Plan Would Use Fewer Paramedics

The Los Angeles Fire Department is preparing to test a controversial paramedic deployment plan in the San Fernando Valley that calls for eliminating two-paramedic ambulances, a move that critics say will compromise emergency care.

Fire Chief William Bamattre wants to staff ambulances with one licensed paramedic and one emergency medical technician. Such technicians receive one-tenth the training of a paramedic. In the most serious emergencies, a second paramedic assigned to a fire truck will meet the ambulance at the scene, a so-called “one plus one” system.

The plan is designed to help alleviate a shortage of paramedics assigned to ambulance duty and will reduce average response time in the Valley by about 1 1/2 minutes, Bamattre said.

The firefighters union, two professional associations representing firefighters and paramedics, and many emergency care experts say the new deployment plan will hurt emergency services by doing away with the all-important “second pair of eyes” that they say is critical in the first minutes of emergency treatment.

“They’re going to water down the system and spread paramedics thinner across the city,” said Evie Anguiano, president of the county Assn. of Prehospital Care Coordinators, a group representing hospitals that direct paramedic care in the field.

If the program is approved by the Los Angeles County Department of Health Services, which has jurisdiction over emergency medical care, the Fire Department will launch a one-year trial in July and then consider taking it citywide.

The county’s emergency medical services commission, a 17-member advisory panel, is scheduled to consider the proposal Jan. 19.

Shortening Arrival Time

“What I can guarantee . . . is that with the majority of calls, I’ll be able to get a paramedic there sooner,” Bamattre said of his proposal. Under the new plan, the first paramedic would arrive on scene in an average of 6 minutes and 33 seconds instead of 8 minutes and 4 seconds, the current average Valley response time, according to department projections.

But paramedics say that shaving a minute or two off the response time would not make up for the diminished quality of care that a single paramedic would provide.

“The concern of the paramedics is that they’re going to be hung out there to dry alone,” said Fire Capt. Robert Linnell, interim president of the Los Angeles Paramedics Assn. “I’ve had paramedics tell me that if it comes to that, they will drop their license--that they will not practice in an urban area as busy as Los Angeles if they’re put out there alone with just an EMT partner.”

Trained in basic life support, emergency medical technicians can administer oxygen and perform cardiopulmonary resuscitation. But they are not permitted to start IVs, administer drugs, interpret electrocardiograms or call base station nurses for treatment directions.

Without a second paramedic as a partner, said city firefighter-paramedic Bill Ramsey, “you’re trying to do all this with one hand tied behind your back.”

Ramsey said he was recently called to save a baby having a seizure in the northeast Valley, and his paramedic partner called the base station nurse for treatment directions. The nurse prescribed the wrong dosage of Valium, but Ramsey said he caught the mistake.

Without a second paramedic, he said, the team might have given the incorrect dose, which “virtually would have had no effect at all.”

“There are varying degrees of expertise out there, and what the two-person system does is it gives us some backup,” Ramsey said.

The controversy comes at a time when the Fire Department is called on to save victims of car accidents, heart attacks and other medical emergencies far more often than it is summoned to battle blazes. Today, almost 80% of its calls are for medical service. More than half of the patients treated require an ambulance, according to city records.

Yet the department has trouble finding paramedics who want to work the grueling, round-the-clock, fast-paced shifts on ambulances.

The tough workload--and a department culture that many veteran paramedics say favors firefighting over emergency medicine--is such that many paramedics prefer working on fire engines.

Under Bamattre’s plan, at least one paramedic would be assigned to each of the Valley’s 35 fire stations, with the majority working on fire engines and the rest on ambulances. Currently, five Valley stations do not have paramedics.

Dr. Marc Eckstein, the department’s medical director, says the new plan is better than the status quo.

“I think the one-plus-one system has medical merit and will save more lives than the current system, until such a time as we can get more ambulances and more paramedics,” he said.

The debate is complicated by a lack of data showing medical outcomes for patients treated under the different systems.

“There is no science to prove either side’s contention, which unfortunately leaves it in the political arena,” observed Jim Page, publisher of the Journal of Emergency Medical Services.

Paramedics Prefer Fire Companies

There are no national standards that recommend a specific number of paramedics per vehicle. California law requires that at least one paramedic be present for major life support treatments, such as intubation and administering certain drugs.

Bamattre has stated that he already has enough paramedics on staff; there are about 500 in the department, more than 300 of whom are also trained as firefighters. The problem, he said, is that most of them would rather work in fire companies where the workload is lighter and opportunities for promotion have traditionally been better.

The bottom line, said Fire Commission President David Fleming, is that the city’s 113-year-old Fire Department is today more of an emergency medical department, but the deployment does not reflect the change.

He said the one-plus-one system is “not the best program, but it’s better than what we have now.”