Of course. But which of those outcomes is improved by hiring experienced paramedics vs training your own? Which outcome is improved by the paramedics having high-speed "advanced" protocols vs run-of-the-mill ALS protocols? Which outcome is improved by the medical director telling the paramedics "I want you to act like a clinician, not a technician" (as if simply saying that can make it actually happen)? Which outcome is improved in a system that hires outspoken, critical paramedics vs. ones that are more likely to go with the flow and not rock the boat? None, likely.
Mortality-wise, we don't know and probably never will know the difference between experienced medics, brand-new students and literal van drivers in most high-volume semi-urban EMS systems. Functionally, the protocols are pretty topped out for most of these places in terms of what is commonly accepted- but if my time at EMSA was any indication, many of the portions of the protocols were simply never used in favor of diesel boluses. Looking at "high-performance" places, I see a lot of average or high-median medicine being passed off as the best and latest woth a heavy underlying emphasis on transport and ignoring all but a few spicy patient types in order to bring all resources to bear on those- and relying on hospitals to pick up the slack.
The point here, again, is that an EMS system's primary responsibility is NOT to provide a comfortable job to paramedics or to stroke their ego with meaningless catch phrases about clinicians vs. technicians and guidelines vs. protocols. The primary responsibility of any EMS system, rather, is to design a system that is efficient at responding to requests and focused on accurately measuring and constantly improving patient outcomes. Everything - QI, staffing, deployment strategies, training, protocols - should be focused on improving clinical outcomes. That is why EMS exists - for the patients, not for the paramedics.
Agreed on the mission, but I disagree on the direction that you are taking this. Functionally, if you wanted to improve certain metrics (ie resuscitations) you could and should simply build your system to be fanstastic at those things- like Medic One has. However, medicine is more than just isolated metrics or fields of metrics, and I think that overall clinical outcomes are best improved by being good at almost everythIng. To do that, you need to retain staff- and that's why agencies need to be concerned about their medics.
And here's the rub: It is very likely that doing a good job of improving clinical outcomes does NOT require advanced protocols, does NOT require the paramedics to all have CCP/FPC/TCP/whatever-the-newest-whizbang-moneymakingscheme-oops-I-meant-certification-is, does NOT require nice comfortable stations for the crews, does NOT require the hiring of experienced paramedics. In fact, the more I think about it I can see why places that are really QI and PI oriented might prefer to mold their own people and weed out the paragods that think they are too good play the role of a small cog in a big machine. Similar to the way that everyone who joins the military goes through the same basic training, no matter their previous life experience.
You miss the point here almost completely. I broadly agree that improved outcomes do not necessarily require advanced protocols, tools or alphabet soup, but those things are the building blocks of health care that goes beyond transport and starts saving money, resources and a few lives along the way. Better pain meds, slightly more optimal resuscitation measures and even fancy lab equipment are certainly helpful in the emergency-response setting, but in a broader and larger sense, these things (along with increased training requirements) become vital for mission diversification and expansion. You point out that QI and PI focused agencies prefer to mold their own- but look at the functional result of that. They're reinforcing the echo chamber and want to ensure that the sole vision and measure of success is their leadership's.
Your contrast with military training is flawed. The military, contrary to popular belief, is not about breaking people down. It is about challenging them to adapt to adversity and work towards a common goal harmoniously. Training is not intended to remove initiative, it is intended to develop it. The military is rigid and inflexible in its command structure, but look at it from an operational point of view: when properly managed, the details of operations are left to the level of the individual soldier or Marine, with leadership responsible for ensuring that every one of their people is ready and capable. The military is nearly the opposite of a high-performance EMS provider in that they are not trying to "weed out" the "paragods", they seek to make the paragods mindful of the world around them and make the meek confident that they can perform as a paragod despite adversity. HP EMS just tries to weed out those who don't fit.
I don't begrudge anyone looking for a system that does provide those things, because they are nice to have. But let's be honest here and admit that these are things we want for ourselves, and stop pretending that we want them because they are somehow better for patients, and stop pretending that systems that don't provide those things are inferior, as are the people who willingly take jobs there.
I know that's a hard chunk of meat for a lot of people to swallow, but there you go.
You are straight-up wrong here, Remi. I am a better provider when I am not worried about myself, my finances, or trying to fight off sleep. We provide better, more compassionate, more polite, and more professional care when we are not literally living at work. We are happier and healthier and far more tolerant of patients and their problems when we respond from an air-conditioned station in a clean truck in a clean uniform than when we respond in a filthy truck in summer heat in a bad mood. Systems that do not provide their employees with a livable wage, adequate equipment, or that deploy them in such a way as to guarantee apathy and discomfort are inferior to those that care for their employees as people, not assets. The people are not inferior, but I feel many of us are brainwashed to some extent- we accept poor treatment because we do not know any better!
