I thought the ALS/BLS thread has the potential of taking a realistic look at modern day EMS staffing but this fell by the wayside. I've taken a while to ponder how to pose my question twist on the subject.

There are some given facts
- both the UK and the US governments local and national have undergone massive budget cuts
- the educational standard of EMS is bottom of the barrel poor
- neither country really has national recognition for its EMS clinical staff both in regulation and pay
- as patients change and agencies change the "basics of ambulance care" are gradually dissapearing amongst overworked, tired and under equipped EMS providers

Really the threads of the subject is WHAT CAN/DO WE DO?

Our Patient Satisfaction Surveys shows that the public do not understand the differentiation of grades of staff and at the time do not realise there is a difference. With the only noticeable difference shown in the management of pain in comparison with EMT/Paramedic...from a clinical standpoint of the approx 7milliom dispatches only 10% required paramedic skill set intervention.

We now show that for every 100 dispatches, 27 have care completed on scene by the crew.

Baring in mind that the public can't tell the difference, we can't agree on raising the education standards and the majority of the time the traditional paramedic is not needed. Should we begun to refocus our service model. Move to double EMT crews supported by a team of appropriately qualified responders in cars?

Is there a way to cope with rising demand for services and a reduction in funds to provide for them?

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Which begs the questions.....do we have to accept that "rising demand for services" and "a reduction in funds to provide for them" are fait accompli and can not be influenced?

I'm a stubborn sort - right now I refuse to accept that!

Hi,

Being a Paramedic in the UK I can only comment from the UK perspective for justification of Paramedics. A Paramedic in the UK has a more Autonomous Practioner role in which we can refer patients on a more appropraiate Care Pathway for their medical/social needs rather than admitting each patient to A&E department, this saves money in the long run. EMS/ Technicians are unable to make these decisions due to not being registered with HPC (Health Protection Council). There are many other procedures/ drug administration a Paramedic is able to do compared to an EMS which also can provide much needed Pre Hospital care. Paramedics training is now mainly based in University so are trained to Degree or Diploma level over 2 or a 3 year training course with many hours on the road practical practice with a mentor. 

We are also introducing a new Triage System that will be an updated NHS direct system so advising patients over the phone where their appropriate medical needs will be best treated.

I do believe educating the General Public on when A&E/ ED department is appropriate and perhaps educate people on helping themselves with their medical concerns, eg cut finger, tooth ache etc..

 

This is the first time I have replied on any forum so I do hope I have got the genral gist of what is going on... If not please let me know!!

Kind Regards

Katie

Hi Katie, 

Good to finally have more people swimming the inter web atlantic to take part in discussions!.

Skip - In answer to your question, I don't believe EMS in either the UK or the US is taken seriously on a political level. In a sense both our countries have a chief surgeon, a chief nurse and a chief allied health professional. But no chief paramedic, no National Director of EMS. Therefore, we subject services to a breakdown into small local voices with not enough balls to shout for what we need. 

- If we follow our private sector counterparts in manufacturing or industry we see that if there's problems they don't blame the workers, they redesign the system or production method so overcome the problem. In EMS if an ambulance misses the onscene KPI we blame the driver. We don't examine the human and technological factors at play. dispatcher puts incorrect address, AVL system fails to send job to the crew because the ambulance has powered down. Many factors at play. 

I guess I'm advocating a re vamp of the EMS model. Because the notion of a paramedic on every vehicle doesn't make sense from a business or a medical point of view. Making guarantees that we'll get a paramedic to every patient who needs one is also difficult to do. 

So is it more crews, less crews, bicycle paramedics, care assistants working with a paramedic, Dr's responding on behalf of EMS. I really don't know. 

Katie - I am a UK paramedic myself and university trained, however I disagree with the comments. The Health Professions Council has little to do with somebody gaining physical skills an EMT if trained could intubate a patient. The Health Professions Council is a Cash Cow Quango, which does little to represent the Paramedic Profession, £150 a year lighter to get a laminated card that tells me I'm a paramedic. They do little to stop the profession being shown in a bad light, the whole reason the profession moved regulation to them was to protect the paramedic profession from rouge providers. It has nothing to do with the public, because in all fairness the public wouldn't know there's any difference between the two people walking through their door. 

Referring patients to alternative care pathways is actually more expensive for the health system to do. Increased Risk to EMS alongside a loss of revenue for the Hospital. In the UK the hospital receives £70 per each minor injury they treat. In the US its no doubt more. The hospital relies on minor injuries being treated there, a major case like an MI gets the hospital £200 but the drugs, time of a senior physician and so on far outweigh the income. 

The question I guess really becomes that in terms of your conventional paramedic response ALS, ATLS and so on there is very little for this grade of clinician to do. Evidence is telling us that in cardiac arrest less is more, in Trauma its about load and go as fast as you can. I really do wonder if a change in how the systems are run would inevitably make life a lot easier for everyone???

Hi Neil

Just a quick reply before I go off to my calling bed,

Does the alternative care pathway not save on the Ambulance cost?!? Its also surely about the most appropriate care for the pateint and not just dragging them off to a hospital for the sake of it because you do not feel confident enough to leave them home with safety netting in place..

Also would you expect ECA/EMS to be on the same wage for the increse in duties?!? Surely you would have different levels of EMS? Not all people that work for the Ambulance service want an increase in responsibilites.

 Kind Regards,

 Katie

Neil White said:

Hi Katie, 

Good to finally have more people swimming the inter web atlantic to take part in discussions!.

Skip - In answer to your question, I don't believe EMS in either the UK or the US is taken seriously on a political level. In a sense both our countries have a chief surgeon, a chief nurse and a chief allied health professional. But no chief paramedic, no National Director of EMS. Therefore, we subject services to a breakdown into small local voices with not enough balls to shout for what we need. 

- If we follow our private sector counterparts in manufacturing or industry we see that if there's problems they don't blame the workers, they redesign the system or production method so overcome the problem. In EMS if an ambulance misses the onscene KPI we blame the driver. We don't examine the human and technological factors at play. dispatcher puts incorrect address, AVL system fails to send job to the crew because the ambulance has powered down. Many factors at play. 

I guess I'm advocating a re vamp of the EMS model. Because the notion of a paramedic on every vehicle doesn't make sense from a business or a medical point of view. Making guarantees that we'll get a paramedic to every patient who needs one is also difficult to do. 

So is it more crews, less crews, bicycle paramedics, care assistants working with a paramedic, Dr's responding on behalf of EMS. I really don't know. 

Katie - I am a UK paramedic myself and university trained, however I disagree with the comments. The Health Professions Council has little to do with somebody gaining physical skills an EMT if trained could intubate a patient. The Health Professions Council is a Cash Cow Quango, which does little to represent the Paramedic Profession, £150 a year lighter to get a laminated card that tells me I'm a paramedic. They do little to stop the profession being shown in a bad light, the whole reason the profession moved regulation to them was to protect the paramedic profession from rouge providers. It has nothing to do with the public, because in all fairness the public wouldn't know there's any difference between the two people walking through their door. 

Referring patients to alternative care pathways is actually more expensive for the health system to do. Increased Risk to EMS alongside a loss of revenue for the Hospital. In the UK the hospital receives £70 per each minor injury they treat. In the US its no doubt more. The hospital relies on minor injuries being treated there, a major case like an MI gets the hospital £200 but the drugs, time of a senior physician and so on far outweigh the income. 

The question I guess really becomes that in terms of your conventional paramedic response ALS, ATLS and so on there is very little for this grade of clinician to do. Evidence is telling us that in cardiac arrest less is more, in Trauma its about load and go as fast as you can. I really do wonder if a change in how the systems are run would inevitably make life a lot easier for everyone???

Does the alternative care pathway not save on the Ambulance cost?!? Its also surely about the most appropriate care for the pateint and not just dragging them off to a hospital for the sake of it because you do not feel confident enough to leave them home with safety netting in place..



This is the big issue with EMS practice on both sides of the pond, and well evidenced that paramedics in the current syllabus do not have enough education to make discharge calls safely. (As much as we'd like to think we can) The underpinning evidence to the Advanced Paramedic role showed that Advanced Paramedics sent more people to hospital than their counterparts because of extended knowledge about disease processes. 

To answer your question, yes the Alternative Care Pathway (if done properly costs money not saves it) to discharge someone appropriately takes double the time a standard treat and transfer does. Tying vehicles unavailable elsewhere. The problem lays in that we don't have the right skill mixes doing the right jobs. 

A otherwise well patient with a minor abdominal complaint does not require a paramedic to travel with them. I don't play the what if game assess the patient right in the first place. 

Not all people that work for the Ambulance service want an increase in responsibilites.

This is the trouble in order to make substantial change its going to take several generations of natural wastage before we get the right education for the right person in the right role to meet the modern day EMS. Providers hitting 65, 70 years old mean well but the job they do now, compared with the job they did when they were trained is hugely different. Remember many of these providers gained paramedic status through grandfathering (they happened to be in the right place at the right time) without any additional underpinning knowledge. Unfortunately we have created roles in EMS for people who mean well, rather than actually being a benefit for the patient.

In the emergency operations there should be 1 grade of clinician trained to the same standard and then deployed in ways to suit the local community. 

Wow,  I have a bunch of thoughts and will try to pass them on effectively.

In your original question you asked if we should be staffing with two EMT's with quick response medics in part, because the public doesn't understand the difference in our levels of licensure.  Do doctors have the same issue?  Does the public understand the difference between an MD, DO and a PA?  What about nurses?  Does the public understand the difference between an LPN, RN and BSN?

Let's quit lamenting the fact that Joe Q. Public doesn't understand the difference between a paramedic and an EMT much less expect them to understand what an advanced practice paramedic is.  When a citizen of the community I serve calls 911, they have certain expectations.  1.  An ambulance will come promptly to their location.  2.  The people on that ambulance will look and act in a professional manner and treat them with respect.  3.  The providers on the ambulance will help them to feel better, wether it be by taking them to a hospital or treating them.

I am not paid to determine if the person calling 911 is worthy of or deserves my help.  I am paid to answer their call and take care of them with the best clinical care I can provide and treat them with the dignity and respect they deserve.

Next, educational levels.  Here in the US we have the DOT who sets the standard for the EMT and Paramedic curriculum.  We have a new curriculum coming out in the next year or so that raises the bar for some of our skills.  The problem isn't there, the problem is at the school level in determining how long the instructor has to teach the curriculum.  Being a current paramedic instructor, I have the frustration of figuring out what topics I can skim over and which I will have the student self study in order to have the proper amount of time for others.  I know the DOT has a minimum hour requirement and most states do as well but these vary and cause consternation and frustration for the providers.  Anyway, I digress this is topic for another thread.

Having all providers be of the same level with the same grade of clinician.  I don't know how it is in the UK, but here is the US many communities are not and can not financially support any ambulance much less enough EMT's and a couple of paramedics to staff one.  Many counties pool the resources of the communities in them to have enough to finance one and possibly two ambulances full time.  But talk with those providers and you will find problems with pay and other areas.

Everybody being a medic or EMT is not the answer. I don't know what the answer is, however, I think I can see soem frustration in the original post that is bothersome.  I see it quite a bit in EMT's and Medic's that I personally know and work with.  I am seeing and hearing providers talk about patients in downright rude disrespectful ways that should not be allowed or tolerated. 

I find myself saying this quite a bit lately to my crew and those I work with.  "It doesn't matter why the patient called.  Ask them 'What is your medical complaint today? What hospital would you like to go to?' and then offer them a seat on the cot so you can transport them."  The nature of people is not something that we are going to change but berating, lecturing, or treating them with disrespect. 

As to providers who are "older," or "more seasoned."  Let me say that most of those providers that I know who fit this have learned and forgotten more about prehospital medicine than I have learned in 15 years.  Just because they are advanced in age does not mean they are taking up a spot or we have to coddle them.  If they are asked they can provide a wealth of knowledge and experience that others of us cannot provide yet.  Use them as a resource instead of disregarding them.

Okay, I'm done now.  Hope I made myself clear and have a good day.

I agree with a lot of what Dave has said - and thanks for making the points about the approach to the patient.  Those folks who think that they can discourage 911 use by being unkind and disrespectful to the patients are just plain wrong.

The DOT does not set the curriculum.  The DOT published a recommended minimum (developed by group input from the EMS community), that is recommended as the floor for EMT, (now Advanced EMT), and paramedic education.  It is we in the EMS community who tolerate the recommended minimum, the floor, becoming the ceiling, with our educational institutions budgeting minimum numbers of hours for the level.  If we really cared, we would "flash mob" the advisory committees and department chairs and insist on adequate (not minimum) education.

I do not buy the notion that communities "can" not afford EMS.  There may be some, but most (the vast majority) make a choice.  They pay teachers, they pay people to plow the snow, they pay accountants and nurses and pharmacists.  They CHOOSE not to pay for EMS because in their lifetimes, so many EMS "hobbyists" have been and still are willing to provide the service for free.  A friend of mine once proposed to an elected board in a rural community, "How about if this winter, we pay the EMTs to work the ambulance and ask for volunteers to plow the snow.  It requires a whole lot less training and education.  Let's see how that works out."  The silence was overwhelming.

The American EMS community CAN solve it's own problems, IF it will get up off it's collective lazy, complacent, whiny buttocks and take control of its environment and its destiny.

I'm not done.  I've only just begun!

Interesting, this is my key study interest in EMS, in that how many similarities exist in two different health care systems in providing the best possible care for a community. 

The major difference in the UK is that small rural communities have no say over their EMS cover and in fact many rural hamlets have either no cover or a volunteer first responder trained in first aid only. With ALS units being 30 minutes + away travelling to transport. 

In some places they have been testing retained EMS staff fully qualified EMS staff who have day jobs and respond to an emergency living in the town/village and collecting the ambulance. They are paid per job. It is still the National Health Service and still the same training and standards. The Fire service have been doing it for some time. As we move more to an annualised rota system, we will start to see agencies playing with seasonal employees and even split shifts. 

I'm not sure what the utopia service model would look like yet but certainly the UK is at breaking point, in many ways

Skip and Dave both have some great points, and I'm sure Skip can blow anything I say out of the water, he usually can at least.  But lets talk for just a second about sustainability and money.  First of all let me say that you can't fix the world, only your part of it.  I know that Governments waste money on all sorts of things other than EMS, but I have no say in those things at all right now, so I will focus on EMS.  Imagine a system in which a call could be triaged, and sent to the most appropriate unit.  BLS for routine, ALS for advanced or critical.  I'm not saying its perfect, but it might work.  I've worked ALS EMS for many years now, and more often than not, my "skills" aren't required, my knowledge sometimes is, and my compassion and or patience always is.  Doom and Gloom and scare tactics of "the next call might be a code!", or "might be a critical child!" don't fly, not in the real world.  The system as it stands is underfunded, overburdened and geared towards antiquated medicare and insurance laws.  NOT patient care.  In terms of patient care, I think Neils idea may hold water.  Imagine a world in which I'm working a night shift, a call comes out for chest pain, I am dispatched in a fly car along with a BLS ambulance.  On scene I find a 32 y/o male, 2ppd smoker, no history of cardiac disease, Law Enforcement is on scene and states that the patient requested a call to EMS once they detained him.  Patient states that he was fighting with his girlfriend, they got very upset, neighbors called 911.  I place the patient on 02, while my partner calms him, take his vitals, and run and transmit a 12 and 15 lead EKG to the hospital.  After approximately 10 min on scene the patient feels better, he is not pale, not diaphoretic, and has stable VS within appropriate limits but would still like to be checked out.  The Dr. and I speak and agree that we see no abnormalities on the EKG, and that the patient should be transported per his request to the hospital for evaluation.  I assist the BLS crew in loading the patient and they begin the 15 minute trip to the hospital.  I am now available again for any other call that pops up, what is so wrong with this? 

Now I gather from what Neil is saying, is that rather than a 10 year medic with some decent training in that fly car, we should be using a "basics" doc or one of the new physicians that I currently work and play with.  Maybe, maybe not, those guys seem to be hit and miss.  Personally though I like the fly car model, I like community based "para"medicine, and I like the idea of allowing a BLS crew to actually do some patient care. 

By the way, the above call has actually happened, many times in fact, but in reality I was the medic on the ambulance, their was no fly car, and per protocol after arguing with the medical control doc or RN answering, the man received an IV, 3 NTG and 324 mg of baby ASA.  Yes, I know how stupid that sounds, and I guarantee you it happens at least 50 times a day throughout the US if not 500 times a day.  But hey, as my old boss says, "at least we billed medicaid for an ALS call".  A total system overhaul is in order, I think flycars, an increase in community health and paramedic education along with a reduction in paramedics and increase in Advanced EMT's might be in order.  A reduction in litigation (some tort reform, NOT all) might be in order as well. 

I can't imagine my view here will really set anybody off, but in case it does...I've worked hospital, worked fire, worked tax based EMS.  I did go college, kept my NR, went to CC, been around longer than some not as long as others.  Currently teaching overseas and seeing a "truly" broken system.  Guaranteed transport and basic care availability with rationed out ALS service is something to think about.  The UK is a socialized system that taxes its citizens somewhere near 20%, if they can't make it work like a well oiled machine...well hell, I'd hate to see what it would take here with our tax code.  -Geoff Horning

Not trying to blow anything away, Geoff - I just have a different vision.  Looking at "today's EMS," I agree tht it could be carved up differently, and in some cases that might be more efficient - less paramedics, BLS transport for most everything.  In fact, I'd even say that there were some good aspects to the NJ system, with BLS done local and ALS provided by hospital paramedics.

What I see that is different is that the needs of the community have changed.  They're still asking for "rescue medicine" like they did in the 1980s ("today's EMS"), but they're also asking for community based, mobile, in-home health care and assistance - the combination to me is "tomorrow's EMS."  The system of the future will be funded to meet those needs, and the paramedic of the future will need to be much better educated to meet that much more broad spectrum of needs.  And we won't bill per call....

Where are you working now?

Love the idea of not billing per call, can't imagine it would lead to any more abuse of the system than we already have, and I think it would increase access in a positive way. Most importantly though, it might get providers at all levels thinking of patient care rather than billing issues.  Also love the idea of in home healthcare and clinic visits.  Unfortunately, I think its decades away for most of the nation.  There are far too many opponents on the nursing side of the house to let us even explore the idea in any of the areas I've worked.  I'm currently working in Saudi Arabia, There are quite a few of us over here (<10), working for the SRCA, working for colleges, working for some of the remaining institutes.  Were putting the Kingdom's next generation of paramedics through their paces. Were using the DOT guidelines, teaching to NREMT standards and using an American EMT-B and EMT-P textbook.  Curriculum development was done before I got here, but it's a 5 year program that will lead to a BSc.  Students take 2 years of prep before they get to us, and then continue taking other classes as they go through the EMT-B and EMT-P books.  They perform clinical rotations throughout the program and then culminate with a 1 year clinical internship.    I can message you details. 

Geoff Horning

geoff.horning@gmail.com


Skip Kirkwood said:

Not trying to blow anything away, Geoff - I just have a different vision.  Looking at "today's EMS," I agree tht it could be carved up differently, and in some cases that might be more efficient - less paramedics, BLS transport for most everything.  In fact, I'd even say that there were some good aspects to the NJ system, with BLS done local and ALS provided by hospital paramedics.

What I see that is different is that the needs of the community have changed.  They're still asking for "rescue medicine" like they did in the 1980s ("today's EMS"), but they're also asking for community based, mobile, in-home health care and assistance - the combination to me is "tomorrow's EMS."  The system of the future will be funded to meet those needs, and the paramedic of the future will need to be much better educated to meet that much more broad spectrum of needs.  And we won't bill per call....

Where are you working now?

I really enjoyed the ideas and responses to this thread and really like the fact that many people use evidence based versus opinion based theories. I do caution though the broad paintbrush idea that so many people like to paint EMS with. I have worked systems all over the US and Internationally and have seen systems that worked despite what someone else in another place laments. One example is the contention that volunteers can cause headaches. In Maryland and Virginia I witnessed county based systems that tried to fold EMS "hobbyists" into their fold to save a few bucks. This caused major issues with inconsistent work ethic, funding issues and even outright attacks from union and career staff that were losing hours and pay. Many of these systems were county based and only provided 911 response. On the other hand, I worked with squads in Pennsylvania that were nonprofit associations that were community based but not community funded. Many of these departments staffed full-time services and relied on volunteers to do community projects like staffing an additional truck for a high school football game, manpower for mass gathering events and even selling hoagies to purchase equipment that could not be purchased without longterm budgeting or the likes (sometimes complicated by delayed or total failure of medicare payments). These volunteers also gave the community a "local" face that resulted in better cooperation with the agency. I believe the same is true when it comes to painting a response model for the masses of EMS rather than the needs of the local community. A community in rural New York may benefit from a BLS truck to handle the majority of community calls while a hospital based ALS responder is available to handle the rare ALS calls that occur over several communities or an entire county. In the meantime, the expense and demand of a more urban department may not allow for such a system as ALS is more often needed and staffing two vehicles for a small footprint of responses seems redundant. To add international needs to the assessment complicates these demands even more. On a recent trip to Belfast I assisted with an ill patient. When I stated the patient should go to the hospital, based on my US experiences, I was told the patient would receive better and faster care from a doctor. My confusion was quickly resolved when a small car arrived, complete with flashing lights and Doctor written down the side, and a female doctor exited with a medical bag and small compliment of medications. This is not possible in the US anymore. Few doctors would pay the high costs of insurance to provide in-home treatment of patients or want to deal with billing for each of their responses. The more systems I work with, the more I witness the uniqueness of the way they operate and the unique demands they fulfill in their communities.

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