Seem to remember recently a study which established that two attending paramedics is incontrovertibly superior than a single provider, but it also stated that additional medics not only did not improve care but actually had a negative impact. Basically article or study said two is best, better than one or more than two. Is this another one of my chronologically induced fantasies or does anyone know the reference so that I can use it in support of some local staffing challenges

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I'd like to comment on the study done by Vanderbilt on double medic crews vs mixed. this study was not done correctly. I was personally involved in this study and there are a couple of things that need to be said. First, and I understand the reason for not telling those involved what the true nature of the study was, we were told that we were testing a new prototype resuscitation mannequin. We were given the impression that we could take our time and all that was important was that we followed our protocols in order. We were told to relax and give feedback on the mannequin's performance as we went...not after the simulation.....during! . It was a laid back environment and we were at NO TIME told that we were being timed or that we needed to perform as though this was a true cardiac emergency. This study makes it sound so cut and dry that two medics are as good as one. I got the impression that this was to feed the needs of a cheaper budget (Vandy happens to be our medical director). Including this study, I haven't seen anything that addresses the fact that two medics cut the work load in half...especially in an urban environment and especially in a service where an IV is considered an ALS skill (most of our EMTs are essentially drivers). What about the cutting the stress level? I realize that stress and exhaustion are hard factors to quantify but having two medics is safer both physically and psychologically. This will be the LAST study I ever participate in for Vanderbilt.


dr-exmedic said:

There was an abstract of a potentially bad study (never published, as far as I've seen) that showed:
...a comparison of the effectiveness of one vs. two paramedics on scene in chest pain calls. This was a prospective study, which is good, and fairly unusual in prehospital research. They compared 92 patients, 37 treated by 2 medics, and 55 treated by 1 medic. The only test that reached statistical significance was that, on average, patients treated by 2 medics had their chest pain resolve 2.4 minutes earlier. There was no statistical difference between time to IV, first nitro, or second nitro (although there was a trend towards decreased times for two-medic crews).
Interestingly, the authors claim that this provided evidence for the superiority of 2-medic crews, which is a bit of a stretch to me, as I noted at the time.

Then, on the split EMT/Medic crew, there was this study, which (despite being of decent design) had a frightening aspect or two (including the fact that one of the crews tested only provided 10 seconds of CPR in an 8.5 minute arrest scenario):
CONCLUSION: Two paramedic crews were more error-prone and did not perform most interventions more rapidly with the exception of intubation. These data do not support the proposition that two paramedic crews provide higher quality cardiac care than paramedic-EMT crews in a simulated ventricular fibrillation arrest.
John Johnson said:

First, and I understand the reason for not telling those involved what the true nature of the study was, we were told that we were testing a new prototype resuscitation mannequin. We were given the impression that we could take our time and all that was important was that we followed our protocols in order. We were told to relax and give feedback on the mannequin's performance as we went...not after the simulation.....during! . It was a laid back environment and we were at NO TIME told that we were being timed or that we needed to perform as though this was a true cardiac emergency. This study makes it sound so cut and dry that two medics are as good as one. I got the impression that this was to feed the needs of a cheaper budget (Vandy happens to be our medical director). Including this study, I haven't seen anything that addresses the fact that two medics cut the work load in half...especially in an urban environment and especially in a service where an IV is considered an ALS skill (most of our EMTs are essentially drivers). What about the cutting the stress level? 

This was not noted in the original article.  This makes my concerns about the artificiality of the environment even more pertinent (as I wrote at the time, "this may not really reflect the real world–it was a tiny study, with a simulated patient").  This might explain the crew that only did 10 seconds of CPR.  This sort of situation is probably going to minimize any differences that might be testable.

 

Nobody doubts that a 2-medic crew in a busy environment lets them alternate, so nobody's going to study that.  :)  The stress level, someone might study if you're lucky enough.  (Sorry, I can't do it here because all city units are 2 medics and it isn't really fair to compare them to the 1+1 crews in the suburbs.)

There is not a lot of easy-to-find data on Lincoln's system but I did find this.

 

It seems to indicate that the fire department is chronically underfunded and that they try to fund EMS entirely from transport revenues - something else that's not realistic in most government-run systems that focus mostly or entirely on 911 calls. 

 

It also seems that the issue wasn't what agency ran the combined fire/EMS system in Lincoln.  Under their new chief, LFR's EMS operation has become much more successful financially, going back to FY2007

 

Most of the rest of what's available is new stories full of opinion but precious little fact.

 

 

I published on the 2 vs 1 paramedic issue back in 2003. Below is the abstract......it may be interesting to repeat the study since our paramedics have expanded their scope of practice and now do more.

 

ARE TWO PARAMEDICS BETTER THAN ONE? James I. Syrett, MD, EMT-P, Eric A. Davis, MD, University of Rochester, Rochester, New York

 

Hypothesis: Staffing an advance life support ambulance with 2 paramedics (ALS2) will decrease on-scene time and will also reduce the incidence of transporting the patient ‘’lights and sirens’’ (emergently) compared to staffing with a paramedic/non-paramedic crew (ALS1) 

 

Methods: Data were collected from a single suburban ambulance service (4,500 calls/year) staffed by a combination of paid and vol- unteer EMS providers. Data included on-scene and transport times as well as team configuration (ALS1 vs ALS2). Team configuration was determined at the beginning of the shift and not influenced by call type or severity. Only runs where a single ambulance responded and required an advanced transport were included. Data were grouped according to whether one (ALS1) or more than one paramedic (ALS2) was onboard the ambulance. Analysis was performed using chi-square and independent t-test (alpha < 0.05). 

 

Results: 7,254 requests for service were made during a 20-month period. 1,639 calls met the inclusion criteria for analysis. Data were complete for 1,488 runs. (ALS1 = 1018, ALS2 = 470). 139 patients were transported emergently to the hospital (ALS1 = 68, ALS2 = 56). ALS2 was significantly more likely to transport emergently (12% vs 7%, p < 0.001). ALS1 spent less time onscene for both patients transported emergently (19 ± 6 vs 21 ± 6 minutes, p = 0.067) and non-emergently (19 ± 7 vs 20 ± 7 minutes, p < 0.01). 

 

Conclusion: Single paramedic units spent less time on scene and were less likely to transport patients emergently. The clinical significance of the reduction in scene time is of questionable clinical significance. However, it is clear that a 2-paramedic crew did not reduce scene time.

I don't think so.  You'd have to look pretty hard to find a clinically lazy medic in this organization.  I think it more has to do with work practices and work flow, and the way teams function. Our medics also don't find themselves "down charts" because we complete the chart at the hospital before we leave.  (I guess you could in theory do 5 treat and release calls in a row, but that would be very unlikely.)

blair4630 said:
Skip Kirkwood said:
>
We found no significant difference between the two, except (again, as I recall) that a two-medic team was more likely to start an IV than a one-medic truck.

Do you think that has to do with laziness. Not taking a shot at your guys specifically, but I know there are lazy ones in every service, and I wonder if when they are dual-medics, they figure "well I'm up for this call, so I'll just do the stuff", vs. a EMT-Medic truck where the thought is "I'm already down 4 charts, this guy is borderline BLS, I don't need a 5th chart"....I observe that with many of our medics that get lazy on that 5th ALS call or that call 15 minutes to shift change when relief isn't there.


Jamie,

 

First, thanks for taking the time to actually do research.  Your study sets a good foundation for what comes next.  Such as "Does scene time matter for a significant number of patients?" etc.

 

One study builds upon the last....we need more of this.


Jamie Syrett said:

I published on the 2 vs 1 paramedic issue back in 2003. Below is the abstract......it may be interesting to repeat the study since our paramedics have expanded their scope of practice and now do more.

 

 

ARE TWO PARAMEDICS BETTER THAN ONE? James I. Syrett, MD, EMT-P, Eric A. Davis, MD, University of Rochester, Rochester, New York

 

Hypothesis: Staffing an advance life support ambulance with 2 paramedics (ALS2) will decrease on-scene time and will also reduce the incidence of transporting the patient ‘’lights and sirens’’ (emergently) compared to staffing with a paramedic/non-paramedic crew (ALS1) 

 

Methods: Data were collected from a single suburban ambulance service (4,500 calls/year) staffed by a combination of paid and vol- unteer EMS providers. Data included on-scene and transport times as well as team configuration (ALS1 vs ALS2). Team configuration was determined at the beginning of the shift and not influenced by call type or severity. Only runs where a single ambulance responded and required an advanced transport were included. Data were grouped according to whether one (ALS1) or more than one paramedic (ALS2) was onboard the ambulance. Analysis was performed using chi-square and independent t-test (alpha < 0.05). 

 

Results: 7,254 requests for service were made during a 20-month period. 1,639 calls met the inclusion criteria for analysis. Data were complete for 1,488 runs. (ALS1 = 1018, ALS2 = 470). 139 patients were transported emergently to the hospital (ALS1 = 68, ALS2 = 56). ALS2 was significantly more likely to transport emergently (12% vs 7%, p < 0.001). ALS1 spent less time onscene for both patients transported emergently (19 ± 6 vs 21 ± 6 minutes, p = 0.067) and non-emergently (19 ± 7 vs 20 ± 7 minutes, p < 0.01). 

 

Conclusion: Single paramedic units spent less time on scene and were less likely to transport patients emergently. The clinical significance of the reduction in scene time is of questionable clinical significance. However, it is clear that a 2-paramedic crew did not reduce scene time.

 

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