New Jersey’s Two Tier ALS System. Time to Advance?

I had missed dinner and was heading in for my first of three night shifts. I made excellent time on the highway, and pulled into a local strip mall just several blocks from the hospital to grab a bite to eat before tackling my shift. Off along the curb a quarter mile back along the state highway was a local ambulance. The lights were flashing, the doors open, with a paramedic chase truck having clearly stopped the vehicle to assist with a patient in the rear. Where the ambulance was stopped is literally less than one mile to the Emergency Department entrance. Expecting the paramedic to have climbed aboard of the ambulance and to be off in moments, I entered the fast food establishment, grabbed my sandwich and soda and sat down to eat. Fifteen minutes later I exited and the ambulance was still sitting there. With New Jersey Highways being the way they are, the only way to assist would be to drive another half mile down the road, find a jug handle, wait for a light, drive in the opposite direction and find another jug handle to return. With only minutes to the start of my shift, I figured I would find out soon enough what was going on.

I arrived at the hospital, put my bags down, hung up my coat, and proceeded to receive sign-out from the dayshift doctor. After receiving report, I asked if the department had been alerted via HASTE for any inbound ambulances. I explained that there was a unit along the road a mile or two back with a MICU unit behind it for a least twenty minutes. At that moment, the squad rolled through the door. An approximately 60 year old was sitting upright on the stretcher, apparently quiet comfortable, wearing a 100% non-rebreather mask, smiling, and looking around. I asked if this was the same unit stopped on the state highway just up the road. The squad gave report of the various treatments and interventions initiated in field curbside along the highway.

Southern New Jersey has a very unique two tier EMS system which, after fifteen years, I am still getting use to it. It is predominantly a volunteer BLS system with ALS being provided by “chase-units”, consisting of Ford Explorers. The ALS units have no transport capability. Typically, the medics would climb aboard the BLS ambulance and provide higher level of care when needed or provide such on scene. Unfortunately, this system has lead to several issues, including the one addressed above.

The opening vignette, in my experience, is not at all unique. Prolonged transports from nursing homes only two or three miles down the road from one of the hospitals I work at for respiratory and cardiac arrests or from neighboring residential developments is not uncommon. There is a very strong motivation to provide advanced life support on-scene care despite the close proximity of a fully staffed Emergency Department. The concept of “scoop and run” by BLS units when close proximity to hospital care is at hand is often mistakenly misplaced for delayed scene times to await the arrival of ALS.

Another product of the two-tier system in New Jersey is a dangerous race of emergency vehicles and civilians in a long, “vehicular parade” to the hospital. The ambulance is followed by the paramedic chase unit, which is often followed or lead by a police car or two. Racing up the rear is usually family in their car despite being told not to try to follow the ambulance to the hospital. Other drivers, when hearing the sirens, usually only expect a single emergency vehicle. Two vehicles, especially if driving fairly tightly behind one another, can easily be unanticipated by motorists. With families trying to keep up with “the parade,” the potential for additional injuries is very real.

With state economics being what they are, funding to advance New Jersey volunteer crews to having ALS level of care is limited. The ideal would be to bring all squads up to the capacity of having a medic available for all runs if needed. Fewer rescue vehicles on the road would have the financial benefits of lower costs in equipment, fuel, and insurance for cash strapped municipalities. This system has been proven to work in New York State for decades. Nassau and Suffolk Counties in New York provide financing to train their volunteers to ALS level of care and limit the number of vehicles on the road for any individual call. Prolonged scene times are a rarity. Meanwhile, New Jersey has not managed to learn from it’s sister states how to manage within the constraints of finances to advance its volunteer EMS system and limit public risk.

I suspect the current system in New Jersey, with the paramedic chase units, represents a product of local politics, limited funding, billable ALS care by these chase units, combined with a hold over from when New Jersey was predominantly farmland with long distances between medical facilities. Southern New Jersey is increasingly not rural. As such, the current system is only adding to the financial costs to townships.

I invite others who read this blog to discuss their volunteer systems. Specifically, how do your systems manage to keep the public safe, provide ALS care, while dealing with the economic austerity affecting all municipalities today?

Comments from paramedics I work within this system are pending. At their request, I will post their thoughts regarding this blog’s subject matter anonymously and without editing.

ADDENDUM: All comments received have been posted provided objectionable language was not included. I have made every attempt to answer as many of the comments posted as I can.

Thank you to everyone who has contributed!

67 Comments

  • CBEMT says:

    I don’t necessarily see it as an ALS issue. It seems to me like a BLS education issue.

    Also seems like ALS providers should have the ability to adapt to the situation, like the one you started the post with, and say “This isn’t going to work. Continue in.”

    • True, however, the ALS units need the foresight to recognize the benefits and risks of transport time/proximity of definitive care/infield treatment. Hence, this is not just a BLS issue

  • jake says:

    I agree. It seems to be a bls education issue. Here in Pennsylvania, we have a 2 tier system, some areas served by bls and a medic would meet enroute for an ALS intercept, or in many cases the private services have both als/bls capabilities. According to pa state protocols, a bls service can transport an urgent ALS patient to the er without a medic, if waiting for the medic to arrive on scene would cause a delay in transport to the closest er. Also, if there is a critical patient that requires a code transport to the hospital, only the ambulance transporting runs lights and sirens. The medic vehicle (weather chase suv or another ambulance), fire vehicle, and family members do not run emergency. We make sure there are enough personnel on the transporting unit and the rest just drive to the hospital normally to pick up their respective personnel. This system does help improve transporting patients to the hospital quicker because in areas with a bls unit, can have a unit on scene within a few minutes and ALS service is usually 15-20 minutes away

  • Melanie says:

    BLS can be educated until instructors are blue in the face. Many times i’ve heard ” this is not how my squad does it” and this is a problem. Also the “let the medics check them out” mentality is spreading far and wide. Until BLS is held accountable for their actions, the delays will continue. EMS in NJ needs to be overhauled in more than one way.

    • If you could share your ideas of elements that need overhaul, I’d greatly appreciate it.

      One of the purposes of this forum is to try to implement change and improvement.

      If you wish to email me privately rather than post, I understand.

      -Jordan

    • Sean Eddy says:

      See I somewhat disagree here. While yes, that mentality is certainly a problem, there is still some educational issues.

      There is no reason that a well-rounded bls provider – especially one who sees a lot of patient care – shouldn’t have just as much of a handle on what’s going on as the paramedic. Patient assessment is a BLS skill.

      Where paramedics come into play is the tools they have to further their assessment or actually treat the patient. Having said that, the “tools” that paramedics bring to the table are only there to reinforce what they already know. If someone is having chest pain and presents with difficulty breathing and pale / cool / moist skin, it doesn’t take an ECG monitor to tell you that this person is likely having a cardiac event. Unless your pushing medications or administering a fluid bolus, the IV that they establish doesn’t actually benefit the patient. I would venture out to say that 9 out of 10 ALS runs don’t involve IV medication administration. The list goes on.

      Your right, we need to get away from the “let the medics check them out” mentality and start focusing on patient outcome. If the bls providers would start thinking “what can I do for this patient” and really consider the benefits and pitfalls of ALS backup, then we would see the scene-time issues nearly disappear.

      BLS providers need to think about what ALS providers actually bring to the table and then make a decision based on the possible outcome of the patient. Starting an IV and placing the patient on an ECG monitor does nothing to better the patient’s condition. They will still arrive at the hospital in the same condition, only 15 minutes later because they waited on the side of the road.

  • Joe says:

    There’s no such thing as an ‘ASL’ patient. There are patients. Attitudes like that are dangerous. This sounds like a BLS education issue, a billing issue, and a political issue. While I believe holdheartly that everything that can be done on scene should be done if it benefits a patient, a medic intercepting a stable patients down the road of the hospital is a waste of resources.
    Sir, also remember that most of the Volunteer ALS in Suffolk and Nassau out here on ths Island aren’t paramedics, they’re EMT-CC’s, which a third of the training as paramedics.

    • I worked as a volunteer firefighter/EMT in Nassau County for years. You are correct that these are EMT level III (by and large).

      The premise, however, regarding wasted resource allocation, finances, and the politics of New Jersey EMS and the development which could occur by looking at other volunteer EMS systems for ideas, I believe, is still valid.

      Do you work for a volunteer system? How is it constructed? What systems are in place to assure quality care and limit wasted resources?

      Thanks!
      Jordan

  • NJEMT-B says:

    I have been volunteering on a BLS truck in NJ for over 10 years and was paid for a couple of those years. This is definitely a training problem in those BLS squads that will wait for ALS on scene instead of transporting. My squad always try’s to be off scene in 10 minutes or less with or without medics. I also think sometimes the training lacks on the ALS side when they forget the “M” in MICU stands for mobile and we are on scene with the patient on the stretcher for an additional 20-25 minutes.

    If we all will work closer together training these care providers will be a lot easier. Which means BLS have to learn that hand holding/ or medic dependency has to stop. And the GOD complex for ALS providers has to stop.

    • Appreciate your input!

    • DarkHorse says:

      While I agree with you that there is also a lack of education on the ALS side, what people don’t see is that the role of the paramedic is and should be evolving. With more medications and procedures being added to our arsenal yearly, we can initiate some the treatment protocols that may be normally started in the ED and improve certain patients quality of care as well as treat their pain or symptoms in a more timely manner.

      Personally, if I need to take 20 minutes to rule everything out and make sure the patient does not require my services, then so be it. I’m not the least bit concerned about annoying someone with that. Afterall, we are there for the patient.

  • SJMICP says:

    This is one reason why I believe that North and South Jersey should be two different states. I have worked as a provider in both and it is two different worlds. There is still a very high percentage protected by the First Aide Council. I have presented as an instructor for there conferences and was amazed at some of the things I heard. I have no problem with volunteers, I was once one myself. But I was held to the same standard as my career conterparts and feel that made me the provider I am today.I understand this blog is presented by a doctor who has no idea how things operate on the “outside”. There is a profound shortage of ALS providers in the state of NJ and chase vehicles are needed at this time. SJ may be becoming “less rural”. But in Burlington there are 5 ALS units, Camden 4 FT and 2 PT ALS units, Gloucester 2 FT and 2 PT ALS units, Cumberland 2 ALS units, Salem 1 ALS unit and Atlantic / CapeMay share mulitple ALS / SCTU units that stratigically relocate based on call volume.

    • I appreciate your comments.

      The shortage of ALS is an element which, perhaps, should be researched regionally. Are there enough ALS units? Are calls being upgraded to ALS runs with delayed scene time where BLS care would have been adequate with rapid transport to a nearby facility?

      I feel obligated to share my EMS background. Yes, I am an Emergency Department physician. I was a volunteer firefighter and EMT with a Long Island, New York fire department, and subsequently worked for private ambulances in New York City. I worked while in college with New York City EMS on a tactical unit out of Queens General after initially being assigned to Brooklyn, NY. I served on the New York State EMS council, have been a base command and facility director in Philadelphia. Currently, I am a medical command physician for several PA ambulance services, one in New Jersey, as well, as the medical director for the EMS training program for the Department of Labor’s Job Corp program in Philadelphia. I have been on the “outside” both in the private and public sectors for twenty five years, including providing base command for the New Jersey MICU units. I recognize that “outside” may represent serving for NJ EMS in the field. That I haven’t done. Being on the receiving end of calls and having served as base command physician in NJ, does, however, provide another prospective on the current system.

      This blog represents my personal interest in trying to foster positive change and development of New Jersey’s EMS system.

      Returning to the initial premise of resource allocation, funding, and transport assignments, if you were to redesign the system, any ideas?

      Thanks for your feedback!

      Jordan

  • Ralph says:

    I don’t think it’s an ALS or BLS issue, it’s political and procedural. This doesn’t sound much different from crews that delay definitive care for a half hour to get a chopper ride, when they could have just driven there in half the time.

    If the crews don’t actually understand their geography or ETA’s to the ED they are going to, that is a training issue. Otherwise, unless the pt is coding in the back and needs ALS intervention *now* (not in two minutes), there is no legitimate reason to stop a transport in progress and intervene so close to the end of the ride outside of being able to bill more. It’s a tremendous waste of time and resources, and took two units out of service that much longer. That said, were the ALS interventions truly time critical and warranted in this case? Need more detail there before casting stones.

    I don’t disagree with the model they have chosen, and I think even in a suburban/mixed environment it could work. The implementation of it may be failing, however once you get past the political “we’ve always done it so that’s it” issue, the procedures and training can be addressed.

  • beenthere says:

    The two-tiered system is not the issue.

    To address your anecdote:

    As a staff member of the ED, you should bear the responsibility of ensuring you and your co-workers accept “ALS” patients coming in once in a while without the emergency IV and blood tubes. It is not only BLS who should be reminded that in theory, advanced life support can be provided in the ED, too, but the ED staff themselves! However, it is all too common for BLS to be scolded and demeaned for not having ALS with them, and asked questions like, “Why did you bring them here.” To which the reply should be, “because Dunkin’ Donuts was on divert.” The ED staff themselves are largely to blame for BLS being afraid to set foot inside the ED doors with a patient who is anywhere on the acuity spectrum.

    • I agree that BLS should not be reprimanded for rapid appropriate transport (ie. Scoop and run). There are several squads I deal with who I routinely make excellent choices and am very proud of.

      All too often there is transference by overworked ED personnel onto the EMS providers. This is wrong. I whole-heartedly agree with you.

      Have you kept a log of these events and reported your concerns to your receiving hospitals’ administrative staff?

      Thanks
      Jordan

      • beenthere says:

        I think it would be less time-consuming to count the times it does not happen. One would be hard-pressed to find anyone in EMS who has not experienced this many times and at almost any hospital where patients are brought. The consequences of a two-tiered system are complex and mostly result in a much HIGHER quality of ALS. If you want a one medic/one EMT system, then it will produce IV lines and blood tubes, but not much else. Be careful what you ask for.

        • Sean Eddy says:

          What it produces is paramedics who treat and transport all of their patients. This doesn’t mean that they start IV’s on everyone.

          The “1 and 1″ system means that the paramedics get much more patient contact – even if it’s patients who only require a BLS level of care – and it also means that they do most of their work en route, which equates to shorter scene times.

          It’s not a perfect system, as it generally produces less-competent EMT’s as they mostly “drive” while the paramedic does patient care, but that’s another complaint for another day.

          I think a mix of ALS ambulances and BLS ambulances is most beneficial. Send the ALS units to the higher-priority calls when possible. If the BLS ambulance arrives on scene and determines that the patient would benefit from a higher level of care (assuming the ETA of the medic ambulance is closer than the hospital) then they can start ALS backup and hand off the patient.

          • beenthere says:

            The two-tiered system is not more expensive or dangerous. That is just the writer’s perception, and not based on fact, and we are simply opining away. If anyone ever did a cost-effectiveness study of not only EMS, but police and fire as well, they would realize it is, in fact, not cost effective. And although these services are anecdotally useful and make us all “feel really good,” knowing they are there (including me), they are mostly a huge waste of money. The truth hurts. Our job as EMS providers is to make people feel good about EMS. Do we help people? YES, sometimes. Are we cost effective, no matter what type of system? HECK NO.

      • Steve Bastian says:

        No EMS provider/agency should be “reprimanded” for bringing the sick and injured to the hospital! That is our job and that is what ED are for!

  • SJMICP says:

    I feel in the above instance both ALS and BLS are at fault. There was no reason for BLS to stop one mile from the hospital, and ALS to stay on the side of the road. It is the “mobile” intensive care unit. Delaying transport for a BLS traige is a waste of everyones time and the same amount of paperwork.

    The above situation does not represent the way the rest of the state operates under the 2 tiered system.

  • Pete says:

    I started my career as an NJEMT-B and worked in a Northern New Jersey Volunteer Emergency Squad. I am now a NREMT-P who works in North Carolina at a nationally respected organization. One who strives to press EMS forward for the citizens we serve and nationally

    First off, NJ EMS system is not broken. To say it is broken is to say that it does not do it’s job. If you call 911 in NJ someone will come and pick you up and take you to the hospital. However, is that what we as a career field wish to be known as, AMBULANCE DRIVERS? I know I do not wish to be called that, so I best not act like it either.

    The first way to not act like “ambulance drivers” is to be educated. Paramedics in NJ are required to have a 2 year degree and that education is very valuable. EMT’s in NJ are another story. And a problem for another day, but as a career field we should work to bring up our education standards.

    Next, we need to work to elimate the BLS vs ALS patient “status”. As stated by Joe they are patients and all should be treated with the upmost respect and given the best care possible in the field. This does not mean we need to run lights and sirens to someones house when they call for back pain that has been bothering them for a week, but it also means we should assure them that when have the big one we will have educated and competent providers arrival promply and give them the best chance of surivial possible. We can do this by using first responder agencies such as the police departments and fire departments. We can regionalize local BLS squads to better deploy our resources. We can work to ensure that good EMD instructions are given over the phone. We can work to ensure that AED’s are well placed and those locations are known by the PSAP centers. We can work to improve the EMT education to include once only “ALS” treatments, such as 12 leads, EPI, BIAD’s and other such treatments that are truly time critical. We can work to get sick patients to the correct hospitals by being patient advocates for them. That means that STEMI patients go to Cath capable hospitals and stroke patients go to Stroke capable hospitals.

    These are just a few of the improvements that EMS in NJ and nationwide can improve on. We need to move ourselves past the idea of you call, we haul. We need to do start doing stuff for our patients and not to our patients as my medical director states. We need to work to ensure that we are the best at our jobs as possible and work hard to find ways to improve ourselves

    Nice article and good luck on the improvements

    • Excellent points! Thank you for your wonderful feedback!

      Sincerely,
      Jordan

    • DarkHorse says:

      Well said, Pete.

      I too believe that part of the issue is indeed with education. There’s been a large gap in education between the ALS and BLS, especially since the change in the national cirriculum of EMT-A to EMT-B. This change has effected many different aspects of care in the state, including the transition for individuals from a BLS to an ALS provider.

    • Tony Correia says:

      Pete having worked in 3 state a major roadblock to treating the patient as a pt, and not ALS or BLS, is having to distinct level of services in NJ. Until we integrate them, this will continue. Every EMT, medic, dispatcher and RN should have to rotate through dispatch, ED, BLS and ALS. It makes all these interrelated disciplines more understanding of each others work and issues. Then maybe we can take the ALS vs. BLS divide out of NJ EMS.

  • Drew says:

    While I understand this is your opinion, many of your facts are way off. For starters, the situation you cited is more of a rarity in NJ. The bigger issue, and situation seen more often, is that an ALS crew is stuck on scene while awaiting BLS. Since most ALS in the state is not allowed to transport, by both rules of the state and volunteer politics, they have no choice to wait until a transport capable volunteer ambulance arrives. Since the state has no control over the volunteers, they can show up if and when they want, dressed how they want, and staffed however they want, sometimes with only 1 trained BLS provider. Instead, they are overseen by the state first aid council, a group made up of volunteer EMTs.
    Billing is not an issue here. The volunteer units don’t bill for their services, and ALS cannot bill if they do not transport. Also, in NJ, paramedics are required to be hospital based and EMTs need sponsorship from an ALS service to go to medic school, so it is not easy to just train the volunteers, or even paid BLS 911 providers to become medics. I do not agree with this system, but volunteers have an amazing ability to make people think they can’t afford to pay for a better service that can be provided for free.
    As for your comparison to NY, Long Island is not the whole state. In reality, besides the major cities, the majority of NY also uses a two tiered system, with most of the BLS being volunteer and most of the ALS being paid. the difference is that in NY, medics can transport too and don’t need to wait for the vollies to arrive, all EMS is overseen by the state DOH, and all meet the same minimum training and staffing standards.
    There is legislation in the works to fix NJ, unfortunately, the volunteers have already managed too get the politicians to hack out important pieces, such as minimum training and staffing standards.
    Many of the issues and the proposed legislation seeking to address them can be found here:
    http://www.supportnjems.com/index.cfm

    • Thank you for your feedback. Your post is accomplishing exactly what I am hoping!

      Could you please elaborate on the current legislation, what has been removed from the bill currently being proposed, and, if you can, the politics behind the opposition to this legislation?

      Thanks!

      Jordan

  • 911isnot411 says:

    I’ve been a resident of New Jersey all of my life, and a BLS provider for over ten years. To say that Southern NJ is “increasingly not rural” does not accurately refect the geography of the area. South Jersey is extremely rural, with pockets of urban areas (Camden, AC, to name a couple). Anyone with access to Google Maps can see that there’s a whole lot of green in South Jersey.

    Is NJ’s system perfect? Of course not. I challenge anyone to show a system that is 100% perfect, with no complaints. Are the volunteers perfect? Nope. How about the paid BLS crews? Hardly.

    Instead of curing the woes of NJ EMS by putting paramedics on every truck, why not train the BLS better, so they can properly recognize the need for ALS, or lack thereof? This can be done in the basic course, CEU courses, or it can even be done during the interaction on a call. Maybe the ALS crew can pop by the volunteer squad during downtime on their shift (rare at times, I grant you), and teach a few things.

    The post isn’t clear if you want ALS available for all potentially ALS jobs, or if you want an ALS provider actually on every EMS truck. With regard to the former, NJ already has 100% ALS coverage in the state. For the latter, I think if you have a paramedic on every ambulance and patient contact, then the BLS skills will only decline further. In my experience, BLS becoming ALS-dependent is quite common. Changing to the proposed system would only solidify that dependence. If that happens, then BLS personnel truly do become “ambulance drivers.” Furthermore, the vast majority of EMS calls are BLS in nature. To me, it seems like a waste of training, time, and money to have an ALS provider working on those. In the current system, they’re only called for incidents of an ALS nature. If they deem the call to be BLS, they triage it and leave, making them available for the next ALS call. Likewise, ALS units are often canceled before their arrival for a large percentage of their dispatches.

    Now the financial concern… It’s a fact that volunteers actually save money for municipalities. We’re talking millions of dollars that is NOT being spent on paid EMS, per year, statewide. Adding proper ALS equipment, meds, etc. to every EMS ambulance (excluding transport services, for argument’s sake), you’re talking about an enormous expense to the agencies involved. Where would those new expenses fall? NOW we’re talking about the municipal funding!

    The best way to effect change is through education. Take those BLS crews and make them better. NJ’s Office of EMS is about to roll out such an initiative involving competency based training and testing for the EMT-Basics. This is something that’s looong overdue, in my book. Instead of medics getting annoyed about being called for an obviously BLS call, they can take that opportunity to teach the BLS crew about why it’s a BLS call.

    Regardless, mistakes will always be made.
    I’ll even put myself on the chopping block further and say that ALS providers also make mistakes.

    BTW, as I’m proofreading this, I realize I sound like I’m banging the drum for volunteers. To a certain extent, that’s true. Volunteers have always been, and continue to be an integral part of NJ EMS. To dump them, and switch to paid services statewide would be an astronomical expense to the taxpayers. However, I’ve seen some pretty awful BLS crews, volunteer AND paid. They’ll only get better with training AND oversight.

    • You make some excellent points.

      I am not proposing the loss the Volunteers. I know how valuable they are and the selflessness they provide the people they serve.

      Funding the squads to have the availability of ALS on some runs would lessen the strain on the current available ALS system, lessen the number of vehicles on the road, the associated insurance, maintenance, and fuel costs. Runs could still be made BLS with ALS use when necessary and when appropriately staffed. Having ALS volunteers in-house would also provide additional quality control within each individual squad.

      What I am proposing might lead to lower net cost to the state.

      Just an idea!

      Thanks for your wonderful response!

      Sincerely,
      Jordan

  • Dave says:

    Completely Agree! I started my EMS career 11 years ago in NJ. I am currently a volunteer paramedic in VA but am still a special member in NJ. Every time I come back to visit family and run calls, I am horrified by two things.

    One is waiting around for 15 minutes for a god in a responder to come hold our hand and tell is our patient will be okay. About 95% of patients can be run BLS with a quick transport. The problem is if you even think about walking into the ER without Medics, the hospital bitches you out and talks like your a bunch of idiots.

    The second thing I can’t stand is how EVERY SINGLE PATIENT gets an Emergent ride to the hospital. Is that not the dumbest thing you have ever seen? You could have someone with back pain from 3 months ago and they go emergently to the hospital??? The only patients that go emergent in VA are the ones on the verge of death. Maybe a stroke or heart alert but thats about it. We don’t even take our codes emergently to the hospital.

    I would love to see the EMS system change in NJ… Might come home more that way.

    • Liability comes into play in regards to why all patients get emergent rides to the hospital. Fear of that back pain for three months ultimately proving to being a walled off retroperitoneal aneurysm which is now starting to leak limits many medical directors from signing off on care and releasing on-scene. It is unfortunately because emergent rides are problematic. Misuse of 911 is a tremendous financial strain on municipalities and an endangerment of our providers. I can’t provide you with a decent solution.

      Thank you for posting your response. I really appreciate your taking the time to do so!

  • NJEMT-B says:

    911 is not 411 said it right. Volunteers are important in NJ. Dave you are right a bunch of of BLS crews volunteer and paid take every call emergent because they feel if you call 911 its an emergency!!! Thats dangerous, fortunatley I’m the current chief of my squad and thats not our practice.

    Now Drew brings up some valid point but some are not correct. All volunteer agencies are not part of the first aid concil thats an option if your agency wants to be part of it. Second in the state of NJ medics can transport but most ALS agencies have switched from ambulances to SUV’s. MONOC has transport capable medic units that over Monmouth and Northern Ocean County. If they are in a part of the county that has volunteer crews they will work together and transport the patient. If by chance the volunteers dont make it out or are tied up on another call the medic unit WILL transport the patient without BLS.

    However when I worked for MONOC and ALS crew called for a BLS crew and waited 25 minutes on scene for us to arrive on scene. This crew was based at the hospital that we transported to. We actually followed them to the hospital 5 minutes away. So ALS needs to learn if they they have the capability to transport do so and not wait for BLS to get there.

  • DRuga says:

    I have been in EMS in south Jersey for over 20 years, as a volunteer EMT,paid(ACEMS),then paramedic.I also have been an EMT-instructor for 14 years. I am very happy to see this dialogue! I believe the system here needs major overhaul on multiple levels(BLS,ALS and education of both). I have been on both sides of the fence. I can say that there are faults to be found on both sides. Yes there is a problem with some squads that will “wait” on scene or pull over a block from the hospital for the paramedics. As an educator I try my very best to address this,but at the root of this issue lies many causes,that are not easily changed.

    1. the poor relationship between ALS-BLS(us v. them- I have never seen it so bad) I was told one time ,by a ALS supervisor, when I tried to talk to a bls member about a patient care issue “Expect nothing from BLS and you won’t be disappointed” Many medics take this stand due to prior situations they have had but I feel that this is not the best way to further good patient care. When I started many years ago most medics worked very hard to make sure the EMT’s learned from them…..today many medics show out right contempt for bls reguardless of prior contact. My husband and I have both seen this first hand when riding as a volunteer(in a rural area)….attitudes change drastically when the ALS provider figures out we are medics.Why?
    I too have been guilty of being very frustrated with bls on some calls. We cannot allow those calls to make us give up on trying to educate and address those that are not meeting the standard of care, and above all it should never excuse being unprofessional and rude.Sometimes it seems futile, but giving up should not be the option here,and many medics need to remember where they came from.We all know well trained EMT is worth their weight in gold on a bad call, but a bad EMT can make even the easiest call difficult.
    2. Lack of confidence/medic dependance of many EMT’s….experience drives action. When BLS makes a mistake and are yelled at by ALS/Hospital staff (often in front of the patient) they have just driven that EMT(s) closer to being medic dependant(ie- let them make the decision next time) and/or resentful(I’ll recall them on everything). Once again this comes back to having better communication/ education. There is really no current training in the S. Jersey area that I know of that allows ALS and BLS to train together. Occasionally there are drills that might incorporate both but they are few and far between and often turn into clusters.Maybe more training together would foster better relationships?Need to work on this.
    3. The lack of accountablilty of the volunteer EMT’s and the attitude that “I am just a volunteer…what are they going to do… fire me”. This has to stop. The job is the job whether you are paid or not.No EMT or group should be opposed to more education.No EMT or group should think that they should be held to a lower standard because they do this volunteer. The new cirruclum should elevate the standard of care of the EMT-B and those who don’t want to increase their field of knowledge should look to exit the field.
    Ultimately the nature of the two tier system promotes discord…not harmony. It is inefficient and ineffective,often times leaving large gaps in ALS treatment for those patients who require it. There are no easy fixes but I believe like the others posted here that education is key and better relations/communication between the BLS/ALS/Hospital staff are vital. We must be willing to embrace the idea that thing are changing in this field and in NJ.Tradition should not be directing where we go from here.
    As for the chase vehicle issues…your right…just needs to stop. Please excuse the rant….feels good to talk about this though :) Thanks for posting

    • Thank you for your excellent comments.

      A great deal of the educational concerns have been discussed in my prior posting “Hiding in the Nursing Lounge.”

      As for the “rant,” no worries! I appreciate you taking the time to add to this conversation!

      Sincerely,
      Jordan

  • DRuga says:

    Just want to clarify the chase vehicle statement I made…..I simply feel that there is no reason to have a second vehicle running lights and sirens behind the ambulance.I think lights and sirens are over utilized….can’t believe how many people think that it is “against the law” to have a patient on board and not run lights and siren. Once again education is the key.

    • New York City, when I worked for them in the 1980s, required box lights on for patients being in the back. Lights and Sirens were limited for Emergent transports.

      I suspect policy varies from region to region.

      Thanks for the input!

  • SJ Medic says:

    New Jersey’s system is not completely broken. Being in the system for 30 years starting as a 5 point first aider to EMT and now Medic, I have seen the many changes to New Jersey EMS. Not only have I been in the system but have spent time studying ours and many others across the country. I am also an administrator of a BLS agency that had to make major changes to survive in these times.

    The biggest issue to me is EMT-B training. 20 Years ago, EMTS were trained to a much higher standard than today. I see first hand people coming out of EMT class and not being prepared for the job. This goes for volunteers and paid personnel. The two tiered system when run properly can be cost effective, efficient and can provide superior services to the residents of New Jersey. I agree that cutting some of the current proposed legislation on training is wrong. However, I also believe the MICU systems which are hosptial based have an obligation to work with the system providers to make it better. They operate on the making money side which is fine because you have to run your “business” but there should be some BLS outreach from these systems. Offer free medical control, offer education seminars, sim-lab sessions, ETC. The system is not broken but all of the stakeholders from Volunteer BLS to Paid EMT’S to Paramedics and ER physicians need to work together to roll up their sleeves to make our system beter.

  • The author of this article has failed to realize certain issues endemic to any EMS system, NJ not being an exception.

    LESS THAN 4% of all EMS responses meet the Medicare criteria for ALS2 treatment. When we facotr in non-edicare patients, that number goes LOWER.

    We can design a system for less than 4% of the patients who need the service, it will never function adequately.

    When the system was originally designed, it used a certificate of need model, so that the number of ALS units was predicated on population and call volume.

    NJ does not NEED a zillion ALS units, and if you think about it, if every city, town, village, etc., in the state of NJ had ONE ambulance, they would NEVER NEED 570+ paramedics showing up for work every day…

    Greater than 87% of the of the ALS1 level calls are in reality BLS (patients who receive nebulized medication, the ubiquitous ‘ALS assessment’, IV and transport – because we all know the IV saves lives).

    Let me ask the author, since having a medic available on every ambulance sounds like a good idea, let me ask you several questions:

    How come every hospital isn’t a trauma center?

    How come every hospital isn’t a stroke center?

    How come every hospital isn’t STEMI center?

    How come every hospital isn’t a burn center?

    It boils down to two factors:

    Money

    Competency

    It costs money to outfit every ambulance with glucometers/monitors/defibs/pulse ox’s….medications that expire…expendable equipment with expiration dates…preventive maintenance of equipment…training of staff…

    Then there are the hidden costs, what about the ‘other’ intangible costs to providing service, clinical coordinators to assure quality, managers to oversee the program?

    Don’t even get me started on competence. How will assure competence when you triple or quadruple the number of paramedics?

    Will there be adequate training to ensure competence in infrequently used skills?

    Or, since the number of paramedics have increased to such a level, it is virtually impossible to assure that they are all adequately trained and providing adequate care?

    DO we ignore the peer reviewed studies showing that ALS does not improve survival? We need LESS paramedics NOT MORE:

    Ontario Pre-hospital Advanced Life Support (OPALS)
    ALS programs showed no improvement in survival rates, compared to BLS with rapid defibrillation programs…more important in improving survival rates were people who witnessed the cardiac arrest doing CPR and emergency personnel administering rapid defibrillation. (OPALS Showed that ALS is only beneficial in cardiac and respiratory emergencies)

    Six Minutes to Live USA Today May 20, 2005 – the highest cardiac-arrest survival rates were in areas with 0.2 paramedics per 1,000 populations. For every extra paramedic in the system over that ratio, the cardiac-arrest save rate declined by 0.8% – Written by Bob Davis a Kaiser Health Fellow!!!!

    How do we assure competency for surgeons, physicians, and nurse? We struggle to accomplish this, now you want to increase the number of paramedics?

    Why so the system can fail as a whole?

    If every hospital, and I mean every hospital in the state isn’t a burn/trauma/STEMI/stroke center, WHY should every ambulance have a paramedic, with the requisite gear etc?

    Realistically this is one of the worst ideas ever, to put a paramedic on every ambulance…because it is attempting to take the ‘easy’ way out and not address the root problems.

    1) Mandate a QI and medical director for every organization in the state, BLS and ALS.

    2) Mandatory reporting requirements for BLS and ALS

    3) Mandatory comprehensive QI Program for every BLS and ALS provider in the state

    4) Mandate a required training program for every BLS and ALS agency in the state

    If the majority of patients require BLS, then the majority of providers should be WELL-TRAINED, WELL-PREPARED/EQUIPPED providers.

    Increasing the number of paramedics will never address the problem it will only make it worse.

    • The implication was not that all volunteers become Paramedics. This, I agree, is not feasible on multiple level and was never intended by the blog. “The ideal would be to bring all squads up to the CAPACITY of having a medic available for all runs if needed”

      Drawing on my own past experience as a volunteer with a system which provided both BLS and ALS level of service, the majority of the rescue squad members were EMTs. A select group, based on performance and skill, were selected by the department to go on for EMT-III training. There was a system in place for quality assurance, frequent drills, and continuous review.

      Most calls ran BLS. I agree with the responder that the majority of runs don’t require advanced medical interventions.

      Our pagers would go off along with the local air horns. We, the volunteers, would assemble. As soon as a crew was prepared, the ambulance would leave the garage. If the call was purely BLS, the ALS members who happened to respond would provide a supervisory role to the EMTs, yet allow the EMTs to run the call. This allowed for a review system to be in place to foster BLS training and select for those who ultimately might be considered for additional advanced training. Conversely, if ALS was needed, the EMT-IIIs ran the call. Occasionally a call would arrive needing ALS, with no member available. During such a circumstance, Nassau County PD would usually be on the scene with their ambulance as back up. Rarely, the need for “Scoop and Run” occurred.

      A system such as this could work in NJ. The benefits of this, I believe, are self evident and should answer the bulk of your points.

      Pennsylvania is currently under Act 37 mandating a medical command physician for all BLS ambulances with AEDs. This is part of Pennsylvania’s attempt to improve quality assurance. Hence, again, as per the point of my blog, there are opportunities for NJ to learn from it’s sister states and improve/advance the current system.

      While I agree we don’t need all squad members to have advanced training, having members of squads with this training who can afford a supervisory role could limit multiple rescue vehicles on the road, lower equipment costs and liability, while fostering an environment where quality improvement and skill development are central.

      Thank you for taking the time to share your thoughts. I apologize if my blog lead to confusion regarding what I was proposing!

      Sincerely,
      Jordan

    • Tony Correia says:

      Dan I agree with most of your post. I believe if we could do away with ALS and BLS and just move to being a EMS system. Isn’t that what you have in Ca? Also I believe have county / regional over site could be big benefit in NJ in coordinating care in specific regions. One of the items you address is advanced BLS skills such as nebs. Would be allowed in the proposed legislation. NJ does have enough ALS providers, just not properly distributed. Many in NJ try to make the point that due having regionally located medics, they get much more ALS skills then medics on ambulance. The reality is each medic only get half the skills that their unit runs. If you split out the medics to some other configuration you could double the coverage, yet still get the same amount of skills. On the high acuity calls you send the advanced care medic who serves as the second ALS provider on those 4% calls.
      The regional oversight I spoke of earlier would allow us to accomplish your recommendations. I know this works in PA. where I currently work as a PT medic.
      Dan I would like to hear more of what we can learn from Ca. Vs. NJ .

  • Could some of the problem stem from hospital staff (especially the ED nurses)? I spent the main amount of time working in EMS in an area in Southern California with a somewhat similar system. Paramedic level care was only provided by the fire departments, so emergency calls originating from assisted living and skilled nursing facilities were tended to by EMTs unless the facility actually called 911 (which was rare). However, despite more than once did I have to defend not calling paramedics, despite the local emergency department being extremely close, including within a quarter mile of the facility.

    While I, personally, have no problem burning off copies of the transport protocol to provide to hospital staff that aren’t happy that a 3rd degree heart block didn’t get paramedics on a call originating less than half a mile from the hospital (A hospital that is also a cardiovascular receiving center. Also, I won’t say that the patient shouldn’t have gotten paramedics, just that this is the facilities fault for not calling 911, not the ambulance crew’s fault for transporting sans paramedics.), but I also knew plenty of EMTs who would end up throwing their hands up and calling for paramedics regardless of their distance to the hospital for no other reason than to placate the emergency department staff.

    • Thank you for taking the time to respond.

      I would suggest, as I have done earlier in the comments to another post, that the squad leaders should have a dialogue with the ER management to avoid this type of interaction. Only through open receptive dialogue can there be improvement and advancement.

      Thanks for taking the time to respond!

      Sincerely,
      Jordan

  • DRuga says:

    would love some feedback on this….I feel that the major problem with the EMT-B training as it stands today is the lack of any real clinical time spent on an actual ambulance. A few hours in an ER to see real sick patients and see the difference between the street and the ED is a good idea….but to not require that the student actually ride on an ambulance and take calls seems wrong to me. When I was certified many years ago the volunteer squads dominated the scene and the vast majority of students were afflilated with a squad.Usually the student was “assigned” a mentor or there were people to take them under wing. Even though I had a cert I had to ride as a third til cleared by my mentor. This process is missing for most students today. We have a large number of students who come to class and have never been inside a rig.(also can have medic students who have no bls experience) We try to encourage them to “ride” some where and offer a program for them to do that but it is not required. I think a best case scenerio would be that the EMT student be required to ride a certain number of calls for basic evaluation with a qualified preceptor and then be allowed to sit for the exam. The current proposal for the national curriculum has expanded the scope of knowledge but does not stipulate a change in the clinical requirements. Not real sure why not, and I fear that it will perpetuate the problem.

    • Please read my attempt at creating a dialogue about this very issue and the ensuing comments under “Hiding in the Nursing Lounge”.

      Thanks for taking the time to reply!

      Sincerely,
      Jordan

  • Skip Kirkwood, MS, JD, EMT-P, EFO, CMO says:

    New Jersey is a product of its EMS history. You had to be there….but that’s another post.

    The problem with putting medics on all the ambulances in NJ is that there are FAR too many ambulances. You would have MANY more medics treating the same number of patients, hence far less proficiency. For example, way back when, there were something like 65 ambulances in Burlington County, for a population of about 425,000. Today I manage a system where 35 ambulances care for a million – but we don’t have 35 separate town squads, we have one county EMS agency. You would get WORSE care, not better, and at much higher cost. Contact me off-line if you want to discuss further.

    • Please read the post made by my colleague and NJ EMT-P regarding EMS history. It was just posted on this blog last night. Interesting read!

      Thanks
      Jordan

    • Tony Correia says:

      Skip’
      Based on what you guys do in Wake, we could do away with about 40% of all ambulances in NJ and provide better service and care. But unfortunately we are a product of our history. We would do well to bring in leaders from other states and countries and redesign the system for the patients in NJ. We who are part of the redesign of EMS in NJ are too close to it.

  • The implication was not that all volunteers become Paramedics. This, I agree, is not feasible on multiple level and was never intended by the blog. “The ideal would be to bring all squads up to the CAPACITY of having a medic available for all runs if needed”

    Drawing on my own past experience as a volunteer with a system which provided both BLS and ALS level of service, the majority of the rescue squad members were EMTs. A select group, based on performance and skill, were selected by the department to go on for EMT-III training. There was a system in place for quality assurance, frequent drills, and continuous review.

    Most calls ran BLS. The majority of runs don’t require advanced medical interventions.

    Our pagers would go off along with the local air horns. We, the volunteers, would assemble. As soon as a crew was prepared, the ambulance would leave the garage. If the call was purely BLS, the ALS members who happened to respond would provide a supervisory role to the EMTs, yet allow the EMTs to run the call. This allowed for a review system to be in place to foster BLS training and select for those who ultimately might be considered for additional advanced training. Conversely, if ALS was needed, the EMT-IIIs ran the call. Occasionally a call would arrive needing ALS, with no member available. During such a circumstance, Nassau County PD would usually be on the scene with their ambulance as back up. Rarely, the need for “Scoop and Run” occurred.

    A system such as this could work in NJ. The benefits of this, I believe, are self evident.

    While we don’t need all squad members to have advanced training, having members of squads with this training who can afford a supervisory role could limit multiple rescue vehicles on the road, lower equipment costs and liability, while fostering an environment where quality improvement and skill development are central.

    Thank you for taking the time to share your thoughts. I apologize if my blog lead to confusion regarding what I was proposing!

    Sincerely,
    Jordan

  • robert says:

    my 1st reply is who cant determine if als is needed?? if the emt’s in that rig were unsure they should be retrained. micu has over gone changes in the last yrs their not treating all the pt’s they used to. some micu programs omly want to arrive on scene to get their evaluation bill and release to bls.. i work 2 paid ems systems 1 urban the other rural. on the rural job its a mininum of 15 miles to the hospital depending where we transport to. in most cases als not avail for us or coming from opposite direction we are transporting to (par for course). on the other job its 0-5 miles to 1 of 3 er’s. in these cases als would not have time to treat properly, if they are truely needed. if micu is needed wether thay arrive on scene or met enroute to er most of the als crews want to “park” on scene or road side & treat. most of the medics coming out now i just dont trust & the “older” medics are being driven out of their programs by mgmnt or co. politics.. nj should move forward to a “emt-I” program & combination trucks micp & emt. hope this helps your thoughts

  • Tony Correia says:

    Doc I worked in the last municipal ALS system in NJ before. It was disbanded by politics. Additionally I was the fire chief of a full service ALS fire Dept. I currently work part time in PA in a ALS EMS service. I think I have a small understanding of other services. I also sat on the committee that developed the current proposed EMS legislation. NJ has great potential to be a comprehensive healthcare delivery service. The issue with the legislation moving through is:
    1. Lack of participation from the EMS community in general to voice the interests and concerns and then ultimately get behind legislation that put the interest of those we serve 1st.
    2. To many competing political interest of those who developed this legislation. We put together a compromise document, not a consensus document.
    I suggest you contact members of the committee that developed this legislation and currently attend hearings where most of lobby for this bill, even with the flaws, as it is better than what we have.
    We still have time to have positive amendments put in the senate version of the bill. If you have other like minded physicians please bring them to process. There are many ways to develop a comprehensive and flexible system given willingness to work in a collaborative manner for the betterment of the pt.

  • Steve Bastian says:

    I do not think that putting more MICP’s on the street is the answer. Appropriate training, education and certification of the BLS workforce, coupled with appropriate utilization of the ALS resources available, are the right directions to go. Triage of ALS to emergencies that require ALS, using evidence based EMD, could alleviate the overutilization, increase availability and improve response time for ALS. Conversely, this will require an increase in the overall level of performance of BLS providers and services. Also, MICU programs need to be a mix of transporting units and intercept. Waiting on scene, with an ALS patient, for an available BLS unit is not in the best interest of anyone. The two tired system does work, but only if both tiers are educated, organized, integrated and utilized properly.

    On the issue of utilization, there needs to be a triage system that is based in the current published evidence, which will place the right people at the right place and at the right time. All of the published research seems point to procedures in the field INCREASING morbidity and mortality! A cardiac arrest does not “require” ALS. As a matter of fact, the AHA 2010 ACLS guidelines emphasize “High quality CPR and early defibrillation”. These are both BLS level skills. Most of the “traditional” ACLS skills, such as intubation and administration of medication, are referred to as “distracters” to quality resuscitation, in the new guidelines. Numerous studies have found that spinal immobilization, in certain subsets of trauma patients, does more harm than good, and that most patients are needlessly immobilized in the pre hospital phase of care. So why do we WASTE so much time on scene immobilizing everyone. Isotonic crystalloid bolus, and even IV insertion itself, have not been shown to increase survival or decrease morbidity in trauma patients; in fact it has demonstrated an increased mortality in thoracoabdominal trauma patients. Yet we continue to consider all of these patients ALS and call for medics, or perform these “skills” if we are medics.

    In over 20 years, both in and out of hospital, ALS and BLS, I have learned that definitive care does NOT happen in the back of an ambulance or helicopter; it is done at a hospital. Don’t believe me, when was the last time that anyone “fixed” a GI bleed, appendicitis, pulmonary embolism, or traumatic liver laceration in the field? You can’t, they need to go to the hospital, and it doesn’t matter how they get there or who is in the back with them. If a patient is two minutes from dying there is little that a medic is going to do in the field to prevent that. The pre-hospital drug of choice for this GI bleeder is diesel fuel!

    The most important thing that any EMS provider brings to the scene of any emergency is not carried in a truck, helicopter, or bag; it is carried between their ears! Education, experience, and strong clinical decision making are the most important “skills” that we as EMS providers bring to the table. Although ALS providers typically have more education and experience that their BLS cohorts, “skills” are not the sole domain of the ALS providers. All the recent evidence supports the scoop and run (read BLS) for most emergencies. The two areas where ALS care has demonstrated an improvement in patient morbidity and mortality are early identification, triage, and treatment of STEMI, and management of respiratory emergencies. Those are the two primary areas where medic level interventions have demonstrated an improvement outcome and mitigating death. These are the types of emergencies that a robust evidence based EMD and an educated two tier system are ideally suited for.

    • I agree with all your points – I need to point out that I never suggested complete conversion of all squads to have 24/7 ALS capability.

      The implication was not that all volunteers become Paramedics. This, I agree, is not feasible on multiple level and was never intended by the blog. “The ideal would be to bring all squads up to the CAPACITY of having a medic available for all runs if needed”

      Drawing on my own past experience as a volunteer with a system which provided both BLS and ALS level of service, the majority of the rescue squad members were EMTs. A select group, based on performance and skill, were selected by the department to go on for EMT-III training. There was a system in place for quality assurance, frequent drills, and continuous review.

      Most calls ran BLS. I agree with the responder that the majority of runs don’t require advanced medical interventions.

      Our pagers would go off along with the local air horns. We, the volunteers, would assemble. As soon as a crew was prepared, the ambulance would leave the garage. If the call was purely BLS, the ALS members who happened to respond would provide a supervisory role to the EMTs, yet allow the EMTs to run the call. This allowed for a review system to be in place to foster BLS training and select for those who ultimately might be considered for additional advanced training. Conversely, if ALS was needed, the EMT-IIIs ran the call. Occasionally a call would arrive needing ALS, with no member available. During such a circumstance, Nassau County PD would usually be on the scene with their ambulance as back up. Rarely, the need for “Scoop and Run” occurred.

      A system such as this could work in NJ. The benefits of this, I believe, are self evident and should answer the bulk of your points.

      Pennsylvania is currently under Act 37 mandating a medical command physician for all BLS ambulances with AEDs. This is part of Pennsylvania’s attempt to improve quality assurance. Hence, again, as per the point of my blog, there are opportunities for NJ to learn from it’s sister states and improve/advance the current system.

      While I agree we don’t need all squad members to have advanced training, having members of squads with this training who can afford a supervisory role could limit multiple rescue vehicles on the road, lower equipment costs and liability, while fostering an environment where quality improvement and skill development are central.

      Thank you for taking the time to share your thoughts. I apologize if my blog lead to confusion regarding what I was proposing!

      Sincerely,
      Jordan

      • Steve Bastian says:

        OK Jordan, I’ve know you for too many years not to call you out on this generic response.

        “I agree with all your points”. If you agreed with my points then you would know that I was not “suggesting complete conversion of all squads to have 24/7 ALS capability” either. I am suggesting that the number of MICP remains the same. There is no need to increase the number of MICPs, we need to do a better job of providing good BLS and use the ALS resources more effectively.

        “The ideal would be to bring all squads up to the CAPACITY of having a medic available for all runs if needed” Volunteer organizations need to stay out of the ALS business, plain and simple. Your past experience not withstanding, most volunteer ALS services in Pennsylvania do not universally provide the best care. The “system in place for quality assurance, frequent drills, and continuous review” that you describe in New York does not carry over in the to the rest of the world, and we can use Pa. as a example.

        There are other considerations to be made. Why should I as a paramedic provide my services free of charge when I could go else ware, serve the same community and get some compensation for my efforts? Do you, as a physician provide, free care in the community where your ED is in? Of course you don’t, it is your paid job. As a system administrator, why should I continue to fund a very expensive MICU program, when I can get a volunteer organization to do it for free? This will not work. I don’t even believe that these volunteer organizations would be interested in funding an ALS program. This is all about money. Traditionally, volunteer FA squads don’t even want to have EMT’s what makes you think that they will welcome medics with open arms?

        “Most calls ran BLS. I agree with the responder that the majority of runs don’t require advanced medical interventions.” This was a large part of my original post regarding the over utilitization of ALS for BLS level transports, and all that you respond with is one sentence? Come on, I know that you are smarter than that. If you agree that most calls are BLS then the emphasis should be on BLS and not on adding more unnecessary ALS providers to the mix. Model EMS systems like Wake County NC and King County, Washington, have very small ALS to larger BLS provider ratios, and they have some of the best pre-hospital resuscitation rates in the country. In the end the facts don’t support your argument. There is no need to add medics to volunteer organizations, there is a need for better educated, funded, organized, equipped, and regulated volunteer organizations.

        “Our pagers would go off along with the local air horns. We, the volunteers, would assemble. As soon as a crew was prepared, the ambulance would leave the garage.” All the while this is happening now in New Jersey, the MICU is on scene with a hot STEMI and no way of getting the patient to PCI. Second and third calls are going out to get volunteer crews to assemble and get on the road, or for a call to a mutual aid service. This while the patient extends his/her infarct, and the medic stands in their living room and can do NOTHING! Allowing MICUs to transport could alleviate this.

        Now a don’t want to use a broad brush, there are some volunteer organizations out there that have very good call to response time but we can’t track that in New Jersey because that data is not reported or collected. Again, better educated, funded, organized, equipped, and regulated BLS organizations are sorely needed.

        The remainder of your reply speaks to having an ALS “supervisor” on scene and how that would benefit the organization. I submit that if the current existing MICU’s adopted and integrated their operations with the BLS organizations in a system wide manner you could achieve the same goal without the addition of more unneeded ALS providers, and you would build greater confidence and cohesion instead of the BLS (Basic Lifting Service) Versus MICU (Me In Charge of U) mentality that I see so prevalently in the current system.

        Just my thoughts on the matter, old friend.
        Regards
        Steve

    • Tony Correia says:

      Amen, amen

  • Respectfully I have disagree with you regarding paramedics on the BLS units, I would concur with Skip.

    I would not use Pennsylvania as an example, they have their own issues with intubation success rates, and a host of other problems as well: http://www.post-gazette.com/pg/05200/540050-85.stm (this was shameless on my part I know)

    If you cannot deal with ALS competency, in a successful manner in the state of NJ (and I have over 20 years experience in the state, concurrent paid and volunteer time), how are you even beginning to address the BLS competency issues?

    YOU CANNOT HAVE GOOD ALS WITHOUT GOOD BLS. A GOOD BASIC EMT IS WORTH HIS WEIGHT IN GOLD!

    We need to be brave enough to step up, and build a SYSTEM, not only to deliver SERVICE, but to EDUCATE, TRAIN, and ENSURE QUALITY of CARE.

    With all due respect what you describe regarding the paramedic does nothing to ensure the paramedics competency, and really sounds like a Rube Goldberg approach to fixing the problem.

    The real solutions are NOT EASY, BUT with complex problems they never are. You just have to be brave enough to say enough is enough.

    My question to you is: would you rather be a live politician or a dead statesman?

    • The issues of BLS education I attempted to address and start a dialogue under the blog “Hiding in the Nursing Lounge.” I agree with the importance of BLS and promoting their education.

      My ideas regarding the placement of some volunteers trained to the level of medics and the diminishment of burden to the current MICU system, the promotion of ongoing education for that same volunteer squad from these higher trained leaders, the potentially lowered costs to the townships, are covered in some earlier replies to comments.

      I agree with virtually all of your points and greatly appreciate the time you took to read and post your thoughts!

      Thank you!

      Sincerely,
      Jordan

    • Just read the article you attached. Interesting read.

      Thank you for bringing this to my attention!

      Jordan

  • Tony I just saw your post asking about CA vs NJ
    Please read below for my comments:
    Tony wrote:
    Dan I agree with most of your post. I believe if we could do away with ALS and BLS and just move to being a EMS system. Isn’t that what you have in Ca?
    Dan reply:
    We have in the urban/suburban areas of CA MOSTLY all ALS systems.
    They are FRAUGHT with NUMEROUS problems, competency being a huge issue. Not something I would look to replicate in NJ.
    Tony wrote:
    Also I believe have county / regional over site could be big benefit in NJ in coordinating care in specific regions. One of the items you address is advanced BLS skills such as nebs. Would be allowed in the proposed legislation. NJ does have enough ALS providers, just not properly distributed. Many in NJ try to make the point that due having regionally located medics, they get much more ALS skills then medics on ambulance.
    Dan reply:
    Regional oversight is for the most part is pretty good. We come together on monthly meetings, for QI, operations, communications, and data. One stop shopping in the local EMS agency is always nice as well.
    For EMT-B nebulized Rx, SL NTG, ASA, epi-pen, and supraglottic airway (combi-tube, King tube, etc.) are all BLS skills under the national curriculum.
    EMT-B in NJ should be doing supraglottic airway (king or combi-tube…king is better), SL NTG, AND nebulized medications. It is in the National Standard Curriculum, and should be in the scope of practice for EMT-B.
    They have enough patients/volume these are easy enough to do. Nebulized meds were being done in NYC by basic EMT's (look in pubmed for Markenson, MD, wrote a few studies) with fantastic success.
    Let me ask you a question…how many hours is the basic EMT course?
    If you said 120 hours, you are wrong. 120 hours is the MINIMUM.
    The basic EMT course, can be 250 hours (and will be under the new national gudelines being developed)
    VERY few places teach the 250 hour program, so when you have a guy with 120 hours of education and you want to complain about the care he is providing, that is what you get with a 120 hour EMT.
    Tony wrote:
    The reality is each medic only get half the skills that their unit runs. If you split out the medics to some other configuration you could double the coverage, yet still get the same amount of skills. On the high acuity calls you send the advanced care medic who serves as the second ALS provider on those 4% calls.
    Dan Reply:
    You have too many medics in the system Tony. When Rob Davis, who was Kaiser Health Fellow, did his research, he determined that the systems with the best cardiac arrest survival rates (if that is, or will be, your benchmark) had at MOST 0.2 medics for every 1,000 people…again at MOST.
    For every medic you added ABOVE that 0.2 per 1000 people, cardiac arrest survival dropped by 0.8
    Counter-intuitive to what you would normally think
    Tony wrote:
    The regional oversight I spoke of earlier would allow us to accomplish your recommendations. I know this works in PA. where I currently work as a PT medic.
    Dan I would like to hear more of what we can learn from Ca. Vs. NJ .
    Dan reply:
    I would not use CA as the example or the system to emulate in NJ Tony.
    By and large CA is a county run system, with the local EMS agencies in each county writing their own protocols, policeis, operations manuals etc. No statewide protocols for treatment/operations, etc. They do provide some oversight, but it is the largest state in terms of population in the nation, going from densly urban areas, to rural/frontier.
    Some counties are excellent, Alameda County where I am at (we had a tremendous medical director, Jim Pointer, just retired)., and they would in part or in whole serve as excellent examples for the state of NJ.
    Some are VERY poor. The state system in CA is decentralized in regards to oversight, they leave much of that to the local EMS agencies (county agencies), who have medical directors and staff.
    As an example, every paramedic must pass the NREMT exam and get licensed by the state, BUT then they must apply to the individual county they want to practice in. In some counties it is as easy as filling out an application, in others you must take an exam on the county protocols for that particular county. (and every county has their own treatment protocols).
    The two counties I would look to emulate in CA for NJ if I had a pick would be LA and Alameda…
    Why? Because they have an EMS tax that goes to fund the system, so they are fully funded. They have the best protocols, the best education, generally the best systems, because they have money.

  • MICP 3247 (Inactive) says:

    Pardon me for dragging thsi dead horse up, but……
    I work in a system where 100% of all paid Engines are ALS, all FD Ambulances are ALS, and all Ladders/Spec Ops units are ALS. In fact, they even have paid medics on volunteer engines to provide the mystical ALS power to the citizens.
    Truth is most medic in the system are, compared to my fellow NJ MICPs, horrible. Despite this, we have protocols that blow NJs out of the water. REAL pain management, RSI, aggressive protocols for respiratory difficulty, and we have gotten so good at out of hospital cardiac arrest we just recieved an award for it (IAFC EMS Award), and were a trial site for the CIRC study.
    However, a culture of fear has resulted in almost EVERY patient being an ALS transport with IV. Patients I would have triaged to BLS in a heartbeat if I ever was to be dispatched on them in Jersey suddenly become ALS because of the leading questions on the dispatch card, and a culture of fear of the administration disciplining you for sending a patient BLS who has a far out medical malady has made scardy medics, and thusly, poor medics.
    This year I have ONE intubation.
    Last year, I have 10 in 6 months of working at my job as an MICP in South Jersey.
    More medics are not the solution, as it has been stated. Better protocols for medics, good dispaching, education for BLS, fostering cooperation between ALS and BLS (no more treating BLS like crap! I witnessed it myself plenty of times, and its embarassing.
    My 4 cents for inflation, and coming to the party late.
    Hope work again in Jersey.

  • Larry H says:

    I've been a Paramedic for 22 years and an EMS educator for 15 in Florida. I am from NJ and read the comments c interest as the original post suggests the potential for a delay in either care or prompt transport exists using the 2 tier ALS system. The 2 tier system appears to be first via BLS response and then upon qualifying an ALS unit responds. My current assignment is in medical  quality assurance and we study data regularily c respect to 'golden hour' time lines and adherance to protocols and policy. Our quality assurance program is vital and by having a close relationship c medical directors and hospital administrators we re-define policy prn. Yes, medical care is political and often changes don't occur until something negative occurs. Perhaps by examining the data concering time lines (and care rendered on scene), efforts can be directed to upgrade BLS response to include an ALS unit or even to staff the appropriate units c MICT's in high density areas. In Florida, many of the County's have cross trained fire personnel to at least basic EMT levels and are equipped c I-Gels, LMA's, AED's, and comprehensive trauma equuipment. We track patient outcomes and dedicate  time to extensive in-house training programs using preceptors if remediation is necessary. There is also a nationwide trend towards re-educating dispatchers to better qualify calls and reduce the potential for 911 misuse as this has become a challenge as well.

  • Jack says:

    Volunteer EMS? In NJ? Where? Volunteerism is just about extinct, if not nearly wiped out. And volunteer EMT or not, this scenario is flagrant idiocy on the squad's behalf. Ironically enough, this example is NOT uncommon. It happens to me as an ALS provider often, and oftentimes the outcome is as described in your scenario – pt is absolutely fine, and probably didn't warrant ALS in the first place. This is poor decision-making on behalf of those that summoned ALS, thereby making them board on the side of a busy road, etc etc. 

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Jordan Barnett

Jordan Barnett, MD, is an Emergency Medicine Physician in the Philadelphia Suburban Region.  He has previously worked as a volunteer firefighter, was a member of New York City EMS, and provides Medical Command for several ALS Ambulance Services. Dr Barnett provides EMS consultation services. Additionally, he is actively involved with EMS education.
Comments
Abby
Hiding In The Nursing Lounge
Agreed. Very well said.
2013-08-19 00:46:31
Abby
Hiding In The Nursing Lounge
I'm several years too late, but I found these posts interesting. One, the students were clearly in the wrong. Their behavior can't be justified. In any profession you're bound to have good days and bad. People are going to say rude things that are going to make you angry. However, you still must do the…
2013-08-19 00:34:56
Olive
Time for Intelligence in Implementing EMS
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2013-04-15 20:21:25
dan chambers
EMS System in NJ
Hey, really appreciate the post.  Its good to give real life accounts of what it is like to be an EMT and work for the EMS, good and bad.   I really think that would-be students would really love reading this post and others you have written.  Anyway, I have an info blog myself that…
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Time for Intelligence in Implementing EMS
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2013-01-23 23:44:45
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