# A call to educators.



## Veneficus (Apr 29, 2010)

So educators are always talking about making the EMS profession more than just a set of skills and driving an ambulance.

For years we have talked about books we think the students should read. Created lists of "recommended" texts, and complained about the poor quality of EMS texts. 

So can we do something about it? Why do we need a book by AAOS, or Brady, or Mosby that is second rate?

Once you know the principles of medical science, how much is there really to add about prehpspital medicine? 

We know what is the curriculum, we know what is tested. We know how to lecture on everything from communications to ambulnce ops.

Why don't we start demanding more? Why don't we require a reputable physiology, pathophysiology, or pharm text? 

I have reviewed books for years, and anything I have seen that says "prehospital" or "EMS" is second rate at best.

What stops us from requiring a physio text or a patho text instead? Once we teach medicine, it is relatively simple to demonstrate how it applies to the EMS environment.

we need to start saying "no" to Sidney sinus and the rest of the crap that is put in front of us for sale. 

So really, what stops us?


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## atropine (Apr 29, 2010)

Maybe the big block of all is Money, and I mean in all forms from publishing to changing whole programs from ROP, all the way to the comm college level. Just my thought.


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## MrBrown (Apr 29, 2010)

Volunteers, the fire service and the whole mentanlity of "minimal standards"

Our Paramedic Degree requires a seperate anatomy/phys text (generally Marieb), a patho and a pharm text (not sure which ones) as each is a seperate class before you even get into the "medical" aspect of prehospital medicine.

Really with the lack of career progression and recognition in the US I don't see anybody really pushing for higher standards and better quality texts.  EMS in your parts seems to be very much a "skills" trade akin to something like a mechanic or a plumber here; minimal entry standards and minimum education breed minimum resources to deliver minimum outcomes.

I can't remember who it was now but somebody told me of a program in the US which changed from Certificate to Degree and enrolments basically dried up overnight.  They changed back to a Certificate but never got the numbers back to continue the program.


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## Veneficus (Apr 29, 2010)

MrBrown said:


> Volunteers, the fire service and the whole mentanlity of "minimal standards"
> 
> Our Paramedic Degree requires a seperate anatomy/phys text (generally Marieb), a patho and a pharm text (not sure which ones) as each is a seperate class before you even get into the "medical" aspect of prehospital medicine.
> 
> ...



that happened at a school i taught at, but i am sure it has happened to others as well.

But I figure if we can make students spend a couple hundred $$$ and make them read a paramedic text, nothing at all stops us from making them spend the same amount on more reputable resources and making them read those.


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## medic417 (Apr 29, 2010)

Sadly I am beginning to think we should give up on advancing EMS and just downgrade to bare basics.  The majority seem to want no real education so why not just give up.  Lets remove the advanced skills that so many uneducated people that have access to keep screwing up with.  Just become load and go horizontal taxis.  Yes I am ashamed that I feel like throwing in the towel.


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## Veneficus (Apr 29, 2010)

medic417 said:


> Sadly I am beginning to think we should give up on advancing EMS and just downgrade to bare basics.  The majority seem to want no real education so why not just give up.  Lets remove the advanced skills that so many uneducated people that have access to keep screwing up with.  Just become load and go horizontal taxis.  Yes I am ashamed that I feel like throwing in the towel.



No worries, I've been at that point myself too, you eventually dust yourself off and rejoin the fight.


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## John E (Apr 29, 2010)

*Are there any studies...*

that show an increase in patient survival rates with increased educational standards in pre-hospital care providers?

Why should EMS personnel be taught more if it doesn't increase patient survival rates? Would having highly trained Paramedics responding to every person who called 911 for a medical emergency result in more lives being saved? Seems like it would but does it?

We all think that increasing the educational standards will somehow magically "help" but no one seems to be able to explain just how it will increase the average patient's chance of survival. And if it's not increasing patient survival rates, what's the point of it at all? Does it matter if I've taken a class in anatomy and physiology if the patient I'm treating can be in a hospital within 10 minutes of my arrival on scene? What does my increased education do for that patient that doing the ABC's and rapidly transporting wouldn't do? 

And of course, if increasing the education of every pre-hospital provider results in better patient survival rates, who's going to pay for it?

Not trying to start an argument, I'm honestly curious.


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## MrBrown (Apr 29, 2010)

Thats half the problem, the USneeds to *stop* focusing so much on the emergency side of ambulance practice.

I've said this before but the US systems seems to focus 90% of everything on the emergently sick or traumatically injured patient and it really does show.

With the only disposition for your patients being a refusal or the hospital then no, you can probably get away with bare bones education.  Infact if every patient I went to had to go to the hospital I could get away with carrying about 6 meds (adrenaline, salbutamol, GTN, aspirin, 10% glucose and morphine).

Outside the US the foci of ambulance really is shifting away from the emergent side of ambulance towards more sub-acute patients, alternate dispositions and referrals and very high levels of knowledge.

Oh and this is really what annoys me about the prhophets of evidence based anything; lack of evidence does not mean evidence of absence!


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## fortsmithman (Apr 29, 2010)

As I have stated previously in this forum I believe that EMS personnel should have the following education.

EMT 2 yr diploma (Canada) associates degree (USA)
Paramedic 4 yr bachelors degree

With the increase in education would come an increased scope of practice.


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## medic417 (Apr 29, 2010)

John E said:


> Does it matter if I've taken a class in anatomy and physiology if the patient I'm treating can be in a hospital within 10 minutes of my arrival on scene?



Not all of us have that luxury.  Some of us have to have enough knowledge to actually treat rather than just transport.  

Besides if Paramedics were properly educated even city Paramedics could begin treatments prior to arrival at the hospital saving easily minutes and perhaps hours at busy services, thus saving cardiac or brain cells ( see St Johns in Missouri ).


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## Veneficus (Apr 29, 2010)

John E said:


> that show an increase in patient survival rates with increased educational standards in pre-hospital care providers?
> 
> Why should EMS personnel be taught more if it doesn't increase patient survival rates? Would having highly trained Paramedics responding to every person who called 911 for a medical emergency result in more lives being saved? Seems like it would but does it?
> 
> ...



It is a fair question.

Anyone measuring the effectieness of an EMS provider by patient survival of life threatening conditions or resuscitation is using a flawed measure.

In all of emergency medicine, cases that are actually life an death are relatively few. (commonly measured around 6-4% depending on the year and source) by that standard, an EMS provider would only be beneficial to 4-6% of all patients. Why would anyone pay for that? Why would you pay above minimum wage? Why provide advanced equipment?

EMS usage is not even standard through different areas. A paramedic in Jersey City is very different from one in Austin, and one in Oakland. How do you go about comparing these proiders?

From a basic economic standpoint, the only way to have resources (like your pay) devoted to you, is to demonstrate the ability to generate or retain wealth. In medicine that is the ability for the patient to have a productive life. To benefit the society, family unit, etc. In order to even have a future, EMS will have to adopt a model that measures usefulness this way. Not because I say, but because every profession in hstory has had and continues to. while there are a few hanging around, how much opportunity is there for a blacksmith, a wheelwright, or a weaver? 

If you look at successful EMS agencies around the world and especially in the US, you find they all branch out from simple transport or "life saving." A Basic EMT on every block would be cheaper and save more lives than a bunch of ALS stations or units.

But what else is EMS positioned to do to add value to its consumers? Some think prevention, some diversification of consumers (like SWAT teams, etc.) All of these will play a role. But the one thing all EMS has in common is the fact no matter where you are, it is a portal to the healthcare system. Whether it is 911 emergency of life threatening conditions, carting some old person to the ED for a med refil, triage/treatment at a sporting event, industrial health, or whatever role you can think of that a paramedic can provide. (Even working the triage desk in the ED as a tech.) 

What opened these opportunties is education. Nobody is fool enough to think that with an increase in education states like CA will suddenly catch up to other states in role and responsibility of EMS providers. That Pay will magically go up instantaneously, suddenly EMS will have respect among other Healthcare professions, or any of the other dreams for EMS.

But the education creates opportunity. (like all other education) It allows you to branch your service and therefor value beyond being a glorified taxi. Will it save more cardiac arrest patients? Certainly not. But certain EMS implementations can prevent more cardiac arrests. Which not only "saves" more lives in a way that cannot be measured by survival to discharge, but it also preserves quality of life and function. It can reduce Emergency department costs and burdon, at a level of savings that makes it worth paying more for. Nothing other than education can achieve that. 

As an example, (i know there are many, but I am using this one) What was the role and opportunity for a nurse in 1865? What is the role and opportunity today? (even if i don't agree with all of it) 

I know for years US EMS has used response time and cardiac arrest resuscitation as a quixotic measurement that seemed easy for the public to understand as a measure of effectiveness. But honestly, look how stupid a measurement it is:

How well are you able to be everywhere and anywhere at any given time of need in time to make a difference?

How many people can you resurrect from the dead and return to normal or even productive function?

By those standards even the best doctors in the world would be worthless. 

even I don't find it valuable to pay a fire/medic, private medic, or 3rd service medic a middle class wage to be useful on (lets be overly generous) 10% on all patients they see.

Even if you take arrest data saves, how much percent of EMS patients are arrests? The best places can save 24% and that is with major resources to prevention, education, and community involvement. It is not just a measure of the effectiveness of showing up timely and providing an ACLS algorythm.

A community CPR program has far more capability to generate a positive patient outcome than an ALS ambulance. Look at what an AHA CPR instructor can generate in income! I get $20 an hour for that. All I hve to do is play a video tape, physically correct hand positions, tell people where to stand or sit next, and mark checks on a premade test. I turn down work there is so much. The training center I work at turns 39K people a year through various programs. I get paid even more to teach PALS and ACLS, and providers need to sign up months in advance for a spot. 

Imagine the value you could generate if hospitals could just spend a $100 or so dollars to send their staff to the local FD or have EMS agencies take care of that for them. (outsourcing) Imagine if you add high schools and commercial, and industrial programs for first aid, CPR, etc. Hell how about having a health and welness coordinator at a factory or a paramedic in a jail?

Those opportunities exist today. With expanded education, you open even more and drive up the wages because the local hospital might have to compete with the local EMS agency and the local office park for the same providers.


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## AnthonyM83 (Apr 29, 2010)

Veneficus, the problem is the accompanying increase in the school's length and possibly entry requirements. This is fine, but the problem comes in making in financially feasible both to the institution and to the incoming students. Not sure what the answer is. If the government or certifying agencies made a widespread change in requirements, that would probably force everyone to figure out an answer, though. But again, how to get THAT done.


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## John E (Apr 29, 2010)

*Well Mr. Brown...*

I guess the fact we're on a forum dedicated to EMERGENCY medical services and the fact that the original poster asked about EMERGENCY medical personnel and the training that they receive or don't receive, is why we're having this discussion.

Perhaps you could start a thread about whatever topic it is that you're talking about?

As for you having problems with "the prhophets (sic) of evidence based anything", medicine is a science, science is based on the observation of evidence. Do you think that the protocols and standards under which you work were arrived at by chance?  

As for having luxuries as posted by medic417, you're right but does it make sense to require the same educational standards and practices for every locality and in every circumstance?

I don't know the answers, the part of me that enjoys learning and putting knowledge into practice tells me that increasing educational standards is a great idea, the part of me that pays taxes and knows that the majority of the population in the U.S. live in metropolitan areas and are within relatively easy access to hospitals tells me something else. 

There was another thread a while ago that dealt with one county in California increasing it's scope of practice for Paramedics even after the medical director for that same county acknowledged that there was little to no evidence to show that increased ALS interventions actually resulted in increased patient survival rates. If there's no evidence that shows improvement, why do it?

John E


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## Veneficus (Apr 29, 2010)

AnthonyM83 said:


> Veneficus, the problem is the accompanying increase in the school's length and possibly entry requirements. This is fine, but the problem comes in making in financially feasible both to the institution and to the incoming students. Not sure what the answer is. If the government or certifying agencies made a widespread change in requirements, that would probably force everyone to figure out an answer, though. But again, how to get THAT done.



What is the cost of a bachelor's in business. What is the salary and opportunity?

How about a bachelor's in Art? (not of arts)

Institutions run programs and students sign up every day.

Something closer to EMS, how about a degree in "criminal justice?"

Do you make more as a cop or parole officer with that degree than you do as one without?

(no, but if you need it to apply,or distinguish yourself from the other 2000 candidates it sure is worth it)


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## medic417 (Apr 29, 2010)

But saves are flawed as well when you consider it another way.  How many hypoglycemics do you run on every year?  If no one checked them, lifted them out of bed, no one administered d-50, how many would have died each year?  Even many times they wake up and sign refusals even though they were just a few minutes from death or permanent brain and/or organ damage, how would we document these?  Often times we in EMS complain about the diabetics but we actually benefit them more than those in unwitnessed cardiac arrest.  Now we could argue family or even emt's could just load patient and take them to the hospital.  But how many would go into full respiratory or cardiac arrest with the delay of care?  

My point with that is there is no way to truly fully evaluate the benefits of EMS. 

 Even many that sign refusals may have had enough done to save their life and organs.  One of the greatest flaws I have seen was a study of comparing what was an emergency by saying if a patient was admitted to the hospital that it was an emergency.  Many Paramedics would evaluate patients and say they did not need an ambulance.  But because once at the hospital they were admitted that study said the Paramedics were wrong.  

So again my point with that is there is no way to truly fully evaluate the benefits of EMS. 

So sometimes we have to say there are obvious benefits though not provable benefits.  There is no way to conduct a study with blinds etc that would not be seriously flawed as you would have to endanger patients lives to do so.


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## medic417 (Apr 29, 2010)

John E said:


> IAs for having luxuries as posted by medic417, you're right but does it make sense to require the same educational standards and practices for every locality and in every circumstance?



Yes it makes sense.  During a disaster any area can become a long way from a hospital.  In other words earthquake strikes California and destroys all major infrastructure.  Tons of deaths and serious injuries.  Now that patient in you ambulance or triage area is yours for hours possibly days.  If we only required a basic in Cali because there is a hospital on every street corner people would die that could have survived.  By having a standard level of education nationwide everyone would at least have something to draw upon if they get stuck in situation.  

Now I agree you would want the ability to add additional times to subject matter that is more common in an area but you should not leave out the education because it may never be dealt with in an area.


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## AnthonyM83 (Apr 29, 2010)

Veneficus said:


> What is the cost of a bachelor's in business. What is the salary and opportunity?
> 
> How about a bachelor's in Art? (not of arts)
> 
> ...



If the companies in your area take that stuff into account. Around here it's not really looked at where you went to EMT school. They just want to know you have the EMT license. That comparison doesn't quite work...unless I'm not seeing the angle


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## CAOX3 (Apr 29, 2010)

The educational system is there as are the texts.  We should get rid of "training" institutions altogether, if your not affiliated with a college or university then shut it down.

I would vote for one provider, all these levels and expanded scopes are ridiculous.  Why not require a BS degree or AAS for entrance then an additional year or so of focused education skills and internship.  You would have the educational foundation to build on.  Everyone is so afraid of traditional education it isnt really that difficult take a course some time its actually quite enjoyable.

As far as basing opinion on "save rates" is also ridiculous, life and death calls are so far and few between but quality of the transport can be greatly improved with an experienced paramedic when needed.  I witness daily paramedics who through corrective treatment can avert a life ending crisies.  Now if you don't provide the necessary training and education needed so your BLS providers are able to determine what is outside their scope and just rely on the so called 120 hours of training then your doomed to failure and you probably wont even recognize it. 

Do I believe a paramedic needs to be on every truck?  No, however if your system doesn't have a quality CQI department extensive continuing training, educational opportunities for their providers, dispatch requirements and just sends the BLS unit because the woman doesn't "feel right" then yes a paramedic should be on every truck.  Here and other areas tiered systems have been proven effective.  Will it be that way forever?  Probably not, but until that changes there is a system in place based on scientific findings and it is quite successful.


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## dudemanguy (Apr 29, 2010)

MrBrown said:


> Thats half the problem, the USneeds to *stop* focusing so much on the emergency side of ambulance practice.




But WHY does the US NEED to stop doing this? Thats what I dont understand. You seem to be upset over the fact the US health care system is different than the Australia/NZ systems. 

There you apparently have patients being diagnosed and treated on scene by paramedics with a 3 year degree, or maybe 5 years in some cases. In the US patients are transported by paramedics or EMTs, given EMERGENCY care and treatment on scene and en route as necessary, and then diagnosed and treated by physicians with 11 plus years of education and training, supported by nurses and other health care professionals. 

I admit your way is cheaper, which is probably why it's done, socialized health care and all. But I dont know if its automatically better for the patient, which is why you cant produce statistics or evidence showing that it's superior.

Here our paramedics are EMERGENCY medical technicians. They are trained for that role, they arent really trained or used as doctor-lites. 

I'm sure some of the EMT's and medics on here have responded to calls and discovered a patient had been seen earlier at the ER for a non emergent problem, the patient was released, and 911 was called after their condition deteriorated, maybe to the point they were no longer saveable. I know I've seen this. If anything, your system would likely increase these incidents, since instead of being seen by a physician, patients are being diagnosed and treated by a paramedic with far less training. You can call them mica paramedics or super duper paramedics, or whatever u want, they still have far less training than a doctor.
[/QUOTE]


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## Veneficus (Apr 29, 2010)

AnthonyM83 said:


> If the companies in your area take that stuff into account. Around here it's not really looked at where you went to EMT school. They just want to know you have the EMT license. That comparison doesn't quite work...unless I'm not seeing the angle



Should the rest of the US be held back because CA doesn't utilize EMTs r medics to the full capacity?

Let me give an example this way. (factual) I worked at a major academic hospital that had a large anesthesia residency. RRTs (as in therapists, not techs) were not permitted to intubate anywhere in the hospital. Since they were not intubating in one location (that hospital), should we remove that requirement from the education of all RTs? Should we pay them less because they are not using their full education? Do you pay an Emergency physician less because they do not perform emergent thoracotomies at hospitals that have critical care surgeons 24/7?

I am sorry CA ems is a fragmented set of systems operating in 1970s levels. But it just doesn't justify holding back an entire profession. 

If RRTs were trained to area specific standards, they would need additional education to move or even apply for a job at a local hospital that did utiize all of their abilities. The whole purpose of a university education is to be able to take it anywhere. 

I can see your point about local companies taking a degree into account. But if I was a hiring manager and I could get somebody with a 4 year education in a field related to my industry for the same price as I could get somebody with a GED and a cert, I would take the college grad everytime. 

Look at the amount of people here practically begging for advice on getting an EMT basic job in CA. What makes any one of them more worth hiring than anyone else?  a 2 or 4 year degree to always make sure you are on the short list for a job seems like it is worth every penny. 

I even know a person who applied for a state level EMS job with a 4 year degree not even related, and when they interviewed only those with a degree they eliminated more than 100 applicants (with considerable experience in the field many at the rank of chief) down to 4 applicants with a 4 year degree and hired my friend. (even though her degree has nothing to do with the position) Degrees open doors and put people to the front of the line. Maybe not everytime, but more often than not.


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## medic417 (Apr 29, 2010)

dudemanguy said:


> Here our paramedics are EMERGENCY medical technicians.


[/QUOTE]

Seems that is no longer to be the case.  Under the new Paramedics are .............Paramedics.  EMT's are basics.  Perhaps as the change takes place the public will finally begin to understand the difference in possible care based on the title with the responders name.


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## AnthonyM83 (Apr 29, 2010)

Veneficus said:


> Should the rest of the US be held back because CA doesn't utilize EMTs r medics to the full capacity?


 I think your clarification went off on a tangent. I was explaining why it would be hard to get students to pay for certification programs with significantly harder and higher standards that took longer and were more expensive. I did that because it's the thing that's stopping many of the suggestions in your original post from happening.   - Identifying problem -

If you don't have those problems in all other areas, then identify whatever is slowing it from happening there. There was no suggestion of using local problems as an excuse to slow progress in other areas if feasible. Though I imagine there are problems to identify in other regions, also.


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## Veneficus (Apr 29, 2010)

AnthonyM83 said:


> I think your clarification went off on a tangent. I was explaining why it would be hard to get students to pay for certification programs with significantly harder and higher standards that took longer and were more expensive. I did that because it's the thing that's stopping many of the suggestions in your original post from happening.   - Identifying problem -
> 
> If you don't have those problems in all other areas, then identify whatever is slowing it from happening there. There was no suggestion of using local problems as an excuse to slow progress in other areas if feasible. Though I imagine there are problems to identify in other regions, also.



yes, tangent, sorry, i was thinking of too many replies to multiple messages at the same time and I think I botched them all.


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## dudemanguy (Apr 29, 2010)

Seems that is no longer to be the case.  Under the new Paramedics are .............Paramedics.  EMT's are basics.  Perhaps as the change takes place the public will finally begin to understand the difference in possible care based on the title with the responders name.[/QUOTE]

Yes Paramedics in the US have significantly more training and responsibility than EMT-Bs or Intermediates. I'm not arguing that.


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## Veneficus (Apr 29, 2010)

*tangents*

Ok, 

I used the local CA explanation, which I did not articulate very well to point out the that because a small area (Any Area. but I felt lke picking on CA, you know, they seem to have issues with just about everything from herbs to fiscal responsibility, and they do really give a bad impression of EMS systems to me) does not utilize the universal education of a provider, does not make obtaining that education less valuable except for that area.

In a private reply I pointed out, but would like to here, that a flawed measurement is not better than no measurement. I gave the example of earlier scientific practice of using skull volume to quantify mental ability.


Somewhere, I mentioned that the US cannot continue with EMS running as it has so far economically.

Please forgive me as I mixed all these replies up I think. 

Anyway this whole thread is a tangent now, because the purpose was to ask educations why we don't require our students to buy higher level textbooks for classes now and settle for lesser quality ones that cost the same or more?

If you could buy an astin martin (cause i can spell that) for the same price as a ford, why on earth would you settle for the ford?


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## MrBrown (Apr 29, 2010)

dudemanguy said:


> Here our paramedics are EMERGENCY medical technicians. They are trained for that role



Until you stop focusing on the emergent patient and getting them to the hospital quickly nothing will change.

Why? Because you do not need an overly labarious education to shock somebody in VF, give some salbutamol to an asthmatic or infuse some fluid into a trauma patient and drive them to the hospital.

The US systems does not seem interested in stepping out of the "public safety" realm of lights and sirens and "saving" sick patients by transporting them to the hospital quickly.  The rest of the world is developing models of care which expand the education and options for Paramedics away from the minority of ambulance work towards better assessment, referral and disposition of patients.

Until the attitude of the US changes away from "emergencies" to dealing with the other 90% of the workload in an effective, meaningful way there will be little need for increased education and supporting materials.

Why? Because the patient will always end up at the hospital.


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## mycrofft (Apr 29, 2010)

*MrBrown. after that now I can go cook supper in peace.*

Yes. Yes. Yes.*
Quit with the "Ricky Rescue" mindset. Maybe we need to set NHTSA to work again, give them three years in private, then they announce the new universal standards, undermining of which gets your DOT and other federal monies cut off.
1. Two _*degrees*_, period. No more little additions and optional proficiencies. EMT-B wants to intubate, get a certificate, but don't create a new variety of EMT to justify it. Want to do IV's and intubate? Get your
 EMT-P. Want to crack chests and suture? Get your MD, PA, or FNP.
2. Create a big primary care and indigent care sector and put people into it, don't keyhole them through ED's trying to discourage them. The first time a patient dies in your ER who was there longer than twenty minutes without care, the ED and facility administrators should be arrested, booked and arraigned for manslaughter, or third degree murder. The grand jury cracks open your books like a watermelon at a summer picnic. And if your county gets topheavy with plastic surgeons and podiatrists but deficient in OB/GYN and primary care docs, they can start doing mandatory work in clinics or they can move themselves out.
3. Mandate pay and benefits for EMS workers which can attract and hold professionals.
4. Medical transport companies, small, impoverished or rural areas...make exceptions, but no BS. If plastic surgeons start flocking to Juneau Alaska and they builld a new luxury resort and longer runway, kick out the jams and drop the hammer.

And about EMS district protocols etc? In most areas, heck YES they are not based on science. They are based on what others are doing so they are "reasonable" in "the community", and arrived at through a political process including undue influence by current shareholders.

Is my fifteen minutes up yet?

*Well, almost yes. Prompt transport makes sense if it is needed. We need to quit trying to do "Single Combat With Death" in someone's living room if transport time versus urgency of care can't be reconciled by care in route or a definitive treatment allowing the time factor to recede and the urgency to abate.


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