Experience, high volume urban-vs-rural

[Ken Lawson-Williams <Macgyver@FlightMedicMail.com>]

Another perspective on this issue from Canada - where 95% of ALS paramedics are urban (except in Alberta at 65%). Most paramedic students do their clinical rotations (about 1500 hours, so 8 months or so) in a high-volume urban centres and hardly ever get past first-line treatments. In fact approx. 30% of trips tend to be interfacility BLS, 40% BLS 911, leaving 10% ALS transfers and 20% ALS 911. (This is in a tiered system with dual BLS and dual ALS cars that does all medical transportation in a city of 650,000).

Most new grad's first jobs are rural, simpply because cities pay more thus have more aplicants so tend to screen out new grads based on experience (Similar to Flight programs!!). Mine was even more so (by choice, ski-bum) - 75 minutes code 3 from base to the edge of service area and 3.5 hour code 3 ground trips from cottage hospital to trauma centre. 90 minutes from base to closest airfield (mountainous area). Patient contact time per month was just under 20% below what it turned out later to be in suburban setting and almost the same as it was in the city. In opinion of many in the industry around here, ALS is needed far more in rural areas than urban areas, where on-line advice, short transports, tertiary care level facilities and less time (generally) from injury to EMS contact exist. Problem is that $ exist in urban areas due to tax base. And ALS requires $ (as do paramedics!).

Now granted, still a learning curve when a new grad no matter how good your student experience was, but that rural service's curve was STEEP. Codes to the end of the available ACLS algorhythms. HAPE compounded CHF. Grizzly attack (partly eaten) trauma. Glacier crevasse and mountain cliff rescue hypothermic trauma. Wildlife Ranger exposures to fentanyl derivative with transdermal properties for which the LD-50 was 0.3 micrograms and the liquid concentration 10mg/ml. High velocity mushroom bullets (375 H+H, .416 moose/bear hunting rounds etc). 3 years of that was incredibly good at developing assessment and judgement - despite lack of "volume". 

Next job for most is back to suburban areas (similar to the area described by Jeff )with a reduction to 'only' 30-45 minutes maximum response/45-60 minute max transports (both code 3) on gravel roads at 
-30 before wind chill. In my case boring from a clinical perspective. Less chance to excercise judgement, assessment skills or progress through the protocols (both services were off-line on standing orders) Only difference was more alcohol and drug related assults and MVA's. Doesn't take long for most to plateau there despite highest per-capita murder rate in Canada (native reserve of 7000). Repetitive after a year or so even though all 911 work (55% ALS) with absolutely no interfacility transfers and a BLS car to take the bulk of the drunk and stupid calls.

On to flying. Say 5 or so years after grad. In my case the experience that helped me the most was not the 3.5 of high acuity/volume trauma/cardiac arrests but the 3 of remote full spectrum ALS. How to keep people alive past the golden hour. How to cope with the complex medical presentation or childbirth complications. How to think critically under pressure when no backup was possible and no communications with a ER MD existed. How to adapt to the situation and overcome the problems - medical and logistical.

So I tend to agree with Jeff. A simplistic requirement for high volume urban ALS does the profession a disservice in my opinion. It screens out some very capable clinicians. No matter if 3 years or 5 years are required. If 5 years of "quality" ALS experience is required, 2 each in urban high volume and rural/remote would be a better preparation in my opinion. Or 2 rural/remote and 1 year urban if a 3 year requirement. 

The goal should be to recruit staff who are skilled, competant and able to think critically and independantly under pressure or when faced with situations that mitigate against patient survival (logistical, time or medical). Makes it harder to screen candidates as experience has tio be evaluated, but just as one simple protocol doesn't work for all chest pain, neither does one simple guideline work for hiring suitable staff.

Ken L-W  CCEMT-P/WMT

>I can understand the rationale behind the "high volume 9-1-1 service" 
>requirement...more calls, more experience 
>-- but having worked in urban, suburban, and rural EMS areas, I 
>wonder if that "high volume" component is limiting?>
>Some (actually MANY) of the most challenging calls I've ever run were in 
>rural areas when aeromedical evac was not available (insert reason 
>here...weather, on another call, etc.), and we had a LONG way to go.  
>Fourty-five miles by ground thru 3 feet of snow and a -15F windchill with a 
>CHF patient that has crappy vitals can make or break a medic.
>
>And to the contrary, in my current job as a medic/Field Training Officer in 
>a high volume urban service, its rare that our transports with critical 
>patients last longer than 6-12 minutes (for you statistic freaks, the median 
>is 9.2, mean is 8.6, SD +/- 1.1.)  Barely enough time to really figure out 
>what the problem is and do anything about it.  Re-assessment and alterations 
>to the treatment plan?  Please...
>
>So....Is the 'high volume' a good idea?  Or is there another way to measure 
>the experiences and capabilities of a potential employee?

_______________________________________________
Flightmed mailing list
To unsubscribe or change your email address, go to http://www.pairlist.net/mailman/listinfo/flightmed