July 1st LA County - No Longer Sending Paramedics to Every Call

[wtferick]

LA county no longer sending Paramedics to every call.

Any thoughts?

Is this how other systems run?

 

[Jim37F]

As of right now, only calls triaged in dispatch as Sick-BLS and Injury-BLS are NOT getting a Squad auto dispatched with engine/quint and ambulance. Lots of other systems don't send medics to every call. Even in LA, City Fire routinely sends BLS ambulances to lower level calls in place of ALS units. Some systems lower acuity calls may never have a medic unit dispatched, only EMT unit. I believe Hall Ambulance (aka Kern County EMS Agency lol) has some dual EMT BLS ambulances they send to lower acuity 911 calls...and almost none of the FDs up in Kern are ALS for example.

 

[akflightmedic]

Such backwards thinking and I do not understand how anyone thinks this is logical. I get initial triage via dispatch...great improvement.

However, every citizen deserves higher level care as first point of contact. It absolutely makes more sense to have a paramedic in a squad, a car, or even on a motorcycle to get there first. There is a paramedic on damn near every corner in the US (this is hyperbole)....there is no reason for the more populated areas to meet the requirement of sending in a medic to start with. A BLS staffed but ALS equipped ambulance should be headed that way (no L&S unless dispatch triage indicates higher priority) and then the medic on scene can either ride in with the ambulance or he can triage it down to the EMTs.

This is a much more effective and logical approach to delivering pre-hospital EMS. I can expand more, but maybe this will generate some comments.

 

[Tigger]

Such backwards thinking and I do not understand how anyone thinks this is logical. I get initial triage via dispatch...great improvement.

However, every citizen deserves higher level care as first point of contact. It absolutely makes more sense to have a paramedic in a squad, a car, or even on a motorcycle to get there first. There is a paramedic on damn near every corner in the US (this is hyperbole)....there is no reason for the more populated areas to meet the requirement of sending in a medic to start with. A BLS staffed but ALS equipped ambulance should be headed that way (no L&S unless dispatch triage indicates higher priority) and then the medic on scene can either ride in with the ambulance or he can triage it down to the EMTs.

This is a much more effective and logical approach to delivering pre-hospital EMS. I can expand more, but maybe this will generate some comments.

The idea that a lower educated provider will have the ability to truly understand when a higher educated provider is needed has never made sense to me.

Also, the interventions that ALS has that are proven to work require some degree of time sensitivity, and to not have them on scene initially seems to be poor form. Furthermore, many of the "non-proven" interventions are not life saving, but they are still good patient care (symptom and pain relief). It seems that patients in tiered systems are less likely to receive these treatments as they are not "worthy" of receiving timely paramedic care and are thus given a rather glorified BLS taxi ride.

 

[aquabear]

But let's be honest here, the LA County EMS Agency has never been known for being "cutting edge," "modern," or "good." The EMS agency has to restrict the paramedic's scope of practice for a number of reasons (huge number of medics/provider agencies, the policy of "drafting" medics, etc.) that an ALS provider in the county is on par with most AEMT's else where in the country. Will this policy shift be good for the squadies? Probably. Good for patient care? I would argue that it won't be. If the problem is the squads are getting run into the ground, maybe it's time to staff more squads and less engines and quints, but IAFF won't be down for that.

 

[Jim37F]

Personally I think it'd make more sense to cut the suppression apparatus instead of the medic squad....seems like this is a half baby step in the direction of the other extreme of everyone gets a medic to look 'em over to the "don't send medics to every bls call instead save them for the ALS runs" mentality floating around out there. Just my $.02 on what I think they're ultimate intentions may be.

 

[EpiEMS]

Well, many areas of the country have EMT/Medic staffed ambulances...

But optimally, your system is probably best served with medic fly car responses followed by a BLS, or perhaps ILS, ambulance.

One problem that LA county seems to have is the limited BLS (and ALS, or so it seems) scope, there's a large gap between what is state of the art/science care and what's done in LACo. So, there's another problem.

A fourth, semi-related point: Suppression apparatus are superfluous for many calls...and expensive, very expensive.

 

[CodeBru1984]

As of right now, only calls triaged in dispatch as Sick-BLS and Injury-BLS are NOT getting a Squad auto dispatched with engine/quint and ambulance. Lots of other systems don't send medics to every call. Even in LA, City Fire routinely sends BLS ambulances to lower level calls in place of ALS units. Some systems lower acuity calls may never have a medic unit dispatched, only EMT unit. I believe Hall Ambulance (aka Kern County EMS Agency lol) has some dual EMT BLS ambulances they send to lower acuity 911 calls...and almost none of the FDs up in Kern are ALS for example.

Hey now... That's not fair to call us out like that! Hahahahaha.


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[RedAirplane]

I have heard issues of ALS providers becoming incompetent at the high risk skills (intubation etc) because many of their calls do not require those interventions. That is what changed my thinking from "more is always better."

Would it not be better to train EMTs on better assessments and have fewer paramedics triaged to the higher risk calls, but the latter actually able to perform the skills within their scope because they haven't forgotten how?

 

[NomadicMedic]

That's the basis of the Delaware system; fewer paramedics responding to more higher acuity calls. Not enough calls to burn you out, but enough true ALS level calls to prevent skill rust out. Fewer paramedics, performing more skills and interventions (when they're really needed) makes the most sense to me.

 

[akflightmedic]

Agreed, however when we are discussing places like FL and CA where you cannot turn in a circle without bumping into one, the focus turns onto how best to deliver the care using the abundance of resources available and what is best for the patient...cause these medics are not phasing out or going away anytime soon.

So with that in mind, the citizens deserve the higher level assessment FIRST and then a downgrade to the BLS side as opposed to BLS getting there and then upgrading to ALS. That kind of approach is bass ackwards...

 

[Bullets]

Hi, welcome to NJ!

I disagree, this whole state is structured that way. Every call gets a BLS ambulance provided in some way by the municipality and then an ALS unit is assigned based dispatching criteria or unit on scene request. The numbers support this. The majority of 911 calls are BLS level complaints, so this keeps our ALS available for the serious calls and gives the medics a high rate of skill utilization. This is why NJ Paramedics have statistically higher rates of intubations then other state systems. The municipalities i work for have similar numbers, and its almost 85% BLS calls vs ALS calls. The way the dispatch works gives a low index of suspicion for ALS dispatch. They have like a 60% cancellation rate on the calls they are dispatched to. Keeping these medics pointed towards high acuity calls if a more effective use for them. Otherwise they are just sitting on scene with a BLS patient waiting for a BLS unit to come.

 

[medicsb]

The idea that a lower educated provider will have the ability to truly understand when a higher educated provider is needed has never made sense to me.

Also, the interventions that ALS has that are proven to work require some degree of time sensitivity, and to not have them on scene initially seems to be poor form. Furthermore, many of the "non-proven" interventions are not life saving, but they are still good patient care (symptom and pain relief). It seems that patients in tiered systems are less likely to receive these treatments as they are not "worthy" of receiving timely paramedic care and are thus given a rather glorified BLS taxi ride.

"Lower educated" providers make decisions all the time regarding patient care. Most EDs staff triage with RNs. Sure, RNs have much more education than an EMT, but it still pales compared to an doc. (Of course, some EDs do put docs in triage, but this is more of a metric-based intervention since many hospitals like to track time to doc, and what better way to improve this than to put a doc in triage. The only docs that like this are the ones behind desks in some office who maybe work 1 shift a week in the ED.) Many specialty services have PAs or NPs take consults and then speak with a physician. Again, much more training than an EMT (and medic), but they are not as good as a doc. My point is that using a "lower level" provider to determine need for a higher level provider is part and parcel to medicine. EMS is no different.

I have no doubt at all that systems can achieve the same results with fewer paramedics, even many of you in "good" systems who don't have ALS engines - you could cut your number of medics to 1/2 or 1/4 of what you have and not have an impact on patient care. In some (I'd guess many) cases, you'd see certain outcomes improve.

For EMS, there are few "proven" interventions. But, at this point the ones with the most impact are actually pretty basic and can be provided by EMTs: epi-pen, CPR/defibrillation, albuterol, BVM, naloxone, rapid transport for trauma. Be that as it may, no one really thinks that time to paramedic arrival is not important, but I think many of us would say that arriving within 8 minutes is not necessary. To me, the idea that every EMS caller should get a paramedic is preposterous.

Also, pain management, well actually opioid-based pain management, is now finally being shown to be over-hyped, not better, and in many ways detrimental to patients. Only in certain case would I ever use analgesia as metric of quality. The idea that systems need more paramedics so that patients can get fentanyl faster is, to be blunt, stupid.

 

[akflightmedic]

When the entry level education and clinical time of a paramedic equals that of a nurse, then we can compare apples to apples. However in the streets, what we have and what the question is, is this: does a Paramedic have higher level of education, skill set and possibly experience than the EMT? Is there an abundance of paramedics in certain systems? If so, then how is it preposterous to suggest that the initial triage be performed by a paramedic in a fly car (faster response, more mobile) and then he/she turf the call to BLS if warranted or jump on the ambulance and ride the call in if ALS? Please explain how that is preposterous.

Yes, the majority of calls are BLS, that is not being argued. However, let's talk about medicine. We can remove the true cardiac arrest, the airway obstruction and the trauma calls as a lot of evidence suggest BLS is adequate and in some systems I would wholeheartedly agree. Let's talk about the patients who are medical emergencies but not yet life threatening...they are teetering on the edge. Do you stand firm in the assumption that delayed ALS is better, just to ensure we do not waste our paramedic resources? Or does it simply make sense to send in the paramedic first (again fly car envisioned here) with BLS unit en route slow roll until told otherwise (safer for all citizens) and allow the medic to then determine the necessary resources and practice some medicine at same time?

 

[medicsb]

When the entry level education and clinical time of a paramedic equals that of a nurse, then we can compare apples to apples. However in the streets, what we have and what the question is, is this: does a Paramedic have higher level of education, skill set and possibly experience than the EMT? Is there an abundance of paramedics in certain systems? If so, then how is it preposterous to suggest that the initial triage be performed by a paramedic in a fly car (faster response, more mobile) and then he/she turf the call to BLS if warranted or jump on the ambulance and ride the call in if ALS? Please explain how that is preposterous.

Yes, the majority of calls are BLS, that is not being argued. However, let's talk about medicine. We can remove the true cardiac arrest, the airway obstruction and the trauma calls as a lot of evidence suggest BLS is adequate and in some systems I would wholeheartedly agree. Let's talk about the patients who are medical emergencies but not yet life threatening...they are teetering on the edge. Do you stand firm in the assumption that delayed ALS is better, just to ensure we do not waste our paramedic resources? Or does it simply make sense to send in the paramedic first (again fly car envisioned here) with BLS unit en route slow roll until told otherwise (safer for all citizens) and allow the medic to then determine the necessary resources and practice some medicine at same time?

If there are so many paramedics that a medic can be on scene prior to BLS the majority of the time then consider me to have low faith in the medic training and experience. I don't think they'll be that much better than an emt in a system w low number of medics. A patient teetering on the edge will likely be best stabilized w basic measures first. I do not that not think an extra 5 minutes for a medic will result in marked morbidity or mortality.

 

[Tigger]

"Lower educated" providers make decisions all the time regarding patient care. Most EDs staff triage with RNs. Sure, RNs have much more education than an EMT, but it still pales compared to an doc. (Of course, some EDs do put docs in triage, but this is more of a metric-based intervention since many hospitals like to track time to doc, and what better way to improve this than to put a doc in triage. The only docs that like this are the ones behind desks in some office who maybe work 1 shift a week in the ED.) Many specialty services have PAs or NPs take consults and then speak with a physician. Again, much more training than an EMT (and medic), but they are not as good as a doc. My point is that using a "lower level" provider to determine need for a higher level provider is part and parcel to medicine. EMS is no different.

I get your point, but EMTs are lucky to have more than 120 hours of initial education. That is just not enough time to develop an ability to comprehensively assessing patients.

I have no doubt at all that systems can achieve the same results with fewer paramedics, even many of you in "good" systems who don't have ALS engines - you could cut your number of medics to 1/2 or 1/4 of what you have and not have an impact on patient care. In some (I'd guess many) cases, you'd see certain outcomes improve.

For the urban areas being discussed, I'd imagine you're correct. In rural areas if we didn't have the paramedics on the ambulance they'd never make it on scene.

For EMS, there are few "proven" interventions. But, at this point the ones with the most impact are actually pretty basic and can be provided by EMTs: epi-pen, CPR/defibrillation, albuterol, BVM, naloxone, rapid transport for trauma. Be that as it may, no one really thinks that time to paramedic arrival is not important, but I think many of us would say that arriving within 8 minutes is not necessary. To me, the idea that every EMS caller should get a paramedic is preposterous.

To my knowledge there is not great data correlating EMD coding without actual patient presentations. If we can be more accurate, reducing ALS responses would certainly be easier.

Also, pain management, well actually opioid-based pain management, is now finally being shown to be over-hyped, not better, and in many ways detrimental to patients. Only in certain case would I ever use analgesia as metric of quality. The idea that systems need more paramedics so that patients can get fentanyl faster is, to be blunt, stupid.

Which is not at all what I said in the slightest. If we really think that symptom and to a certain extent pain relief is not a job of EMS, the industry needs to reevaluate its priorities.

 

[Martyn]

If there are so many paramedics that a medic can be on scene prior to BLS the majority of the time then consider me to have low faith in the medic training and experience. I don't think they'll be that much better than an emt in a system w low number of medics. A patient teetering on the edge will likely be best stabilized w basic measures first. I do not that not think an extra 5 minutes for a medic will result in marked morbidity or mortality.

Goes back to the old BLS before ALS

I get your point, but EMTs are lucky to have more than 120 hours of initial education. That is just not enough time to develop an ability to comprehensively assessing patients.

My course had 480 hours for EMT (and considering I failed first time around and had to do it ALL again that made nearly 1,000 hours).

 

[SpecialK]

I completely agree there is no need to send paramedics to every call There are lots of examples of calls which can be closed with telephone advice or referral, this is widely used in the UK and is being rolled out elsewhere; currently about 4% of our workload is being closed this way. For those people who do require a physical response it can be a single officer in a car if an ambulance response is most appropriate, otherwise it can be another more appropriate person such as the district nurses, GP (for those few who still do home visits!) or mental health team (usually 2 mental health nurses but sometimes includes a psychiatrist).

There will always be the people who need a traditional ambulance staffed with paramedics, but there are increasingly more options for those who do not an call anyway. You can never stop people calling, it's just what you do with them.

 

[Tigger]

Goes back to the old BLS before ALS



My course had 480 hours for EMT (and considering I failed first time around and had to do it ALL again that made nearly 1,000 hours).

BLS before ALS is a tired saying. It's patient care.

Your n=1 experience does not mean that the majority of EMTs (myself included) in this country are woefully undereducated.

 

[gotbeerz001]

Goes back to the old BLS before ALS



My course had 480 hours for EMT (and considering I failed first time around and had to do it ALL again that made nearly 1,000 hours).

This is not accurate. You do not have 1000 hours of education, you have 480... It just took you 1000 to learn it. There is a difference. [emoji482]

#softball


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