FDNY In Single-Medic Uproar

[x635 4,066]

FDNY In Medic Uproar - New York 

NYPost.com

A battle between the FDNY and its medical personnel is heating up over a new department bid to staff ambulances with one paramedic instead of two. 

The debate is whether the plan will save lives, or risk them. 

Of the city's current 550 daily ambulance shifts, just 147 are staffed with paramedics. 

The FDNY says it wants to improve its lagging response times to life-or-death medical emergencies by splitting up paramedic pairs and placing them with a lesser-trained partner in 100 more ambulance shifts a day. 

Under the current system, two paramedics must staff each advanced life-support ambulance, which handles serious cases such as cardiac arrest. 

Two lesser-trained emergency medical technicians staff each of the city's basic life-support units, which provide first aid and transport.

The FDNY is now calling for a rule change to allow ALS ambulances to be staffed with one paramedic and one EMT. 

This would get ambulances with at least one paramedic to patients faster. The downside, critics say, is that the quality of care could suffer. 

Only paramedics can install breathing tubes, start an intravenous line and administer medications. 

"I think for people who require a paramedic immediately, it would make a big difference in improving their chance of survival," said John Peruggia, the FDNY's chief of emergency medical service. 

"The first arriving unit would have the ability to begin advanced life support, where today that's not always the case," he said, adding that a second paramedic ambulance would be dispatched to help in heart cases. 

The plan will be introduced Tuesday to the Regional Emergency Medical Services Council, which sets rules on ambulance staffing and protocol. 

"We don't like it," said Robert Unger, spokesman for city unions representing EMTs and paramedics. 

"When paramedics arrive at a cardiac arrest, you need two people with the skills and authority to treat you. When your heart stops, you don't want a situation where one person does the whole job." 

The FDNY says paramedics should arrive at life-threatening calls in less than 10 minutes in 90 percent of cases. 

Jan 9, 2005, 02:08

 

http://www.nypost.com 

[JBE 328]

Why don't they just do the right thing, and train/hire more medics??

[Pudge3311 5]

Its not about training and hiring more medics. There is a shortage of medics all over the country, and when one can go to the private sector and make more money than working for the city, you quickly find yourself trying to play catchup.

[tbendick 27]

There also could be a lot more to this that meets the eye.

For example FDNY Engines ride as CFR-D units. Most have only 4 FF's and one Officer. Maybe the 5th person will come back but as a FDNY Medic (Not a FF/Medic). Now you have an ALS response unit. Also EMS LT's and Capt's can do ALS care in the field if they are alone. Now they would be able to do so.

Also what wasn't stated is that they are not planing on reducing the amount of medics (atleast they say so) what they want to do is put out extra ALS units with only 1 Senior Medic. Jr. Medics will still have to ride on a 2 person ALS unit.

____________________________

Fire Department City of New York

Phone: 718-999-2770

9 Metrotech Center Fax: 718-999-0112

Brooklyn, NY 11201

Maximizing ALS Response

A Proposal to Change the ALS Staffing Requirements

FDNY's Plan to Maximize ALS Response

A Change to the REMAC ALS Staffing Standard

Introduction

The New York City "911" EMS system responded to 1,109,287 requests for EMS assistance during calendar year 2003. Of these, 402,652 were categorized as potentially life threatening medical emergencies (priorities 1 through 3) through the use of EMS dispatch prioritization algorithms. Furthermore, 329,914 of these were determined to require the response of an Advanced Life Support unit.

During 2003, an average of 315 Advanced Life Support (ALS) tours (34%) were fielded daily of the 922 total tours fielded.

The Problem

Ideally 100 percent of patients who have medical conditions that would potentially benefit from ALS would receive an ALS ambulance to the location rapidly. Our goal has been to have an ALS ambulance on the scene in less than ten minutes.

According to statistical reports compiled by FDNY, only 96% of the nearly 330,000 ALS calls were assigned an ALS unit. That means that over 13,000 potentially life-threatening assignments that required ALS units did not receive one.

Only 81% of the ALS recommended assignments received an ALS ambulance on-scene within 10 minutes. It took 12 minutes and 31 seconds for an ALS unit to get to 90% of all ALS recommended assignments.

The stated goal for FDNY is to have 90% of ALS assignments to receive an ALS ambulance on-scene under 10 minutes.

Current State of ALS Response in the NYC 911 System

There is a shortage of paramedics, both in the City and throughout the Nation. Recent articles in national EMS journals (JEMS, EMS Insider, EMS Magazine, etc.) describe that every major city is having difficulty recruiting paramedics. There are discussions, at both the State and Federal levels, questioning the impact of the training curriculum on paramedic staffing.

This shortage of paramedics is taking its toll on staffing in NYC, and the Department is having difficulty recruiting trained personnel. The Department has employed the following strategies to increase the number of ALS units to respond to ALS calls:

1) A nationwide advertisement campaign to hire paramedics,

2) A scholarship program to pay EMTs employed by the Department to attend paramedic programs to upgrade members to paramedic status.

3) A review of current ALS responses to ensure that ALS units respond to the most appropriate calls,

4) An increase in the number of Voluntary ALS units participating in the 911 System, and

5) Reinstatement of the full time paramedic program to train members to become paramedics.

Even with all of these efforts, the Department is unable to achieve the goals for ALS units to ALS recommended assignments, and will not be able to in the near future.

It is estimated that an additional 100 ALS tours are needed to achieve the ALS response goals. With current ALS staffing requirements (two paramedics per ALS ambulance), it will take more than seven years to sufficiently increase the numbers of paramedics available to staff enough units to achieve these goals.

ALS Staffing Arrangements

Since 1974, the City has utilized Advanced Life Support (ALS) ambulances to enhance the level of pre-hospital medical care that can be provided to the public. The current REMAC ALS staffing standards have guidelines for the provision of ALS care for both 911 generated calls and non-911 generated calls. Currently two EMT-P's per ALS unit are required for 911 generated calls.

Throughout the country there is no set staffing level of ambulances. Below are some examples of staffing levels that are seen in the industry:

1) One EMT and one chauffer,

2) One or two EMTs,

3) One Advanced Emergency Medical Technician-Critical Care who is met by a police escort who drives the ambulance from the scene,

4) Two Emergency Medical Technician-Intermediates,

5) One paramedic and one EMT,

6) One Emergency Medical Technician-Intermediate and one paramedic, or

7) Two paramedics.

There is no published data that shows improved clinical effectiveness by ALS ambulances that are staffed with two paramedics.

The NYC REMAC has previously discussed changing the staffing requirements for 911-ALS ambulances. The most recent TAG to put forth recommendations on this topic was chaired by Dr. Kevin Brown (dated 5/7/2000. It is now clear that changing the staffing requirements would allow for substantial benefits to the 911 EMS system (as stated above).

A Three Pronged Approach

The Department is proposing a three-pronged approach to changing the staffing standard. This approach was designed so that some needs could be addressed immediately while allowing for discussion of other points that may be more involved. The three-pronged approach includes:

1. Allow for staffing of ALS Units with one paramedic and one EMT when a disaster occurs or there is a significant threat of an impending incident that may require a sizeable increase in ALS resources.

2. Allow for the staffing of ALS First Response Units (ALS-FR) with one paramedic and one EMT.

3. Allow for the staffing of ALS transport units with one EMT and one paramedic.

The Department requests that the Regional Emergency Medical Advisory Committee approve all three of these standards; however, each standard should be evaluated on its own merit so one isn't delayed pending discussion of the remainder.

Disaster Response/Terrorism Response

Large Scale Multiple Casualty Incidents (MCI) can strain the resources available to the point where the mission of providing pre-hospital care cannot be accomplished. For ALS response, this means that there will not be sufficient ALS resources to respond to the disaster and the normal 911 calls received. In times of MCIs, the Department needs to field additional ALS Units to handle the increased demand. Because of the limited supply of paramedics, the only alternative available to the Department is to modify the staffing requirement. Also, when the Department receives credible threats, additional units may be staffed to ensure proper response.

The Department will make a decision based on the capability of the system to provide ALS resources to the incident, the nature and credibility of the threat, and the availability percentage of ALS units in the "911" system.

First Response ALS Units

The Department is currently reviewing plans to deploy specialized ALS First Responder Units. These units would be staffed with one EMT and one Paramedic. These units would be assigned to incidents where specialized training may be required to access patients and provide appropriate treatment unusual circumstances. These incidents include, but are not limited to: collapse, contaminated environment, and high-angle rescue.

Normal "911" Ambulance Units

In light of the staffing difficulties discussed and the need to increase ALS resources in order to achieve performance standards already established, the FDNY is seeking to increase ALS resources through implementation of a modified staffing model.

A portion of the ALS ambulances in the 911-system would be staffed with one EMT and one Paramedic. These units would be assigned to ALS assignments and when necessary, would receive an additional ALS resource consisting of a traditionally staffed ALS unit, an ALS-FR unit or another single medic ALS unit.

Presently, the FDNY requires that its paramedics complete a 960 hour field internship before being permitted to work with one another. All Paramedics on these single-medic ALS units would have successfully completed this internship.

Traditionally staffed ALS units would continue to operate and be staffed with two Paramedics. A portion of these would be utilized as training units for paramedic field internships.

Protocol Review

The NYC REMAC allows for the use of Advanced Life Support Protocols for five different staffing models:

1) An ALS Service, operating in the 911 System, staffed by two paramedics,

2) An ALS Service, not providing care in the 911 System, staffed with a paramedic and an EMT,

3) An ALS Service, not providing care in the 911 System, staffed with one EMT-CC and one EMT.

4) A BLS service that operates with ALS personnel, providing limited ALS care.

There is no difference between the protocols used by a two paramedic unit operating in the 911 System and a single paramedic unit responding to calls outside the 911 System. There is no difference between the care provided by a single paramedic operating for a BLS service and the current care provided by a single paramedic operating on a BLS unit in the 911 system. The only staffing model with any difference between protocols is the dual paramedic and the single EMT-CC. The EMT-CC protocols use the skill set and formulary. The only difference between the EMT-CC and paramedic protocols is the point in the protocols when contact with medical control is required.

Based on this review of protocols used by all providers and the knowledge base of the paramedic, there is no adjustment to the current protocols needed in a single paramedic system.

Quality Assurance Review

As each component of the plan is implemented, the Department will conduct a Quality Assurance review to ensure that quality of care is maintained. Some specific areas to monitor may include:

1) ALS response time and the fractal ALS response time.

2) On-scene times.

3) Patient condition upon transport.

4) Successful completion of ALS interventions.

These markers would be under constant review to determine if the program is succeeding. Any negative indicators will be analyzed and the program will be adjusted for improvement.

Summary

The FDNY is evaluating our performance objective as it relates to ALS assignments and would prefer evaluating performance based upon the ability of an ALS unit to respond an ALS assignment 90% of the time in under 10 minutes. For 2003, 81% of the time an ALS unit responded to an ALS call in under 10 minutes. To achieve this goal, roughly 100 additional ALS tours would be necessary.

Present staffing requirements call for two paramedics to staff an ALS unit, this would require nearly 400 additional paramedics.

Because of the shortage in paramedics, the need to increase our ALS response capability, and the lack of evidence supporting any staffing model, the Department is requesting a change in the ALS staffing requirement.

By approving and implementing these proposals in a coordinated and controlled manner, we believe that the number of ALS tours could be increased and that the performance standards discussed could be achieved in a timely manner.

[mikerabbit 2]

Well it works in Westchester. Most of our systems have just one medic with EMTs or even just a "driver" as their partner.

[Guest]

HEY, JUST TO CLEAR SOME THINGS UP.... CAPTS AND LTS COULD BE EMT-B ONLY NOT ALL BOSSES ARE MEDICS.... MEDICS COULD ALWAYS INTUBATE AND MANUALLY DEFIB WITHOUT A MEDIC PARTNER.... NOW ONLY IV AND MEDS CAN BE GIVIN IN THE PRESENCE OF OTHER MEDICS (STUPID!) I HAVE WORKED IN MULTIPLE SYSTEMS DUAL MEDIC AND SINGLE AND ALTHOUGH ITS NICE TO BE ABLE TO BOUNCE IDEAS OR HAVE THE SAFETY NET OF ANOTHER MEDIC I DON'T FEEL ITS NESSECERY. I HAVE NEVER HAD HAD SITUATION THAT WENT "SOUTH" DO TO AN EMT-B PARTNER RATHER THEN A MEDIC. JUST MY OPINION. PEACE!

[Guest alsfirefighter]

If any system could truly benefit from having ALSFR engines, its NYC. However we all know how the CFR program went and is going.

I don't see what the union feels they are getting from this, and how can they justify they need a 1 plus 1 system when much of the country rides with the 1 and 1 (medic/emtb). It makes no sense to me. I can see still having some bls busses, but having 2 medics on a bus as a necessity makes no sense to me. If anything it allows weaker employees with crappy skills to hide behind their partner.

[x635 4,066]

If anything it allows weaker employees with crappy skills to hide behind their partner.

Not always.

I've worked in and with many EXCELLENT double medic systems (Boston, Worcester, UMDNJ,etc) , both in states where it's reuqired (MA and NJ) and I think having a double-medic system can be quite a benefit. First, in critical patients, many interventions can be delivered considerably quicker. It's nice to have an ALS level partner who can interview the family while you assess the patient. It's nice to have a partner that's on the same level as you, both for professional discussion and to bounce things off of when your not quite sure. It's nice to have a double medic on a busy ALS truck whether transfer or 911 to share the call load with. It's nice to have an partner who can restock you appropritely. It's nice to have that partner to assist with difficult tubes or lines. It's nice to have a partner that is a professional equal in terms of education.

In single-medic systems, a lot of the time "weaker employees with crappy skills" can just plain hide period. In double-medic systems, everyone knows who these medics are, and often it is better having them as partners then having a weak BLS partner. (Although a strong EMT at select times can be much better than a crappy medic, lol). And a lot of the times, these medics skill can improve greatly by working with other medics.

Just because "most of the country" rides EMT/Medic does not neccarily mean it's right. I feel 99% of the reason behind EMT/Medic combos is cost. If there were to be more Medic/Medic systems, I beleive quality of care and the strength of individual medics would go up.

Again, "weaker employees with crappy skills" can hide comment. Firefighters work as a team and rarely alone, don't they? They must be able to function as a team first and foremost, but individually too?

[jps385 0]

FDNY EMS not having enough medics is it own fault. They treat their EMS employees like second class citizens. Lousy stations and equipment, poor working conditions, five day work weeks, and constant mandations. This plus lousy pay. Many EMS supervisors run around like little dictators writing crews up for mundane offenses, and general making life miserable.

In general anyone who can leaves for PD, FD, or a Hospital based system. Most hospitals pay starting a medic more than a senior ems Captain!! The only remotely apealing benefit is the 25 and out pension, but even that is based on a lousy salary with high employee contributions, and not many people can physically last 25 years working in the system.

That having been said, a patient is better off receiving ALS care from one medic sooner than having to wait or not receive any als care at all. Anyone with experience in NYC can tell you that the call triage is pretty bad and BLS tends to get more ALS jobs than the medics anyway. The rantings of the EMS union are just their ussual attempt to complain about everything in hopes of someday doing something for their members.

[fac911 33]

jps385 I could not say it better myself, your are so right!

[Guest]

The plight of ems in the city just never ceases to amaze me. I always used to laugh when I saw EMT's in the medic upgrade program. They were all competely stressed out, not able to make any overtime because they had to study too much, and then when they came out were still making crap money.

I said in an earlier thread that it's not brain surgery to get more medics, they just need to get paid more. Who wants to work for the fire department for enough money to cover your gas back and forth to work? Why should you take a job only to have to take a second one?

It's great that the fire department tries to train it's own medics, but when you train lousy emt's to be medics, all you get are lousy medics. The standards for ems in the city should be raised (and I mean FD, although it's another post to talk about whether or not FDNY should run all EMS), and if you increased the pay enough, you'll attract the right kind of people who would be willing to go through the medic program.

The only good (for the job) that could possibly come out of riding 1 and 1 would be for the union to use it as a barganing chip to take back some areas from the privates, thereby increasing revenues, and maybe increasing your pay. As far as the city goes, you split the medics, you have twice as many medics, you get twice the people getting the care they need instead of two emt's walking in on an arrest, and then doing cpr until you get backup from halfway across the borough.

Anyone who currently or has worked in the city knows that ems is the red headed stepchild of emergency services, espescially in the city. everyone is out to get you and you have to look out for number one, unfortunately that usually means a second job.

Now with all that out of the way I will say that I had a blast working for the city and would do it all over again, even for free like I was before. Everyone should do a tour of duty in the war zone down there. You just have to enjoy it, no point in being miserable.

[MGMedic 0]

I work as a medic for FDNY. If "the stated goal for FDNY is to have 90% of ALS assignments receive an ALS ambulance on-scene under 10 minutes", there are other things they could be considering, although i doubt they are. A lot of us believe there are too many ALS units in parts of the city. Sometimes we sit within site of each other. They just aren't being utilized efficiently. The triage system is frustrating. A lot of times the reason BLS is sent to ALS jobs is because all the ALS is tied up doing what are very obvious BLS calls (i know it happens everywhere, not just in NYC). Altough i'm not familiar with it, i am willing to bet my (very small) paycheck that they aren't using the most up-to-date triage system. To even bother discussing the salary issue and how it affects recruiting is just beating a dead horse. How do you attract medics when you offer 34K to start and top out at 47K after 5 years?

FDNY EMS Chief Peruggia is going in front of REMSCO Tuesday to propose the changes. It looks like the beginning of a looong battle...........

[Guest]

If you've ever been out to brooklyn to see dispatch the triage system is just what you would expect. The CRO's have an index card system kinda similar to a rolodex in front of them. When they hear chest, sick, leg, car, etc, they look up the corresponding card and it has all the questions they need to ask the caller.

Only a sharp dispatcher can change it from that point in time, and they are few and far between. Sometimes you've noticed the CRO change the call from a BLS to an ALS when they get more calls. I once had to ask the dispatcher to assign me an ALS bus after getting my OTHER upgraded to an unconscious, and she didn't assign ALS for almost six minutes after it popped up on my screen it got changed.

[jps385 0]

The best example of this nonsense is the unconcious call type. 80% of the time its a drunk. It used to get an ALS and BLS unit. when both arrived and it was an intox the BLS would transport and the als would be back in service for a real als call. Then they decided this was innefficient so they now send only als. This way the medics get to spend their time in the subways with homeless drunk while BLS runs to arrests.

[Guest]

Don't forget when cops upgrade the calls because they don't want to wait anymore with a bs call. IE the call we had on the Concourse after the Yankee game got out of a "a/p pd, intox now having multiple seizures." When we got there it was just an obnoxious local drunk wondering out loud where the hell all these people came from.

It's a mess, and by the way, the reason the city doesn't do it like that is two-fold. One, the city isn't like the rest of the country, and two, they try to be as ignorant as possible when it comes to ems and interagency programs.

[27east 19]

Des anyone know if the proposed ALS-FR would be ambulances or more like fly-cars? I believe FDNY had looked into using "paramedic response vehicles" in the past (1997?) but they dropped the plan.

[mikerabbit 2]

How about billing? Will the city be able to charge more for transports because they will be taken ALS? I wonder if that has anything to do with the decision.

[Guest]

The city charges for everything it can get away with when it comes to EMS.

[Guest]

also remeber it is up to remac and the docs what type of service they want for ems in the 911 system. it willl be the docs decision who are on the remac committe if they want single or dual medics. this has been brought up before and the docs shot it down. i wouldnn't expect remac to decide to go along with it. this was brought up since fdny has been running ems

[MGMedic 0]

The decision by NYC REMSCO was thet they weren't yet "comfortable" with this change. I believe they are waiting to be presented with data that shows this would actually be beneficial to the general population. They have allowed for the splitting up of medics in an instance of a disaster. Dr. Gonzalez said he would do that regardless in a disaster without asking first (you gotta love him. right to the point) What constitutes a disaster/emergency?......well, it was supposed to snow 1-3 inches today. Sometimes that becomes a OEM Level A (i believe) emergency. I'm sure eventually the "brass" will convince themselves if that is enough to mandate and enforce one-for-one relief, then it is "emergent" enough to split us up.

[tbendick 27]

Can someone confirm that they also agreed to spliting up EMT's into EMT/CFR Ambulances? I know this is in the FDNY books, but was told it came up at the meeting.

[Guest]

medic fly cars in nyc will not work unless they increase the number of bls units. it has been tried mult times before and failed. the reason being is they will remove an als ambulance and make them a pru. while they remove the als ambulance they do not increase or even replace that als ambulance witha bls unit. so they actually decrease the transport capability. as well the pru gets stuck sitting on scenes with bls patients awating a transport unit. then this is followed by a longer wait because dispatch says they have other calls to dispatch and does not have a free unit to send the pru for the transport. its been tried before and does not work in nyc. if there were a sufficent amount of bls units then it would work. without them forget about it.

[MGMedic 0]

I haven't heard anything regarding putting EMT's with CFR's, but.................one never knows.

[WAS967 97]

medic fly cars in nyc will not work unless they increase the number of bls units. it has been tried mult times before and failed. the reason being is they will remove an als ambulance and make them a pru. while they remove the als ambulance they do not increase or even replace that als ambulance witha bls unit. so they actually decrease the transport capability. as well the pru gets stuck sitting on scenes with bls patients awating a transport unit. then this is followed by a longer wait because dispatch says they have other calls to dispatch and does not have a free unit to send the pru for the transport. its been tried before and does not work in nyc. if there were a sufficent amount of bls units then it would work. without them forget about it.

Plus in the seedier areas of town, who would want to be the only one on scene in some of these places?

[MGMedic 0]

Condition bosses (patrol lieutenants) do it every day without anyone watching their backs....PD sergeants get a partner riding with them (not to mention the various firearms)

[MGMedic 0]

This topic has not been visited in a while, however.....NYC Remsco, against the wishes of many seasoned medics and dr's, has agreed to let FDNY*EMS run a "pilot" study staffing a paramedic with an EMT. Details to follow.....

[JBE 328]

Cross your fingers, hold your breath and hope for the best.

[Guest]

I was told that the medic/EMT mix was going to be "tested" in the city. They are taking the medic certified patrol bosses and team them up with an EMT of that bosses choice. Nothing I heard yet of this starting, but the bosses at my station are talking to a couple EMT that they want to work with.

[jps385 0]

They'll put out single medic trucks with hand pick people and then (shockingly) there will be know problems and it will be implemnted citywide within the next 18 months or so. From what I have heard the Remac was against it but FDNY managed to force the issue with the state.

I'm not really against this whole idea, but you can be sure it won't be evaluated fairly, and just approved.

[tbendick 27]

They'll put out single medic trucks with hand pick people and then (shockingly) there will be know problems and it will be implemnted citywide within the next 18 months or so.

They didn't get the ok yet for single medic ambulances. They did get the ok for single medic response units. Ie. EMS supervisor unit, Cushman, Engines, Etc.

Also part of the single medic ambulance issue is that FDNY maintains dual medic ambulances. This way junior medics will still have to ride with a senior medic. They would also only be able to put a senior medic on a unit as a signle medic.