One Paramedic or Two?... and the Crash of United 173

I’ve been in health care and EMS now for 32 years (it doesn’t seem possible) – and for 30 of those years there has been an argument about the efficacy of one-paramedic vs. two-paramedic systems. I’ve had the ability to witness this debacle from all four corners of the continent and even weighed in on the discussion in systems on foreign shores.

I’ve also had the blessing of being able to work in and with other industries and work environments which allows me, perhaps, to provide a little different perspective on many issues – including this one. One such detour occurred during my fellowship when I was with NASA in the development of the first Crew Resource Management (CRM) programs which are now mandatory training in the airline industry and techniques from which are making there way into the health care delivery field.

The genesis of this effort was the crash of United 173. This flight was a DC-8 that crashed short of the Portland airport because the Captain became fixated on a landing gear warning light and ignored the communications from his crew that they were having a “fuel exhaustion” problem – i.e. they were running out of gas. This lack of communication was a function of what is we now call Human Factors Engineering – which is really the study of how people interact in, and how relations effect the processes in the work environment.

Given this bias - I have come to believe that it is this issue – the issue of Human Factors – that serves as the critical question in the debate over staffing models, not only in para-medicine, but in health care delivery in general. Strange as it may seem – there is some data – which although taken from disparate environments, may – just may – when viewed in aggregate, may support my hallucination.

Bayley, et al (2008) conducted a study of one- versus, two-paramedic treatment scenarios in a simulated cardiac arrest. While intubation times for the 2-medic crews were substantially lower than in the single medic scenarios, based on errors of sequence, commission, and total errors combined in the resuscitation effort, the study concluded that:

“...two paramedic crews were more error-prone and did not perform most interventions more rapidly with the exception of intubation. These data do not support the proposition that two paramedic crews provide higher quality cardiac care than paramedic-EMT crews in a simulated ventricular fibrillation arrest.”

While this may seem counterintuitive, there are a couple of interesting studies that, in the context of our understanding of human dynamics and what we have learned from our complex study of the role of hierarchy through the development of CRM, may make this a little less counter intuitive and point us toward a new approach to the debate about paramedic staffing levels.

Marsch, et al (2004) and (2005) conducted studies regarding the effectiveness and efficiency of resuscitation efforts in intensive care units of a hospital. One study involved a simulated event where a full arrest is discovered by a single nurse, with two other nurses (i.e. peers) and a physician (superior non-peer) being available to assist, once being called upon to run the code. In the other study, the researchers constructed teams of peers (i.e. nurses and physicians acting together on separate teams). A full arrest was then simulated and the performance of the team was monitored and evaluated.

In both these scenarios of simulated witnessed cardiac arrest almost two thirds of teams composed of qualified health-care workers failed to provide basic life support and/or defibrillation within appropriate time frames.

When compared to a metric of hierarchical leadership/direction the “absence of leadership behavior and absence of explicit task distribution were associated with poor team performance.” In other words, it was not the level of accreditation that mattered; it was the effective construction and deployment of an effective team.

In the mixed peer scenario (nurses and physicians) the study found that “the early availability of a physician increased the number of countershocks administered and greater protocol compliance.” In other words, based upon the expectations of the work environment, the presence of the hierarchical superior resulted in more appropriate protocol administration.

The lessons here are several. First and foremost, more research is needed on my developing hypothesis that levels of clinical certification are not as important as effective team formation and goal orientation. Having said that, the cumulative effect of this research, I think, serves as a starting point to redefine how we evaluate the issue of staffing configurations in our EMS system designs.

As we learned from United 173, ultimately it is the expectations of those that comprise the work environment that set the standard for appropriateness. As all of us in the emergency services know, there is a certain flexibility required in our leadership style throughout a given day because of the widely fluctuating demands of our work environment.

If nothing else, I think this literature reinforces the need for all of us in the EMS community to focus on how our relationships impact the care we provide our patients – and by relationships I mean all relationships – between people and organizations.

Oh...one more thing. One other result of the Marsch study – when asked to recall and recite the actions and treatments of the simulated full arrest, delays and inactions were consistently not recalled. This supports a rather consistent body of literature that demonstrates that “..self reporting of effectiveness is unsuitable to reliably assess performance.” So how effective is your system in delivering care?.... and how do you know?