# ALS = Medic/Medic, Medic/Basic, Medic/Intermediate?



## MMiz (Aug 12, 2006)

The county I live in requires Medic/Medic for an ALS unit.  *Do you believe that a Paramedic/Paramedic unit provides higher level of patient care?

*Personally I like the idea of Paramedic/Basic.  The Paramedic provides ALS services while the EMT does the BLS.  I can't think of a single ALS-only call.  The Medic/Basic also provies the EMT the ability to learn from the medic, which leads to a more competent crew, and the possibility of an EMT that is more prepared to transition to the ALS role.

What's your take on it?


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## divinewind_007 (Aug 12, 2006)

i have always run medic/emt trucks myself. Like you said...the emt does their stuf while the medic does the als. And yes you do learn alot wokring with a medic. However, i can see how a double medic truck could benefit too. It gives both medics the ability to do ALS skills. If one can't get a tube...maybe the other can. Or maybe one is tubing while the other is starting a IO. i could see the benefit from it.


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## MariaCatEMT (Aug 12, 2006)

MMiz said:
			
		

> The county I live in requires Medic/Medic for an ALS unit.  *Do you believe that a Paramedic/Paramedic unit provides higher level of patient care?
> 
> *Personally I like the idea of Paramedic/Basic.  The Paramedic provides ALS services while the EMT does the BLS.  I can't think of a single ALS-only call.  The Medic/Basic also provies the EMT the ability to learn from the medic, which leads to a more competent crew, and the possibility of an EMT that is more prepared to transition to the ALS role.
> 
> What's your take on it?



*I agree with you.*


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## ffmedic (Aug 12, 2006)

I have had it both ways. My first 7 years I almost never had another medic. I learned to make do and really became better for it. Our EMT’s learned a lot too. Most of our best medics had been drivers for us. They just sort of “soaked” it up. Most of the new guys will have trouble matching my numbers of calls because of my working “alone” those years. Still when the stuff hits the fan I love having a partner that can do as I do and not have to be limited in their skills. 

Our county rigs have two medics now because the union negotiated that hard and won. Lots of miles and long transports with sometimes questionable help from certain VFD’s made it possible. I enjoy my later years having a medic partner to sort things out with. 

Not sure what you mean by “all ALS” call but I can think of many were any BLS stuff was minor compared to the thrash ALS needed. When I need an IV or two and a tube I don’t need them minutes apart. Throw in a chest tube or two and it can get tense. Sure one medic can do it all but two do it better. 

Also it’s not good for the powers to hear ”we only need one medic”.  Two medics are better and the system grows. The more of us there are the better we get due to our numbers.  Of course in some systems this isn’t practical I realize and there are considerations on numbers of calls. The balance between enough calls to stay competent and so many you burn out is a fine line.


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## Jon (Aug 12, 2006)

Around here, we run either BLS/ALS tiered or EMT/Medic "MICUs."


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## Firechic (Aug 13, 2006)

We have and hopefully will always continue to run a 2 paramedic MICU.


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## Guardian (Aug 13, 2006)

We run P/B trucks here and it's actually worked out well for the most part.  I personally think the more paramedics, the better.  Around here however, we don't have enough paramedics to run double ALS.


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## doc5242 (Aug 20, 2006)

no matter how trucks are run remember the phrase :

_*Paramedics save lives..EMT's Save Paramedics*_


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## fyrdog (Aug 21, 2006)

2 Paramedics provide better patient care. I'll grant you on 80% of my calls it is routine 1 medic is just fine. But the other 20% - one can do Airway whille the other is starting an IV, giving meds, EKG monitor, Pacing. Also 2 heads are better than one.




If Paramedics save lives and EMTs save Paramedics what do medical first responders do?


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## gradygirl (Aug 21, 2006)

fyrdog said:
			
		

> If Paramedics save lives and EMTs save Paramedics what do medical first responders do?



Save the EMTs?


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## doc5242 (Aug 21, 2006)

fyrdog said:
			
		

> If Paramedics save lives and EMTs save Paramedics what do medical first responders do?




Drive the ambulance....

just kidding


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## Jon (Aug 21, 2006)

fyrdog said:
			
		

> 2 Paramedics provide better patient care. I'll grant you on 80% of my calls it is routine 1 medic is just fine. But the other 20% - one can do Airway whille the other is starting an IV, giving meds, EKG monitor, Pacing. Also 2 heads are better than one.
> 
> 
> 
> ...


There was an article on JEMS last year that debunked that theroy - the arguement was that services like Boston EMS (80 medics) and Medic One in Seattle have better arrest save rates than LA city, where every fire truck is ALS-equipped.


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## Hightoweruk (Aug 21, 2006)

But who saves the First responders ???


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## gradygirl (Aug 21, 2006)

Certainly not the canaries.


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## MedicPrincess (Aug 21, 2006)

fyrdog said:
			
		

> 2 Paramedics provide better patient care. I'll grant you on 80% of my calls it is routine 1 medic is just fine. But the other 20% - one can do Airway whille the other is starting an IV, giving meds, EKG monitor, Pacing. Also 2 heads are better than one.
> 
> If Paramedics save lives and EMTs save Paramedics what do medical first responders do?


 
I disagree.  An P/B team works great here.  We also have fire as first response, and some of those FD's are ALS here.  But if we get a BLS department....

A FF is all over the airway, bagging another is on compressions.  If FD isn't there, PD or SO is and they can do it too.  In the time it takes me to get the Cardiac Monitor 4 leads on and the Combo pads on she has the IV.  Quick look at the monitor tells us if we're shocking.  If its shockable, she does that while I set her up for intubation.  If its not, I still set her up while she gets her first round of drugs in.  Once she is set up, takes none to long to intubate - I hear a monkey can do it - and she is onto her drugs while I get the second line, and then I am driving down the road.

Sounds simple right....does anything ever really go that smoothly??

As a matter of fact when we get ALS fire on scene, us, and our shift commander is dispatched to all codes...well sometimes there are to many medics...

Point is, our protocols allow for the EMT to start IV's, apply the monitor, run 12 leads, glucose checks, administer albuterol, strap on CPAP....lots of stuff a lot of systems dont (Heck, our neighboring county only lets EMTs drive.  its what they are hired to do.  The medic does all patient care, ALS or BLS).  So for our system a P/B crew works fine.....so long as they both can pull their weight.


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## ffemt8978 (Aug 21, 2006)

Also, if all you run is a P/P rig, how do -B's or -I's get the patient contact experience they need to become -P's?

Jon, the article that you were referring to, is that the one that stated systems with fewer ALS units do better because they get more practice in their ALS skills?


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## Jon (Aug 22, 2006)

ffemt8978 said:
			
		

> Also, if all you run is a P/P rig, how do -B's or -I's get the patient contact experience they need to become -P's?
> 
> Jon, the article that you were referring to, is that the one that stated systems with fewer ALS units do better because they get more practice in their ALS skills?


Yeah... I think that was part of it... something about LA City's medics not even getting 2 tubes a year, on average.


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## Ridryder911 (Aug 22, 2006)

doc5242 said:
			
		

> no matter how trucks are run remember the phrase :
> 
> _*Paramedics save lives..EMT's Save Paramedics*_



One of my most hated quotes.. Only developed to sell T-shirts, belt buckles, and caps. Sorry, never seen an EMT save me, or another medic in my career of 30 yrs as a Paramedic. This is a team approach, and I can assure you I have seen many times medics have saved the arses of some basics, of their misinterpretation or lack of medical knowledge. 

Two paramedics should be the 'gold standard" this allows each other to trade off, and decreases the demand of the single Paramedic provider. The old saying "two heads are better than one" is true, where one might had missed part of the history, exam, etc.. as well as less stress on the sole Paramedic. 

Although, this would be nice to have, realistically and cost effective it is not going to happen soon. I personally would like to see all EMS have the capability of having Paramedic level at the least.....

R/r 911


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## Guardian (Aug 22, 2006)

I agree with rid.  If emts in your area are saving paramedics, then your paramedic classes suck and there needs to be higher education standards.  On the flip side, many times basics hurt pt care because they are programmed to think critical pt = faster ride to the hospital.  My response is, "we are not a taxi service, we are ems.  When a pt is turning blue,  I need to do what they would do at the hospital only 15 mins faster to prevent brain damage"  If I had my druthers,  I would do away with emts and only teach at the paramedic level.  Paramedics should be the gold standard.


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## ffemt8978 (Aug 22, 2006)

Rid and Guardian,

I agree with you that Paramedic should be the gold standard of care, but I'm curious as to how you would implement it in rural areas with volunteer services and almost no funding.


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## Guardian (Aug 22, 2006)

EMTPrincess said:
			
		

> I disagree.  An P/B team works great here.  We also have fire as first response, and some of those FD's are ALS here.  But if we get a BLS department....
> 
> A FF is all over the airway, bagging another is on compressions.  If FD isn't there, PD or SO is and they can do it too.  In the time it takes me to get the Cardiac Monitor 4 leads on and the Combo pads on she has the IV.  Quick look at the monitor tells us if we're shocking.  If its shockable, she does that while I set her up for intubation.  If its not, I still set her up while she gets her first round of drugs in.  Once she is set up, takes none to long to intubate - I hear a monkey can do it - and she is onto her drugs while I get the second line, and then I am driving down the road.
> 
> ...





Intubation so easy a monkey can do it?  You heard wrong.  Ex.  12 y/o with severe anaphylactic reaction.  The child is turning blue and if you don't intubate right then and there, the child will die.  Onlookers at the scene include the childs parents and family, the FF first responders, your partner, your supervisor, police, etc.  You insert the laryngoscope blade and can't see a thing because of angioneurotic edema.  At this moment, your career, your reputation, EMS's reputation, and most importantly this childs life is on the line and dependent of your ability to intubate.  Intubation is *NOT EASY!*


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## Guardian (Aug 22, 2006)

ffemt8978 said:
			
		

> Rid and Guardian,
> 
> I agree with you that Paramedic should be the gold standard of care, but I'm curious as to how you would implement it in rural areas with volunteer services and almost no funding.




Just curious, are your firefighters and police officers trained at a substandard level as well?


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## ffemt8978 (Aug 22, 2006)

Guardian said:
			
		

> Just curious, are your firefighters and police officers trained at a substandard level as well?


Nope, but they don't require a two year program to become one either, and our FF's are our EMT's since we're a combined department.


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## Guardian (Aug 22, 2006)

ffemt8978 said:
			
		

> Nope, but they don't require a two year program to become one either, and our FF's are our EMT's since we're a combined department.




You're right.  Two years is way to long and expensive when dealing with something as petty as human life.

In reality, rural ems needs highly trained paramedics more than urban ems does.  My answer to your first question is do what ever you have to do to get the money.  Have your governor declare a state of emergency or at the very least post your concerns here.  Don't give up and say to yourself "the best we can do here is BLS."  You never know, you might be the one having an MI that turns into cardiac arrest.  Paramedics are saving more and more cardiac arrest victims these days while BLS/AED number of saves remain the same.  Work on making EMS a real profession.  Your teachers who teach your kids all have at least 4 years worth of college don't they?  Volunteers are great if they can meet the gold standard but if they can't, you need to try something else.


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## Guardian (Aug 22, 2006)

The only reason I'm so passionate about this is because I've seen what ALS at the paramedic level is capable of doing.  A few weeks ago, a 68 y/o woman collapsed.  CPR was started and an AED attached.  No shock advised.  At this point, with only BLS, she would have died.  I showed up and put her on the monitor which read slow PEA.  With high quality CPR, intubation, IV, Vaso, Atropine, and more CPR with an autopulse, the pt regained a pulse and is alive today.  There are and will continue to be significant changes in ACLS that improves cardiac arrest outcomes at the paramedic level.  Two years worth of education is not to much to ask for.


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## ffemt8978 (Aug 23, 2006)

Guardian said:
			
		

> You're right.  Two years is way to long and expensive when dealing with something as petty as human life.



I never said it wasn't...as a matter of fact, you were trying to compare apples and oranges (police/fire/ems).



			
				Guardian said:
			
		

> In reality, rural ems needs highly trained paramedics more than urban ems does.  My answer to your first question is do what ever you have to do to get the money.  Have your governor declare a state of emergency or at the very least post your concerns here.  Don't give up and say to yourself "the best we can do here is BLS."  You never know, you might be the one having an MI that turns into cardiac arrest.  Paramedics are saving more and more cardiac arrest victims these days while BLS/AED number of saves remain the same.  Work on making EMS a real profession.  Your teachers who teach your kids all have at least 4 years worth of college don't they?  Volunteers are great if they can meet the gold standard but if they can't, you need to try something else.



Okay, I agree and disagree with you here.  I agree that rural EMS needs ALS more than urban areas, where the transport times to an appropriate facility are much shorter.

I disagree with you on your last statement in particular.  It's very easy to say that if volunteers can't meet the standards of ALS, then something else needs to be done.  Maybe it's slipped by you, but the reason that there are volunteer agencies is because the community they serve is unwilling/unable to support paid services.  My agency serves about 5,000 people over 248 sq. miles.  There is no way that we could afford to man an ALS service without a three-fold increase in taxes, something we are prohibited by law from even placing on the ballot.  In addition, out of the 5,000 people we provide service to, only about 2,000 are voters, the rest being migrant workers.

So what's wrong with people becoming paramedics on their own dime and returning to these rural agencies, you say?  It still comes down to cost.  The cost of the drugs, equipment, and continuing training.  You're asking an awful lot of someone that doesn't even get paid for what they do.

The only way that I see all EMS meeting the gold standard of paramedic level care is if the government (federal or state) mandates and 100% funds it.  Otherwise, our current system of tiered response will remain unchanged.


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## gradygirl (Aug 23, 2006)

Guardian said:
			
		

> You're right.  Two years is way to long and expensive when dealing with something as petty as human life.



Dude, four years is too short and that's what doctors receive in terms of formal education. I'm sorry, but they :censored::censored::censored::censored: up royally, too.

And please let's not forget that EVERY paramedic started as an EMT-B. It's your basic level of treatment, simple as that. It's the foundation by which every career in EMS is built on. By no means am I going to stay a Basic, but that doesn't mean I have any less respect for Basics. I've gotten over the whole "well, I'm just a Basic" thing because I know at the end of the day, I can save a life, maybe not as well or without using as cool toys as a paramedic, but a save is a save.


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## Guardian (Aug 23, 2006)

Cost isn't an excuse.  We live in the richest country in the world.  We find ways to fund public schools, police, etc., I know we can find a way to fund ems.  Hospitals seem to be well funded through private and public funds, maybe we can do the same for ems.  ALS at the paramedic level should be a basic necessity and not just something thats nice to have.


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## ffemt8978 (Aug 23, 2006)

Guardian said:
			
		

> Cost isn't an excuse.



You're right, it's not an excuse...it's the reason.


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## MMiz (Aug 23, 2006)

Guardian said:
			
		

> Cost isn't an excuse.  We live in the richest country in the world.  We find ways to fund public schools, police, etc., I know we can find a way to fund ems.  Hospitals seem to be well funded through private and public funds, maybe we can do the same for ems.  ALS at the paramedic level should be a basic necessity and not just something thats nice to have.


 I'm going to have to call you on this one.

Cost *is* the excuse.  Quite simply, some areas, in fact *many* areas, can't afford ALS services.  Many areas can't even afford BLS services.  

*Many* areas *can't* find ways to fund public schools.  *Many* communities *can't *find ways to fund police and fire departments.  *Many* areas *can't *find ways to fund EMS.

Hospitals are struggling.  Even the best and biggest hospitals aren't doing nearly as well as we think.

I'm worried that you're not seeing the problem.  I'm worried that you don't see the lack of funding.  

I moved from a very wealthy area, one with some of the best schools public schools in the nation, and only the newest FD equipment.  Only 15 minutes away there were *multiple* communities that can't fund their PD, FD, or EMS.  They literally closed up shop and stopped providing services.  The county stepped up and provides country patrols, the FD will respond if the block is on fire, and EMS is dispatched to multiple privates, hoping one will run the call.  *This is the reality we live in.

*As a teacher do I really need to go into the state of our public schools?  Public schools are failing and closing at an alarming rate.  Many public schools can *no longer afford to stay open*.

In rural environments there is generally a lack of ALS care, not because the people don't want it, but because they can't fund it and find people willing to work the shifts.  When you can't afford it you can't afford it, I'm not sure what else you can do.

In this country less than 2% of the population owns more than 98% of the wealth. 

I agree, there *should* be an expanded Paramedic curriculum.  You've seen my many posts on it.  I *do not* believe that everyone will benefit from the curriculum, simply because many communities can barely staff BLS units.

I believe there are nearly 20,000 *volunteer* fire departments in America.  The need for volunteers generally has grown out of an inability to afford or staff full time paid squads.  Without those departments 20,000+ communities would not have service.  That's the reality right now, and we're speaking in ideals.  We might as well throw in the request for a pretty pony at this point.


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## Guardian (Aug 23, 2006)

So i guess you don't have public schools then.  I guess your community is so poor, none of you children get educated.  Part of the reason people are not willing to pay for paramedics is because they think they already have them.  You'll go around calling yourselves medics and the general public doesn't know any better.  You have a local government with a court system, you have police, you have waste disposal, you have schools, but for some reason the money ends right there.  Absolutely no more money for anything else.  Do you really expect me to believe this?


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## Ridryder911 (Aug 23, 2006)

Have Sheriff or Police department?.. have District Attorney?.. then there is money out there, it is not a priority to the citizens. Not everyone, will be able to have Paramedics, the same way not every community can justify a hospital as well.. but, you improvise and this will have to be a mind set change of maybe contracting out.. rendezvous with an ALS, roving Paramedic... etc... I have placed Paramedic units in towns as small as 2000, so it can be done.. but, the citizens, community leaders and yes other emergency services (FD, EMS, LEA) has to be willing to work and create a way. 

It will not be easy, but it is not going to get any easier later as well... and without emergency care that is equal to and same, communities will not be able to recruit business, and population to grow. 

R/r 911


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## ffemt8978 (Aug 23, 2006)

Guardian said:
			
		

> So i guess you don't have public schools then.  I guess your community is so poor, none of you children get educated.  Part of the reason people are not willing to pay for paramedics is because they think they already have them.  You'll go around calling yourselves medics and the general public doesn't know any better.  You have a local government with a court system, you have police, you have waste disposal, you have schools, but for some reason the money ends right there.  Absolutely no more money for anything else.  Do you really expect me to believe this?



You don't believe me then bring your paramedic self out to my area and work a job picking fruit in an orchard so you can volunteer to be a paramedic with my service.

Yes we have schools, which are in financial trouble; Yes we have law enforcement, underfunded and understaffed; No, we don't have a hospital because of so few people in our area.

How much does it cost to equip an ALS unit?  Let's leave staffing out of it for right now.  Keep in mind that we have three stations, which means three ambulances.
- We would have to purchase three 12 lead ECG's
- We would have to purchase everything necessary to intubate patients for three rigs and to have on hand supplies at the station for restocking
- We would have to purchase all of the drugs except D50 and Albuterol

That's a lot of money to lay out for a community of 5000 people.  We have an ALS unit that is approximately 30 minutes away, and our community knows this.  Our community knows we are not paramedics but EMT-I's, EMT-B's, and First Responders.  We have educated our community as to what services we can provide and what we can't.  The people in our area that expect every amublance to be staffed with Johnny and Roy paramedics are the ones that come and visit our area from a community that has every ambulance staffed with ALS (such as Seattle).


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## gradygirl (Aug 23, 2006)

Guardian said:
			
		

> So i guess you don't have public schools then.  I guess your community is so poor, none of you children get educated.



Whoa, whoa. I go to a very well endowed school, and we damn well nearly pay out of our pockets for things. At almost $45,000 in tuition a year per student and about 2,500 students (go ahead, do the math), our squad has a meager spending budget and we are totally volunteer. We're having real staffing issues because of this; our numbers are starting to drop and we've had to cut back our call times by about a third. We're only now, after 10 years of being a proud vollie service, fighting to get some sort of monetary compensation and incentives for our current and prospective members. And trust me, we wouldn't be if it weren't for our dwindling numbers.

Our budget is another thing we must fight for; we are guaranteed a budget only because we provide an invaluable service to the school. As y'all know, EMS is not at all cheap to restock; we also pay for our member's training. Every dime we are given is spent trying to keep us on an even plane.


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## Guardian (Aug 23, 2006)

ffemt8978 said:
			
		

> You don't believe me then bring your paramedic self out to my area and work a job picking fruit in an orchard so you can volunteer to be a paramedic with my service.
> 
> Yes we have schools, which are in financial trouble; Yes we have law enforcement, underfunded and understaffed; No, we don't have a hospital because of so few people in our area.
> 
> ...




When you said yes to having police and schools, you told me everything I needed to know.

Your people really know the difference between EMT-I and EMT-B, are you saying that with a straight face?

No hospitals, you guys really really really need the gold standard then.


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## MMiz (Aug 23, 2006)

Guardian said:
			
		

> So i guess you don't have public schools then.  I guess your community is so poor, none of you children get educated.  Part of the reason people are not willing to pay for paramedics is because they think they already have them.  You'll go around calling yourselves medics and the general public doesn't know any better.  You have a local government with a court system, you have police, you have waste disposal, you have schools, but for some reason the money ends right there.  Absolutely no more money for anything else.  Do you really expect me to believe this?


I think it's time for a field trip.  I'd like to welcome you to Detroit.  When you're done you can check out Highland Park.

It's hard to fund the services when there is either a very small tax base, or a large population with a very small population that pays taxes and for services.


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## Guardian (Aug 23, 2006)

MMiz said:
			
		

> I think it's time for a field trip.  I'd like to welcome you to Detroit.  When you're done you can check out Highland Park.
> 
> It's hard to fund the services when there is either a very small tax base, or a large population with a very small population that pays taxes and for services.




I already know they have schools in detroit and highland part.  No reason for me to go there.


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## ems_is_4_me (Aug 23, 2006)

I Just Have To Say Some Thing I Work For A Small Service In Oklahoma And We Are Paid And It Is Hard To Find Paramedics That Are Willing To Work For The Pay And Dont Say Pay More   Not All Service Are Made Of Money


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## gradygirl (Aug 23, 2006)

Guardian, where do you work to have the luxury of not having cost as an excuse?


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## Guardian (Aug 23, 2006)

Some of you will disagree with me.  You're entitled to your opinion just like I am.  I'd like to make one last closing argument on this topic.  Nobody knows where the universe ends or if it ends.  We are capable of anything.  It is possible for humans to live and thrive on the surface of the sun.  Nothing is impossible given the right amount of time and resources (when I say resources, I'm not talking about something as petty and meaningless as money, I'm talking about ambition).  When someone says they can't do something, what they are really saying is they don't want to devote the time or resources to do it.  We are capable of anything until someone proves otherwise.


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## MMiz (Aug 23, 2006)

Guardian said:
			
		

> I already know they have schools in detroit and highland part.  No reason for me to go there.


Detroit is closing over 100 schools in the hopes of possibly being able to go on, not as a long-term solution.  In 1999 the schools were taken over because of the lack of fiscal responsibility and student achievement.  They now only have half the students they did in 1999.

Detroit EMS is getting their butts kicked.  They too call the local privates, hoping one will take the call.

The US may be the richest country, but we also have the most debt.  Debt in the economic sense isn't purely bad, but it puts things in perspective.


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## MMiz (Aug 23, 2006)

Guardian said:
			
		

> Some of you will disagree with me.  You're entitled to your opinion just like I am.  I'd like to make one last closing argument on this topic.  Nobody knows where the universe ends or if it ends.  We are capable of anything.  It is possible for humans to live and thrive on the surface of the sun.  Nothing is impossible given the right amount of time and resources (when I say resources, I'm not talking about something as petty and meaningless as money, I'm talking about ambition).  When someone says they can't do something, what they are really saying is they don't want to devote the time or resources to do it.  We are capable of anything until someone proves otherwise.


I agree 100%.


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## Ridryder911 (Aug 23, 2006)

Part of the problem (especially in Oklahoma) is poor management and billing. Look at collection rates, look at cost individual services instead of EMS districts, and school bond/EMS funding, etc.. as long as one looks for excuses there will be one instead of answers. 

Yes, it is hard.. yes, it can be done, That means we have to support lobbying at the Capital foe a bigger piece of the budget, start examining grants, increase billing procedures, working and collaborating with neighboring services, but it can be done. 

EMS is usually considered a luxury, not a necessity in most communities. There is no 'requirement " like other emergency services, therefore until we can officially require such we will have to invent and create funding... EMS has been ALS for over 40 years... shame that there is still communities not even able to provide as much care as the "Johnny & Roy" did 30 years ago.

R/r 911


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