Working to Get Patients’ Wait Down

If you or a family member were experiencing a life-threatening, time-critical medical emergency, which would you choose: one paramedic to arrive in five minutes and the second paramedic in an additional three minutes, or two paramedics arriving together in eight minutes?

The controversial “one-plus-one” plan recently proposed by the Los Angeles Fire Department would essentially provide the first choice, staffing most advanced life support ambulances with one paramedic and one emergency medical technician (EMT) instead of two paramedics.

Under our current configuration, when someone calls 911 with a medical emergency the closest fire engine and closest paramedic ambulance are simultaneously dispatched. Because there are more than twice as many fire engines as paramedic ambulances in Los Angeles, the engine company typically arrives first and the ambulance several minutes later. The engine company, staffed by firefighters who have received 120 hours of training as EMTs, is capable of providing basic first aid, cardiopulmonary resuscitation and defibrillation. Paramedic ambulances, staffed by two firefighter / paramedics who have received approximately 1,200 hours of medical training, can provide advanced life support and administer intravenous medications, provide advanced airway management for patients unable to breath on their own, and monitor the heart to treat potentially lethal cardiac dysrhythmias.

More than 80% of all emergency responses by the LAFD are for medical calls. With only 56 paramedic ambulances throughout the city, there are times when the engine company arrives, only to wait 10 minutes or more for the paramedic ambulance. The proposed one-plus-one plan would provide a paramedic on every fire engine in the San Fernando Valley, enabling the patient to receive earlier advanced life support assessment and intervention. Because both the engine and ambulance would be dispatched simultaneously, the second paramedic would usually arrive shortly after the first, still providing two paramedics to provide care.

What is the benefit to the community? This proposal would enable a paramedic to arrive faster than is currently accomplished. In some cases, minutes can make the difference between life and death. If a child is suffering a severe asthma attack or is experiencing an allergic reaction compromising breathing, an injection of epinephrine may be lifesaving. Under the plan, the first responder engine company could initiate these time-critical interventions, rather than wait for the paramedic ambulance to arrive several minutes later.

In addition, when the call load in the city is particularly heavy, as was the case with the recent flu outbreak, ambulances are often delayed in transferring care of the patient at overcrowded emergency rooms. Deploying only one paramedic on the ambulance would leave the second one available on the engine to respond to the next call.

This proposal has medical merit, which is why I believe it will save more lives than our current paramedic deployment. This is also why it has the support of the Department of Health Services, which oversees the entire EMS, or emergency medical services, system in Los Angeles County. Why, then, is there such vocal opposition from the very people who provide the care?

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Paramedics in our city are highly trained, highly dedicated and extremely overworked. The job, particularly working on an ambulance, has become more and more difficult because of the inordinate call load, the increasing complexity of EMS and the difficulty of working in the most challenging environment imaginable. Population growth has strained our EMS system to the limit.

Paramedics and firefighters now serve as the primary entry point into the health care system for patients with nowhere else to turn. In addition, many calls are not for emergencies, further taxing the system by tying up scarce resources.

Paramedics say the one-plus-one plan would degrade service because they would lose the benefit of having two paramedics simultaneously evaluate the patient. No one would disagree that having two paramedics working together is better than one paramedic with one EMT. However, as a physician and former paramedic, I believe that the benefit of getting a paramedic on scene sooner for almost every call outweighs having only one paramedic on an ambulance.

This proposal would enable a paramedic to arrive faster than is currently accomplished. In some cases, minutes can make the difference between life and death.

We most certainly do need more ambulances in Los Angeles; we should not have to worry about their availability when tragedy strikes. This plan will not only ensure that there is a paramedic on every fire engine, but it will also add four additional advanced life support ambulances, which are so much in demand, while leaving our five busiest ambulances staffed with two paramedics.

Until the city is able to provide additional paramedics and is willing to add even more ambulances, the one-plus-one plan offers an opportunity to save more lives and help more people more quickly than is currently possible. With the time-honored dedication of the men and women of the LAFD, one-plus-one staffing will be successful. Although change is never easy, we must be mindful of what is in the best interest of the community we have sworn to serve.