Paramedic Engines

[Craig Alan Evans]

Hey check out my new blog post on ALS Engines and how to operate as an EMS assault team.

http://craigalanevans.blogspot.com/2013/06/the-ems-enginehow-to-be-ems-assault-team.html?m=1

 

[medicsb]

ALS engines are vital to patient care? Sounds like you been guzzling the IAFFs cool-aid.

Prove to anyone that these programs are anything more than wasteful spending that does nothing other than severely diluting paramedic experience to the detriment of patients.

 

[Craig Alan Evans]

It's definitely not like that in my neck of the woods. ALS Engines operate just as I have described. If that's the IAFF cool aid it sure tastes good, and it benefits the patient to be assessed and treated with this team approach.

 

[medicsb]

The evidence. Where is it? Prove that your program or any other has been associated with a decrease of morbidity and/or mortality. If such an expensive program is so vital to patients, then surely you have more than anecdote to back up you claims.

 

[MrJones]

 

[Rialaigh]

The evidence. Where is it? Prove that your program or any other has been associated with a decrease of morbidity and/or mortality. If such an expensive program is so vital to patients, then surely you have more than anecdote to back up you claims.

To be fair to the guy, prove that any paramedic program (not just fire based) has been associated with decreased morbidity/mortality....


and yes, giant waste of money when looking at anything other than public perception...

 

[Carlos Danger]

I didn't read the entire blog post closely, but I skimmed over it and I wanted to point something out.

In the airway assessment section of your piece, you wrote:

A Mallampati class I will be a Cormack-Lehane grade I in 99%-100% of cases. You can proceed with paralyzing the patient to establish an airway without any concerns.

In actuality, the Mallampati score by itself has been proven to be a very poor indicator of the difficulty of intubation. A person can have a class I airway and still have a very difficult airway.

In Predicting Difficult Intubation in Apparently Normal Patients: A Meta-analysis of Bedside Screening Test Performance, the investigators found that the best bedside predictor of difficult intubation was a combination of the mallampati test and thyromental distance. But even this combination had poor sensitivity.

Even if the patient is anatomically perfect, there are still physiologic factors (which I don't think your article even touched on) that can make airway management very difficult. I would be extremely cautious about suggesting that prehospital airway management can ever be done "without any concerns".

With all due respect, I think these are some very important errors that should be corrected.

 

[Dwindlin]

To be fair to the guy, prove that anything in EMS (not just fire based) has been associated with decreased morbidity/mortality....


and yes, giant waste of money when looking at anything other than public perception...

Fixed that for you.

 

[Craig Alan Evans]

Halo, I agree with you. Thanks for the input. I didn't want to get too detailed into any one aspect of an overall patient assessment.

 

[Craig Alan Evans]

So explain to me where all the money is wasted.

 

[Arovetli]

So explain to me where all the money is wasted.

"The concept of the ALS Engine has been a great posititive impact on the fire service and the communities we serve"

I think they would like you to offer proof.

 

[medicsb]

So explain to me where all the money is wasted.

Payroll
Cost of ALS supplies and maintenance
Training
Con-Ed
Increased wear and tear on engines
Increased fuel costs for engines
Insurance for the paramedics

Anyhow, I know you (or any proponent of the ALS engines, even Gary Ludwig) don't have any evidence to provide. In the few decades that places have been putting medics on engines, I have yet to find any thing that shows any benefit. (I would bet that someone has actually studied it to some extent, but without the results being being published. Probably due to no evidence of benefit.) However, there is fair amount of evidence showing that "more" paramedics is not better and may be detrimental to patients.

 

[JPINFV]

However, there is fair amount of evidence showing that "more" paramedics is not better and may be detrimental to patients.

There's that study from a few years ago that show that more fire fighters allow tasks to be done slightly faster with zero indication that the minimal decrease in time spent is in any way clinically relevant.

 

[abckidsmom]

There's that study from a few years ago that show that more fire fighters allow tasks to be done slightly faster with zero indication that the minimal decrease in time spent is in any way clinically relevant.

Here's what I know from working isolated on my ambulance with me and a BLS partner: when we have help, life is so much easier. It is hard work to gather a history, assess the patient, and move him to the ambulance, directing my partner to do each and every task he does because he's inexperienced and young.

Adding the layer of first response would be extremely worth it, from where I sit, an hour from the hospital, with a run on very high acuity patients lately. I don't know if you can measure the clinical significance of the medic who's not totally dragging at the end of the shift.

Lessening the workload on the way would help with that.

 

[jwk]

I didn't read the entire blog post closely, but I skimmed over it and I wanted to point something out.

In the airway assessment section of your piece, you wrote:

In actuality, the Mallampati score by itself has been proven to be a very poor indicator of the difficulty of intubation. A person can have a class I airway and still have a very difficult airway.

In Predicting Difficult Intubation in Apparently Normal Patients: A Meta-analysis of Bedside Screening Test Performance, the investigators found that the best bedside predictor of difficult intubation was a combination of the mallampati test and thyromental distance. But even this combination had poor sensitivity.

Even if the patient is anatomically perfect, there are still physiologic factors (which I don't think your article even touched on) that can make airway management very difficult. I would be extremely cautious about suggesting that prehospital airway management can ever be done "without any concerns".

With all due respect, I think these are some very important errors that should be corrected.​

Kinda difficult to predict a Mallampati score and adequately judge 3:3:2 on an unconscious and/or traumatized patient, which would of course be the patients most likely to benefit from airway interventions.​

 

[Handsome Robb]

Haven't read it. Going to when I wake up tomorrow cause I'm exhausted but we have mostly ILS engines with ALS engines in the outlying areas and I think it's beneficial considering you have a Medic and usually one if not two EMT-Is to the patient sometimes 15-20
Minutes before we are, especially if we are low levels and responding from a central location.

It's also key that we have good relationships with many of those medics because they work PRN for us or used to work full time or both. Obviously there are some crews that butt heads with each other but that's unavoidable.

 

[Wheel]

Like I said in the other thread, I think you're mistaking your abnormally high speed, motivated system for the standard, rather than the exception to the rule. In this I'm including most non fire ems as well. Fire based is often very redundant, and I can imagine it is in your system as well. How much can six medics really do on a scene? There are only so many ALS skills, and 99% of patients don't get many, some don't get any, and only a handful will get all of them.

I think it's great that you're motivated to provide excellent care. I hope you and your system continue to do that, but please don't extrapolate on incomplete (read: no) data and assume that fire based EMS is God's gift to America, because it isn't. Some of the most outstanding systems in the world (Australia, NZ, Canada) and in the US aren't fire based, and there is a reason for that.

 

[RocketMedic]

Craig, that fancy 6- or 4-man engine would be much, much, much more useful parked in a garage. Give the fire medics a small SUV and get them doing flycar stuff.

 

[Craig Alan Evans]

Kinda difficult to predict a Mallampati score and adequately judge 3:3:2 on an unconscious and/or traumatized patient, which would of course be the patients most likely to benefit from airway interventions.

Agree, which is why I try to emphasize sizing up airways on all your conscious patients that may be going down the road to more advanced airway management. Be ahead of the game is what I preach. The patient population you are referring to will require airway management regardless and we just have to use all of our tools to do so.

 

[46Young]

Craig, to be fair, for every engine company, it would cost about the same to put two ambulances on the road. ALS engines can be useful as a band aid if the system can't afford he extra ambulances, since they're already existing. When an area grows in population over time, the increase in EMS runs will dwarf the increase in suppression calls. My county's answer is to add stations with an engine and medic, instead of just adding medic bravo units.

For example, instead of opening up sta 442, it would have been much, much cheaper to put up M429B and M425B instead of building a new station, and creating six new positions (engine/medic) instead of just four jobs for the two ambulances.

It could be argued that a fire based system uses ALS engines to save on deploying more amblances. This isn't exclusive to the fire service. How many EMS services use system status management/PUM? How many EMS systems have murderous call volume? How many EMS systems are private-based and (on the down-low) give priority to IFT over 911 calls whenever they can take that risk?

My opinion is that the more rural and financially strapped a system is, the more relevant ALS engines are for coverage. The more urbanized an area is, the more effective a seperate (meaning single role) system is (think NYC for example).