How Many Paramedics Does It Take To...?

No! This is not the opening line to a joke like, “How many paramedics does it take to change a light bulb?” or “How many paramedics does it take to deliver a patient care report to a nurse?” The focus point of this column is, “How many paramedics are needed on an ambulance?”

This question is asked frequently. Talk to paramedics and the usual response is “two.” Talk to city managers or budget crunchers and you’ll hear “one.” Why? Because one is cheaper than two. Traditionally, EMTs are paid less than paramedics. Therefore, if you have one paramedic and one EMT on an ambulance, the operating cost per hour is less than if you were to have two paramedics on duty.

This controversy arose recently in New York City, when the fire department proposed reducing the number of paramedics from two to one on ambulances providing advanced life support (ALS) care. FDNY says the change will reduce response times since it will double the number of ALS units available for life-threatening emergencies. The union representing the paramedics called the plan the “stupidest and most dangerous proposal that the Fire Department has made.”

But New York is not alone. Other communities, Washington, DC, among them, are ready to roll out a “One-Plus-One-Staffing” program that places one paramedic and EMT on each ambulance. Washington, DC, plans on moving beyond the pilot program to a phased-in process of converting two paramedic ambulance crews to a paramedic and EMT ambulance crew.

I frequently receive e-mails asking how many paramedics should be assigned to an ambulance. This is tough to answer. I prefer to answer by asking how many paramedics should be on the scene of a life-threatening situation? Two paramedics responding to a scene in the same vehicle is not what matters. EMTs are just as capable as paramedics at driving, reading a map book or talking on a radio. What matters is how many paramedics are on the scene to treat a patient with a life-threatening emergency. What also matters is how many paramedics should be transporting such a patient to a hospital.

The National Fire Protection Association (NFPA) 1710 standard states that personnel dispatched to an ALS emergency should include a minimum of two people trained at the EMT-P level and two people trained at the EMT level – all arriving within eight minutes or less, 90% of the time. The two paramedics need not arrive on the same unit or respond from the same department.

Some EMS systems capitalize on this and put one paramedic on the ambulance and the other on a first-responder engine. Assuming both the engine and the ambulance are dispatched to the scene, if the patient’s condition is life-threatening, the paramedic gets off the engine and rides into the hospital with the patient and the other paramedic. Both paramedics usually tend to the patient in the rear of the ambulance and the EMT who was originally assigned to the ambulance drives the vehicle to the hospital.

Since most fire departments have more engines than ambulances available to respond, the other benefit with a paramedic assigned to the engine is that they may arrive on the scene prior to the ambulance and begin advanced life support care much sooner. Unfortunately, many fire departments do not have enough paramedics to staff all their engines on three shifts. The end result in systems with one paramedic and one EMT assigned to an ambulance is the possibility that only one paramedic will be on the scene of a life-threatening emergency. This is not good for the paramedic or the patient.

One important benefit of having two paramedics on the scene of a life-threatening emergency is a built-in provision of a “checks-and-balances” system. Having two paramedics working together to interpret an EKG strip is better than having just one. The saying “two heads are better than one” is certainly true in these cases.

There have not been too many studies that show the benefit of two-paramedic crews versus a one-paramedic/one-EMT crew. In fact, the only study I have been able to find comes from Melbourne, Australia. In 1999, the Metropolitan Ambulance Service of Melbourne began implementing its emergency operations plan of 1998. One initiative was the addition of “mixed crews” – crews that each had one advanced-skills paramedic officer and one non-advanced-skills paramedic officer. Previously, every ambulance crew had two advanced-skills paramedic officers. The study focused on the concern that the mixed crews would record longer on-scene times than a crew with two advanced-skills paramedic officers.

The study was done retrospectively and picked three mixed crews and three non-mixed crews to determine whether there was any significant time difference on the scene with critical patients. The study also looked at ALS procedures attempted and paramedic procedure failure rates.

During the three-month study period, there were 1,700 time-critical cases, of which 1,537 had valid data for calculating scene times. A total of 714 cases were attended by mixed crews and 823 by all-paramedic crews. The mean scene time for mixed crews was 15.54 minutes and 16.92 minutes for all-paramedic crews. In essence, the on-scene time for a “mixed crew” was less than an all-paramedic crew. The all-paramedic crews performed a slightly higher number of ALS procedures than the mixed crews. There was no significant difference in failure rates.

The conclusion of the study was that the mixed crews demonstrated shorter scene times than the all-paramedic crews. Although it was deemed clinically insignificant, the concern that mixed crews would have longer scene times was not substantiated and should not be considered a barrier to the development of mixed crew staffing models in Melbourne.

Study or no study, having two paramedics on the scene of a critical patient is better for patient care. Besides the checks-and-balances of two paramedics, sometimes multiple ALS procedures need to be done. A cardiac arrest is a prime example. While one paramedic is intubating the patient, another can be starting an IV. In these situations, when time is critical, the patient truly benefits.

Another phenomenon is that some paramedics are excellent at starting IVs and can hit veins not visible to the eye or the touch of a finger, but they are mediocre at best at intubation. Others have no appreciable difference in skills. Two paramedics on the scene increase the opportunities for successful advanced procedures. No matter what category you fall into with this debate, all I know is that I was happy at those times when I could not get an IV on a critical patient and I heard another voice say, “Let me try.”