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ALS staffing: What do communities really need?

A new law has been passed in Mass. that allows municipalities and private ambulance companies to reduce the number of paramedics who work in advanced life support ambulances

Lawmakers in Massachusetts have passed a new law that allows municipalities and private ambulance companies to cut in half the number of paramedics who work in advanced life support ambulances, The Boston Globe revealed this week.

Officials from the Massachusetts Ambulance Association, which represents the majority of the state's private ambulance companies, said it brings Massachusetts in line with the policies of nearly every other state in the United States. The Fire Chiefs Association of Massachusetts said the law will allow towns more flexibility in how they deploy their ambulance staff.

However, there is some opposition, specifically from Robert B. McCarthy, president of the Professional Fire Fighters of Massachusetts, who told the newspaper, "People are going to die because of this law." James W. Hooley, chief of Boston Emergency Medical Services, was reported as saying it could be detrimental to patient care in some cases.

I enjoy being a paramedic. And, I have a passion for training EMTs. Each level of EMS provider — Emergency Medical Responder, EMT Advanced EMT, and paramedic — occupies a niche of the prehospital care profession.

Each level has its strengths and weaknesses in terms of training, scope of practice, authority and responsibility. Given the diversity of the country we live and work in, I think it's an excellent — and necessary — way to provide prehospital care services across the United States.

Sure, it would be terrific to have paramedic level services in all areas. In certain situations, I'd advocate for two paramedics working side by side. But to say that the absence of a dual paramedic — staffed unit would put the public in harm's way — that's going a bit too far.

Please show me the data that would prove the allegation that "people are going to die" because of the new Massachusetts's law eliminating dual paramedic staffing. This rhetoric is baseless, and useless to the evolution of EMS systems. So far, studies that have looked at the provision of ALS services haven't been very flattering.

I can put it another way: When I first became a paramedic in 1985, coincidentally in Massachusetts, there were only a few paramedics in the state. Most prehospital care was provided by EMTs. Paramedics worked together and supplemented the primary BLS tier, providing additional services in the more critical cases.

Fast forward to 1990, and I worked in San Francisco in an all ALS EMS service, consisting of about 130 paramedics staffing an average of 10 ambulances daily. For the most part, each system worked — there were enough ALS contacts for each paramedic to maintain a certain level of proficiency necessary for competency.

We seem now to be in an era where more is better — more paramedics, that is. I don't believe it's a healthy approach to managing the public's health. It isn't as if there are more intubations and more critical patients that need to be managed — in fact, with better technology available today, we can avoid placing patients at risk entirely by utilizing procedures that are more effective. Paramedics are needed, no doubt — but not in an environment where the supply far exceeds the demand.

Perhaps ironically, I do like working alongside another paramedic. There's the ability to throw ideas and check ALS assessments with a paramedic partner. But, a well trained EMT can be as effective in the partnership. Systems need to have that flexibility to help preserve services when the economy is suffering. It's not a perfect world we live in, and until the evidence proves otherwise, responses like these won't help improve very much of anything.


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