This is an old article (2007) on the dangers of oversaturation of paramedics vs. EMTs. Well written, timely , and evidence based. Written by Matt Zavadsky. The original website, www.emsnetwork.org, is now defunct so I repost it so it doesn't get lost forever.

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INSIGHTS
Insights: How Much is Too Much?
Nov 15, 2007 - 11:42:17 AM
Insights: How Much is Too Much?
To coin the tag line from Bill O'Reilly, "You are about to enter the 'No-Spin' zone". Hang on to your hats boys and
girls for a soap box speech like none other!
One of the common themes in the series of "Insights" columns has been the need for EMS as professional to prove our
worth to our primary stakeholders, the patients we serve. While measuring true outcome-based performance has been
elusive, there is a growing body of research beginning to support one outcome that we probably don't want to talk
about. However, it is one we owe it to our communities and the thousands of people to have committed their
professional lives to our profession to address.
How many paramedics are enough??
On the surface, it seems pretty benign, right? If one paramedic is good, two is better, right? You can never have too
many paramedics, right?
Current cutting edge research is finally proving that is actually WRONG!
The Theory:
Paramedicine is a technical skill that requires practice to perfect. Consider this - many great paramedics get promoted
in our agencies. Along with the promotion usually come fewer patient encounters. At some point, that great
paramedic becomes a great supervisor, operations manager or deputy chief and a mediocre paramedic. Eventually,
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Insights by Matt Zavadsky, MHA focuses on the
implications of recent news from around the world and it's impact on
EMS nationally and in your home town.
Matt Zavadsky, MHA
About the columnist: Matt is the Director of Tri-State
Ambulance, a not-for-profit subsidiary of the Gundersen Lutheran
Healthcare System located in La Crosse, Wisconsin. Tri-State serves
as the sole 9-1-1 advanced life support provider for the 2,200 square
mile greater Coulee Region local in Western Wisconsin and Eastern
Minnesota.
He holds a Masters Degree in Health Service Administration and has
25 years experience in EMS including volunteer, fire department,
public and private sector EMS agencies. He is a former paramedic
and has managed private sector ambulance services from 10,000 to
more than 100,000 annual call volume in locations including
Fairfield, Connecticut; Augusta, Georgia and Orlando, Florida. He has
also served as a regulator in Lincoln, Nebraska and Volusia County
(Daytona Beach), Florida.
Matt is a frequent speaker at national conferences and has done
consulting in numerous EMS issues, specializing in high performance
EMS system operations, public/media relations, public policy,
employee recruitment and retention, data analysis, costing strategies
and EMS research.
He has served as the American Ambulance Association as Chair of
the Industry Image Committee and membership on the Professional
Standards, Strategic Development and Management Training
Institute Committees.
Matt is an Adjunct Faculty for the UCF's College of Health and Public
Affairs teaching courses in Healthcare Economics and Policy, Ethics,
Managed Care and US Healthcare Systems.
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2. that great chief or director is a dangerous paramedic, unless they continue to actively engage in patient care. This is
nothing personal against the paramedic, just reality.
Now, consider the tale of two EMS systems with similar demographics and patient care volume, but much different
approaches to the medicine in emergency MEDICAL services.
System A (say perhaps in a large urban area in the southeast) has an unlimited number of paramedics. In fact, the
stated goal of the department is to have all their personnel certified as paramedics. Consequently, when they respond
two units to every EMS call, all seven personnel on scene are paramedics. That patient:paramedic ratio is 1:7. This
means that once out of every 7 patients, one of those medics will do a complete patient assessment, start an IV,
intubate, or interpret a 12L ECG.
System B (say perhaps in a large urban area in the northwest) decides to limit the number of paramedics so that only 2
arrive on-scene for medical calls resulting in a 1:2 patient:paramedic ratio. This means that once in every 2 patients
one of those medics will do a complete patient assessment, start an IV, etc. Which system as the better skilled
paramedics? More importantly, which system generates better procedural success rates and patient outcomes?
Now, I know what some of you are saying already... "But, we train on mannequins to maintain our skill levels!"
I've been in EMS for nearly 30 years and have been blessed to work with some of the best paramedics in the world
throughout many outstanding EMS systems. Not once has a paramedic ever said "ya know, I had a mannequin do the
most confounding thing to me last year", or "That Fred the Head had one of the most anterior airways I’ve ever
tried to intubate". No matter how advanced a plastic dummy is; it is not the same as a real patient. Simply ask any
anesthesiologist, or cardiac surgeon, or emergency physician and they will tell you that you have to acquire skills
treating REAL people.
Another common misconception relating to this concept was recently articulated by a hospital administrator. He said
'as long as they meet the minimum standards, a paramedic is a paramedic'. I wonder if that's the criteria he uses to
choose a staff neurosurgeon for his hospital? Decades ago, most state governments put into place Certificate of Need
laws for hospitals and specialty care centers. Why did they do that? They knew that in order to assure high quality
patient care systems, they needed to control the proliferation of high risk, low volume care centers. That is why to this
day, there are REGIONAL trauma centers, REGIONAL stroke centers, REGIONAL burn centers and the like. This
regional concept concentrates the experts in medical procedures into catchment areas designed to assure a high
utilization for trauma centers for example. Why is there not a trauma center on every street corner? Because it's
better for the patient to be cared for by a few well practiced trauma teams then by numerous rarely utilized teams.
Think about it in a personal way - would you want your loved one who needs cardiac bypass treated by the surgeon
who does 100 real cases and simulated 100 cases a year, or the one who does 1,000 real cases a year? The same
principle is true in EMS.
But don't let the theory alone convince you…
The science :
A study published in the May 2006 Academic Emergency Medicine Journal demonstrated that patient survival from
sudden cardiac arrest was directly impacted by the patient care experience level of the field paramedics. Sayre,
Hallstrom, Rhea, et.al. found that patients treated by paramedics with a cardiac arrest patient experience level of 4.68
cases per year had a 27% survival rate; while patients treated by paramedics with an average of 1.63 cases per year only
had a 4% survival rate. [i] >>Fewer medics = better patient outcomes<<
Another study presented at EMS Today in March 2007 by Dunn, Dunn and Krowka at Denver General compared two
cities served by the same EMS system with identical demographics, response times and run volumes. The only
difference between the two cities was that one had an ALS 1st Response tier and the other had a BLS 1st Response tier.
The results were compelling. 100% of the patients in the BLS 1st Response city were successfully intubated, while
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3. only 78% were successfully intubated in the ALS 1st Response city. ALS 1st Responders were unable to intubate 53%
of the patients attempted. 38% of the BLS 1st Response patients had a ROSC, but only 13% of the ALS 1st Response
patients had a ROSC. >>Fewer medics = better patient outcomes<<
The now infamous research by Wang and Yealy published in Annals of Emergency Medicine [ii] found a 25% rate of
unrecognized misplacement of endotracheal tubes. They indicate that the low frequency of intubation practice is the
primary determiner of proficiency. >>Fewer medics = better patient outcomes<<
Finally, there is personal experience with data. During my time as the EMS Director for Volusia County, Florida, we
launched a comprehensive operational and clinical data collection process. The results were very telling. That system
had about 175 paramedics, 100 assigned to 1st response ALS fire engines and the rest employed by the county-wide
paramedic ambulance provider. Over the period of 3 years we closely monitored the intubation and IV success rate of
all providers, individually and by agency. There was virtually a 1:1 correlation between the number of
patient:paramedic encounters and the paramedic's IV and intubation proficiency rate. On average, a 1st Response
Agency paramedic treated 9 ALS patients per month, while the average ambulance paramedic treated 31 ALS patients
per month. Guess what? The intubation procedural proficiency rate for the 1st Response medics averaged 45% while
the proficiency rate for the ambulance medics was 88%. >>Fewer medics = better patient outcomes<<
Notice a scientific pattern here?
The Politics:
It is not surprising that agencies aspire to achieve paramedic level service. In many instances, paramedics make a big
difference in the overall comfort and clinical outcomes of some clinical presentations. The problem occurs when
politics forces communities to have more paramedics than the system can clinically support. Sometimes that "politics"
comes in the form of organized labor pushing for higher skill-based pay for their members, or an agency head lobbying
to have every employee as a paramedic. A politician recently said to me "we have the right to put paramedics in xxxx
fire department if we want to." While that may be statutorily correct, having the right is much different than doing the
right thing. What many politicians do not realize is that by diluting the patient:paramedic experience level, they risk
lowering the clinical capabilities of all the paramedics in the community. It is for this reason that politicians are ill-
prepared to make EMS system design decisions. Those decisions should rest with physicians who are experienced in
emergency medical care and who supervise the clinical activities of paramedics.
Well, it's time to climb off this soap box before I get hurt, or someone shoots me with an Ativan dart...
Hopefully, responsible EMS system leaders will step up and take a good, long, hard look at their own paramedic skill
utilization rates and make decisions regarding the appropriate number of paramedics that is based on sound clinical
standards, not convenient politics.
When it comes to the number of paramedics treating patients in EMS systems, science is proving that less is definitely
more...
It's time to change a paradigm!!
[i] ACAD EMERG MED May 2006, Vol. 13, No. 5, Suppl. 1 www.aemj.org
[ii] Annals of Emergency Medicine . 2006;47(6):532-541
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