# Is anyone afraid that Evidence-Based Medicine will kill EMS?



## thegreypilgrim (Jan 21, 2010)

It seems like there is a growing movement among EMS physicians and researchers to just cut their losses and bring EMS back to the "scoop and run" method of days gone by. No real interventions...maybe some oxygen and an IV at TKO/KVO but the real intervention is just diesel therapy. As justification for this would be the very real possibility of study after study on EMS practices demonstrating or "interpreted as demonstrating" that pre-hospital ALS confers virtually no effect on overall patient outcomes.

Please don't take this as a rant against evidence-based medicine or research in general. If this is what research ends up indicating (I doubt it, but I don't doubt that some people will interpret it as demonstrating such), then so be it...I guess I'll find another career.

Is this something anybody is afraid will happen? 

Or do you see EMS going the other direction and continuing to advance as a profession?


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## Aidey (Jan 21, 2010)

It is a distant concern that I have that I think has a much higher chance of happening if we don't increase the education standards and start requiring college degrees. 

As I mentioned in the thread about multiple Bicarb doses, it may be that some of the stuff we do is only effective in very select cases, but we try it on everyone. The whole when you have a hammer, everything is a nail issue. This results in the "evidence" showing that treatment X statistically doesn't work. 

If we keep diluting the sample pool by using treatments on patients that probably aren't appropriate eventually all the statistics are going to show that nothing works. 

I think that education will save us because it will enable us to have more treatment options available. This means we can use more appropriate treatments which will result in more patients successfully treated and statistics that aren't as diluted. 


Dealing with statistics gives me a huge headache, there are just so many variables, especially when dealing with medical statistics. So much is subjective, and there is really no way to restrict a lot of the variables that affect outcomes. There is also almost no way to have control group to compare pts who received treatment vs patients who didn't. 

For example, you mentioned the statistic that ALS has been shown to have negligible affect on patient outcome. Look at the total number of ALS ambulances in the US, and the number of transports they do, and then look at how many of those transports are ALS level transports. If you compare the total number of transports vs the patients that ALS interventions made a difference in numbers are going to be dismal since there are so many transports and only a very very small fraction of them receive ALS intervention during transport.


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## MrBrown (Jan 21, 2010)

I do not see the future of the ambulance service in the emergent realm and this is a radial shift away from what has been the norm.

The ambo of the future will not simply look at scoop and run vs stay and play with the ultimate goal being transport to another facility.  It will change to where transport may be an option but not necessarily to a hospital nor will soley responding to 911 (111) "emergencies" be thier mainstay.

A hybrid RN/PA/Paramedic model is needed with people out in 4WDs whose specturm is "out of hospital" care as opposed to "prehospital" and I think the words "prehospital" and "emergency" should be removed from ambulance.

Scope of practice adjustment are not really needed but referral pathways and dispositions to other than an emergency department are required.  The hospital is not the only place to recieve care so why make everybody go there?

Medical emergencies will continue to happen and these require a certian level of response however we must go beyond the traditional "ALS" skillset and include a much broader base of education on public health, complex assessment and management and include the ability to Rx certian meds and tests eg x-rays.

Future demand will not be met by traditional ALS/BLS/emergency response but moving beyond that to encompass the ability to manage patients other than transporting them to the hospital.


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## firetender (Jan 21, 2010)

My vote is things will not go back to load and go as long as it's easier to document death through neglect than it is to determine the efficacy of any one approach.

When all is said and done we must, at the very least, APPEAR to be doing something to prevent useless deaths, even though everyone must die.

The impetus to improve rather than curtail the availability of advanced services would be furthered any time an individual of high prominence would get caught in an area of sub-standard care and die.

The Medical/Legal/Corporate Complex, first and foremost is designed to protect its own and will respond accordingly. Going back to load and go would withdraw some of that protection.

(Hmmm...that's pretty cynical, ain't it?)


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## BLSBoy (Jan 22, 2010)

STEMIs, CHFers. 
You just pick them up and go to the closest facility, you fail your patient.


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## Smash (Jan 22, 2010)

No.  No more frightened of that than of EBM killing medicine in general.



> STEMIs, CHFers.
> You just pick them up and go to the closest facility, you fail your patient.



Or TBI's, DKA, Sepsis, Strokes, even multi-system trauma, or indeed pretty much any of our patients.

EMS is medicine.  It _has_ to be evidence based or we will both fail our patients and our industry and become increasingly irrelevant.  If evidence suggests that in some circumstances minimal intervention is required, or that interventions that we used to rely on are no longer appropriate, then so be it.  The motivation should be to provide the best care possible to your patients, not to use the shiniest, most interventionyest toys we can, just because we can.

What we need to do is to stop being afraid of change, and stop having change thrust upon us, but to take the lead and drive the change ourselves.  [oprah] Own the change![/oprah]

In many countries EMS has taken on this challenge and have a degree as the _minimum_ entry level; are represented on committees at local, state and national levels; instigate change in protocols/procedures based on EBM themselves; carry out research that benefits their patients, EMS and medicine in the short and long term and adds to our pool of knowledge.

If we fail to meet these challenges, then I suppose EMS will be 'killed', but it won't be EBM that kills it, it will be us.


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## DrParasite (Jan 22, 2010)

BLS saves lives.  ABCs, bleeding control, oxygen and defib.  That and making good decisions on where to take the patient

ALS prolongs living, makes the situation better, and improves quality of life.

I'm sure people will say "but on this call, ALS saves the life" and "BLS can't do anything, they don't know enough."  and you are right, there are times when BLS can't do anything and ALS did save a life.  

but the evidence as a whole says that most of the time under most situations, ALS procedures don't save lives, BLS ones do.


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## John E (Jan 22, 2010)

*Don't tell that...*

to any of the Paramedic students who think they're all going to go save the world...

One wonders how people who think that getting more training so they can do more procedures will deal with facts that show that simply getting their patient to a properly equipped hospital will do more for them than all the in-field 12 leads and IV's ever will.

How long before the usual suspects start crowing about more education solving every problem facing EMS...?

3, 2, 1...

John E


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## Aidey (Jan 22, 2010)

I don't know about where you are, but a 12 lead in vitally necessary in getting the patient to the properly equipped hospital in my area.


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## John E (Jan 22, 2010)

*Well at the risk of being obvious...*

my location is in both my profile as well as in whatever you call that little block of text that appears with my name.

I take your point but ask yourself this, what are the statistics for long-term patient survival using ALS in the field now vs say 10 years ago? More people may be surviving the trip to the hospital but are they surviving beyond that and if not, would limiting in-field ALS procedures increase that survival rate? 

The point that I think was being made was that there is mounting evidence that suggests that delaying transport in order to let field personnel do more and more procedures in the field is not necessarily leading to better long-term patient survival. And if that isn't the overall goal of any branch of medicine, then what's the point of any of it?

At the risk of stirring up another hornet's nest, the OPALS study indicated just that. I'm not going to go into more detail as some people here will start shouting about the location of cities in Canada and the difference between ALS modalities of treatment in Canada and the U.S. which is of course, not the point of the study in the first place. It showed that using more and more advanced in-field ALS procedures did not always correlate to longer patient survival rates. I'm paraphrasing obviously but that's the gist of it. I won't be getting into any arguments with Paramedic students about OPALS again.

Sometimes more education teaches us that fewer procedures may be better for the patient, even if the Paramedic doesn't get to use the newest gadgets all the time.

John E


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## JPINFV (Jan 22, 2010)

The key with OPALS is sperating the trauma portion from the medical portion. Heck, I can post a study that shows that transport by POV saves more lives than BLS ambulance in trauma patients.


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## Veneficus (Jan 22, 2010)

It never ceases to surprise me that every population in the world values education except the US. People in poor nations beg for and risk their lives for education. Could it be education is the road from poverty? That it creates opportunity? Oh well, ignorance is bliss I guess.

Why is it that the same educated people so passionately encourage education for others? Perhaps a perspective others do not see?
What is the motive behind such support? Altruism or personal gain?

Will education solve all the problems of EMS? Probably not. But why is it that the only people who argue against education are the uneducated?

Hubris?
Envy?
Self importance?

Our colleagues across both Oceans have embraced education and while they are not without problems, they have enviable systems that progress as the knowledge of man does. Their systems respond to the changing needs of the community. Their societies value their services enough to pay wages higher than working at McDonalds.  Getting paid as an EMT-B by anyone is one of the biggest cons ever in the US. Even Bernie Madoff would be envious of the money spent for a horizontal taxi ride with a person who spent 120 hours studying step by step instructions printed on the inside lid of a first aid kit.

While you are reaing your OPALS study, maybe you should look at the ones showing the harm and ineffectieness of long boarding. That calls into question probably 1/2 of EMT Basic education.

Feel particularly useful yet? 

Not to worry, I won’t make you suffer through any more on why EMS providers should get an education. 
But I will leave you with this question: “What will you do when the US cannot or will not pay for EMS service?”

Maybe one more question:
“You want fries with your hero burger?”


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## John E (Jan 22, 2010)

*If you could please...*

just point out a single instance in which I or anyone else that's posted in this thread has done any of the things you're complaining about, I'd greatly appreciate it.

This thread is asking if evidence based medicine might end EMS as we know it.

It's not about any of the things you wrote about. Perhaps you sent your message to the wrong thread?

As for not making any of us suffer any longer, you could do that if you actually addressed the topic of the thread instead of going off on some imaginary anti-education rant based on something you obviously read elsewhere.

Just for the record, not that you'll bother to read it and not that I particularly care about your opinion but I for one am one of the most pro-education people I know. If I wasn't, I wouldn't have gone back to college in my 40's to continue my own education. You seem to think that debating topics relating to the way things are done in EMS is an attack on medical education, where you get this idea from I'm not sure, perhaps you've been reading some of the other people on this forum who's reply to a question as innocuous as "what's the weather outside?", is to start ranting about EMT's not having a 4 year college degree. Also for the record, I'm strongly in favor of EMS workers being required to have more education, not training but real education. But this thread isn't about that topic and I don't want to further derail it as you've attempted to do.

As for your last 2 questions, if you want to start a thread about who's going to pay for EMS in the future, you should do that and let those of us who are discussing an all-together different topic continue to do what we're doing. 
I have to admit I have no idea what you're referring to with your final question. I have noticed a tendency of people who have failed to make an otherwise legitimate point in an argument using the "burger flipper" as some sort of last ditch effort to make their point but in this case, your use of it in this case is not only silly, it doesn't serve to illustrate anything. 

And lastly, it seems I was incorrect about one thing, it took 4 posts for someone to try and derail this thread with a misguided and inaccurate rant about EMS education, not 3. My bad.

John E


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## Veneficus (Jan 22, 2010)

*allow me*

_
to any of the Paramedic students who think they're all going to go save the world...

One wonders how people who think that getting more training so they can do more procedures will deal with facts that show that simply getting their patient to a properly equipped hospital will do more for them than all the in-field 12 leads and IV's ever will.

*How long before the usual suspects start crowing about more education solving every problem facing EMS*...?

3, 2, 1..._


I didn't want to deny the response of the usual suspects with this antagonism.

Over the last 20 years there has been a constant struggle to increase the "training" and education of US EMS providers so that more procedures and decisions that do make a difference could be performed rather than just trying to come up with one size fits all algorythms that are not statistically effective. Pick a treatment, long boarding, fluid challenges, oxygen therapy. None of them seem to hold up to scrutiny.

But the same treatments are used in the hospital where they are effective on smaller patient populations. It is not the treatment that is the problem, it is which patients getting it. (Goes back to education) By being educated enough to select appropriate treatments the statisitics on effectiveness should match that of the hospital.

EMS and its destruction is directly dependant on its value. OPALS is not the only study calling into question the value of EMS. It is not a far jump from a study showing ineffective EMS practices to a populous in today's political climate coupled with a pressing need to reduce medical costs, to decide too much is being paid for EMS with too little benefit. (cost vs. perceived benefit)

Perhaps I give too much credit to the average American, but generally when they figure out they are not getting their money's worth they stop paying. (Which would end US EMS as we know it)

I have also posted in a similar thread about the care that must be taken when basing decisions off of studies that have not been reproduced or have biased methodology. Particularly given the "publish or perish" academic environment. Moreover it is important not to superimpose or extrapolate a cohort where one does not exist. (Like with OPALS)

The Future of EMS is inexorably connected to funding, education, and effectiveness. Trying to seperate them even in discussion is folly.

One of the very reasons effectiveness studies are done is to determine the cost/benefit ratio.(evidence based "medicine")

It will be the cost(aka value) that ends EMS as we know it. EMS is extremely resiliant to maintaining practices that have been scientifically called into question. (see above)

Another one of the biggest problems with evidence based medicine in EMS as we know it is new treatments have a large burdon of proof to be determined beneficial. While existing treatments require the same outrageous level of proof they are not effective and even then not discontinuing them. (with cost being a factor)

I am sorry for implying the connections in my earlier post and not pointing them out directly. I keep forgetting that since we have the same discussions for decades not everyone has seen them ad nauseum and may not know the intricacies.


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## John E (Jan 22, 2010)

*Well at least...*

you tried to connect your thoughts with the subject at hand.

Since you yourself have pretty much decided what you've decided and since this isn't the place to do so I won't get into it with you other than to point out that it would be hard for you to have been having these discussions here for decades give that you've only been posting here for less than 2 years.

If you're claiming that you've had discussions with people about the state of education in EMS outside of this forum for decades now, well only you know how long you've been in the EMS field.

Did the thought ever occur to you that maybe the folks who have advocating for fewer ALS interventions done in the field may have had a point after all?

I certainly hope that you're including any studies that support increasing ALS interventions when you bring up studies that can't be reproduced or have biased methodologies 

To try and bring this back to the original topic, any system of health care that is as you say, "extremely resilient" to change even when faced with scientific proof is one that perhaps needs to go away. Science did away with the barbers and the leeches, for the most part anyway, maybe the idea that a Paramedic in an ambulance really isn't a substitute for a hospital and a team of health care providers is correct. I don't know where the truth lies, but I do know this, there isn't any magic "education" button that is gonna improve patient survival when it comes to EMS. Unless that includes studying whether the whole premise of what EMS means needs to change.

As for the assertion about my antagonism, you brought it, I only replied to your vitriol. 

John E


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## Jeffrey_169 (Jan 22, 2010)

DrParasite said:


> BLS saves lives.  ABCs, bleeding control, oxygen and defib.  That and making good decisions on where to take the patient
> 
> ALS prolongs living, makes the situation better, and improves quality of life.
> 
> ...



This is an outstanding point, and I am happy someone realized it. To say BLS doesn't saves lives is like a plumber doesn't fix a leaky faucet. BLS is intergral to EMS, and there are times when in certain rural areas they are closer then ALS, and if they weren't there there would be no viable patient for ALS to work with. 

EMS as an occupation has one very real enemy: a lack in education and as a consequence, accreditation. Many states, including Texas, is considering new standards for both scope of practice, standard of care, and educational requirements. There is currently talk in the state legislature concerning the issuance of prescription drugs; antibiotics, pain killers, and certain others would be allowed for the "Licensed Paramedic", while the Certified Paramedic would be about the same as the current standard. 

It is unfortunate the reason why we are far off key in our profession is becasue all too often insurance companies, the government run ones in particular, will not cover certain hospital visits unless an ambulance is called and transports the patient. It is also unfortunate pts. have resorted to the ER as their primary care physician for basic care. The cold reality is our hospitals are no longer ran by doctors, but crooked insurance companies and executives who are only in it to make money. An ambulance ride is sometimes the only way these people can get care, or they believe they will be seen faster if they go this route instead of by POV. 

It is not the patients fault, they are simply doing what they must in order to get care. Medicine is no longer driven by the desire to heal the sick and injured, but rather by the need to generate large sums of money. This causes us to have to transport far more patients whose care is not emergent, and is far more expensive to deliver then it would be if they simply went to the local Dr's office; but in some cases this is not an option; when you know we won't turn you down, and the ER can't legally turn you away, you will take the only option you have to get the care you need. Its a matter of survival. 

So, when you take the rising cost of heath care, the lack in education of Paramedics, the dwindling number of qualified professionals in EMS, the corporate take over of medicine, and nearly 1/3 of our nation uninsured; all this coupled with rising transports and rising transport costs, you have a system which is no longer making the difference it was intended to make, and you have a system being asked to do more then it was intended to do and which it not what its job is designed for.  Right tool for the right job, but it is a major and complex problem, and one we need to get a grip on quickly before we find ourselves in an archaic profession.


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## Veneficus (Jan 22, 2010)

John E said:


> Since you yourself have pretty much decided what you've decided and since this isn't the place to do so I won't get into it with you other than to point out that it would be hard for you to have been having these discussions here for decades give that you've only been posting here for less than 2 years.
> 
> If you're claiming that you've had discussions with people about the state of education in EMS outside of this forum for decades now, well only you know how long you've been in the EMS field.



Clearly it would then seem logical that my participation in these discussions did not start here.



John E said:


> Did the thought ever occur to you that maybe the folks who have advocating for fewer ALS interventions done in the field may have had a point after all?.



Certainly, but it is not globally applicable. In an urban environment with short transport times, a plethora of ALS treatments delays the time to the hospital. I stipulate in a rural environment the outcomes of just transporting will not be as positive. But as I pointed out, BLS interventions are equally in question. As well the benefit of an ALS intervention is not always life saving. But it can be life altering. Everyone likes to talk about pain control, and I could add perspective about that on neuropathic pain, but to be original, hypoglycemia causes cell death, and while oral glucose absorbs faster than IV glucose, it is not always the best idea to start adding a gel to the mouth of an unconcious person. 




John E said:


> I certainly hope that you're including any studies that support increasing ALS interventions when you bring up studies that can't be reproduced or have biased methodologies



I was refering to interventions not done in EMS currently because they require more precise selection of patients, that may have a positive impact. I am not able to produce studies to show the effectiveness or lack of  with treatments that have not been part of EMS in the past. But I would be more skeptical of somebody who could.




John E said:


> To try and bring this back to the original topic, any system of health care that is as you say, "extremely resilient" to change even when faced with scientific proof is one that perhaps needs to go away.



Best of luck implementing that. A great many experts have not managed to remove spine boards from everyday use on patients. 




John E said:


> Science did away with the barbers and the leeches, for the most part anyway, maybe the idea that a Paramedic in an ambulance really isn't a substitute for a hospital and a team of health care providers is correct..



I don't think anyone disputes EMS is not a substitute for a hospital. Leeches do work quite well for microvascular surgery, as well as maggots for wound debriding. Goes back to better selecting who gets what treatment.




John E said:


> I don't know where the truth lies, but I do know this, there isn't any magic "education" button that is gonna improve patient survival when it comes to EMS. Unless that includes studying whether the whole premise of what EMS means needs to change.



I disagree. An increase in education makes selecting the treatments for indvidual patients more accurate. If selecting the most appropriate treatment for a patient doesn't have a benefit then we need to close the hospitals too.

There are several current threads that deal with what EMS needs to change into. Not surprisingly, those same arguments have been played out before this forum.

Are you studying nursing?


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## Jeffrey_169 (Jan 22, 2010)

Veneficus said:


> It never ceases to surprise me that every population in the world values education except the US. People in poor nations beg for and risk their lives for education. Could it be education is the road from poverty? That it creates opportunity? Oh well, ignorance is bliss I guess.
> 
> Why is it that the same educated people so passionately encourage education for others? Perhaps a perspective others do not see?
> What is the motive behind such support? Altruism or personal gain?
> ...



Well put...very well put indeed. 

I only have one more comment to add; if you have education without common sense, all you have is an educated dummy. There needs to more taught on clinical decision making skills, trauma assessment, medical assessment, and most of all PATIENT ADVOCACY. Too many of us in our profession forget to listen to the patient, and too many of us are judging our patients and making fun of them after the call. "I hate transporting bums" I heard a fellow medic say once. I told him. "Then find another job!!!" They are people too, and its important we remember this fact.


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## fire_911medic (Jan 22, 2010)

*Evidence Based medicine*

I have no problems with evidence based medicine - however I do have the concern that the majority of these studies are conducted within densely populated urban areas with close access to multiple hospitals.  I am fairly certain that if moved to a rural area that has extensive transport times (ie like the area I service it is 2 hours via ground L/S to reach definitive care) .  I think you may see altered results.  Of course understand that research studies can be altered based on the patients chosen to read whichever way they want them to.  

I'm not against evidence based medicine, but I would suggest several trials in both urban and rural settings (as I discussed before - 1 hour plus transport times) with consistent results before proposing changes.  If evidence is consistant, then by all means change it for the good of the patient, but don't change results based on what you see in an urban setting alone.  It may be more convenient for your study, but remember it will affect everyone.  Also another concern that this brings up is that patients that do require ALS interventions in rural areas they may say, "well just call a helicopter".  That's fine but they can't always fly and I look for safety measures to be tightening flight parameters considerably within the next few years.  Something to consider also is do you want to give a patient that requires maybe a little ALS intervention (and codes are tough to work in the HEMS environment many will not fly eminent or working codes due to that) a 16,000 + bill compared to a 600 dollar bill?  Something to think about.


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## Jeffrey_169 (Jan 22, 2010)

fire_911medic said:


> I have no problems with evidence based medicine - however I do have the concern that the majority of these studies are conducted within densely populated urban areas with close access to multiple hospitals.  I am fairly certain that if moved to a rural area that has extensive transport times (ie like the area I service it is 2 hours via ground L/S to reach definitive care) .  I think you may see altered results.  Of course understand that research studies can be altered based on the patients chosen to read whichever way they want them to.
> 
> I'm not against evidence based medicine, but I would suggest several trials in both urban and rural settings (as I discussed before - 1 hour plus transport times) with consistent results before proposing changes.  If evidence is consistant, then by all means change it for the good of the patient, but don't change results based on what you see in an urban setting alone.  It may be more convenient for your study, but remember it will affect everyone.  Also another concern that this brings up is that patients that do require ALS interventions in rural areas they may say, "well just call a helicopter".  That's fine but they can't always fly and I look for safety measures to be tightening flight parameters considerably within the next few years.  Something to consider also is do you want to give a patient that requires maybe a little ALS intervention (and codes are tough to work in the HEMS environment many will not fly eminent or working codes due to that) a 16,000 + bill compared to a 600 dollar bill?  Something to think about.



This is very true. I worked for such an agency in NM, and we had a ground transport time of almost 2 hours, and this was on a good day. They think a blanket solution is a cure all, when in reality different populations in different areas require a different approach. I live 2 miles form both of our hospitals, so yes ALS or even BLS probably wouldn't make a difference in the long run in most cases, but in other areas it couldn't be more different. It really falls on us; we need to speak up and defend our occupation, and consequently our patients. We need to tell the WHOLE story, not just the part which is convenient for the profiteers and these think tanks who study stats and not medicine. They study medicine from afar, we study up close and personal. 

I am not against statistics, but there is far more to medicine then meets the eyes, and far more complicated then a piece of paper can adequately define and explain. A few studies are not conclusive for the entire profession, but our silence has enabled this mentality. We need to speak up!


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## JPINFV (Jan 22, 2010)

fire_911medic said:


> I am fairly certain that if moved to a rural area that has extensive transport times (ie like the area I service it is 2 hours via ground L/S to reach definitive care) .


How long does it take you to return from definitive care without lights and sirens? The studies on L/S are pretty consistent that they save time. The problem is that the time saved is generally not enough to even begin to hope to be clinically significant. Similarly, in those 2 hours how much impassible slow traffic (please don't get me started on the stupidity I saw in MA with ambulances going L/S on the freeway when going the speed of traffic) or red stop lights do you encounter? Alternatively, are lights and sirens used as a legal justification for speeding (I'm from California, so it would be wrong of me to judge someone else on speeding, so don't take it like that)?


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## fire_911medic (Jan 22, 2010)

Those are valid points JP - 

As far as traffic - we are straight interstate after we reach certain areas, but due to distance, yes the average cruising speed is around 80 with L/S - around 65 -70 (65 speed limit) without.  Though caution is exercised at all times.  Going through town, into university or one of the other areas, it's not unusual to experience traffic so badly you cannot get through and frankly people just don't give a care.  I think common sense should be applied, and if not neccessary, L/S should not be utilized.  however, protocol dictates that if exceeding the speed limit by more than 5 (which is general flow of traffic) then they must have L/S activated - even on interstate, or if going through heavy traffic and attempting to maneuver around it.  With the exception of a few miles, there is little extreme back up as we are not even remotely close to a densely populated urban area.  Even university is not located within a major metropolitan area and is a far cry from larger cities such as Chicago and Houston.


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## JPINFV (Jan 23, 2010)

In otherwords, it's not lights and sirens that saves time. It's speeding (I'm from an area where the speed of normal traffic is 80, even though the speed limit is 65), and yes, 20 mph over that distance will save time, but it's not the L/S that's allowing you to do that.  The one thing I can see rural areas needing L/S for is for going around slow moving farm traffic or getting them to yield sooner, which was what I was going after for impasible traffic.


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## fire_911medic (Jan 23, 2010)

JPINFV said:


> In otherwords, it's not lights and sirens that saves time. It's speeding (I'm from an area where the speed of normal traffic is 80, even though the speed limit is 65), and yes, 20 mph over that distance will save time, but it's not the L/S that's allowing you to do that.  The one thing I can see rural areas needing L/S for is for going around slow moving farm traffic or getting them to yield sooner, which was what I was going after for impasible traffic.




Yes, it speeding that saves the time.  However, it is department policy which permits them to speed only utilizing L/S.  Without that justification, they would not be permitted to speed and if caught going excessive speed (or heaven forbid ticketed) without patient requiring that level of transport or on a return leg they will receive strict disciplinary action from both the service and the state.  It is so rural in many of these areas that it could safely be passed without the use of L/S.  But point is understood.  Thanks for clarifying though.  I misunderstood where you were going with the comment.


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## DrParasite (Jan 23, 2010)

Veneficus said:


> Will education solve all the problems of EMS? Probably not. But why is it that the only people who argue against education are the uneducated?


Point of information:  Do you have a bachelor's degree?  masters?  maybe even a doctorate? 

I have my bachelors.  But I'm only an EMT. Does that make me uneducated?  there is someone on these boards with the SN EMSLaw.  I am pretty sure he has his Juris doctorate, but I don't think he is a medic.  is he uneducated?  There is a guy from Syracuse NY named Brad Pinsky.  He's a volunteer EMT and volunteer firefighter.  and he has JD after his name.  is he uneducated?

There are quite a few paramedics in this country that used to be medics, who are now supervisors, and are now simply EMT basics because they don't need to do all the recert stuff as a medic to do their supervisory job.  are they uneducated simply because they are only EMTs?

BTW, I hope Jeffrey_169 realizes that the point that he described as outstanding was stated by an "uneducated" EMT.  But thing again, what does an uneducated person know


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## JPINFV (Jan 23, 2010)

You don't get the entire "exception to the rule" thing, do you?




> There are quite a few paramedics in this country that used to be medics, who are now supervisors, and are now simply EMT basics because they don't need to do all the recert stuff as a medic to do their supervisory job. are they uneducated simply because they are only EMTs?



They are, 100% without a doubt, undereducated if they didn't keep up with CMEs and maintain their paramedic certification if they are involved with clinical oversight of paramedics.


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## Veneficus (Jan 23, 2010)

DrParasite said:


> Point of information:  Do you have a bachelor's degree?  masters?  maybe even a doctorate?
> 
> I have my bachelors.  But I'm only an EMT. Does that make me uneducated?  there is someone on these boards with the SN EMSLaw.  I am pretty sure he has his Juris doctorate, but I don't think he is a medic.  is he uneducated?  There is a guy from Syracuse NY named Brad Pinsky.  He's a volunteer EMT and volunteer firefighter.  and he has JD after his name.  is he uneducated?
> 
> ...



Do you argue against education?


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## Outbac1 (Jan 23, 2010)

I don't believe that EBM (Evidence Based Medicine), will end EMS. Quite the contrary, I believe it will change EMS. EMS will change as we take the lessons learned and apply them to our patients. We can affect our pts by what we do before they get to the hosp. 

 How far from a hospital shouldn't be part of the equation. Why should a pt have to wait to be admitted to an ER to have nitrates or CPAP administered when they have CHF? Why should they wait for tx when the 10 min. drive with little traffic turns into 40 mins or more because of heavy traffic or obstruction. It is because of the evidence that CPAP and nitrates work that we can do these things prehospital. 

 We have the opportunity to have a positive effect on the lives of many of our pts. We can do this because of the education in medicine we receive and the progression of medicine in general. 

 Education in medicine needs to be ongoing. A family Dr. does not do heart surgery. They need substantially more education to do that. But they have way more education than a paramedic.  

 They say there is a Dr. shortage and people don't have family Drs. There are about as many Drs. now as about 20 years ago. They are not working as many long hours and thus are not seeing as many pts. They actually want a life. Imagine that! This opens the door of opportunity for us. With more education and the progression of medicine there will be more things we can do for pts without bringing them to the hospital. Evidence based medicine will be a part of this and we need to be involved. Especially if we want trials and experiments to benifit us.

 The comments about education need to be focused to the subject at hand. A person with a Doctorate in history  may be considered "educated" but not in medicine.

   Here in Canada (most places), an EMT-B isn't qualified to drive an ambulance letalone attend pts in the back. If the US wants to move forward in EMS you need to get on the bandwagon with the rest of the world. Increase your standards and education.


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## Jeffrey_169 (Jan 23, 2010)

John E said:


> you tried to connect your thoughts with the subject at hand.
> 
> Since you yourself have pretty much decided what you've decided and since this isn't the place to do so I won't get into it with you other than to point out that it would be hard for you to have been having these discussions here for decades give that you've only been posting here for less than 2 years.
> 
> ...



I believe the post in question is on point if you read it in the proper context. He is saying there would not as many ALS transports to analyze if we had the education to treat and release on scene. He is referring to those who do not need transport to a trauma or advanced facility, but rather a simple fix such as basic suturing, prescription and administration of basic antibiotics, etc. I believe he is also referring to the patients who do not require ALS interventions, but get it becasue they called 911. If we could treat on scene we could eliminate unnecessary transports, which would in turn reduce the statistics which say we are useless in the field in ALS care. There are too many transports which are not needed, and so when we intervene via protocol we are giving interventions which are not needed which provides the illusion we are ineffective. 

He is also stating these interventions are not in our scope of practice, education, or protocols, but if we are to improvbe our ALS transport  ratios we need to diversify to a capacity where we are able to. 

He has a valid point if the point expressed is out into context. I agree no magic wand or cure all soiolution will fix the issues we face, but we do need to consider more education as a means of repairing our image to both the practitioners and Joe Public.


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## Jeffrey_169 (Jan 23, 2010)

John E said:


> you tried to connect your thoughts with the subject at hand.
> 
> Since you yourself have pretty much decided what you've decided and since this isn't the place to do so I won't get into it with you other than to point out that it would be hard for you to have been having these discussions here for decades give that you've only been posting here for less than 2 years.
> 
> ...



I believe the post in question is on point if you read it in the proper context. He is saying there would not be as many ALS transports to analyze if we had the education to treat and release on scene. He is referring to those who do not need transport to a trauma or advanced facility, but rather a simple fix such as basic suturing, prescription and administration of basic antibiotics, etc. I believe he is also referring to the patients who do not require ALS interventions, but get it becasue they called 911. If we could treat on scene we could eliminate unnecessary transports, which would in turn reduce the statistics which say we are useless in the field in ALS care. There are too many transports which are not needed, and so when we intervene via protocol we are giving interventions which are not needed which provides the illusion we are ineffective. 

He is also stating these interventions are not in our scope of practice, education, or protocols, but if we are to improve our ALS transport  ratios we need to diversify to a capacity where we are able to. 

He has a valid point if the point expressed is out into context. I agree no magic wand or cure all solution will fix the issues we face, but we do need to consider more education as a means of repairing our image to both the practitioners and Joe Public.


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## alphatrauma (Jan 23, 2010)

> Point of Imformation: do you have a degree?  masters?  maybe even a doctorate?
> 
> *I have my bachelors.  But I'm only an EMT. Does that make me uneducated?*



Generally speaking, no. Then again, I don't think this discussion is about generalities... it's about medical science and the practical application/advancement of prehospital medicine as a profession. 

If I may inquire... Bachelor of _____?  



> there is someone on these boards with the SN EMSLaw.  I am pretty sure he has his *Juris doctorate*, but I don't think he is a medic.  is he uneducated?  There is a guy from Syracuse NY named Brad Pinsky.  He's a volunteer EMT and volunteer firefighter.  and he has *JD* after his name.  is he uneducated?



Do any of these degrees/disciplines have concentrations in chemistry, biology, physics? Are they educated... by all means yes, but they are at a considerable disadvantage when it comes to the practical application/understanding of emergency medicine (prehospital), as opposed to someone with an advanced degree in the health/medical related area of study.



> There are quite a few paramedics in this country that used to be medics, who are now supervisors, and are now simply EMT basics because they don't need to do all the recert stuff as a medic to do their supervisory job.  are they uneducated simply because they are only EMTs?



Unfortunately, as we (myself included) are becoming painfully aware of, being a "medic" does not automatically equate to being adequately educated. Semantics not-withstanding, we can split hairs all day about what being "educated" actually means... but I think we all know what the bottom line is.


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## DrParasite (Jan 23, 2010)

Veneficus said:


> Do you argue against education?


in general?  no.  I think education is a good thing and you can never have too much education.

however, I don't think it's right to raise standards unnecessarily.  The paramedic program, as it stands now, requires strict oversight, a medical director who approves every protocol, and a lot of cookbook medicine.  The paramedic's job is to stabilize the patient as best as they can so they can be transported to definitive medical care, which is a physician.  

Also remember, that a paramedics education, the entire year or two they spend in school, is DIRECTLY related to paramedicine.  no electives, no making you a well rounded person, no courses just to give you a good background on things that are useful to know.  the entire paramedic program is entirely devoted to what you need to know to be a paramedic.

As a side note, there is an Assoc Physician Asst Program, a Bachelors Physician Asst Program, and a Masters Physician Asst program, depending on what school you go to.  After you complete all the programs (which ever one you get into), you still take the same PA-C test, and clinically you are considered a PA, regardless of the degree you have.  just saying.

Back to your original question:  am I against education?  no.  would I be against every medic needing a masters degree with the current system?  yes.  if the field changes, would the educational requirements need to change as well?  absolutely.

Now, do I think that 120 hours is enough for an EMT class?  yeah, I do.  It's your baseline, the bare bones.  you still should be taking PTHLS, ICS, PEPP, CBRNE, HazMat, and CPR, as well as refreshers, con ed on burns, psychs, strokes and other various topics to expand your knowledge.  Plus, your agency should have their own in house training program so you can learn how they do things, and so you can gain experience.  Remember, experience, especially when you do screw up, can be one of the most valuable tools in the medical field.  and it's the EXACT same way in hospitals (why do you think they have big meetings where seasoned doc critique the actions of younger docs?).

Will it prepare you for everything?  absolutely not.  it s doctor who finishes med school, which culminates with 8 years of college education, ready for everything?  absolutely not.

So am I against education?  no.  am I against artificially inflating the educational requirements when it won't benefit the patient?  yep.


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## Jeffrey_169 (Jan 23, 2010)

alphatrauma said:


> Generally speaking, no. Then again, I don't think this discussion is about generalities... it's about medical science and the practical application/advancement of prehospital medicine as a profession.
> 
> If I may inquire... Bachelor of _____?
> 
> ...



This is absolutely true. Level of education is important, and the relevance to the field being studied is also important. there are, however, other aspects to be considered as well. Just becasue someone is educated doesn't mean they are qualified of creditable. A pharmaceutical company conducted research into the effects of certain drugs on pediatric patients. The results were quickly contradicted by several studies which were instigated by the obvious conflict of interest. My point is when a study in conducted it must be scrutinized to gain creditability, the person(s) conducting the study must be educated in the field they are studying, and the results must be able to be repeated. Using one study to base all conclusions on is not only presumptuous, but dangerous.

One a separate note, just becasue someone is educated does not mean they have common sense or creditability. In such cases all you have is an educated dummy.


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## DrParasite (Jan 23, 2010)

oh, and Veneficus, I am still waiting to hear what your formal education level is.

Alphatrauma, my degree is a Bachelor's of Science.  coursework (including ones I have taken after I graduated) includes biology, chemistry, psychology,  organic chemistry, some chaos theory, calculus, and most history courses than I care to admit.  

Oh, and for the record, you can major in basket weaving and be premed, so what your degree is might not be the best line of thinking when determining what someone's science background is.

The only reason i mention the lawyer people is because someone said EMTs were uneducated.  For some, this is their second career.  they have knowledge far surpassing that of a medic.  might not be field related, but in their industry, they are the expert.  they value education, have gone to college, often grad school, so to accuse someone of being uneducated because they chose not to go to medic school and become a medic, or because they think the current standards are adequate.  I would take an active EMT in a busy system who has done the job for 10 to 10 years over a medic who has had their card for less than 2.  experience plays a big factor in education


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## Veneficus (Jan 23, 2010)

DrParasite said:


> in general?  no.  I think education is a good thing and you can never have too much education.
> 
> however, I don't think it's right to raise standards unnecessarily.  The paramedic program, as it stands now, requires strict oversight, a medical director who approves every protocol, and a lot of cookbook medicine.  The paramedic's job is to stabilize the patient as best as they can so they can be transported to definitive medical care, which is a physician.
> 
> ...




Interesting perspective.

I would like to ask how you determine that increasing educational requirements would not benefit the patient?

Also, do you think the field should change prior to needing a degree or after? If prior, how do you treat all the people currently in the field? Suddenly raise their scope and change responsibility with "good luck, figure it out?"

What a lot of people do not understand is that jobs where you don't need an education are decreasing both in number and in value. That is a trend that will continue as it has in all modern nations. With near 10% unemployment, it is just as easy to replace union workers with new people who would demand less. I think Regan made that point quite clear in the 80s.


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## Veneficus (Jan 23, 2010)

DrParasite said:


> oh, and Veneficus, I am still waiting to hear what your formal education level is.



As posted on my profile: MSIV, as in medical student 4th year. 

I really don't like posting my resume or titles, but i broke down on this forum because I got tired of certain people thinking because I am also a medic that that was the limit of my education.


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## JPINFV (Jan 23, 2010)

DrParasite said:


> The only reason i mention the lawyer people is because someone said EMTs were uneducated.  For some, this is their second career.  they have knowledge far surpassing that of a medic.  might not be field related, but in their industry, they are the expert.  they value education, have gone to college, often grad school, so to accuse someone of being uneducated because they chose not to go to medic school and become a medic, or because they think the current standards are adequate.  I would take an active EMT in a busy system who has done the job for 10 to 10 years over a medic who has had their card for less than 2.  experience plays a big factor in education



Prior education means little if it's not in that field. Even a PA or NP who enters medical school still has to take all of the medical school courses at most schools. Even the schools that offer students the ability to test out of a course still requires their students to take their tests. Just because someone already took gross anatomy elsewhere doesn't mean that they get a pass on GA. 

Then again, I guess I should be advocating myself to EMT-SB (EMT-Super Basic) since I'm a basic with a masters degree! 



> however, I don't think it's right to raise standards unnecessarily. The paramedic program, as it stands now, requires strict oversight, a medical director who approves every protocol, and a lot of cookbook medicine. The paramedic's job is to stabilize the patient as best as they can so they can be transported to definitive medical care, which is a physician.



If you want to change the system, you have to change the education requirements first, then the system. Otherwise it's like building a house first and then once the house is built, trying to build a foundation.


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## Veneficus (Jan 23, 2010)

JPINFV said:


> Just because someone already took gross anatomy elsewhere doesn't mean that they get a pass on GA.



Love your example, especially since I took it for undergrad and got to do it again in med school. But GA is much easier the second time around.




JPINFV said:


> Then again, I guess I should be advocating myself to EMT-SB (EMT-Super Basic) since I'm a basic with a masters degree!



Especially if that is a biochemistry degree. People should get a special patch or something for that.


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## fire_911medic (Jan 23, 2010)

DrParasite said:


> I think education is a good thing and you can never have too much education.
> 
> *Okay good, so glad we agree, now why are we having this debate?*
> 
> ...



I respectfully state I am forced to disagree for all the reasons highlighted above.


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## rhan101277 (Jan 23, 2010)

I think there are some terrible medics out there that make the good one's look bad to.  It may not be their fault, maybe their educational program wasn't good.  On a couple of my ambulance clinicals, the paramedic I rode with was very good.  If he thought someone didn't need to go to the hospital, then he would say, I can take him if you want me to but he is breathing fine, vitals ok etc.  That way we don't jam up the ER and its there for people that really need it.  Some people call 911 out of loneliness or they forget to take their beta blockers and get worried when their BP goes to 228/90.  You need to know enough to see past things that are non-emergent, do an accurate and detailed assessment and only transport people who really need it.  Of course if they demand to go then so be it.  Always make them sign a refusal though and give them good medical consultation.

Many paramedics I talk to say, "You don't want to be the paramedic that brings every call to the ER."  Maybe sometime, when people obviously aren't in any need of emergency care, you develop rapport with the patient and explain you can take them if they want to go, but everything seems ok.  I know its tough to do, but I guess only seasoned medics do this type stuff.


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## VentMedic (Jan 23, 2010)

rhan101277 said:


> they forget to take their beta blockers and get worried when their *BP goes to 228/90.* You need to know enough to see past things that are *non-emergent*, do an accurate and detailed assessment and only transport people who really need it. Of course if they demand to go then so be it. *Always make them sign a refusal though* and *give them good medical consultation*.
> 
> Many paramedics I talk to say, "You don't want to be the paramedic that brings every call to the ER." Maybe sometime, when people obviously aren't in any need of emergency care, you develop rapport with the patient and explain you can take them if they want to go, but everything seems ok. I know its tough to do, but I guess only seasoned medics do this type stuff.


 
You're kidding, right? You consider this BP nothing to worry about? Was the patient symptomatic? Regardless of it being the patient's fault that they forgot to take their beta-blocker, it is no reason to blow off a situation that may need to be addressed such as a systolic BP of 228. PO beta blockers will not work immediately and if this BP has been sustained for any length of time you shouldn't just tell them to take their pill and call a doctor. If the patient was on beta blockers there is a good chance their BP may have been an issue in the past and this may not be something to write off as BS. Sometimes people who are elderly or even those with various disease processes regardless of age do forget to take their meds. Not everyone is noncompliant or looking to abuse the system. Even if they didn't take their beta blockers because they were "feeling better", that is no reason to cop an attitude with the patient to where it can skew your medical judgment. 

Just getting a patient to sign are refusal does not release you from liability especially if you document a systolic BP of 228. Of course if it was only your partner that witnessed you taking the BP, you could lie and say the BP was 128 on your paperwork to justify your nontransport of the patient.


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## CAOX3 (Jan 23, 2010)

Yeah why would you worry about an indicator for CVA  .  We shouldnt be dismissing anyone with signifigant BP elevation.  

Im going to give you the benefit of the doubt here and say bad example.

As far as education everyone needs more education, however until its mandated we cant expect providers to just "educate themselves." 

I think the problem with evidence based medicine is it takes forever to reach the provider.  Something proves effective and ten years later it becomes common practise in EMS. Some systems are proactive and some are not.

One provider, one treatment guideline thats my vote, amount of education is debatable two years or four years.   Will I see it in my lifetime nationwide? Not likely.


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## rhan101277 (Jan 23, 2010)

VentMedic said:


> You're kidding, right? You consider this BP nothing to worry about? Was the patient symptomatic? Regardless of it being the patient's fault that they forgot to take their beta-blocker, it is no reason to blow off a situation that may need to be addressed such as a systolic BP of 228. PO beta blockers will not work immediately and if this BP has been sustained for any length of time you shouldn't just tell them to take their pill and call a doctor. If the patient was on beta blockers there is a good chance their BP may have been an issue in the past and this may not be something to write off as BS. Sometimes people who are elderly or even those with various disease processes regardless of age do forget to take their meds. Not everyone is noncompliant or looking to abuse the system. Even if they didn't take their beta blockers because they were "feeling better", that is no reason to cop an attitude with the patient to where it can skew your medical judgment.
> 
> Just getting a patient to sign are refusal does not release you from liability especially if you document a systolic BP of 228. Of course if it was only your partner that witnessed you taking the BP, you could lie and say the BP was 128 on your paperwork to justify your nontransport of the patient.



Well the c/c was high BP pt had his own home BP machine and got that value I posted earlier.  Upon arrival it was 168/84, I am just a student and I was with a preceptor.  I noticed a pulse that was not normal, but patient was asymptomatic, medic said patient probably lived with it.  I don't know what it could have been since he wasn't hooked up to a monitor but now that I think about it, it may have been sinus arrhythmia.

Seem like his heart would skip a beat during breathing and then normal up, hard to say.

The patient didn't want to go to hospital anyhow.

Where can I got to look at these reports of evidence based medicine results?


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## VentMedic (Jan 23, 2010)

rhan101277 said:


> Well the c/c was high BP pt had his own home BP machine and got that value I posted earlier. Upon arrival it was 168/84, I am just a student and I was with a preceptor. I noticed a pulse that was not normal, but patient was asymptomatic, medic said patient probably lived with it. I don't know what it could have been since he wasn't hooked up to a monitor but now that I think about it, it may have been sinus arrhythmia.
> 
> Seem like his heart would skip a beat during breathing and then normal up, hard to say.
> 
> The patient didn't want to go to hospital anyhow.


 
I have many more questions about this scenario but back to the topic.  

However I will say sometimes the facts in EMS are skewed by the providers which also makes researh difficult.  Example: the number of intubation attempts or what even qualifies as an "attempt".  



rhan101277 said:


> Where can I got to look at these reports of evidence based medicine results?


 
Since you are a student, the library should have access to the "Prehospital Emergency Care" journal.

http://www.naemsp.org/publications.html

http://www.informaworld.com/smpp/title~db=all~content=t713698281~tab=subscribe?waited=0

http://www.naemsp.org/

http://www.naemsp.org/position.html


Here's a few articles to look up: (Also, look to the right of each article for more articles as well as the references used in each article.)

http://www.ncbi.nlm.nih.gov/pubmed/18379908


http://www.ems.gov/portal/site/ems/...toid=e8e2ae1ea540f110VgnVCM1000002fd17898RCRD

http://www.ems.gov   is  a good source for information.


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## MrBrown (Jan 23, 2010)

EBM will not kill EMS but it will change it dramatically away from an emergent response capability to an out-of-hospital community health resource.

I truly believe in the next decade or so the Paramedic of today will cease to exist.

We need to stop using the words "life support", "prehospital" and "emergency" as they just foul up the whole damn mess.

Now this might be a bit crystal ballish but here we are already working on a system that will allow ambo's to tap into our national health database and this system exists in parts of Australia and Canada too.

I sincerely hope we will see the death of traditionalist BLS/ILS/ALS, call-taking, firefighter/paramedics and any fire department involvment within my lifetime and I think we will.


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## CAOX3 (Jan 23, 2010)

MrBrown said:


> EBM will not kill EMS but it will change it dramatically away from an emergent response capability to an out-of-hospital community health resource..
> 
> I truly believe in the next decade or so the Paramedic of today will cease to exist.
> 
> ...



Yeah and the AFL CIO is going to allow that .  I not to concerned about what color truck you show up in as long as you can handle your business.

Whats wrong with call taking?

And BLS and ALS is a billing detail in my area.  We dont have ILS so I dont know what that consists of.


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## VentMedic (Jan 23, 2010)

MrBrown said:


> I sincerely hope we will see the death of traditionalist BLS/ILS/ALS, call-taking, firefighter/paramedics and any fire department involvment within my lifetime and I think we will.


 
Aahhh a dreamer...  I hope you plan on living for many, many more decades.   Even the NREMT changes planned it will take at least 10 - 20 years  to see any progress with just these relatively minor changes.  It is also absurd that accreditation is something to be debated after well over 40 years.    

Did you see this article?  

http://www.emsresponder.com/features/article.jsp?id=11832&siteSection=18


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## mycrofft (Jan 24, 2010)

*For the love of ...and I thought I was full of gas.*

1. The biggest factors in big "Change for EMS" will be political and economic, not science.

2. Your response time to the pt, then/plus to the definitve care site, should dictate what measures make sense, then training and materials should follow. More EMTs spread out better, or more hospitals or whatever likewise spread out to minimize response and return times, would mean less ALS necessary.


Delay (of proper defintive tx) _*plus*_ inability to address the insult (sickness or trauma), _*times*_ insult, _*equals death*_. You can call that Mycrofft's Law. Loitering to get or do anything which will not offset the resultant delay or immediately institute definitve tx (like a succesful Heimlich) lessens survival (Mycrofft's Corollary One). You can do and observe a lot all at once (Corollary Two), shortening delay and so reducing likelihood of death.

Evidence based medicine over the centuries has yielded some of the biggest advances because, when done properly, you are talking science. Why are people afraid of science unless it tips their apple cart?


Well, I am still full of gas.


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## medichopeful (Jan 24, 2010)

DrParasite said:


> The paramedic's job is to stabilize the patient as best as they can so they can be transported to definitive medical care, which is a physician.



Why not raise the education and training given to paramedics so that instead of just stabilizing them, they can start treating them as well?


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## Smash (Jan 24, 2010)

> Originally Posted by DrParasite
> The paramedic's job is to stabilize the patient as best as they can so they can be transported to definitive medical care, which is a physician.





medichopeful said:


> Why not raise the education and training given to paramedics so that instead of just stabilizing them, they can start treating them as well?



Indeed.  And where I work, that is exactly what happens.  Definitive care begins from when we arrive.  We improve outcomes not just in terms of survival to hospital (which is a bogus measure anyway) but in real terms of survival to discharge and long term neurological outcomes not just for cardiac arrest, but for trauma such as TBI.  We improve quality of life for patients and we reduce the cost to the health system and society as a direct result of our practices.

Of course where I work you require 4 years of full time university study and a minimum of 2 years on road consolidation with instructors and senior medics to be able to practice at ALS level.  Maybe we could have the same impact with a 6 month course and being let loose with a drug box... 

*However* we seem to have gone somewhat off course here in discussing EBM and gone back to the old battle ground of education/no education/more education/enough education/what-the-heck-is-this-edumacashun-business-anyway?

So!  I would like to pose a question to those out there who are still a bit anti-EBM (I know you're out there!)

If not EBM; i.e. if not the "The judicious use of the best current evidence in making decisions about the care of the individual patient... integrating clinical expertise with the best available research evidence" (thank you Dr Sackett), then what?

What is the alternative to EBM?  If we are not examining research, doing research, applying research, then what is it we are supposed to base our practice on?  

I genuinely am curious, because I am genuinely perplexed at the number of people who seem to be affronted by EBM.

So please, tell me, if not EBM, then what?


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## zmedic (Jan 24, 2010)

People seem to be forgetting about efficiency. For most calls it is way more efficient to handle them at the hospital than trying to do it in the field. Look at a suture call. To show up to a simple laceration you have to asses the patient, stop the bleeding, irrigate the wound, apply your local anesthetic, set up a sterile field, set up good lighting (which may not be easy in someone's house), sew the lac, dress it, update the patient's tetnus shot, and ensure follow up to get the stitches removed and check the wound. And don't forget antibiotics. 

So now you have this ALS ambulance that is out of service for, what, 45minutes to an hour, that has to carry suture supplies, addtional medications, sterile drapes etc. The medic needs hours of additional training in antibiotics, suture techniques, local anesthetic use, additional assessment etc. And how many times are they going to get started and realize that there is a possible tendon rupture or maybe a piece of glass and the patient has to be transported anyway? Or you give the antibiotic and leave and the patient has a bad reaction. In the ED the patient's are going to sit there for a few minutes where they can be cared for if they have a reaction. EMS is going to leave when they are done sewing. 

The reason why we have hospitals is that it is more efficient to bring the patient to the hospital than to have the doctors making house calls.  

Most US medics aren't even close to being ready to handle a call like I described above in the field. And I think most EDs would argue that it isn't worth the massive expendature on training to save them a suture case.


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## Melclin (Jan 24, 2010)

zmedic said:


> People seem to be forgetting about efficiency. For most calls it is way more efficient to handle them at the hospital than trying to do it in the field. Look at a suture call. To show up to a simple laceration you have to asses the patient, stop the bleeding, irrigate the wound, apply your local anesthetic, set up a sterile field, set up good lighting (which may not be easy in someone's house), sew the lac, dress it, update the patient's tetnus shot, and ensure follow up to get the stitches removed and check the wound. And don't forget antibiotics.
> 
> So now you have this ALS ambulance that is out of service for, what, 45minutes to an hour, that has to carry suture supplies, addtional medications, sterile drapes etc. The medic needs hours of additional training in antibiotics, suture techniques, local anesthetic use, additional assessment etc. And how many times are they going to get started and realize that there is a possible tendon rupture or maybe a piece of glass and the patient has to be transported anyway? Or you give the antibiotic and leave and the patient has a bad reaction. In the ED the patient's are going to sit there for a few minutes where they can be cared for if they have a reaction. EMS is going to leave when they are done sewing.
> 
> ...



That's certainly true of suturing. And most extended care models I'm aware of don't involve normal emergency ambulances doing sutures in the field. It is entirely appropriate for a case like that to go to an ED. However, the models for extended scope I have seen would involve triaging this person to an appropriate level of care to be exactly what you want - efficient. But you then need your paramedics to be educated enough to know if the lac needs a plastics consult and surgery or a simple suture and a few other things, before they can decide on GP or ED. Education, education, edu....   

You can't use that inappropriate example and then suggest that extended care models are inefficient. There are a million examples of cases that currently go to ED or are left at home with no care at all (both go on to be an unnecessary burden to other health care professionals), that could easily be dealt with definitively or extensively by paramedics, with the added benefit being that the trip out there was not a waste of time. Efficiency.


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## Veneficus (Jan 24, 2010)

zmedic said:


> People seem to be forgetting about efficiency. For most calls it is way more efficient to handle them at the hospital than trying to do it in the field. Look at a suture call. To show up to a simple laceration you have to asses the patient, stop the bleeding, irrigate the wound, apply your local anesthetic, set up a sterile field, set up good lighting (which may not be easy in someone's house), sew the lac, dress it, update the patient's tetnus shot, and ensure follow up to get the stitches removed and check the wound. And don't forget antibiotics.
> 
> So now you have this ALS ambulance that is out of service for, what, 45minutes to an hour, that has to carry suture supplies, addtional medications, sterile drapes etc. The medic needs hours of additional training in antibiotics, suture techniques, local anesthetic use, additional assessment etc. And how many times are they going to get started and realize that there is a possible tendon rupture or maybe a piece of glass and the patient has to be transported anyway? Or you give the antibiotic and leave and the patient has a bad reaction. In the ED the patient's are going to sit there for a few minutes where they can be cared for if they have a reaction. EMS is going to leave when they are done sewing.
> 
> ...




I agree with what you have said here, but I think it is not a good example of what can or should be accomplished with a more extended scope of EMS practice.

I think the overall goal should not be to add on more procedures providers are performing, but to make sure that somebody who calls is directed to the proper resources. 

Emergency care is extremely expensive in the US. With an average wait times in the ED, the absolute outrageous costs associated, and the lack of ability to effectively treat chronic illness on an outpatient basis, simply taking people to the hospital is not financially sustainable.

Obviously I cannot speak for everyones’ local facilities but of the ones I am familiar with. The charity hospital often charges $500 for a non acute ED fee. Add in a Physician charge of $500 plus any diagnostics, and your simple laceration can run you over $1000. The area private hospitals can exceed these costs by 1/3 or more. (The highest in the area 280% more.)

Now I realize that the total bill is rarely collected from even 80% of the patients, some will have insurance that has negotiated a lower rate, some will meet federal poverty guidelines and pay nothing at all, and some will successfully petition the physician to forgo or lower that part of the bill. 

With most, and the last number I heard but cannot substantiate, 87% of all US bankruptcies are related to medical expenses, if the number was even 51%, it means if you get sick or hurt and make above federal poverty level, but do not have insurance, (call these people the working poor) it basically equals considerable financial hardship if not outright ruin. 

Considering if you show up at the ED for your chronic disease, you will get a repeat of several diagnostics, the usual department and physician bill, and if not admitted, a temporary measure and referral, which may take months for an appointment. Average wait NEJM published a few months ago was 47 days to see a GP. (don’t remember which issue, I read them every week) How many times could that patient wind up repeating this ED sequence prior to an appointment? How many places leave it up to the patient to find their own GP or specialist?

Have you seen exactly how that plays out?
Open up the yellow pages, start calling in order. One of the first questions: “What insurance do you have?” After a while people give up and try to live with the condition until they wind up back in the 911 system. Nothing is being done but the generation of bills for ineffective care.

Even in larger EDs that have on site social services, etc. The emergency department is an extremely ineffective gateway to the healthcare system in the US. 

Cost will be the driving factor in EMS expansion, not the efficacy of additional procedures.


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## fire_911medic (Jan 24, 2010)

There was actually an attempt to set up a "paramedic clinic" where people could go for minor things - very similar to the doc in a box deal for urgent treatment clinics.  They would work in communication with a dedicated medical director there for reading of basic x-rays etc.  It was on the verge of being set up, however, what it was realized later is that they were unable to do so under the current limitations of the scope of practice (within this state, I'm unsure about nationally).  If that were expanded to include these options then education would be forced to expand allowing us to provide the services to the community.  Granted it wouldn't be done on the truck, but they could be transported to the paramedic clinic for sutures, basic sprains/strains, things like that.  I could see the definite benefit to the community as it was quite similar to what we did within our Occ Health clinic - however we performed these functions under direct oversight and with the luxury of having x ray and things on site which I think would have to be required.  I don't see any reason we couldn't expand out to cover these.

As far as evidence based medicine, I think much of it has to do with the fact that people are terrified of losing cool to do skills and that we may see the scope of practice tightened to more what is most beneficial for the patient.  Also it may force the level of education to be raised - ie class may take longer and a better understanding must be achieved.  I think the two will go hand in hand.  It's not neccessarily about a sheet of paper, it is about what will be ultimately best for the patient.  Yes intubation is a fun skill - I dont argue, and the skill itself typically isn't that difficult.  However teaching someone when to intubate and when not to is a little trickier.  Also, evidence is already showing that most medics don't do it enough to adequately maintain their skills and so they need to be required to do OR or ER time in order to keep those skills up - but that would require additional initiative on the part of those people to both set up and attend - otherwise I'm all for taking the skill away.  I'd rather you not have the skill, than to do it poorly and possibly be detrimental to the patient.  That's just one example there are many others.  If evidence is pointing that way then we need to adjust our skill set to fix the problem then we will be following the rest of medicine in that we're trying to find the best treatment for the patient.  It's not about us, it's all about the patient !


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## mycrofft (Jan 24, 2010)

*Finite resources and "definitve" care.*

Good point about stretching assets. "Time equals people"; if you have units tied down treating at homes and in parking lots, you need more units. If and when you can send out medical people who can fully engage a pt at the site, treat, then leave the pt there (no transport), thereby effectively extending the hospital to the pt, without the diagnostic and logistic resources of the hospital, THEN you can start calling field work "definitive".

Oh, wait, that was once called "house calls", and that was pretty well killed once we started using xray machines, stat labs, CT scanners.

Field suturing...revisiting the past here. Suturing is the last step (before billing), beforehand you need to clean, debride and sometimes surgically alter the wound. If not, sepsis results. Trauma Medicine 001. Are you prepared to do surgery, no matter how "minor"*, in someone's kitchen or the back of your van? If things get dicey, do you want to explain to the family that "Well, I thought we had it under control, then we decided it realy needed to go to the hospital" (note the substitute use of "we" for "I", and "it" for "your loved one").
"Field EMS" is a means of forestalling death, pain and disablity until definitve (meaning the reasonable best you have) care is possible. This is not counting mobile medical treatment in time of war out in the outback somewhere; you are not Hawkeye and Trapper John, you are not Marcus Welby, you are Johnny and Roy/Squad 51. Drop the "single combat with death" bit and concentrate on what the pt needs, nt what we want to do.

(My bosses once declared they were "going to set up an E.R." at our facility. I said "Great! Where will be lay out the xray, lab, ICU and operating departments?". End of discussion).

The entire discussion of "definitve care", "snatch and run", and "why can't I suture in the field?" are prim examples of why EBM (i.e., "science") is necesary.

http://www.medicine.ox.ac.uk/bandolier/

*"Minor" means it is happening to you, not me.


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## Outbac1 (Jan 24, 2010)

Veneficus said:


> I agree with what you have said here, but I think it is not a good example of what can or should be accomplished with a more extended scope of EMS practice.
> 
> I think the overall goal should not be to add on more procedures providers are performing, but to make sure that somebody who calls is directed to the proper resources.
> 
> ...



  I must admit this is a scenario I am not familiar with. Here in my little corner of Canada you don't pay for ER or Hospital services. Some hospitals in the province have Paramedics working the ER. They do all the triage, and about 90% of the suturing and casting. Inbetween the triage and tx the Dr. assesses the laceration, decides on the tx for it. Cleaning, plastics, antibiotic and follow up. Then leaves to attend another pt. The paramedic then follows the Drs. orders. This frees up the Dr. to see more pts. The pt goes home without an ER bill. Depending on their insurance or gov't coverage they may have to pay all or part of the antibiotic prescription.


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## VentMedic (Jan 24, 2010)

It's great to talk about the future of U.S. EMS as having an expanded scope but what about the immediate future? What can be done to improve QC/QA outcomes or to even get agencies to take monitoring their Paramedics seriously? Those that do are still being pulled down by those who don't. It will be difficult for just a few good agencies and Paramedics to change all of EMS in this country. We've already seen this over the past few decades. I do find it disturbing that we now have "fly cars" with well trained Paramedics doing what many Paramedics at one time had been capable of doing such as intubation, RSI, determining the correct hospital and giving a few medications that are not used everyday. What is being bragged upon as new really is doing what the Paramedic is supposed to be doing. We've also had community service models that existed back into the 80s but fell to the wayside because the majority of Paramedics in those agencies did not want to work clinics or make house calls. Many signed up for the Paramedic program because of prehospital emergency medicine. If they wanted to work clinics and make house calls they could have become an RN or even an LVN which would have been just a couple more months of training than the Paramedic. 

EMS must first define itself as to what role it will go with in Emergency Medicine, read the literature and do well in adapting to changes. If they believe strongly in something then they must provide their own evidence that it makes a difference. I seriously doubt if we will hear from Seattle or many of the flight teams that ETI is useless in the field but most will not leave base without alternatives either. It's not about making something obsolete but about finding the best resources to save time, perform safely and get the best patient outcomes. If your agency can not find a way to prove ETI makes a difference because your track record is not up to par with those that can, you either improve or find an alternative that still produces good results. 

The same goes for other simple concepts such as IVs. Are the IOs being used first in some areas because of a loss of skill in starting peripheral IVs?

How about 12-Lead ECGs? I recently linked to the AHA survey that there are still many agencies that do not have the capability of doing 12-Lead ECGs. Yet the data is out there that this is important and it has been around since the 80s proving itself. Here is the link again and it states only half of EMS agencies have 12-Leads ECGs on 75% of their trucks.

http://americanheart.mediaroom.com/index.php?s=43&item=677

What about all the medications? 30 meds and even less in a few states are are not always enough. What can be done to show that EMS is ready for the meds that are shown effective in the literature?

Let's take CPAP as another example. It has been around for well over 60 years and has been well studied. There has been technology being used on transport by specialty and flight teams since 1980. Very user friendly equipment has been around well over 10 years for ambulances. Yet, there are still agencies that have not embraced it. 

And, we still have many parts of the U.S. that relies only on BLS and there are EMTs that do not want any change to come to their community. The old BLS vs ALS mentality must leave EMS since you should be educated and trained well enough to recognize when to do something and not to do something. It shouldn't be "BLS has always been good enough" since that statement is not appropriate for all and does the community a disservice. Part of the controversy of EBM in EMS has been "we've always done it like that". However, if you can not convince a few people including those who are involved in EMS that the few skills of the Paramedic are important, how are you going to convince anyone that expanding the scope of the Paramedic is a good idea at this time. It would take years to get up to speed with the education requirements and then petition for reimbursement for your services. Look at the NP and the PA. Their education standard is now at Masters and Doctorate with achieving true physician extender status. The Paramedic in no where near that. With bar now at the NP and PA level, why should the public want anything less since both the NP and PA are still way less than MD? Do we want the public to keep settling for less as they do with BLS only EMS in some areas? 

The NP and PA already have their community models in action but still must have very strong national and state organizations making their presence known for the right bills to be passed. EMS still does not have a strong national voice with every state and EMS agency having its own agenda. Only the strongest will come out with the funds and reimbursement. Right now the FDs are getting EMS because of national, state and local tax reform. EMS as a whole in the U.S. is still struggling for a true definition of what they do, since it varies from one side of the street to the next, and without it there may be little choice but to place it with the FD which has an identity. 

EMS must first show it has what it takes to make the most of the EBM out there to improve outcomes in their own profession right now. EMS must achieve some unity to have a voice for education in a positive way. EMS must stop protecting the low denominators and making excuses for them. The level of EMT should also not be determining the future decisions for the Paramedic.

Getting grand ideas of becoming a true Physician Extender is not going change what is happening right now in EMS. If the Paramedic can not make the best of what they already have to show positive outcomes then why even consider expanding to a scope when the Paramedic is still a long way off from achieving a basic educational standard for what they do now.

Look at the NP and PA.

NP

http://www.aanp.org/AANPCMS2

NP Research and that doesn't include all the articles that have been published for their EBM.
http://www.aanp.org/AANPCMS2/ResearchEducation

PA

http://www.aapa.org/

Emergency Medicine PAs
http://www.sempa.org/

Post grad PA programs
http://www.appap.org/

Look at the doctors now in home health.

Academy of Home Care Physicians
http://www.aahcp.org/

examples of companies:

http://www.physicianshousecalls.com/

http://www.mobiledoctors.com/

http://www.doctorinthefamily.com/

Now what has EMS done in comparison to move forward with the NPs and PAs as well as all the other health care professionals already involved in home and community health?   A handful of EMS programs that are making house calls as welfare checks but not really setting a standard for overall education and training requirements are not enough.


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## VentMedic (Jan 24, 2010)

Let's add on a couple more associations that involve health care professionals trying to make a difference.   They are involved in getting funding for the patients who can not afford health care. 

Case Managers
http://www.cmsa.org/

Social Workers
http://www.socialworkers.org/

Public Health
http://www.apha.org/

In the U.S., funding will still have to be provided to put Paramedics into home health and there will still have to be proof that the Paramedic is qualified for government and tax funding to perform additional skills.  Right now petitioning for reimbursement by "professional" status is still foreign to the Paramedic in the U.S.    You can argue that the Paramedic can do it cheaper but isn't it also a goal to raise the Paramedic to a professional level?  Is cheaper care always the best care if standards that already exist are sacrificed when it comes to the patients?   But then again, the FD is keeping and taking over more EMS agencies for a reason here in the U.S.


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## Veneficus (Jan 24, 2010)

Vent,

I am of the mind that the politicians and ultimately the public will start lowering what is being paid as reimbursement for both medicare/medicade as well as tax levies due to the new financial realities. 

Basically, the system will crash and when it does, is when the opportunity to change things will come. 

When it does there will be an opportunity to make EMS what it could be. I encourage people to get an education before that happens so they are not one of the minimally trained providers holding the bag. 

If what is being paid to healthcare facilities and doctors is on the chopping block, how much time before the current "BLS and "ALS" reimbursement is cut?

Without bias, how many fire departments will want to be involved in EMS when it is no longer a revenue stream?

How many private services will still be in business if the current funding levels decrease even 10%?

I agree with all you said in your post. But to add a bit, I think EMS has lost the ability to decide what its own future will be. Change will be decided for it. If I was a nurse or PA I would be beating down the doors in DC showing how superior my education and services I could provide would be. I would start legislating that a RN or PA be the minimum to provide prehospital care and demand just compensation and demonstrate savings with home health and prevention as opposed to just response. 

Love 'em or hate 'em they have positioned themselves to be what EMS could have been. All they have to do is reach out and take it.


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## VentMedic (Jan 24, 2010)

Veneficus,

I agree.  *ALL* the other allied health care professions have positioned themselves through education.  Physicial Therapy is a leader in and out of the hospital for their services with well documented data that shows they make a difference in the long run for cost effectiveness and patient care even though that are expensive.   OT and SLP are right there with them.  Respiratory Therapists have introduced a Bill to expand their services in the clinics and home care which includes a Bachelors minimum with Masters preferred to provide these services.  They knew a mere two year degree would be laughed at before the Bill was even being presented.   Public Health nurses including those involved in school nursing recognize they must require a Bachelors degree.  Even the Athletic Trainer established worth many years ago by establishing a Bachelors degree minimum and working under standing orders and directives of a referral base with a medical director.  

As far as the FDs, some are taking on the responsibility of EMS for the wrong reasons or without wanting it but find they must in order to keep funds coming in at a minimum to prevent cuts to the FD itself.   Health care districts that may operate some hospitals are feeling the pinch as are those who are involved in trauma districts.  Combine that with state tax EMS and Fire district reform, you have the public paying an impressive tax bill.    The hospitals themselves are lobbying to keep clinics open to relieve their stress of the patients in their ED who would normally go to government funded clinics.   We have or had these services already in place and they did work well but with funding cuts, they are vanishishing. Why reinvent something that will take years to come about and has still to prove what differences can be made especially if there are no diagnostic or prescribing privileges associated with it?    I do know the other health professions found it was better to ally with a profession that is established with a strong lobbying body to combine resources for common goals for patient care than to go off on their own.   Right now EMS still functions on its own island.


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## Veneficus (Jan 24, 2010)

*Not sure what you question is?*



VentMedic said:


> As far as the FDs, some are taking on the responsibility of EMS for the wrong reasons or without wanting it but find they must in order to keep funds coming in at a minimum to prevent cuts to the FD itself.   Health care districts that may operate some hospitals are feeling the pinch as are those who are involved in trauma districts.  Combine that with state tax EMS and Fire district reform, you have the public paying an impressive tax bill.    The hospitals themselves are lobbying to keep clinics open to relieve their stress of the patients in their ED who would normally go to government funded clinics.   We have or had these services already in place and they did work well but with funding cuts, they are vanishishing. Why reinvent something that will take years to come about and has still to prove what differences can be made especially if there are no diagnostic or prescribing privileges associated with it?.



But let me give it a go.

I was not advocating that anyone who doesn't have prescriptive powers would get them. 

I do not advocate that medics or RNs run around as an independant provider. 

What my point is specifically is that some form of out of the hospital provider needs to be more involved with publichealth, keeping people out of the ED when an ED is not the best resource, and as a consequence of that making sure the patient gets to the proper resource.

I have heard of only a handful of EMS agencies in the US that can make alternative transport decisions. In the past I worked for an EMS agency that could deny transport, but not transport to an urgent care clinic. (personally I think that is madness) 

Urgent cares, community clinics, and all the other resources that exist are great. But people need to be directed to the proper ones. Somebody needs to help people navigate the system. 

A prehospital provider doesn't have to be an expert at it, all they have to do is know who to call when and for what. A think RNs in particular are well suited for this. 

If i could impose my will, I envision a system where a nurse and possibly a driver come in to work in the morning with a schedule of patients to look in on. A few units in reserve to handle emergencies. 

Making sure somebody went to a doctors appointment, dialysis, is taking care of themselves, prescriptions refilled, and contacting the resources like "dial a rides," PCP, etc. Interfacility as well as 911 response would be part of the responsibility also.

The educated providers are there. The resources destinations are there. Help navigating the system as well as preventive services are not. It is far cheaper to make sure somebody's furosimide prescription is filled than to treat them in crisis through the ICU stay. 

Making sure people understand when and how to take their prescriptions and are doing so, including not taking discontinued ones I don't think is asking a lot. I don't think making sure some elderly person is put in touch with social services to arrange a "meals on wheels" program before a crisis is asking too much of today's providers. Nor is making providing transport to a doctor's office or taking blood at the home and sending to a lab to check warfarin levels on a home bound person outrageous. Considering as you said the "money being spent," and an aging population not familiar with the complexities of the modern healthcare system, I think these types of services are required in order to not have the ED be the primary safety net. 

I understand that is a significant change in mentaility as well as shifting of function from primary response to primary prevention. But the system we have now isn't working. There are access problems, tremendous resource waste, and economically cannot continue. Even if congress votes not to cut payments to anyone from current levels healthcare costs even at today's levels are financially unsustainable. How do you plan on addressing that by continuing what is being done now?

I just don't understand the point you are trying to make.


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## Jon (Jan 24, 2010)

JPINFV said:


> The key with OPALS is sperating the trauma portion from the medical portion. Heck, I can post a study that shows that transport by POV saves more lives than BLS ambulance in trauma patients.


Philadelphia PD is part of such a study. Shooting patients that enter the ED via the back of a PD van have a higher survival rate than folks that come in with ALS care.
Philly PD has a habit of scooping and running with the sickest, and anytime they are impatiently waiting for EMS to arrive.

More and more, trauma is being shown to be a BLS  or NO LS game.


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## JPINFV (Jan 24, 2010)

How did PD van compare to an EMT-Basic ambulance? That's my contention with the "trauma=BLS" argument. It isn't "trauma=BLS" it's "trauma=time." Just because something doesn't validate paramedics doesn't mean it automatically validates basics. In the case of trauma, it could very well mean that no prehospital care short of transport and bystander first aid matters.


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## rhan101277 (Jan 24, 2010)

Maybe EBM will change protocols, but with the 911 system embedded in everyone's mind, it will never go away.  Paramedics will always be needed regardless of how dumbed down the protocols get.  Many medics go to schools that aren't even accredited, which accreditation isn't required now but will be soon.  I think some of these medics makes good medics look bad.  Low quality education = low quality medic = maybe everything needs to be EBM.

Here is MS. paramedics can decide whether or not to spend time at the scene doing cervical spine precautions and backboarding.  If its bad just get them in, try to get an IV in 2 minutes or less, if not just go and control what you can.

I can usually start one in 30 seconds with supplies ready.


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## VentMedic (Jan 24, 2010)

Veneficus said:


> But let me give it a go.
> 
> I was not advocating that anyone who doesn't have prescriptive powers would get them.
> 
> ...


 
My question was not necessarily addressed at you but rather to point out that home health is complex and if we just add another "provider" to the mix with limited abilities that must still be supported from some funds, then we haven't really found a solution. Even for places like Wake County that have a fly car, they must fund that extra Paramedic and provide the individual cars as well as all the insurance and upkeep. The same for FDs and EMS agencies that do welfare checks with their ambulances and expensive Fire Trucks. The extra mileage and maintenance adds up.

To say the system now isn't working is relative to the magnitude of the problem. For those who are in the system or who had been in the system before the cut backs, it did work or EMS and the EDs would literally be swamped more than they are. You would be amazed at how many people are being taken care of outside of the hospital without requiring any EMS involvement at all. 



> Making sure somebody went to a doctors appointment, dialysis, is taking care of themselves, prescriptions refilled, and contacting the resources like "dial a rides," PCP, etc. Interfacility as well as 911 response would be part of the responsibility also.


 
We do have people that see these needs are met in the form of case managers and social workers. To add another provider to the mix who can not really fill out the paper work or spend hours connecting the services may just add confusion and duplication. However that is not to say EMS agencies can not contact Social Services to get people into the system. I approached that subject on another forum and was bashed for even suggesting such a thing because EMS is not in the hand holding or social work business.

Right now Paramedic programs across the country can not even agree on prerequisites like A&P or Pharmacology at a college level. The other things that would have to be included for the Paramedic to be effective in home health would be identifying the patient's ability to care for oneself, support systems, recent lifestyle changes,more indepth geriatric and pediatric medicine, psychosocial issues and long term care. Even some critical care medicine should be involved especially with the technology that is now in the home care situations. We still have members in EMS that have yet to be educated about the many types of venous access devices, IV pumps, pegs, the many different trachs or airway devices and all the technology attached to them. 

Thus, it will take years of preparation to get the Paramedic to assume an extensive role in something other than an emergency medicine focus which still has to be perfected as well.


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## lsetzer (Jan 24, 2010)

EMS will always exist in one form or another regardless.  I think the question you need to ask is: Will evidence based medicine kill EMS as we know it?

And I think the answer to that question is: yes, absolutly.


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## Veneficus (Jan 24, 2010)

VentMedic said:


> Thus, it will take years of preparation to get the Paramedic to assume an extensive role in something other than an emergency medicine focus which still has to be perfected as well.



Which is exactly why as more and more time passes with the lack on EMS interest, I think the ole best filled by a nurse.

With a BSN many already have the education and qualities you cited.

there is a limited amount of physician house calls, and I understand that it is slowly growing. But I do not see house calls becoming wide spread.

I understand the amount of people being taken care of outside the hospital. I also understand how the care of indigent populations work. (or doesn't rather) 

I am not particularly worried about the people with outstanding insurance or the ability to pay, I am cocerned with the 25-60% of the population (depending on whose numbers you like) that the system doesn't work for. It is those people that are in need of the safety net that the ED has become. As the population ages, that need by anyones account will only grow. 

I don't think you would doubt that the ED is not capable of handling chronically ill patients as a primary provider.

Maybe down in Florida the demands are met by the resources, but across the nation particularly in "old world" economy states. The system is woefully inadequete. It is absolutely outrageous that things like this need to be provided across the country.

http://www.ramusa.org/projects/reach.html


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## VentMedic (Jan 24, 2010)

Jon said:


> Philadelphia PD is part of such a study. Shooting patients that enter the ED via the back of a PD van have a higher survival rate than folks that come in with ALS care.
> Philly PD has a habit of scooping and running with the sickest, and anytime they are impatiently waiting for EMS to arrive.
> 
> More and more, trauma is being shown to be a BLS or NO LS game.


 
So do we cater EMS to only those who are going to be shot? The majority of EMS calls still involve the medical side. BLS education in the U.S. does not prepare one for to adequately decide how serious or o treat the emergent medial patient. It doesn't really qualify them to do routine ITF transports.

The OPALS study for trauma is difficult to use as a comparison in the U.S. since the length of education for the BLS providers in that part of Canada is longer than the U.S. Paramedic. Thus, what other countries may term as "BLS" may actually surpass ALS in the U.S.


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## triemal04 (Jan 24, 2010)

Veneficus said:


> What my point is specifically is that some form of out of the hospital provider needs to be more involved with publichealth, keeping people out of the ED when an ED is not the best resource, and as a consequence of that making sure the patient gets to the proper resource.
> 
> <snip>
> 
> ...


I don't disagree with any of that, it'd be a good program and it has been done before, and I think is still being done in some areas; DC of all places had something similar for a time, and San Francisco had a similar program that focused on the homeless, though I think that was a privately funded deal.

The problem that comes up though, is where does the money to fund this come from?  If it was a municipal service that does it you could argue that various departments (fire, PD, sanitation, etc etc) could cut out the waste from their budgets, but, contrary to what many people think, (and I know there are exceptions on both sides) there isn't that much monetary waste, especially with how many city services are cutting their budgets due to lack of funds.  The next logical spot would be from insurance, but I'd bet that the majority of people that this type of program would be targeting would not have insurance, and would be either relying on private pay, or medicare.  And given that medicare is cutting reimbursement rates...that's an issue.  Of course, higher education should bring about higher rates of return, but again...if payments are cut no matter what, the money just won't be there.

I don't disagree that things need to change and that this wouldn't be a good way to go...but like a lot of the problems we have, the solutions will cost, and that cost has to come from somewhere, AND be factored into making the decision to change.


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## VentMedic (Jan 24, 2010)

triemal04 said:


> and San Francisco had a similar program that focused on the homeless, though I think that was a privately funded deal.


 
San Francisco has a couple different programs both of which are provided by the city. 

One is "Healthy San Francisco" which provides affordable health care to the uninsured who are enrolled in the plan.

The other is for the homeless which is "Care not Cash" which was created out of a Proposition voted in by the citizens of SF a few years ago.

The primary goal of "Care Not Cash" is to reduce homelessness and improve the health and welfare of homeless indigent adults receiving cash assistance through permanent housing opportunities and enhanced services. 

The funding for "Care Not Cash" has also allowed for the creation of a Behavioral Health Roving Team. The goal of the Behavioral Health Roving Team is to provide medical and behavioral health services to tenants living in the Single Room Occupancy Housing Program in order to stabilize them in housing and avoid future episodes of homelessness. The case management part of the team is supervised by UCSF/City-Wide Case Management and consists of two Clinical Supervisors, five social workers and a substance abuse specialist. The medical part of the team is comprised of a psychiatrist and two nurse practitioners employed and supervised by the Department of Public Health. 

However, the City of SF is in the same financial mess as the State of CA with the future of many programs offered by Human Services Agency of SF in jeopardy.


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## Veneficus (Jan 24, 2010)

There are only two options to fund it. 

1. Local Tax
2. increased federal funds (most likely wth a tax increase)

As painful as it is, if you want programs, you have to pay for them. 

At one point I suggested that the current local EMS providers be given funds directly from health and human services with an increase in their budget federally. But that solution was not well received. Even if it was there would likely be a tax increase. 

Its not that I want a tax increase, but I am a bit of a realist. The entire structure of the US is failing. From bridges to schools, to healthcare. We have the lowest tax rate of any western country. If we want things like roads and services, we will simply have to pay the cost. If not, then we can't have it. 

I agree there simply is not that much local waste. I also think that federal waste is exceedingly hard to reduce.

I also understand that many people are opposed to paying more. Especially people who really are just making it now. But particularly in healthcare, if you want it to be a value you'll have to pay.

The US has ong dropped education from its list of values. If you cannot afford it you cannot have it. It hasn't worked out very well.

When a nation becomes if you can't pay you can't have it, what you get is an India or Pakistan. What charming conditions those are.


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## Veneficus (Jan 24, 2010)

Maybe this thread should have been split a few pages back 

alas, I do not have the power.


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## VentMedic (Jan 24, 2010)

Veneficus said:


> Maybe this thread should have been split a few pages back


 

Maybe, maybe not...

As the financial environment changes, EMS agencies both Public and Private may be held more accountable and the need to review EBM for implimentation will become more obvious to meet the needs of the community and the standards of the insurers.


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## triemal04 (Jan 24, 2010)

Veneficus said:


> There are only two options to fund it.
> 
> 1. Local Tax
> 2. increased federal funds (most likely wth a tax increase)
> ...


That's true, but good luck getting the masses to actually believe that.  (and good luck cutting out enough gov't monetary waste which should really be done first)  

Unfortunately, the system that has been in place for...well...the majority of the time this country has been a country is what people are used to.  Getting people to change an ingrained behavior, especially if it's something they think is one of their "rights" would be a battle of epic proportions.


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## Outbac1 (Jan 24, 2010)

To raise taxes to pay for things is not always the solution. We pay more taxes here (both income and sales tax) and still gripe about our roads, services and healthcare. 

 However taxes pay for our provincial healthcare which includes Emergency Health Services. Our EHS bill is about $85 million per year. This includes all ground ambulances, a dispatch center and a helicopter. We have a little under a million people in an area about the size of West Virginia. This works out to under a $100.00 per person per year. 

  I'm curious, does anyone know how much is spent in your state per person per year for similar services? This may be a hard figure to get as you need to include both government spending and the cost of privately operated services. Any thoughts as to how our model would translate to a larger geographical area and larger population?  One of us is getting a better deal for our money, but which one??


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## EMTinNEPA (Jan 25, 2010)

I got into this conversation a little late, so forgive me if I'm rehashing anything...

First off, why is there a separation between BLS and ALS?  Medicine is medicine is medicine.  Any EMT who thinks that ALS is useless or that "EMTs save paramedics" need to be put in their place, and any medic that forgets the basics needs to go to EMT school again.

Second off, as has already been stated, the are situations where pre-hospital ALS can have a dramatic effect on patient outcome... STEMIs, CHF, flash pulmonary edema, SVT, rapid a-fib, sepsis, significant trauma, stroke, GI bleeds, and so on and so forth.  Any study advocating "Scoop and run", especially in rural systems where you may be 30 minutes from the closest hospital or even 45 minutes from the closest appropriately equipped hospital isn't worth the paper it's printed on or the ink used to print fallacy after misleading statement.

Third off, protocols are meant to be a guideline, not a cookbook.  It's up to you whether you treat the patient based on the protocol or treat the patient based on their presentation while keeping the protocol buried in the back of your mind.  Do you want to be a robot or a healthcare professional?

I fully advocate evidence-based medicine.  Change is definitely needed in EMS in the US... screw MAST trousers, give me blood or something...


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## Jeffrey_169 (Jan 25, 2010)

EMTinNEPA said:


> I got into this conversation a little late, so forgive me if I'm rehashing anything...
> 
> First off, why is there a separation between BLS and ALS?  Medicine is medicine is medicine.  Any EMT who thinks that ALS is useless or that "EMTs save paramedics" need to be put in their place, and any medic that forgets the basics needs to go to EMT school again.
> 
> ...



I agree. As a rural volunteer IO know all too the well the value of ALS and BLS. We don't need to revert, but we do need more education. 

Alos, I agree we should treat the pt., not the machines, the textbooks, or the protocols.


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## Veneficus (Jan 25, 2010)

triemal04 said:


> That's true, but good luck getting the masses to actually believe that.  (and good luck cutting out enough gov't monetary waste which should really be done first)
> 
> Unfortunately, the system that has been in place for...well...the majority of the time this country has been a country is what people are used to.  Getting people to change an ingrained behavior, especially if it's something they think is one of their "rights" would be a battle of epic proportions.



That is exactly why I am glad I don't have to be the one to fight that battle. 

I think basic economics will bring about the change irregardless of how people feel, what they are used to, or what they believe they are entitled to.


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