How Many Paramedics Does It Take To...?

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

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

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

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

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

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

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

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

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