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, 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<<