Mar 6, 2011

Staffing Dynamics; A tale as old as time

Since the beginning of all conceivable time it has been wondered what is the best way to staff an ambulance. It has been debated amongst the paper pushers, Emergency Managers, Director's, Board Officials, Supervisors, and Preparedness experts. Though no single perfect solution had ever been forged from these discussions.

So what is best for the system as a whole? Double Medic rigs, Medic/Basic trucks, Double Basic with ALS Fly car, Medic with Driver only, or Double Basic's with hospital being ALS? Frankly how do you even debate when the idea of Best is so foreign also. Best for patients, Best for sustainability, Best for retention, Best for profit margin?  Obviously we have to do whats in the best interest for the patient, but if we can not retain staff how does this benifit patients? If we can not afford to be paid and stay in business how does that benifit patients? When the idea of whats best for the patient is so abstract and different from system to system how can we possibly define how to best serve the system with out being with in the system?

As usual I have gone on a bit of a tangant so; Locally the career shops run Medic/Basic or Medic/Driver only rigs as the standard. Occasionally Double Medic trucks as the staffing allows, though its not the set precedent regionally. The majority of the volunteer world has what they can get, mostly who shows up to the call, which would lend to a lot of Basic only trucks. 

Now obviously I don't intend to have the all mighty answer that will change the world of EMS staffing dynamics as we know it. I realize that it really is system dependent on what works for your area. If you hoped for a large volunteer base to staff Basic rigs in hopes to only rely on paid ALS Fly cars you'd have to plan for the increase death rate due to poor volunteer turn out in my system. Though if this works for your system I applaud your community and believe that you turn out much stronger and more confident basic providers than other systems.

The way I see it, the use of Double Medic trucks have the ability to demoralizing providers over time with a constant barrage of patients who do not require advanced interventions. It allows the poison to seep in and self questioning of why am I a paramedic if I only do BLS calls. This along with the lack of exposure for Basic providers will create weaker providers by not exposing them to calls. Inevitably decreasing our future recruitment by excluding those who want a bit of exposure to see if its for them.

Use of Medic/Basic trucks allows a proper assessment by a medic and transport by a basic if warrented. Which seems to be an excellent idea for doing whats best for a patient. On the other hand having a Medic right there is a bit of a crutch for a Basic provider. Knowing that a ALS assessment occured and it must be a BLS call can lead to weaker providers. Can these folks handle being with no medic as a safety net?

Use of Basic only rigs where as the hospital acts as closest ALS leads to a rapid mentality. Everything is a load and go situation, everything is hurried in fear of the patient crashing. In the unlikley occurance of an ALS assist can they calm themselves and revert from the load and go mentality of rushed care.

 Use of double Basic rigs with ALS fly car of course strengthens the Basic providers skill set but they also get engrained with the crutch mentality knowing that ALS is coming. Can they handle themselves in a system overload situation? Where they must transport to the hospital due to all fly cars being tied up is unseen.

So as I knew I wasnt going to have a solution, rather just open up discussion and set forth my opinion. When it comes down to it, it really is system dependant and there is no real solution that fits everyone. Though I'm sure you all knew that.

Be Safe
Ambulance Junkie


  1. Having worked/volleyed/trained systems using all the variables above I have to advocate for double medic/double basic trucks.

    A benefit of double medic is that the level of care decision does not need to be made prior to transport. Initial assessment, vitals and packaging can be done onscene, transport can be initiated and if, during the continuing assessment, the provider decides to initiate ALS care they can do so. If a medic triages a patient down to their BLS partner, both providers are taking a risk that there is no missed/underlaying condition.

    Double basic ambulances force EMTs to gain strength and confidence in their skills that are lost when they have a ALS crutch 24/7.

    Finally switching off each call (or tour) with your partner provides a stable nwork environment and is much less likely to overwhelm providers.

    Just my $0.02 :)

  2. All interesting points. . .in my opinion the ideal situation is highly dependent on the service area that a particular service is responsible for. What are the demographics of the area? How many of the calls really require ALS? How close is the community hospital? Trauma Center? PCI Center? Stroke Center? How readily is aeromedical resources available? Do weather patterns support regular use of these aeromedical resources?

    Once the data is analyzed an intelligent dialogue can begin about what is best for that particular community. But the data is really only the beginning; how does the rate of ALS calls compare to the rest of the region? State? Nation? Or, more importantly, a community of comparable demographics? If it's too high, perhaps the most efficient thing to do is identify the reason for all that ALSing -- the same holds true if the opposite results appear.

    Personally, I am a big fan of BLS ambulances supported by ALS fly cars. . . Why? Painting in broad brush strokes and making some sweeping generalizations: most of our calls do not involve life or death -- many do not involve life or limb; most patients can successfully be managed at the BLS level without declines in patient outcomes. That said, the ones that need ALS should get it (and not just limited to life-saving maneuvers -- pain management, ememsis/nausea control, etc all are absolutely warranted in the field and should be treated aggressively).

    Fly car based ALS allows for "controlling" the ALS population so that there are enough calls that allow them to maintain proficiency in their skills without over saturating the market causing a degradation of skill level. More medics in a system is not always better...

    Ben Krakauer