Can’t swing a dead cat…

USA today had an article dated May 21, 2006 on paramedics, well, too many paramedics… A new study found that survival rates for out-of-hospital cardiac arrest were higher in cities with fewer paramedics per capita. This mirrors USA Today’s findings, first published in their special report, “Six Minutes to Live or Die,” in 2003, that called into question the national trend of putting firefighter-paramedics on fire companies.

The reason, at least the one stated publicly, that fire apparatus are carrying paramedics is to decrease the response time for paramedics in medical emergencies. Fire stations are everywhere, and it’s extremely impressive on paper to have ALS capabilities in less than 4 minutes on every medical call. In cardiac arrests, especially ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), it is absolutely essential to have a defibrillator on scene within 4-6 minutes for the patient to have any chance of meaningful survival with limited disability.

However, the majority of 911 calls for medical assistance are not cardiac arrests; instead they are for such minor medical problems as cut fingers, ‘flu-like symptoms, homeless alcoholics, baby spitting up, etc. This is not to discount such requests, but certainly an ALS engine response and an ALS ambulance response is a bit of a waste of resources, like arresting, without evidence, a teenager who wasn’t driving for a hit-and-run that no one saw. In tiered systems, calls deemed to be not life-threatening are handled by BLS units, simply because there is no need for ALS personnel who can be better used on more serious calls. In other words, save the paramedics for the good stuff. Paramedics would be thrilled to be able to avoid calls that any taxi can take care of.

Now, some have suggested that the use of paramedics on fire apparatus is motivated by self-interest. Fire departments have – along with powerful unions and excellent public relations machinery – big budgets. But years of public education, prevention and enforcement, coupled with modern construction techniques and strict building safety codes, have so dramatically reduced the number of fires that fire departments don’t have much to do these days. Simply put, in order to justify their budgets, they respond to medical calls to bump up their call volume, which, for the reasons stated above, isn’t necessarily a bad thing, especially in VF/VT arrests. Fully 70-80% of a typical fire department’s responses are for medical assistance, and the other 20-30% are not all for working fires.

The other problem with ALS fire apparatus is more subtle and wasn’t easily envisioned before it actually happened. In some regions, a paramedic license increases enormously one’s chance of getting through the ultra-competitive firefighter recruitment process, so some of these paramedics may not have the right motivation to begin with. Also, many  firefighters are firefighters because they want to respond to fires, not medicals. As a result, some firefighters view medicals as something they’re forced to do by their management, and we all know what happens when you have to do something you don’t want do. This is a source of tension between ambulance crews and ALS fire crews. (I personally don’t care as long as everyone’s nice to each other.) Add to this the longstanding fact that EMS is extremely trying on your patience most of the time anyway, and sometimes quality goes straight out the window.

Back to cardiac arrests and having so many paramedics that you can’t swing a dead cat without hitting one on medicals… The defibrillator needs to be available within 4-6 minutes of the onset of cardiac arrest, but it doesn’t have to come with a paramedic. So why not have BLS fire apparatus (and their very short response times) equipped with defibrillators respond to cardiac arrests, followed by an ALS ambulance? As it turns out, the EMS systems with the best survival rates do exactly this, and they have been doing it way before these specials and studies were produced.

Wipe my butt

Code 3 for the diabetic problem.

Man in his 30s on the toilet, having just had some soft bowel movement. Pretty smelly too. It’s all over the toilet. There’s an electric wheelchair in the bedroom. His arms look like he had a stroke or two in the past.

“I just need help off the toilet. And can you help wipe me? I’ve been here since 9 last night.” It’s now 2am. He does NOT want to go to the hospital. Just needs a lift. And clean-up.

Four male firefighters and I look at each other, frozen by the thought of having to wipe a grown man’s butt. That’s why we’re not nurses.

The firefighter/paramedic says to my EMT partner, “Where I’m from, the EMTs get to do this.” Kinda snotty attitude, if you ask me. Paramedics have 10 times as much training as EMTs, but that doesn’t mean EMTs shovel shit everywhere they go.

Thankfully my female partner was cool. In fact, she was the only one in that room who had any idea how to wipe this man’s butt.

“Can you imagine how embarrassing it is to have to rely on other people to wipe your butt? And you guys just stood there!”

My partner is very mature and thoughtful.

Background

Hi, I’m a paramedic in a poor urban area with a high call volume.

The county’s EMS (Emergency Medical Service) agency has immediate local oversight of all of its different EMS providers. All of the fire departments in the county have ALS (Advanced Life Support) engine and truck companies. A few of them have ALS ambulances. The primary ambulance service provider operates the majority of the ALS ambulances in the county for the EMS system.

An ALS fire unit carries at least one firefighter-paramedic, and an ALS ambulance carries at least one paramedic. Firefighters trained as emergency medical technicians (EMTs) make up the rest of the fire unit, and one EMT works with the ambulance paramedic. Sometimes there are more than one firefighter-paramedic on a fire unit, just like there are dual-paramedic ambulances.

When a person dials 911 on a landline, the call is routed to a PSAP (Public Safety Answering Point). If the call is for medical assistance, the PSAP dispatcher transfers the call to an Emergency Medical Dispatch (EMD) center, where an EMD dispatcher obtains the nature of the call and other relevant information, provides pre-arrival instructions in certain situations such as CPR, bleeding control, etc., and dispatches the appropriate personnel and equipment. Fire units are “toned out” from their stations, station-based ambulances are called via landlines, and flexibly-deployed ambulances are dispatched via radio.

In general, a code 2 response simply consists of an ambulance response without lights and sirens. A handful of fire departments send a crew on these code 2 calls. A code 3 response consists of a fire apparatus and an ambulance, both lights and sirens. A fire crew is known as the first responder, and they turn over patient care to the arriving ambulance for transport. On more serious calls, the firefighter-paramedic accompanies the ambulance crew during transport. The Base Hospital is available to crews for medical consultation via telephone or radio. In some cases, air ambulances are utilized, usually in more remote parts of the county or during rush hour.

Most transports are code 2, no lights or sirens. The Emergency Department (ED) at the Receiving Hospitals is notified with a brief report prior to arrival. Patient care is transferred to the ED staff, and a Patient Care Report (PCR) is submitted if time allows.

Time to go available.