A Tale of Two, Two Tiers

Disclaimer:  I appologize for the format of the text as this is one of my first blog entires with this interface, and for some reason it and Word didn't want to play nicely.  I tried to fix it up best I can.  Future posts will not have this problem.

It’s interesting that Dr. Barnett picked a topic in the previous blog that is so near and dear to my heart. Rather than post a comment, I decided to create a new entry, because it’s going to be lengthy in nature, and I would like to see separate comments and feedback.  Why, might you ask?  Well, I’m a true believer in EMS, and in the ability of providers to bring quality basic and advanced pre-hospital care to the public. 

Throughout the fifty states and assorted territories, each individual EMS system needs to adapt to specific needs of the community.  It is not a “one size fits all” system.  Some states have system wide mandates whereas others leave it to each individual organization or municipality to decide on how they are  going to operate their EMS system.  All must operate within their regulations, but some allow for more self rule than others. With this, I am going to go a little more into detail on the “chase” system in New Jersey and how we differ and compare to other systems that are run through the country.

I believe our system is “unique”, and, dare I say BETTER in some ways, while antiquated in others. To understand EMS in New Jersey, we need to look way back in the past to when the EMS system in New Jersey was conceived.  Since we are focusing on southern New Jersey (which for those not from this area, is COMPLETELY different from the north), I am going to use references and examples from this region to simplify things.  The Office of Emergency Services (OEMS) was created in 1967, and was charged with the task of creating standards as well as regulations regarding pre-hospital care.  At this time, calling pre-hospital care basic life support was a stretch at most.  Certifications evolved, and we went from the 5 points certification, to EMT.  Now, we must not forget that OEMS was not the only “organization” that had an interest in EMS in New Jersey at this time.  Back then, EMS was run completely by volunteers that would pick up the ambulance and race to the call from home when the air siren blasted, or the old Plextron would alert.  The New Jersey First Aid Council (NJFAC) , which even today exists as a private organization, was a place where volunteer ambulance squads could join to share ideas, support each other, and come together to lobby for a specific cause:  volunteer EMS in the state.  Back then, EMS was run 100% by volunteers. 

Things, however, began to change. Up to this point, there was NO ALS in the state.  I’m a little rusty on specific dates, but ALS didn’t evolve in NJ until the mid to late 1970’s; do we all remember “Emergency!”?  New Jersey’s Department of Health wrote regulations which allowed for advanced pre-hospital care, but it was set up with a rather unique frame work.  ALS could ONLY be provided through a hospital system, not by local EMS agencies.  Also, in order to provide ALS care to a specific area, a hospital system that was interested in providing these services had to submit a formal request to OEMS in order to be awarded a Certificate of Need (CN).  This CN would authorize a hospital system to provide ALS care within a specific geographical region, usually one or more counties. In the southern most counties, Camden, Burlington, Gloucester, Cumberland, Salem, Atlantic and Cape May, there were three main sources of ALS care, provided by three hospital systems: West Jersey, Underwood and Burlington Memorial. This CN system still exists to this day.  A CN may be taken away and re-awarded if it is proven by a challenging agency that their area is being underserved by the current provider. Regulations that governed ALS care were written so that a two tiered system was created, which would allow for local volunteer ambulances to transport the patient, while the ALS unit would intercept the ambulance if advanced care was needed.  There were wivers created which allowed for some systems, particularly up north, such a UMDNJ and Jersey City, as well as a few others, to provide ALS transport-capable ambulances.   But they were the exception.  

The MAIN reason a chase system was created was due to the local volunteer squads as well as the NJFAC.  They didn’t want “outside people” to come in, transport “their” patients to the hospital, and illegitimize their existences.  These volunteer organizations felt extremely threatened, and lobbied to the state so that they could maintain their local control, while allowing ALS intercept vehicles to come into the mix if needed.  Added to this was a lack of ALS providers, as well as long transport distances which didn’t allow for paramedics to accompany every patient to the hospital.

Fast forward to today.  We now have more ALS units (or less depending on where you live), more advanced scopes of practice, as well as more aggressive protocols.  Some areas fared better than others financially, and those that were able to keep their heads above water, expanded their services and took over those that weren’t able to compete.  In the beginning, ALS care was very profitable.  Even though the volunteer squads wouldn’t charge for services, the hospitals would.  All was well and dandy up to the point that Medicare started to reform its billing regulations.  

Now keep in mind, New Jersey is NOT the only state that runs a completely tiered ALS system.  WHAT!? Yes, it’s true.  Some might call shenanigans on this, but it’s true.  Our neighbor to the south, Delaware, has the EXACT same system that we do.  They run a regionally based ALS system, chase vehicles with two paramedics that would intercept a BLS ambulance to provide ALS care.  The main difference between the two states is that rather than being mandated to be hospital based such as we are, Delaware ALS is completely run by county governments.  Granted, Delaware only has three counties, but it’s still a regionally based, tiered ALS system with extremely high quality of care, and run with great efficiency.  Not to mention their volunteer and paid BLS agencies are all held to the same standard. (Can’t say the same about NJ!)  There’s a reason I bring Delaware into the mix.  You’ll see in a bit.

Medicare reformed its billing practices, and stated that only one agency is allowed to bill for services. Now, these ALS agencies have to contract with local squads, in order to bill for services through them.  For example, let’s say an ALS ride to the hospital would cost $1,000, but the BLS agency bills for services which costs $500.  The ALS agency has to submit their bill through the BLS agency, and spilt the difference in cost.  So now the ALS and BLS agency both get $500.  This is not very profitable if you have a low call volume.  If the BLS agency doesn’t bill for services, then the ALS agency can send the bill directly to the insurance company, and get the full amount without having to share anything.  Why do I bring this up?  Because with this system in place, hospitals were unable to support their ALS services, and many were gobbled up by larger systems.  My point is that hospitals aren’t able to maintain ALS coverage due to expanding populations without losing profitability, since they would have to staff more units, without being reimbursed their full amount to break even. 

New Jersey brags that the state is 100% ALS covered, but what they fail to tell you is that it’s not 100%, 100% of the time.  All too often, citizens go without ALS care, because there are no ALS units available. On a positive side, I feel that the tiered system is the way we should provide services in this state; however, I feel that ALS coverage needs to be expanded so that there are fewer gaps in coverage due to increased demand.  The consensus on response times is that you should have BLS level care within 8 minutes or less, 90% of the time, and ALS care within 12 minutes or less, 90% of the time.  While there are no regulations or laws that state this, it stands as a general consensus throughout the country.  Now, working as a paramedic in New Jersey, I can say that the agency I work for is able to meet the 12 minute mark, 90% of the time.  I can’t say the same, however, for  BLS.  There are countless times where I have sat on location, waiting for an ambulance for 20, 30, even 40 minutes at a time.  Unacceptable.  Many would argue that if paramedics were staffed in ambulances, we wouldn’t have this problem.  True, but if agencies were regulated and mandated to meet minimum response time criteria, we wouldn’t even have this discussion.  But that’s a different blog….

Still, one asks, why a tiered system?  Simple; all one has to do is compare the amount of sick people, critical skills that are needed, and the amount of providers there are to provide these advanced interventions.  Let me bring this more into perspective.  Only about 3 – 5% of 9-1-1 calls for medical emergencies are actually life threatening in nature. Wouldn’t it make sense to have a proportional amount of people that can treat life threatening situations to the demand that actually exists?  It doesn’t make sense to have a paramedic on every ambulance.  Here’s another example.  Let’s say that there are 1,000 highly invasive skills that are going to be performed within one year.  If we had more ALS providers, say 26,000(roughly the amount of EMT’s in NJ), the chance that a good majority would encounter one of those 1,000 skills is highly unlikely.  Now, let’s say we have 1,700 ALS providers (roughly the amount of paramedics in NJ).  The likelihood that they are going to encounter one of these skills increases dramatically.  Because we have a higher exposure to only extremely sick and critical patients, we are able to maintain our skills and a much higher clinical standard. 

As a paramedic in New Jersey, I do notr respond to every broken bone, stubbed toe, cough, cold and tooth ache. We also have lower staff injury rates due to the fact that we don’t typically operate stretchers or other carrying equipment, and we are able to keep highly experienced medics because they are able to work longer due to lack of injury.  I get sent to only life threatening emergencies when deemed appropriate.  Everything else warrants only a BLS response.  If BLS arrives on location and judges that we are required, they request our services, and we arrive on location typically within the 12 minute window. Here’s another interesting perspective.  Some people actually come to work in NJ as paramedics from other states with single level response systems, in order to maintain their ALS skills.  In their previous systems, they get sent to more basic, non life threatening calls, and have a lack of exposure to highly invasive procedures.  How comfortable would you feel if you or your family member was being treated by such a medic?  Would you want a medic that only does 1 or 2 intubations a year intubating you?  Or would you want someone that quite literally may do several a week?  It’s a no-brainer.  Because we have such a high exposure, we are able to perform much more aggressive and invasive procedures.  Remember I mentioned Delaware way back?  That’s because they have the same tiered system we do with similar competencies and skills.  And you know what, we have comparable success rates in high risk, low frequency procedures.  Both New Jersey and Delaware prove that a tiered system works where appropriately applicable.  Over-saturation of ALS providers is unnecessary; we must not have our skills be watered down.  We merely need to have enough ALS providers to provide complete coverage within twelve minutes, ninety percent of the time, to calls where we are specifically required.

As for the legislation that is working its way through the Senate at this time, it would allow for a much needed overhaul of the system.  Yes, there were provisions that were removed because of the lobbying from the NJFAC, but those things can be tackled at a later point in time.  Personally, I don’t care about the training fund.  Leave it for the volunteers.  I paid my way through paramedic school, as well as additional certifications and higher education and certainly don’t miss the training fund.  As for the two EMT standard, that’s ok as well.  It’s better than NO EMT at all which seems to be the status quo for volunteer squads.  As of right now, only BLS services that are licensed by OEMS are required to have two EMTs.  Those that are not licensed do not have to have ANY EMTs.  And no, as of today, there is no law or regulation that requires a BLS agency in the State of New Jersey to be licensed by OEMS.  They basically regulate themselves, and do as they please.  This piece of legislation would thankfully change that. In regards to EMT education, right now the Department of Health is revamping the way in which EMTs are trained in NJ, including the amount of classroom time and clinical hours required for testing.  I agree with many of the responses to the previous post, that education standards need to increase, as well as minimum number of exposure hours to field and clinical settings.  This too will get a future blog.

I found the comments regarding emergent mode of transport to a receiving hospital rather amusing.  Personally, I only transport to the hospital with lights and sirens about 5 – 10% of the time.  Unless the patient is next to death’s door, or needed to be in the hospital “yesterday”, they get no lights.  With that, I believe BLS transport should ONLY be no lights or sirens, unless the patient deteriorates, or there is an immediate threat to the crew due to a combative patient, for which you should have a police officer present anyway.   I once told an EMT that was transporting us to the hospital to use no lights and sirens.  Her response “We don’t do that.  It’s our policy, all patients get lights and sirens.”  And so I replied “Too bad, no lights.”  I’m not endangering my life for a stable patient, whom I can easily manage, by going lights and sirens for no reason at all.  My agency encourages this position as well. Ok, this was long enough.  I hope I was able to enlighten a few people about our lovely system (note the sarcasm), the pros, the cons, and the direction that our state is headed.

Comments and suggestions are encouraged. Future entries to come.

Armor Medic

12 Comments

  • DisruptoMedic says:

    I am also a New Jersey Paramedic (of over 20 years’ experience) in the ‘semi-urban’ north. Your history is very accurate & relevant to the present NJ EMS milieu. I will also totally agree that northern & southern NJ differs.

    One of the issues we medics experience (& one of my serious concerns) with NJ’s BLS system is the frequent “medic dependency” we experience. Medics get dispatched for many unnecessary reasons.

    Why? While there are many very competent caring BLS providers, there are many (both paid and volunteer) who, due to deficient training/oversight, lack the confidence to assess/triage the need for ALS.

    I’m not even touching the issues of spotty EMD protocol use and ALS “babysitting”.
    So, what happens? Medics (second tier) respond lights/siren: they arrive, perform assessment, & triage/release the patient to BLS. At times, ALS is met at the door with “we don’t need you, but why don’t you check ‘em out while you’re here?” So the medics have now risked their safety responding, for BLS ‘insecurity’. On the financial side, ALS project management may bill for “ALS assessment”.
    NJ has a very viable system, for many of the reasons enumerated. It can only be made better by the pending legislation.

    • Armor Medic says:

      Funny you bring this up, as I had a conversation with my partner the other day about this exact topic.

      I joke to people that are not in the emergency services, that the most stressful and dangerous part of my day is when I have to drive lights and sirens. Now add to the fact that a lot of the time we are responding because there is a presumed life threat, but more often than not, it’s usually not even close to the fact. When this situation occurs its just like you said, either, A) Horrible EMDing or B) BLS that is not able to make a competent decision and become dependent on ALS. Risking my life due to BLS incompetence is very frustrating indeed. I always try to educate the crew on why I triage a call down to them, so that hopefully they are able to learn, and if a similar situation were to arrive in the future, they’d be more comfortable with making a better decision. Almost always they are comfortable with my decision and my explanation. I can’t really complain if I don’t do something to try to fix it, right?

      This problem is a double edged sword. My project (what we call ALS services in NJ, for those that are not from NJ) does NOT charge for an “ALS assessment.” However, there is a project that borders us in a neighboring county that does such a thing. It’s gone so far that their medics are not allowed to accept a recall on location, prior to patient contact, and must assess the patient. Now my problem is that this is ethically wrong on many levels.

      1.) An ALS unit is being tied up when BLS has determined that their services are not needed. This unit could be available for another call.

      2.) We are teaching and allowing the BLS to not think independently and make critical decisions. This directly contributes to their “dependency.”

      3.) They are charging for services, such as an assessment, simply because they were not canceled prior to arriving. Now they may decide to triage to the BLS crew, but they are still charging for an “assessment.” I personally feel this is fraud. Not to mention, these projects are contributing to rising healthcare costs, by charging for a service that was already deemed to be unnecessary.

      One must not forget, that a hospital is a business, and the bottom line is the all-mighty dollar. This is why I feel a hospital system providing an essential service such as EMS is a conflict of interest. They may claim that everything is in the best interest of the patient, but we mustn’t forget that they have a business to run, and beds to fill.

      This legislation WILL change many, many things. Give it time, but things will get better.

      Thank you for your input, and I look forward to more in the future!

  • SJ Medic says:

    Armor Medic – Thank u very much for provided and educated and thorough explanation of our system. I love my job and the way I do and as a EMS instructor very excited about whats to come in the future on the BLS level to improve working relationships.

    I sat in the ER today with my Medical Director and utilized both blogs to open conversation about how we can improve within our own MICU system

    P.S. I still believe there NJ should be two different states

    Thank you

  • Tony Correia says:

    I would like to respond to your post. Many of the items you covered were well thought out and accurate. being a 30 plus year medic. providing service in 3 states in both medic and leadership positions I have experienced EMS from many perspective. This doesn’t make be me more knowledgeable, but just different perspectives. I thought my perspective could be complimentary in this conversation. The following are my ramblings and thoughts regrading your post.
    Just some further clarification on the start of ALS in NJ. There were 9 different projects from 1975 to 1980. All the projects had different designs to theoretically find which might be the best for all of NJ. I started in the Mercer “Lifemobile” project which was designed around placing a medic on volunteer ambulances in most municipalities in Mercer County. This program evolved to most communities paying for at least daytimes staffs that included at least 1 medic. These units treated and transported both BLS and ALS patients. From a pure delivery of service for efficiency and effectiveness this system worked quite well. These systems for most part were taxpayer supported, none that I know of billed. At night times most communities had a 1 volunteer medic staff a fly vehicle, while the EMT’s trained to the “Paramedic Assistant” level manned the ALS capable ambulances. The EMT’s were very integral in the process of providing all the set up and support for ALS calls. This system turned to mostly BLS municipal ambulances after the state DOH changed the requirements to require 2 medics on a ALS unit. Only Hamilton Twp. stayed on as a daytime ALS transport system until 1999. In addition the the ALS hospital advised they could provide ALS services for free, by billing the patients’s insurance. Additionally back then ALS could bill medicare A & B, along with none of the BLS providers, except for TEMS billing for Ambulance transport. This history will fit in later in the discussion.
    I’m not sure what assessment the state DOH performed to determine what was the best delivery service model was for NJ. It appears the shook up a few bones in a bowl and threw them on the table to determine their mandate for NJ. Which as you described is: CN,hospital based non transport, 2 medics per unit. Initially it was 1 ALS unit for every 100,000 residents. My belief and this is only my opinion is the state set up this system for several reasons.
    1. It provided for a stable funding process through medicare and insurances, since the hospitals could also bill for some of their services also. 2. it gave the state control over at least 1 segment of EMS in NJ, the segment that treated the most critically ill. The reason for two medics was a hypothetical analysis that many skills needed more then 1 medic.
    Now let’s move to modern day EMS. Many things have changed. As you stated there are more and more career squads, almost all who bill for services. This makes dividing the medicare dollar more of an issue. I haven’t been involved in billing in 8 years, but when I was, the division of payments mostly went to the transporting agency, since thats what Medicare was paying for primarily. Back then a ALS treat “level 2”, yielded approximately $500. total. approximately $350. went to the transporting squad and about $150 to the ALS service. To make up for this the ALS hospitals charge exorbitant rates to the private insurances. A KVO and transport starts at $1600. in this State. years ago I saws official reports that showed the highest ALS providers in the state charging in excess of $2,000 for putting a teflon catheter in your hand and administering approx. 10cc of salt water. The ALS EMS agency i work for in Pa at its highest billing level, charges no more than $1200. for any call. This is one of the major factors in our current Jersey system. It very cost ineffective. This business model would never work in the private sector. An ALS call in NJ takes 4 people and 2 units to do what 1 unit and two people can do. While I don’t have the numbers today, 8 years ago only 40% – 50% of all ALS dispatches require ALS services. This in it self makes it very hard for the current system to survive and coexist.
    Another factor that has changed the face of EMS today, is more research and Evidence Based Medicine. Less and less of what we thought made a difference in ALS is truly beneficial. In the 1 area that we were supposed to make a big difference, was save lives in Cardiac Arrest. The OPALS study shows probably no benefit from ALS Services in Cardiac Arrest. it does show the need for early and aggressive BLS. We already know in Trauma, ALS makes little difference and can be hazardous when we hang around on scene treating or waiting for a Medevac. A Philadelphia study showed more penetrating trauma victims lived being transported in the back or a Police car, then in a Ambulance. While I know there are certain circumstances in both those categories where ALS is beneficial most times it is not. The 1 skill we ALS providers protect, Intubation, could and should be replaced with King LT or similar devices. Don’t get me wrong I love to pass a tube, but no science to prove it’s beneficial with the advent of King LT, Combitube, etc. On top of that we now have skills that paramedics only performed; defibrillation, Intubation, (King LT), breathing treatments, epi pens and now CPAP, being performed by EMTs. I know NJ BLS is not doing nebs. and CPAP, but it is national BLS scope of practice.

    Going with the argument only send ALS when truly needed, would reduce the amount of ALS units required based purely on call volume. Obviously this would increase response time substantially.

    I say we rethink our EMS system from the top. With practices that currently are in place somewhere in this country. Lets start by triaging our all non emergent 911 calls from the 911system. With non-emergent calls going to a triage nurse. These callers would be provided another way to obtain treatment that doesn’t require an Ambulance. This would take about 20- 50% of the patients out of the system, based on the community served. Next staff all BLS ambulances with at least 1 advanced EMT and 1 basic EMT. These units would handle over 95% of all calls. There would be only single medics in Chase cars. These medics however would be advanced care medics who only treat the most critical patients. They would be only used on approximately only 1-4% of all EMS calls. When they are not on calls they are providing follow up on “EMS regulars” to try and keep them out of the 911 system. EMS would interact with very closely with or be part of the Public Health system. EMS and Public health would actively collaborate to try and keep people out of ambulances and emergency rooms with preventive care and early interventions at home. The Public Health side would also see the regulars to provide long term follow up.
    For 1 future perspective, lets get really high tech. A healthcare agency would check on Pt’s via computer daily. These patients would have monitoring equipment hooked to their computer or phone to provide vitals signs and a visual assessment. The Pt. wouldn’t have to leave their house and the Health Care Practitioner Could assess patients right from the office.
    In solving our problems for today and into the future, it is my strong belief that we need a paradigm shift that includes innovation, technology and out of the NJ Box thinking. I would like to thank you for creating this dialogue. It is important we exchange thoughts and ideas in a open manner with the interest of providing over improvement in quality of life to those we serve.

    • Armor Medic says:

      Thank you for your input! Like you said, you brought a different perspective on things. I just want to comment a little on some of them.

      In regard to endotracheal intubation, I feel that we should remain performing this skill, even with the advent of other airways such as the King LT. It is considered the gold standard of airway protection, mainy due to the fact that it actually enters the trachea, whereas others are extraglottic, and don’t secure the airway specifically, only the esophagus. Anything other than an ETT sticking out of a patient when you roll into the ED is getting pulled, and replaced with an ETT. If you are skilled and proficient enough to quickly and safely pass an ETT, that should be the first line intervention for advanced airway management. I feel that agencies that are sub-par at intubating people should be remediated until their staff success rates increase in a setting such as the OR. Don’t remove a skill purely because it’s “too hard”, educate remediate and retrain.

      As for the nurse triage system, I couldn’t agree with you more. You are 100% correct. In other countries, such as the Netherlands, which has an Anglo-American EMS system (Paramedic field treatment, definitive care at hospital), they utilize a nurse in the dispatch centers to triage calls, just as we would on the street. The difference however is that it TRUELY begins at the dispatch center. When a call is received, a nurse triages the call and determines whether or not an ambulance even needs to be sent at all! With that, about 40% of calls received are determined to NOT need an ambulance, and the callers are advised to follow up with their general practitioner the following day. Furthermore, 30% of field responses do not end in a transport to the hospital. There is a study online that goes into great depth. Here’s a link. So out of a total of 165,000 calls received in one year, only about 99,000 received an emergency ambulance. Out of the 99,000, only 69,300 were brought to the hospital, the rest were treated and released on location. Do the math. Over here, someone with a stubbed toe get’s an ambulance, in Europe, it doesn’t happen. It’s a misuse of resources. Want to talk about reducing healthcare costs, here’s a perfect first step!!

  • Tony Correia says:

    Armor I agree with your points on intubation. What my point was if we created providers that could perform skills that require less proficiency, such as Advanced EMTs, we could redesign the system in a more efficient and still effective manner. As stated in my last post I believe in Advanced Care Paramedics similar to Wake County to respond to the subset of call they could make the most difference. I do believe in high volume EMS systems could man 1&1 ALS ambulances.
    As part of the workgroup that crafted the current EMS legislation, I did propose the type of system you describe, but it didn’t get much traction. Maybe it can be resurrected once the legislation passes. However I do believe EMS provider like you need to make it know to those lobbying for the legislation, as well as your legislators. While I am a huge supporter of this legislation, I do believe many on this workgroup are looking for what will best serve the special interest they represent. I am a little concerned that the current proposed legislation will not let EMS grow and morph in a way that would be best for the patients we serve. Despite my concerns, I would like to see every EMS provider contact their legislator to show that there is not just 1 organization in NJ representing the EMS community as a whole in this state. To that end get the legislation passed without it being watered down any further. Let’s not only keep the dialogue going, let’s get the word spread across the state.

    • Armor Medic says:

      I believe that the Advanced EMT level could only benefit the EMS system in NJ. I must have mis-read your previous response. My apologizes. I too am a huge proponent of the EMS legislation, and am also greatly disappointed in some of the amendments that have occurred.

      However, with that, I still feel that it is a good bill that desperately needs to be passed. I think at a better political time in the future, (more favorable governor), we can tackle other issues that need to be addressed.

      I think the main reasons why people might have not been responsive to your proposal for the nurse triage system is multi-fold. Like you said, many are indeed looking out for their own interests. If we were triage calls to determine whether or not they actually needed an ambulance, they would lose money on the calls that were deemed unnecessary. Also, from a liability standpoint, everyone is sue happy, and no one wants to be held responsible for not sending an ambulance.

      I have contacted my legislators to show my support, I only hope that every EMS provider that supports this bill does the same as well.

  • Tony Correia says:

    I posted this blog on the new jersey fire and EMS institutes Linkedin page and twitter. These social media sites are to be used as a clearing house and place to disseminate information related to legislation that affects NJ’s fire and EMS communities. I would hope you would encourage others to join both.

  • Vol. EMS SJ says:

    -Armor Medic
     
    Your post is one of the best that I have seen concerning the fate of EMS in NEw Jersey.  Sometimes I feel as though this blog has a high concentration of "NJFAC" oppentents and as a long time member of the NJFAC it is good to see the otherside of the fence. 
    One of the problems with the inadequet EMt in all of my experience has been due to poor training provided by one of the larger ALS companies in NJ.  This company held itself to poor standards for both BLS training and ALS training.  I was lucky to have many teachers along the way for EMS that where able to teach me to think critically and operate more or less on my own (some of the experience also came from poor ALS coverage in my area.)
    Now I understand that you stated that the no EMT rule is a statues quo for volunteer squad and this is something that I find startling.  The NJFAC squads are all mandated, through the council, that one EMT is on a rig.  Not that this always happens but I have never once heard of this happening in large scale.  It might be due to regional differences.  And if it is so prevaliant then things like that need to be addressed.
     
    What I dislike about alot of the legislation that was just passed is that people seem to think that higher number's is better.  For instance the new training standards.  I for one am all for learning and education.  But at what cost? The new training standards are introducing and teaching our new EMTs many items that they will not be able to use in New Jersey.  And the legaslation places alot more power into the Department of Health, which in my eyes, has done little to improve EMS with the tools they are already given.  Items such as advanced airways have been held back from our BLS providers for so long that I wonder if the DOH even really works in this state.
     
    I will state, the difference between myself and some of my contempories at the NJFAC is that I'm not adversed to change.  However I want change with a purpose.  The new legslation, to me, only benefits the many private-paid organizations that helped to write it.  These are the same companies that provide sub-par ALS coverage and BLS training.  Now with all that said,  all of my experiences are very regionalized and my not hold sway over the entire state. But I feel it is nice to start a dialogue across borders without all of the political noice come in-between.

  • You could definitely see your skills within the work you write.
    The world hopes for more passionate writers such as you who are not afraid to say how
    they believe. At all times go after your heart.

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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.

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