Simple dumb question: Why not make everyone a paramedic?

[Bullets]

Point in case, the US is lagging behind the rest of the world. your basic level of care is substandard in most other third world country, it doesn;t even cover the basic needs of your patients, and the systm still rages against the need for change

How can the country who invented modern EMS (go freedom house and that eugene guy) get it so wrong?

You do realize that ROSC means nothing? If you pump anyone full of epinephrine you will get ROSC. But you also nuke the brain, what is the patients quality of life when the are discharged, that's the goal. And time and again studies show that the only thing that is regularly effective in causing decent quality of life upon discharge is electricity and compressions

Just curious as to your experience with the US medical and EMS system?

 

[mycrofft]

The Chinese will bail us out so we can keep buying their stuff.

But Chinese EMS is not the best.

 

[Veneficus]

EMS is the least of our worries here in the US.

At the rate we are sinking I'd bet the farm on a full scale economic collapse within my lifetime. (most likely sooner than later)

All of these self proclaimed expert financial and economic advisors wanna tell us "it can't happen" but the reality is, it has happened in the past and will happen again. Those who don't learn from their history are destined to repeat it.

Granted, healthcare as a whole is broken beyond repair at this point and costs more than anything else currently present in the economy.

At this point it's not about finding means to repair a broken machine it's about building a whole new machine altogether.


I am all for having a sense of patriotism but honestly, America sucks. As already stated we think we are so awesome at everything and even when we are wrong we find a way to belittle the other guy and make ourselves the dominant party.

A patriot loves their country.

A fool cannot see their country for what it is.

It is entirely possible to be a patriot and not be a fool.

 

[OzAmbo]

You do realize that ROSC means nothing? If you pump anyone full of epinephrine you will get ROSC. But you also nuke the brain, what is the patients quality of life when the are discharged, that's the goal. And time and again studies show that the only thing that is regularly effective in causing decent quality of life upon discharge is electricity and compressions

Just curious as to your experience with the US medical and EMS system?

ROSC means nothing? How on earth are we goin to get patients to survive to discharge if you dont have ROSC to begin with? The greater percentage of ROSC's we achieve, the greater the survival to discharge % is

The 30% survival to discharge rate has been achieved by a number of things, early access, CPR, defib all the good BLS thing and in the setting of ROSC they get RSI and therapeutic undiced hypothermia - not a BLS thing

But i see your missing the point,

Im not advocating a ALS system so you can give them bolus shots of adrenaline during your arrest management, im saying that an ALS system offers a better package to the patient than a BLS only system, and it ranges form quality of assessment, management of BASIC patient needs like pain relief and then some of the goodies thrown in on top. You guys constantly bring out this monniker the ALS doesn't save lives in cardiac arrest, but none of you make the argument that cardiac arrest management also includes post ROSC care, and no one ever talks about the patients who were prevented from going into cardiac arrest due to better assessment and trasport decisions, or intital management thorugh correcting hypo-perfusion, or trension pneumo decompression or management of their lethal wrrhythmia or any other tid-bit i cant think to list right now

Ive experienced 8 years if being bombarded with US based counterparts on forums like these, constantly informing me and everyone else of the same shortfalls in your system day in day out, so i tend to believe them

I spent 3 years in university where i ditched dozens upon dozens of peer reviewed journal articles from US based EMS becuase i could not apply them to the setting of australian EMS as they were not a valid comparison.

Some of those same articles are not a valid comparision between US EMS systems.

Broadly speaking, the british commonwealth, (austrlai, new zealand, UK) are or have moved to a Paramedic only system. We have Paramedics and Intensive Care Paramedics. BLS first responders are volunteers in low call volume rural communities and are few and far between, but when they go out on a job they are backed up by a Paramedic car even the basic level is unable to perform basic management.

 

[Veneficus]

Just curious as to your experience with the US medical and EMS system?

This is not really a good argument to go with.

The easy counter is "What is you experience with systems in other parts of the world?"

or worse

"what is you experience as an als provider?"

Oz has a valid point, and defending the current US system, which is deeply flawed and unsustainable, demonstrates either hubris or a lack of in depth understanding of it.

It is ok to want to be proud of the job you do, but success in a position does not equate to a successful system.

 

[the_negro_puppy]

You do realize that ROSC means nothing? If you pump anyone full of epinephrine you will get ROSC. But you also nuke the brain, what is the patients quality of life when the are discharged, that's the goal. And time and again studies show that the only thing that is regularly effective in causing decent quality of life upon discharge is electricity and compressions

Just curious as to your experience with the US medical and EMS system?

 

[EpiEMS]

Well, to follow up the initial question: What are we looking for? What's the purpose of EMS? Is it to reduce morbidity? Reduce mortality? Alleviate pain and suffering? Some combination?
Deciding on what the purpose of EMS is would give us a lot of guidance as to what levels of training and/or education are necessary for practitioners.

 

[Bullets]

ROSC means nothing? How on earth are we goin to get patients to survive to discharge if you dont have ROSC to begin with? The greater percentage of ROSC's we achieve, the greater the survival to discharge % is

No study of any ALS treatment

has shown significant improved survival

to discharge with a functioning brain.

Ever.

However, there is SCIENCE to support that while epinephrine does increase ROSC, it DECREASES a patients chance of survival and functional brain activity 1 month out, so if we are moving towards a total treatment of the patient including post-ROSC care, why are we administering a drug that decreases a patients chance of surviving to discharge

Source:
http://xa.yimg.com/kq/groups/8005323/462524098/name/March212012_JAMA.pdf


I am not advocating for a BLS only system, but a BLS heavy system with ALS in a supporting role as needed. As a 2 tier system it keeps medics sharp on their skills, being only called to incidents in which their skills are truly needed

This is not really a good argument to go with.

The easy counter is "What is you experience with systems in other parts of the world?"

or worse

"what is you experience as an als provider?"

Oz has a valid point, and defending the current US system, which is deeply flawed and unsustainable, demonstrates either hubris or a lack of in depth understanding of it.

It is ok to want to be proud of the job you do, but success in a position does not equate to a successful system.

I do not have experience with New Zealand EMS, and as such i do not speak about it

 

[RocketMedic]

Bullets, most of the US is covered by limited resources. Downgrading those resources that are ALS to BLS with PRN ALS is a great way to ensure that those patients who do need ALS never get it.

I personally think that 911 responses should get a minimum of one paramedic responding.

 

[Veneficus]

I do not have experience with New Zealand EMS, and as such i do not speak about it

But surely as a dedicated professional, you take the time to learn about other systems, and from your experience and knowledge can comment on what you think works, doesn't, or could use improvement?


Oh, and just to point out, a lot of places outside the US have stopped using epi as a first line drug more than a decade ago.

 

[britmedic]

Uk

They are fasing out EMTs here in the UK. Unfortunately they are moving towards having a paramedic and a driver/emergency care assistant/A&E support, which has it's own issues.

To join EMS these days you need to go to uni. Some services do still do inhouse training but they are being fased out too

 

[Bullets]

Bullets, most of the US is covered by limited resources. Downgrading those resources that are ALS to BLS with PRN ALS is a great way to ensure that those patients who do need ALS never get it.

I personally think that 911 responses should get a minimum of one paramedic responding.

I am not advocating for a complete removal of ALS, it is needed in a segment of calls, the majority of patients do not need an ALS provider to treat and transport.

I like the concept of the English system of paramedic fly cars. 2 EMTs in a transport capable ambulance, and 1 medic in a car. This would allow each base to have 2 medics available for their areas instead of two in a vehicle. If the patient needs ALS interventions, the 2nd EMT could drive the fly car.

I just do not see how increasing education requirements and work load would not cause an increased demand in higher pay

 

[Level1pedstech]

I am not advocating for a complete removal of ALS, it is needed in a segment of calls, the majority of patients do not need an ALS provider to treat and transport.

I like the concept of the English system of paramedic fly cars. 2 EMTs in a transport capable ambulance, and 1 medic in a car. This would allow each base to have 2 medics available for their areas instead of two in a vehicle. If the patient needs ALS interventions, the 2nd EMT could drive the fly car.

I just do not see how increasing education requirements and work load would not cause an increased demand in higher pay

It should cause an increased demand in higher pay but it seems that little factor of pay equal to education and experience always gets pushed to the side when this arguement comes up. Short answer is its never gonna happen because the chumps that would take the bait would not be nearly enough to keep staffing levels at a minimum. Even if you based the numbers off of those currently employed as medics.

 

[zmedic]

I think it's great to look at other countries, but there are problems with trying to copy part of their systems without copying the whole thing. My impression of some of these other countries like UK/Australia is their system is set up like this (feel free to correct me from those working there):

1: Long training, but relatively cheap compared to the US. Paramedic training 3-4 years. Some financially support from the government. In the US 3 years of college will run you probably $90,000.

2: More centrally controlled EMS in terms of staffing, more payment coming from the government via the NHS.

3: Smaller systems, both in terms of total area covered and total number of providers.

So while I like a lot of things about their systems, it's hard to say "we need everyone to go to paramedic school for 3 years" unless the US government/state government is going to pay for that schooling, and set standards for payment, and help pay for those paramedics.

I'd also point out #4, these counties have a very different legal climate, so one reason they need less BLS is that they can tell people "we don't send ambulances for that, get yourself to the hospital." I had a friend go to England and someone who was with her got a ring stuck on his finger and it started to swell. They called an ambulance who told them "get yourself to the ER, that doesn't need an ambulance."

In the US a lot of ambulance services are paid by the city, or the county, or by billing patients or their insurance. So just demanding more money for having all medics often won't work. I see of lot of insurance companies saying "I don't care if the call was staffed with medics, this was a BLS call and we are paying the BLS rate."

 

[EpiEMS]

I like the concept of the English system of paramedic fly cars. 2 EMTs in a transport capable ambulance, and 1 medic in a car. This would allow each base to have 2 medics available for their areas instead of two in a vehicle. If the patient needs ALS interventions, the 2nd EMT could drive the fly car.

My system usually does this. Now, I will say, occasionally, when we have the spare crew, adding an extra EMT makes lifts and managing critical calls easier.

 

[mycrofft]

Demand versus supply, never overestimate supply's intelligence.
Example: the US is experiencing something of a lawyer glut. Yet, students keep clamoring to get into law school, and finishing. "Hello, Mr World, here I am with my student loan like a fifty pound goiter...."

 

[OzAmbo]

No study of any ALS treatment

has shown significant improved survival

to discharge with a functioning brain.

Ever.

I understand what your saying, but your not understanding what I'm saying

We have an all ALS system, that has treatment modalities available to it that an all BLS system has. in the case of ROSC our patients are (generally) RSI'd and then get 2 litres of cold saline to induce hypothermia. The hypothermia is then maintained by our hospitals for either 12 or 24 hours (can't remember) then re-warmed

Using this ALS/IC care, 30% of our cardiac arrest patients are discharged from hospital with a functioning brain.

All cardiac arrests are reviewed by a registry and patients with ROSC followed up. The data is then published internally every quarter.

In this scenario, you guys are confused between Basic Life Support and Basic level of care. BLS covers you for your cardiac arrest management, it doesn't cover you for your post ROSC management where the "saves" can actually be made, and thats only in the context of cardiac arrest.

IN the rest of the world that is ambulance, your basic level of care does not cover you for the most basic of patient presentations, and therefore, not up to the job.

 

[mycrofft]

Because it is an emotional decision.

As to how higher level of education and increased workload (how increased?) can still result in lower pay: if there is no lower tier for people to work/be paid at, they will necessarily train up to Paramedic. I don't see the glut of potential EMT's diminishing unless they begin stringent educational intake screening and start failing more people; I would predict, as with nurses, that paramedic mills and easy courses would appear, some in conjunction with local EMS providers and hospitals, thus making entry easier than it nominally would be.

If there is a glut of people wanting in and entry facilitated , then there will continue to be an oversupply; with nowhere else to go except be a volunteer, they will settle to work as a paramedic for the same or less than they are getting now, adjusted for inflation.

And rural/frontier services will lose out if educational requirements are boosted, since after going away to school students often will chose to stay in metropolitan areas to practice, as the medical and nursing students of today do.
(Used to be a running joke; to help get into my college's medical school, you swore you were interested in serving the "outstate" rural areas, then ran for NYC, LA, Chicago, or Dallas-Fort Worth upon graduation).

The only factor against this I see is potential burnout and injury due if staffing and equipment budgets are cut slim.