEMSO) adopted Non Binding standardized titles and insignia for Paramedics and specifically management.

Fixed that. My slaves know who their master is, we don't need no stinking rank insignia.

Edited June 15, 2012 by Arctickat

[Eydawn]

Speaking to my particular setting (Ortho/post surgical floor), when you're in orientation you work with a preceptor with experience. In my case, I worked on the floor with a few different CNAs who had worked on that floor for several years. The new hire RNs are assigned to a partner RN, and keep pretty much that same partner for most of their orientation. My orientation lasted for about a month; the RNs must go through a 4-6 month orientation period before they launch independently.

For both of the levels, there are certain competencies and in house educational programs that must be completed prior to being released from orientation. Including a wickedly dumb scavenger hunt. (You don't get to keep it, what's the point of writing all that stuff down?) But I digress. Once you have done a competency, you can independently perform that skill even while still on orientation (in my case, discontinuing foley catheters and IVs, putting someone in a continuous passive motion machine (CPM), vital signs, etc.) For the RNs, this includes all RN level skills once they're signed off- they can take progressively more patients independently and just check in with their partner (who shares the responsibility for those patients), and perform all necessary interventions. As they progress through orientation, they are expected to take on more and more of the load, until eventually they are responsible for all 4-5 patients with their "partner" just serving as a resource.

As far as pecking order goes, once you're cleared from orientation, you aren't viewed as any higher or lower than your peers really. Everyone is there to work. The charge RN is in charge, the RNs supervise the CNAs and the CNAs bust ass (at least, I do!) Yes, the newer nurses ask for help from the older nurses... but everyone helps each other to do skin checks and dual RN interventions. Nobody is "low man" as far as I've seen.

A lot of it has to do with our leadership. Our manager is very in tune with what's happening, what's working, what's not... he's a big fan of resolving issues as they arise and mediating conflicts quickly and efficiently. I love it.

Wendy

CO RN-ADN Student

[Bieber]

Wolfman and Wendy, thanks for sharing! It's fascinating to see the differences in work structure across such great distances and healthcare environments. I'm always curious about other EMS and medical systems because really my service is the only one I've ever experienced and it seems like in some ways we do things very particularly when compared to other systems (from what I've heard from you guys and other healthcare workers).

[Vorenus]

We don`t have any real ranking structure, apart from emergency physician/RettAss(Para)/RettSan (EMT). An exception is a MCI, where (only talking about the EMS-side of things) an organisatorial leader EMS (OrgLR) and a leading emergency physician (LNA) is added. Until the OrgLR arrives at the scene, the para of the first ambulance at scene has command.

So, how was your shift with as acting lieutnant, bieber?

My first shift as a newly qualified RA (Para) was with an EMT partner, as were most of the shifts I did in my first months. Takes some nerves to get used to it.

[WestMetroMedic]

Our structure is rather simplistic... White shirts and brown shirts. The sups wear white, because they are not covered in crap.

But more seriously, we run strictly paramedics. When you start, you are on probation for the first six months and during that time, you responsibility level steadily increases. Our probies also wear a probationary badge and are not allowed to be union members which allows us to easily clean house if remedial training has not succeeded.

After six months, you become a run of the mill medic with a couple exceptions. The majority of the new employees we hire come to us with a couple years of experience, but even with that, they still cannot work with someone who has less than one year of employment due to the little things they may have missed in their first six months. You also are not assigned a permanent shift until one year of employment.

After you have gotten your full year in, you are the king of your domain, about half of our 135 shifts have two regular partners and the rest have 5ish regular partners. In the event of an incident that we start ICS, the senior medic is EMS command. There are a couple other things that come into play during the course of your day that revolve around senority, but for the most part everyone is an equal.

Next up on the food chain is supervisors, which we have 13, which is where you begin wearing a white shirt. There is always a duty sup who answers supervisorish phone calls, responds to a very select group of calls and is available for whatever else. Each sup also has a specific responsibility that they manage such as QA, STEMI, stroke, MCI, supply chain, facilities, ePCR, fleet management, PR and scheduled events and more. Either way, they work about 40-60 hours a week. Our sups are required to have an associates degree, but most have their bachelors and a couple are working on their MBAs.

Next is our operations manager, who obviously, manages our operations.

After that is our department director who oversees operations, communications and education. Followed by a bunch of people in our hospital management.

[EMS Aficionado]

I think that rigid ranking systems typically operate with several poor practices:

They often equate experience with competence.

They assume an organization always has enough qualified individuals for vacancies.

They typically won't promote a qualified individual unless a vacancy exists.

In my view, the more rigid the ranking system, the less able the organization is to attract and retain talent.

I think that newer ALS providers should be partnered with clinically competent ALS providers that have strong mentorship abilities.