Less Is More

Kelly Grayson, who many of you probably know from his blog, A Day in The Life of an Ambulance Driver has a great column on ems1.com. His most recent article is titled "Too Much of a Good Thing", and it is pretty damn good. He touches on the recent topics of CPR, CPAP, and intubation. He also mentions the ALS vs. BLS debate, and tiered responses.

I think this a very relevant article and just the kind of information I hope this blog will provide. He quickly talked about evidence-based medicine making its way into the prehospital setting. We have learned to question things more, and it will end up improving our practice. We need more people like this.

I just want to touch on the topic of ALS vs. BLS and tiered responses. Kelly stated that more paramedics isn't necessarily a good thing. I whole-heartedly agree! Too many paramedics causes a few problems that extend way past the scene of a call.

  • Problem#1, the more certified paramedics out there, the cheaper it is for an organization to just hire the new guy and mold them into what they want as opposed to hiring a seasoned veteran, or keeping one for that matter. I am all for fresh blood, but we need a mix of experience, in my opinion, and I am seeing with my own agency how this can become a problem. If you can hire a fresh out-of-school medic for $45,000 as opposed to a 10-year medic for $55,000, why hire the experienced guy? I predict this to become more of a problem with this economy.
  • Problem#2, more medics = more egos. For some reason, we aren't very good at learning from our peers. We are quicker to point fingers sometimes, than we are to lend a helping hand. You also might hear "I want the tube". This is the problem with too many medics on a scene. We are leaders by nature, and taking direction may be difficult for some of us. I find it a great idea to bounce ideas around on scene, this may help diffuse that problem(even if you're only with EMTs, this may be something worth doing).
  • Problem#3, The more medics the less accountability. Another problem I see right here in my system. Just imagine having ten kids, would you really be able to spend the amount of time going over all of their report cards?
Of coarse, I am not advocating a BLS only system. The next time you have a CHF or STEMI patient, think about how an EMT only truck would handle that patient. Our ALS modalities are very helpful given the right patient and used appropriately. ECG interpretation lowers door-to-balloon times. CPAP and nitro improve the outcome of a CHF exacerbated patient. Antiarrhythmics acutely improve patient conditions. I believe a tiered response is the way to go. This would decrease the demand of paramedics and there would leave some room for the fixes I think are necessary.
  • Fix#1, Improve the curriculum for paramedics, and make an associate degree a requirement. Six months to a year isn't enough education to do the stuff we do. We should emphasize more ride-alongs, and OR time.
  • Fix#2, We should and could QI/QA every ALS call. At least every priority one call could be reviewed. This would improve overall education, and professionalism. Incidents would be reduced, and a sense of responsibility would spread.
  • Fix#3, The medical director could spend more time with paramedics. This would improve the working relationship, and probably provide some great education. This may also open up some medical directors to more progressive protocols. Smaller systems may be familiar with this idea, because their medical director might know everyone by name and has probably run a few calls with them.
I know it may sound like I am saying that we should get rid of medics, I'm not. I am saying that we should make it harder to become a paramedic, academically. We should, of coarse, keep the positions that are filled right now, but only fill when necessary. We have to show our worth in this economy, and sometimes the most expensive answer isn't the best one. Just look up the OPALS study if you question this. Of coarse the problems and fixes are my own opinions based on what I have read. This topic is open for much discussion, as always.

Are we getting too big for our britches? What do you think?


Rogue Medic said...

Adam Thompson, EMT-P,

We have far too many paramedics in many places. We need to get rid of those, who either are not providing competent care or cannot be remediated to the point where they are providing competent care.

I don't see the problem as a curriculum that is too short, but that we are not educating medic students to be good medics. It isn't the amount of time, but the quality of education. I go into more detail in Death By BVM.

Adam Thompson, EMT-P said...

Yea, catering to a test doesn't teach anything but how to take a test. What do you think about different levels of EMT-P? Like advanced practice or a paramedic 1 & 2 program?

Rogue Medic said...

Adam Thompson, EMT-P,

It depends on whether the place has their act together as far as getting rid or, or remediating, bad medics. If we have a bunch of bad medics, breaking them up into different categories of bad, is just not dealing with the problem.

There are plenty of valid reasons for different levels of paramedic. It all depends on how this is used.

Anonymous said...

I agree with RM. As a student at an accredited school with very high standards, it makes me mad (not jealous) of students who can breeze through an 'insta-medic' program and come out with the 'same' certification (and payscale) as me. I'm hoping that the National Standard Curriculum will be a start in the right direction at getting some REAL educational standards, followed by a requirement for accredited programs. The poor providers both bring down standards as whole and hold back the real practice of paramedicine by giving ample ammunition to those who would seek to reduce prehospital scopes of practice.

Shaggy said...

Anonymous, don't hold your breath. The focus is more on quality than quantity for sure, now, but you will still see a watered down program to meet the needs of those organizations that hinder the forward progress of EMS as a medical profession (ie. fire service, vollies, private for profits).