The Solution to Dilution?

Recently, Austin Travis County started hiring EMT Basics to work with their paramedics in order to create more units in the system and reduce what is commonly referred to as “skill dilution.”  But what is skill dilution?  Does it even exist, and should we worry about it?

I started my career in suburban NJ, a state that, at the time, mandated that every paramedic unit in the state be staffed by two paramedics, operating out of a hospital or under a hospital’s license as an intercept unit.  In my county there were five paramedic units which grew to six, and eventually seven during the summer months.  Seven units staffed for the entire population of the county.  The medics on the truck would commonly take turns tech’ing calls, splitting the work down the middle.  I must say, and I’m sure many would agree, the paramedics that I saw working over the years for LIFE EMS out of Community Medical Center in Toms River, New Jersey were some of the most skilled providers I have ever seen.

As time has progressed though, and I have been exposed to different systems, I see paramedic/EMT trucks more and more.  Call them what you like: P/B; 1-and-1; Medic/EMT, but it is all done with a few ideals in mind: to expand coverage, and to give them more chances at patient contacts.  I wonder sometimes though if it really truly makes a difference, and I also wonder about the consequences.

For example: if patient contacts are so important to the ability of a paramedic to be able to provide care, then does that mean that urban paramedics who may see as many as ten times the patients that a rural paramedic sees in a given year as superior providers?

And what about burnout?  Those of us who work P/B often have had those days when 75% or even 100% of the patients require a paramedic’s care.  When those days turn into weeks, and the overtime mounts up, those borderline BLS/ALS patients can slip through the cracks.  Running P/P trucks gives a system the chance to have a paramedic at a patient’s side from contact to turnover on every call.  If the reason for creating those P/B units though is to increase paramedic coverage, thereby reducing the number of calls a given unit does and as a result reducing burnout, then I am all for it.  But to me, that doesn’t seem to change anything about skill dilution.

Maybe we need to forget about skill dilution and start thinking about creating stronger, more educated providers.  That rural paramedic has to get proficient somehow, and hopefully he or she gets better by studying and taking the personal responsibility necessary to make them self a prudent paramedic.  Maybe systems and their medical directors need to do more to give their medics the skills they need before they encounter their patients and not worry about how many patients they see.

So much of what we do now is cerebral and not hands on.  EKG recognition and knowledge of the meds that we carry trumps one’s ability to start an IV or drop a tube.  It’s the why and not the how that needs to be stressed, and addressing skill dilution over provider education won’t help our paramedics know when they are supposed to start that line or give that medication.  I know what the argument will be: a little bit needs to come from each and a middle ground needs to be found, but the current shortcomings we are having across the board education wise are ones that should be addressed immediately.

We need to get paramedics into classes that they will get something out of with instructors that will give them the ability to present content in such a way that it will be easily absorbed by everyone.  We need to get away from this point and click and “wink and nod” styles of education that currently plague EMS education.  Whether people realize it or not and whether they admit it or not, it happens, and it hurts each and every one of us.

The problem today is not skill dilution it’s about the pollution of EMS education.  Clean that up, and teach the importance of personal responsibility when it comes to continuing education, and not only will we see better paramedics, but we will see better patient outcomes and a higher level of respect both within the field and throughout the medical community.


  1. Danny /


    I think that one of the first questions that we need to ask is what exactly defines proficiency, and how do we get it? A huge problem with paramedicine as a whole is the idea that proficiency should be measured strictly by the number of IV starts, intubations, needle decompressions and the like. We are the only medical profession that quantifies proficiency in these terms.

    Think about it: Have you ever heard of a hospital saying to one of its ED physicians, “Well, Doctor, we notice that you have only done 3 chest tubes this year, so….you’re not allowed to do them anymore.” Yeah, right. They wouldn’t dare. We are also the only medical profession where our scope of practice is continually under threat of being limited, mostly because of these arbitrary definitions of what constitutes proficiency. We need to focus on quality more than quantity.

    Quality matters. Quality of knowledge, quality of continuing education, and quality of the provider’s commitment to mastering their profession matter much more than how many of a given procedure has been done. You may have only done one needle thoracostomy in your career, and that doesn’t matter. What matters is that you have the knowledge and the ability to perform the procedure. Period.

    The point made about rural versus urban providers is a perfect example of quantity versus quality and why it doesn’t really make sense. Yes, the urban provider over a given shift will see more patient contacts. However, with the short transport times typically encountered, how much ALS care is really getting done in a 5 minute transport? For example, chest pain. Maybe you get a 12 lead, some aspirin, a nitro, and if you’re really good, an IV. By that point you’re at the hospital.

    That rural medic doesn’t see as as many patients, but I bet that with a 20 minute transport time, they will be much more involved in the management of that same chest pain patient. Quality. So who is the better paramedic?

    New Jersey paramedicine works for a few reasons. There are roughly 1700 paramedics for a population of about 7.5 million. The system is mandated by state law to be hospital based, which demands a medical focus. There is also a strong QA/QI process at both the program as well as state level. This allows a broad clinical scope of practice, including RSI. It is also as you state, a mandated two medic system. It’s necessary for a few reasons, not the least of which is when there is a critical patient, both providers can perform advanced life support.

    On a more cynical note, I always wonder, just a little bit, if the idea of one medic and one EMT isn’t just a management/bean counter idea to make every patient an ALS assessment, therefore warranting a higher level of billing. Come on, that’s ridiculous, right?

  2. Dilution is at its worst when the whole service only runs emergency ALS units – at least here it is a tiered emergency response system.

    “Maybe we need to forget about skill dilution and start thinking about creating stronger, more educated providers”

    Completely agree. Education is key, not skill level. I believe Australia has gone the right way with the vast majority of new paramedics coming out with a Bachelor of Science under their belt – it will do wonders for research, then someone can get a project going on ideal staffing/education levels!


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