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Sizing up staffing models on ambulances
Many EMS providers have converted their "dual paramedic" ambulance configuration to a "1+1"
By Art Hsieh
The Austin EMS system has had a solid reputation as an excellent service provider. Yet it, too, is not immune to the pressures of change and responding to the various challenges that face all systems.
While I don't know the exact statistic, it seems that many EMS providers have converted their "dual paramedic" ambulance configuration to a "1+1" staffing model. There have been several reasons given:
- It saves money. It is, on the surface, simply cheaper to staff each 1+1 unit compared to dual paramedic.
- In two-tier systems, it can increase the number of available ALS units.
- As this article points out, the experience level may increase for individual ALS providers.
- It standardizes the physical configuration of each unit, simplifying the restock, maintenance and replacement of each unit.
Yet, as an old-time medic, I do mourn the opportunity to work alongside another paramedic.
Make no mistake, a well trained and experienced EMT is a tremendous partner. But to bounce ideas and differential processes off a paramedic partner is different than that with an EMT.
It's a bit like being an airline pilot. The captain flies alongside another pilot, both who are trained to the same level. The junior pilot may have much less experience and may have fewer qualifications, but for at least that plane both individuals can fly it and make the decisions necessary to keep it from crashing.
EMS systems such as the one in Boston deploy such a system, where dual paramedic units support many more EMT-staffed units.
Because we operate in systems, I would love to see more research conducted that outlines the differences in outcomes and efficiency between differently staffed systems.
I recognize it would be tough to define all of the measurements. In addition, each system does have unique characteristics. Yet there must be a way to find the common parameters that can be used to find out what differences exist, if any.
The information would be very useful in EMS system development in the future.
Skip Kirkwood Thursday, February 02, 2012 5:22:22 PM A couple of thoughts. I, too, always enjoyed having another medic as a partner. But that was in a two-tier system that covered a large geography, so there were few paramedic units (3 for 450,000 people). Response intervals were LONG for the paramedic units!
The two-tiered model can work in some places and not in others. Remember that Boston is something like 40 or 60 square miles, with a large population and hospitals throughout. You can get places quickly, and transport times are comparatively short. And it works well.
In a larger geo area, that dynamic changes. Unless you are willing to settle for very long paramedic response times, you can't cover but one or two BLS ambulances with an ALS unit. So your costs go up, rather than down. To really look at that aspect, you need a sophisticated simulation engine like OPTIMA Siren - which is not readily available. When we simulated and considered two-tier for Wake County (860 square miles, then about 800,000 people), we would need something like 15 or 20 ALS units to cover 30 BLS units - or a total of 50 units, while with paramedic-EMT ambulances, we need about 35.
Last, the data seems to suggest that the more paramedics per unit population (or per cardiac arrest per year), the worse the patients' outcomes. That makes continued high-volume adding of paramedics a bad thing to do - one of my issues with the whole "paramedic first response" model that some advance.
Is Austin more like Boston? It sure rhymes better! But some metrics and some good (not politically biased) research out to be able to tease out a strand of truth, if we are so inclined. 
Christopher Paul McGonigall Friday, February 03, 2012 9:03:24 AM I disagree, in times as such as these where EMS services are stretched and why do you need two medics on every truck... A good EMT is worth two mediocre paramedics.. In the UK we are having less and less dual paramedic trucks if at all. We have one para/ Technician (about the same skill level as EMT-I/A) or even one of those two with an Emergency Care Assistant (Less than a EMT-B) we have more and more trucks with lower qualified staff on trucks and higher ones on cars/bikes...
We need a balance we need highly skilled clinicians but where they can be best utilised and in my view that is not two to a truck... 
Tom Wright Friday, February 03, 2012 9:29:38 AM As you say, every system is different and has different problems. In my very small system, staffing is the problem. If we aimed at staffing 1 + 1, then fill-in staff for vacations and sick days becomes VERY hard to come by. By attempting to staff with dual paramedic crews, filling in becomes easier because any level can meet license requirements. Our paramedics often work with an EMT or EMT-I partner and none of them complain about it. 
Greg Friese Friday, February 03, 2012 10:24:17 AM The pilot analogy is a bit off because the "plane" is the patient and not the ambulance. 747 pilots are not likely assigned to the commuter flight between Wausau and Chicago. Some patients are managed well by dual EMTs, some patients will probably do well with a single paramedic and some patients/flights need dual paramedics. Matching the staffing configuration with patient/flight is the tricky part. 
Alexander Kuehl Friday, February 03, 2012 2:26:29 PM What is gained by a second paramedic? BTW I am NOT talking about some intermediate hybrid that many here caLL "PARAMEDICS". The push of unions and their EM physician allies have made many EMS system totally inefficient. 
