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Home > Topics > EMS Management
July 31, 2014
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EMS News in Focus
by Arthur Hsieh

Chicago EMS changes moving in the wrong direction

There's no evidence that putting more paramedics on the street provides better pre-hospital care, and it may worsen it

By Arthur Hsieh

I'm lucky to have found my passion so early in my adult life. As a field-care professional for over 30 years, I've been witness to a few revolutionary steps that shifted the industry.

System status management began in earnest in the early 1980s. The rise of large, private EMS agencies came in the '90s. Then came the introduction of evidence-based medicine in the new millennia.

Each signaled a new era of development in the professionalization of pre-hospital care.

Each change has been met with stiff opposition, as they altered all that came before. These changes have thus far withstood the test of time.

With the current revolution underway in this nation's health care system, there is an opportunity to cement these changes with system-supporting financial resources — but only for systems that demonstrate appropriate and meaningful responses to the changing environment.

Which sadly, gets us to today's report of the modifications in the Chicago EMS system that are heading against the winds of industry changes. To date, there is no study that demonstrates a greater level of advanced life support providers changes outcomes in patient mortality, morbidity, or simply level of customer service.

Indeed, there is substantial evidence that a high density of paramedics within a system weakens skill proficiency. The cost is high as well — which I wouldn't mind if we could show that it would be worth it.

Problem is, we can't.

If Chicago's EMS system didn't take a penny of Medicare or Medicaid funding, it wouldn't matter as much. If the customer-taxpayers of the community were willing to fully fund the system to the level they want, that would be their prerogative.

But neither situation is happening, and given the historical track record of public pension crisis, I'm not sure how much more residents are willing to pay for a level of service that is unproven in its ability to improve public health.

About the author

EMS1 Editor in Chief Art Hsieh, MA, NREMT-P currently teaches at the Public Safety Training Center, Santa Rosa Junior College in the Emergency Care Program. Since 1982, Art has worked as a line medic and chief officer in the private, third service and fire-based EMS. He has directed both primary and EMS continuing education programs. Art is a textbook author, has presented at conferences nationwide, and continues to provide patient care at an EMS service in Northern California. Contact Art at Art.Hsieh@ems1.com.
Comments
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Robert L Graham Robert L Graham Thursday, July 31, 2014 3:04:10 PM Sir, if you had done your homework you would know that in Chicago the Firefighter/EMT-B actually makes more money per year than a Paramedic with the same time. you obviously don't know the EMS system here in Chicago like you think you do!! Under the current system the BLS ambulances have a much lower run volume than the ALS. This is because from the inception the BLS ambulance were never used properly, most residents also call 911 and provide false information about their condition. This is usually in the form of I have chest pain and you get there and they have a cut finger. Over the many years the BLS ambulances have been in service the criteria has been so tight that they are used much less. As you point out above "there is substantial evidence that a high density of paramedics within a system weakens skill proficiency" this couldn't be farther from the truth in Chicago. Since the BLS program has been in place there have been many many times where a BLS ambulance was dispatched to a ALS call because there were no ALS ambulances available. The BLS ambulance most of the time has waited for the ALS ambulance to arrive delaying care or upgraded the call with the paramedic for the engine. Notice I said Paramedic and not Paramedic's as we only run 1 Paramedic on the engine. I know I want 2 paramedics to show up when I have a medical emergency, I certainly don't want 1 medic from a ALS engine that would rather be fighting a fire showing up with a BLS ambulance. I can't see how you could be so short sighted and print a column about a EMS system you know nothing about. You clearly didn't do any research and have all your facts wrong in this case. EMS1.com should evaluate your reporting skills and consider removing you from the staff. My suggestion to you Sir is do some research before you write, if you can't then don't bother writing.
Jason Raymond Jason Raymond Thursday, July 31, 2014 3:07:04 PM I believe you're missing the key points. First, as a cost factor, the cost differential is negligible. CFD pays a FF/EMT-B more than a single role paramedic. The only difference in payroll would be the minimal amount the single role paramedic officer makes over a FF/EMT-B. Second, CFD's BLS ambulances are not utilized in the same manor as the ALS ambulances. ALS ambulances are "floated" to cover areas in which all ambulances are currently on assignments. Whereas the BLS units are not. Some BLS units only run 6 calls per 24 hr shift.
Robert Hutson Robert Hutson Thursday, July 31, 2014 3:42:49 PM I hope you are speaking about system status management as a change not for the better. While it can improve response times somewhat the toll it takes on personnel and equipment is huge and generally deemed not to be worth the cost.
Levi Tucker Levi Tucker Thursday, July 31, 2014 4:06:37 PM Disagree
Pete Hannen Pete Hannen Thursday, July 31, 2014 4:29:23 PM Art if every patient has access to adequate pain relief, then it is worth it.
Michael Mckinnis Sr Michael Mckinnis Sr Thursday, July 31, 2014 5:46:43 PM Sir with all due respect you have no clue about Chicago EMS. have personally been involved in Chicago EMS since 1981. I am currently an Instructor with Malcolm X College EMS program. I have served with Chicago Fire Dept as a Paramedic for over 20 years. Presently retired due to duty disability. There have been multiple reports done to suggest that Chicago Fire Dept needed to increase its ALS ambulances in order to provide a better level of care to its citizens. I personally worked on Ambulances in which days consisted of performing 20 plus call a shift with average runs lasting an hour. That doesn't leave much room for crews to be rested in anyway to be able to perform at a high level necessary to provide efficient ALS service, yet the crews in Chicago have done this for quite some time. I left as a Ambulance Commander. I have seen Chicago EMS from all sides of the situation, Field medic to Administrator(IAD investigator) Hands down most EMS complaints were directly related to crews overwhelmed by the workload that could be reduced from additional crews available. In essence I strongly disagree with you sir Michael E Mckinnis Sr Ambulance Commander Retired Chicago Fire Dept
Cheryl McClinton Cheryl McClinton Thursday, July 31, 2014 5:59:52 PM Everyone is entitled to an opinion and this is merely the authors take on a issue. I wonder if author has ever been to Chicago and not just passing the airport? Has he every been to the South Side? Has he ever dialed 911 and waited 22 minutes for an ambulance while his mother was in cardiac arrest? Does the author know Chicago sees double dight shooting on weekends? If he know theses things he could possible understand why we need more coverage. The BLS ambulance were grossly underutilized. Staffed by firemen that wanted nothing to do with EMS. So convert them to ALS and staff them with medics that want to do the job.
Jason Peace Jason Peace Thursday, July 31, 2014 7:36:08 PM Are you actually trying to imply that because as a provider, we (The Chicago Fire Department) are converting our BLS fleet BACK into a 100% ALS fleet is somehow is a reduction in our "level of customer service?" That's right, I said BACK! Prior to June 1st, 2000 our fleet was 100% ALS and since it's inception the BLS program has been flawed at very best. No longer will the citizens of the City of Chicago depend on an EMT-B to assess them and treat their ailments.... that's right! Soon two Licenced Paramedics will be providing ALL assessment and treatment to our citizens and that is somehow this will not "improve public health?" Cost? Well I'm glad you asked, operationally it costs the city about the same to operate a BLS Ambulance as it does an ALS ambulance....How could that be? Well the BLS ambulance is staffed with Cross-Trained personnel that get a 6.5% incentive to do both jobs. We won't talk about the dis-service to citizens that meet ALS critera and for any number of reasons get a BLS ambulance. Maybe we decided not to follow "the current revolution"....maybe "the current revolution" should consider calling us! If I call 9-1-1 I want the CLOSEST ambulance to respond to my needs and I want TWO licensed paramedics on that ambulance! Why? Because I'm a customer and I deserve the VERY BEST! Jason Peace Lieutenant/Paramedic Chicago Fire Department
Elizabeth Burke Elizabeth Burke Friday, August 01, 2014 7:20:53 AM Amen!
Todd Williams Todd Williams Saturday, August 02, 2014 6:57:05 AM Sir- In the past, I have read and enjoyed many of your articles, and even referred to them in my classes. In this case, I disagree with many of your assertions. System status management is one of those ideas that looks great on paper, but does not always work. For example- theoretically, dynamic deployment can work as long as the system has real time monitoring and good detailed tracking and analysis of response times, and often times this is not the case, but as was noted, it is also not the optimum situation for the providers. As for the notion of more ALS providers causing the degradation of skills- I agree that is the case, but that is assuming the system has enough providers to begin with, response times are being met, and there is a timely response of a transport unit. In other words, if the system is already being run effectively and efficiently. In Chicago, that is simply not the case. As mentioned by my colleagues, there is a severe shortage of ALS providers, response times far exceed national standards, all due to a combination of factors. Obviously personnel shortages are a cyclic issue simply due to attrition- retirements, promotions, reassignments, but due to a combination of factors, we have seen a huge spike in these numbers. Adding more ALS providers will merely bring our manpower up to par levels, not overload the system. As we all know, there are many types of EMS systems, and many different situations, I am simply suggesting that making a blanket statement about the status of an EMS system or solutions to its problems won't be accurate unless you know more about the details of the problems there.
John Franta John Franta Saturday, August 02, 2014 9:21:00 AM Sir, I strongly suggest you put some time in on an ambulance in Chicago before writing an article criticizing a move we are making to better serve our citizens and take some of the strain from 25+ runs off of our crews. I really cant say much more than what Jason Raymond, Todd Williams, Robert Graham, Michael Mckinnis, and Jason Peace have already stated. We will be having a massive hiring to staff our new ambulances. Feel free to apply JohnFranta PIC Chicago Fire Dept
Alexander Kuehl Alexander Kuehl Saturday, August 02, 2014 9:38:03 AM The problem in reaching conclusions is the difficulty in comparing apples and oranges. That tis 2000 hour paramedics with 200 hour emts.. My guess is that the most efficient (in most systems)approach is experienced super EMTs.who respond with a driver/helper.
Bob Kellow Bob Kellow Saturday, August 02, 2014 10:09:09 AM The OPALS study pretty much confirmed your position. However, changing 40-years of largely unfounded opinions and beliefs is another matter entirely.
Adam Blitz Adam Blitz Saturday, August 02, 2014 6:27:33 PM You chicago guys are all proving his point with each text. Keep denying that the rest of the EMS world is moving away from "the more medics, the better" mentality vs tiered systems with more advanced EMT cars and fewer paramedic rigs - and we'll see you in a few years when you realize you now have so many medics that your infrequent skills are even MORE infrequent. You can't get better at a skill by having less and less occasion to do it. A sharper EMT is better than a dull medic. Sorry. The idea is not to get rid of medics altogether because there will always be the need. Just to not saturate a system with them. There is plenty of data proving this. Check out Toronto EMS, for one.
Mark Todd Mark Todd Sunday, September 21, 2014 11:19:16 PM I'm gearing my response in another direction but I feel it pertains to this. I'm curious to know if the study looked at the training and quality improvement of the system. Skill proficiency doesn't decline because more Paramedics are put on the street. It declines because 1) The Paramedic fails to see the importance of always learning and getting rid of the "This is the way it's always been done" mentality 2) The system has a poor training program and quality improvement program 3) Both 1 & 2 happen. The less you perform a skill, the less chances you will be able to perform it with no mistakes. Train with stress. Train for how to respond when Murphy steps in the room and fouls everything up. Have realistic scenario training programs. You don't need a fancy simulation lab, you just have to be creative in the ways you train. You need to work with your Paramedics to let them know what areas need improvement and make sure they follow up on that. Have regular quizzes and tests. This will make sure Paramedics are staying current with new standards. You can give a written test on new protocols, make sure you follow it with a hands on scenario training to see if they truly absorbed the information. Like others have mentioned, crews don't have much rest time in Chicago. If more ambulances are placed it means a reduce work load on crews. To all those who don't agree, just ask yourself this : Would you want an airline pilot to fly your plane on 20 hours on non stop work? Would you want a surgeon to perform surgery on you with 2 hours of sleep who has been working with little breaks in between? In small towns and cities with a low to medium call volume, SSR works well.

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