Revisiting Skill Dilution

A little over a year ago, I tackled the concept of “skill dilution” and its validity as a statement, and reality in the field.  My perception at that time was that a more important component to focus on instead of skill dilution was education for our paramedics.  While I still stand by the concept that we need to better prepare our medics for what they will encounter when they hit the streets, my views of skill dilution have changed a bit.

The EMS system in Massachusetts is quite different from the one that I currently working in.  I know, that is no shocking revelation since it has been said to exhaustion that “if you’ve seen one EMS system, you’ve seen one EMS system” but I find the uniqueness of my current situation interesting in comparison to where I was.  The easiest way to look at it is by evaluating both environments on a county-wide basis.

On a common day, Hampden County, Massachusetts has approximately 25 paramedic level ambulances protecting its citizens.  They respond to emergencies for the most part regardless of the complaint.  Everyone gets the same opportunity to have the most advanced care available to a sick person regardless of what the caller told the dispatcher, or what the Emergency Medical Dispatch (EMD) code says is the appropriate response for that incident.  Do you have a splinter?  You’ll most likely get a paramedic.  Are you having chest pain?  You’ll most likely get a paramedic.  That paramedic’s partner, however, could be an EMT, an intermediate, or even a paramedic.  All that Massachusetts requires is one paramedic to make an ambulance an ALS level ambulance.

In the county I work in now, there are nine paramedic units for the entire county.  None of us transport.  We respond to only ALS level calls as determined by EMD codes, and we are supplemented by approximately 30 BLS level ambulances.  I do not know the exact number, but to me, that “feels” about right.  Every paramedic unit is staffed with two paramedics, and the state requires that each ALS appropriate 9-1-1 call gets at least two paramedics.

According to the 2010 census (and Wikipedia), there were about 463,000 people occupying the 618 square miles of Hampden County.  Maintaining our estimate of 25 ALS ambulances, that means that in theory, each paramedic level ambulance is responsible for about 18,500 people, and 24.75 square miles.  Yes, I realize that with cities like Springfield, and smaller communities like Hamden, those numbers vary, but bear with me.

When looking at the census numbers for my county, we had a 2011 population of 540,000, and we take up about 426 square miles.  We are slightly smaller, and slightly more densely populated than my old stomping grounds up in New England.  Doing the math, we have one paramedic unit for every 60,000 people, and each is responsible for 47 square miles.  Our ambulance to population breakdown, however, is closer to what we see in Hampden county with one ambulance for every 18,000 people.

My view of what goes on in the county I currently work in is a narrow one.  I have not been here very long, and do not have nearly as much experience as some of my colleagues who have been working here for the past 20+ years.  What I can say though is it is my experience that with less paramedics, and a seemingly more effective EMD system, I, as a provider, am seeing sicker patients requiring more interventions.  The result?  My skills are sharper.

This seems to ring true for both slower areas and busier units alike.  Even when a paramedic is not seeing as many patients as another one, they are making up for it by seeing sicker patients for a longer amount of time due to the remote nature of our more rural, slower units.

So basically, what you just read was about 600 words of me apologizing.  I was wrong.  Skill dilution is real.  Obviously if you have less medics, those medics are going to be expected to take care of more people.  That is just the law of averages.  At the same time though, with less medics, each of them is going to see a higher ratio of critical versus non-critical patients which could ultimately benefit the medic in the long run.

I share these numbers about each county not to prove that one county is safer than the other.  The uniqueness of each system has a lot to offer the communities they protect and each of them are very successful at doing just that.  On the other hand though, there is a lot that we could take from the training that each system underwent to prepare them for what ultimately ends up being the exact same set of medical problems.  Education still plays such a huge role in prepping each medic for what they are going to encounter.  A medic can have thousands upon thousands of patient contact, but if they are not properly trained and updated, not refreshed (different concept entirely) then they will not have a full understanding of what they are seeing.  Education is key and should be the priority of each system, leader, medical director and provider who is committed to caring for their patients.


  1. Justin Schorr /

    Devil’s Advocate: Are the patients sicker because there are less paramedics intervening in a time sensitive case, thus requiring more advanced interventions? More skills doesn’t mean better care, it means sicker patients. And discuss.

  2. MedicSBK /

    Justin: I would agree with that position IF the system wasn’t adequately maintaining the volume a majority of the time. While there are less paramedics operating in the system, the EMD being performed is seemingly doing an adequate job of triaging calls, which can be determined by looking at a rate at which calls are triaged down to BLS and triaged up to ALS, and every patient still gets two paramedics which is better than in a lot of systems.

    With each patient getting an opportunity at least to have two paramedics taking care of them, I think they are receiving better care than one paramedic caring for them alone in the back of an ambulance.

  3. Railrob /

    Scott, you know you would hear from me on this one. After working in two double medic systems in different ends of MA for longer than care to think about, I have to agree with your post 100%. One becomes a skilled medic because of constantly seeing and treating sick patients. You learn what “sick” really looks like and makes your skill exceptionally sharp. Heck I have medics in my system now who are afraid to treat patients with one getting their first intubation after working as a medic for 3 years and having plenty of opportunities. Look at Boston and Seattle and see what their ROC is. Each has double medics who do mostly ALS all day.

  4. Railrob /

    Should have said double medic non-transport systems