# How can we improve EMS



## rchristi (Nov 21, 2008)

I am putting this out as a question since I have seen a lot more posts about what is wrong with the way things are presently being done than posts about what we would like to do to improve things.
      My hope is for this to focus on positive steps we can urge upon our leaders and state organizations. Bashing each other is a great way to be stuck with the status quo.
      An example that comes to mind would be to create a level of provider that would be attainable and supportable at a volunteer level, but with enough education and training to provide basic medical interventions without having to resort to multiple level of upgrades or as is being done in my home state, routine variances. I would love to hear from some of you who have these upgrades as to which ones you think are most valuable to your patients.
      Along those same lines, do we need a national system that eliminates the patchwork of certificates and training based on state and county rules.
       What is the best way to ensure that individuals who choose EMS as a profession are fairly and adequately compensated.
        Again, I would like to keep this positive and focused on improvements.
   Thanks


----------



## BLSBoy (Nov 21, 2008)

I shall expand upon it later, but for now

MORE Education
LESS Volunteers.


----------



## Ridryder911 (Nov 21, 2008)

rchristi said:


> An example that comes to mind would be to create a level of provider that would be attainable and supportable at a volunteer level, but with enough education and training to provide basic medical interventions without having to resort to multiple level of upgrades or as is being done in my home state, routine variances


 = Oxymoron 

1). It's simple. Abolish EMT level except to the first responder agency level. NO EMT's are allowed on EMS units except for EVO responsibility. 


2.) Get involved in local, State, Federal organizations that have lobbyist to present bills for EMS legislation and funding bills. 

Otherwise shooting the B.S. on forums and debating is just that B.S.! 

Either be part of the solution or part of the problem, you can't be in the middle. 

R/r 911


----------



## Foxbat (Nov 21, 2008)

Statewide or countywide EMS systems may be helpful by "spreading" the costs of operation so poor areas may afford to have paid staff 24/7 (athough I have a suspicion that then state/county may decide to close, say, rural station that covers 50 mi^2 and runs like 100 calls a year; and then ETAs will become even worse than they were with staff responding from theit homes).

I do not see volunteerism per se as evil; volunteer services that staff their stations 24/7 or combination departments that utilize both paid and volunteer staff should continue to operate as such.

As of EMTs, I think there is a place for them as a secondary caregiver; Israel, for example, uses volunteer _hovshim_ (roughly analog of EMT-Bs) as extra pairs of hands in an ambulance, while paramedic or physician is a primary caregiver. Russia uses (or at least used, until the funding became a problem) _sanitars_ (~nurses aides?) on ambulances to assist a physician or a _feldsher_ (~paramedic).


----------



## rchristi (Nov 23, 2008)

Ridryder911 said:


> = Oxymoron
> 
> 1). It's simple. Abolish EMT level except to the first responder agency level. NO EMT's are allowed on EMS units except for EVO responsibility.
> 
> ...



So the solution is to scrap most of what we presently have and start over?
It sounds like we have a lot of work ahead of us to get the money from whatever sources are available.


----------



## Ridryder911 (Nov 23, 2008)

rchristi said:


> So the solution is to scrap most of what we presently have and start over?
> It sounds like we have a lot of work ahead of us to get the money from whatever sources are available.




Let's look at it logical.. alike what Dr. Phils says_.."Is what your doing working?"...._

Its very apparent what we are doing is *NOT* working. How freaking embarrassing is it that so many places in the U.S. still does not have ALS. Now, really think about it. The old show _"Emergency_" could deliver more advanced care thirty four years ago, than what  is delivered in a lot of the U.S. today! 

Anyone else see a problem with that? 

R/r 911


----------



## gicts (Nov 24, 2008)

Ridryder911 said:


> Let's look at it logical.. alike what Dr. Phils says_.."Is what your doing working?"...._
> 
> Its very apparent what we are doing is *NOT* working. How freaking embarrassing is it that so many places in the U.S. still does not have ALS. Now, really think about it. The old show _"Emergency_" could deliver more advanced care thirty four years ago, than what  is delivered in a lot of the U.S. today!
> 
> ...



Do you believe private services should do away with EMTS as well? 
Though a noob, I agree partially. There should be a big motivation or regulations to complete ALS skills. Perhaps something along the lines of after a reasonable time as an EMT if you don't advance your edu, you are cut to part time to focus on studies? :unsure:


----------



## Ridryder911 (Nov 24, 2008)

Even where I am private services have Paramedics. The only reason to continue for Basic Level in EMS is costs factors not patient care. Unfortunately, the EMT curriculum is not strong enough to provide more than just the initial care. 

Nothing wrong for first responder type services using them but for transport and continuation of care a Paramedic should at least evaluate. 

R/r 911


----------



## mycrofft (Nov 24, 2008)

*Good approach and question. I'm sort of doing this at my work.*

How about EMT's for medi-van and basic convo and other ground level non-superemergency jobs? And stairstep paramedic up from EMT. Go back to the original two tier system (EMT-A, EMT-P). Upgrade basic first aid and first responder training, but stop using them where EMT-A or EMT-P would be better for the public.

Places like Cherry County Nebraska and other heavily rural areas will still need homegrown volunteer units, but state level licensing and funding needs to be "looked at" where professional and volunteer interface, or there is an adequate econmic base to support professional ALS....(then try to hire people to work there!!). 

I've said elesewhere here that most often an EMT can do where a paramedic is called. However,  if paramedics are not used they become unavailable, and they are indispensible if they fit into the EMS plan. 

Another wrinkle comes to mind: the extinction of local and rural clinics and little hospitals, not to men tion the paucity of med school grads who will work anywhere but LA, NYC, Chicago, Miami, or Dallas/FortWorth.


----------



## emtlady76877 (Nov 24, 2008)

I agree with rydrider that the they do need to go als because I volunteer for one while I'm going to school,as an emt-b & the first thing we do if we have anything that amounts to anything is call for the the paramedics from the next town.Which helps me because then I get to go with them as a paramedic student.


----------



## FFMedic1911 (Nov 24, 2008)

First make all ems fire based.No make it all third service.Wait I mean private.Sorry couldn't resist.I think the first thing we could do is have a national protocol that we all follow so we are on the same page.


----------



## JPINFV (Nov 24, 2008)

mycrofft said:


> How about EMT's for medi-van and basic convo and other ground level non-superemergency jobs?




What about them? The EMT-B is still a poor education base for non-emergent jobs. There isn't enough focus on proper body mechanics, geriatric medical care and too much emphasis on "if it's not normal, haul butt to the hospital" (which is completely the wrong mindset when dealing with patients that have multiple chronic diseases and disorders).


----------



## Ridryder911 (Nov 24, 2008)

FFMedic1911 said:


> First make all ems fire based.No make it all third service.Wait I mean private.Sorry couldn't resist.I think the first thing we could do is have a national protocol that we all follow so we are on the same page.



Although it sounds like it would be a good idea, in reality it would suck. Seriously, do you think that the medics of New York protocols should be those of in Montana? I may have a transport time of 50 minutes or more and next time maybe 15 minutes. My treatment and procedures are definitely different dependent on the case and where I am. 

I personally like the least number of pages of protocols. I will no longer will work for a service with more than 20 pages of protocols. Medicine is medicine and not everything should have be covered as a protocol. We should develop *standards of care* that is nationally standardized i.e. splinting, check for pms, suctioning, oxygen administration in other words generally most of all basic material, and probably over half of the advanced level as well. Do we really need a protocol to place oxygen or in fact when to establish an IV? When there are national standards in place. 

The same reason I am totally against any State having statewide protocols. They have left the medical director and their local community out of the loop. What might be needed in one community may not be needed or may needed more in another. 

Something to think about....

The first requirement to change within EMS is professional standards. The ability to demonstrate one can read and write and have at least high school science level. Then all advanced level *license* (not certification) has to be a graduate of an accredited college degree program.

R/r 911


----------



## BossyCow (Nov 24, 2008)

One of the deal breakers for ALS is the 24/7 availability. A lot of rural agencies respond to less than 200 calls a year. You can't pay for 24/7 availability at a wage high enough to keep the personnel from quitting to get a 'good job' and stay solvent.


----------



## Ridryder911 (Nov 24, 2008)

BossyCow said:


> One of the deal breakers for ALS is the 24/7 availability. A lot of rural agencies respond to less than 200 calls a year. You can't pay for 24/7 availability at a wage high enough to keep the personnel from quitting to get a 'good job' and stay solvent.



What about regionalization? I believe alike hospitals, communities will soon learn to keep any type of provider they will have to regional and combine services alike everyone else in the health care industry. 

I know we are looking at the same thing. We are now covering areas that are up to 40 miles away (not normally in our coverage area) with a substation. Water rates have increased $9.00 a month to pay for a Paramedic unit to be there. We have lost over 40 EMS services within the past five years and prediction is we will loose almost that much within the next year. So regionalization is not just talk but will have to be a way for the future. Not all communities will get to have their own EMS. 

R/r911


----------



## BossyCow (Nov 24, 2008)

Ridryder911 said:


> What about regionalization? I believe alike hospitals, communities will soon learn to keep any type of provider they will have to regional and combine services alike everyone else in the health care industry.
> 
> I know we are looking at the same thing. We are now covering areas that are up to 40 miles away (not normally in our coverage area) with a substation. Water rates have increased $9.00 a month to pay for a Paramedic unit to be there. We have lost over 40 EMS services within the past five years and prediction is we will loose almost that much within the next year. So regionalization is not just talk but will have to be a way for the future. Not all communities will get to have their own EMS.
> 
> R/r911



And who staffs the substation? 24/7? Most of our citizens are on private wells, so no infrastructure there to tap. Our latest levy attempt failed so property taxes are out. The nearest agency just drastically reduced its service/coverage area dropping from ALS to BLS and the privates can't make a profit so they aren't interested.


----------



## rchristi (Nov 24, 2008)

BossyCow said:


> And who staffs the substation? 24/7? Most of our citizens are on private wells, so no infrastructure there to tap. Our latest levy attempt failed so property taxes are out. The nearest agency just drastically reduced its service/coverage area dropping from ALS to BLS and the privates can't make a profit so they aren't interested.



So what things could be done that would help your service and others like it to provide better patient care and outcomes? I understand how hard to operate on a shoestring budget.  From what I have read in your posts, you have a lot of experience and are really committed to EMS in rural settings. I would like to hear how you would change things. Thanks for all you add to this discussion


----------



## BossyCow (Nov 24, 2008)

rchristi said:


> So what things could be done that would help your service and others like it to provide better patient care and outcomes? I understand how hard to operate on a shoestring budget.  From what I have read in your posts, you have a lot of experience and are really committed to EMS in rural settings. I would like to hear how you would change things. Thanks for all you add to this discussion



We figured that the main stumbling block is the awareness of the public to the problem. Since our department has always been extremely press shy, no one was aware of what we did and how. We have started to change that with more public education. We do presentations at the local Grange, we teach classes at the high school and we are planning a program of community education classes on both first aid and fire prevention. 

We hope by getting more of the public into the building, and familiar with the personnel its a stepping stone to more awareness of what kind of work we do on how little money. We hope to increase our volunteer participation and maybe even eventually pass a levy!


----------



## rchristi (Nov 25, 2008)

Ridryder911 said:


> Even where I am private services have Paramedics. The only reason to continue for Basic Level in EMS is costs factors not patient care. Unfortunately, the EMT curriculum is not strong enough to provide more than just the initial care.
> 
> Nothing wrong for first responder type services using them but for transport and continuation of care a Paramedic should at least evaluate.
> 
> R/r 911



      My concern with a solely Paramedic EMS would be the risk creating a system where getting people certified as Paramedics for the least cost would become a competitive advantage. The numbers crunchers in both the public and private sectors tend to be less concerned with quality than with bottom line cost.
      I am not saying that this is an unworkable plan, I do feel that it would require close attention to accreditation and testing to keep the Paramedic standard of care high.
      I would also suggest that the EMT Basic curriculum should be strengthened. I realize that NREMT has changes in the works, but will they be sufficient? Even after a long absence from EMS I thought I was presented with very little more information in my EMT-B class than I had in my First Responder class back in the late 80s. I would still like to elicit suggestions from this group as to whether EMT can be made strong enough to make a difference in care offered and outcomes achieved. If this is not possible then maybe it is a dinosaur whose time has passed.


----------



## FFMedic1911 (Nov 25, 2008)

Ridryder911 said:


> Although it sounds like it would be a good idea, in reality it would suck. Seriously, do you think that the medics of New York protocols should be those of in Montana? I may have a transport time of 50 minutes or more and next time maybe 15 minutes. My treatment and procedures are definitely different dependent on the case and where I am.
> 
> I personally like the least number of pages of protocols. I will no longer will work for a service with more than 20 pages of protocols. Medicine is medicine and not everything should have be covered as a protocol. We should develop *standards of care* that is nationally standardized i.e. splinting, check for pms, suctioning, oxygen administration in other words generally most of all basic material, and probably over half of the advanced level as well. Do we really need a protocol to place oxygen or in fact when to establish an IV? When there are national standards in place.
> 
> ...



That is what i was getting at.Thanks for placing it in that context.Much better worded.


----------



## BossyCow (Nov 25, 2008)

My concern with federal regs is that we go to the lowest common denominator as far as standards are concerned. I do not anticipate the feds setting a standard at the level highest in all states, but rather setting the bar a bit lower.


----------



## Ridryder911 (Nov 25, 2008)

Personally, I would love adopting Canada's system. They took our ideas and grew where we regressed. 

R/r 911


----------



## KEVD18 (Nov 25, 2008)

gee....another paid v. volley, als v. bls, fire v. private v. third and lets not forget urban v. rural debate. thrilling..........


----------



## VentMedic (Nov 26, 2008)

KEVD18 said:


> gee....another paid v. volley, als v. bls, fire v. private v. third and lets not forget urban v. rural debate. thrilling..........


 
This thread has mentioned some thought provoking points and there has not been intended to be an us against them attack. 

I agree with Rid's comments especially about the Canadian system and BossyCow makes a good arguement for it being easier said than done in some areas.


----------



## BossyCow (Nov 26, 2008)

KEVD18 said:


> gee....another paid v. volley, als v. bls, fire v. private v. third and lets not forget urban v. rural debate. thrilling..........



Probably the only post which contributed nothing to the discussion.


----------



## bstone (Nov 26, 2008)

Ridryder911 said:


> Personally, I would love adopting Canada's system. They took our ideas and grew where we regressed.
> 
> R/r 911



Can you explain their system?


----------



## KEVD18 (Nov 26, 2008)

bstone said:


> Can you explain their system?



http://en.wikipedia.org/wiki/Paramedics_in_Canada


----------



## traumateam1 (Nov 27, 2008)

bstone said:


> Can you explain their system?



lol! Nooooo. No we can't. (haha sorry, just not a very big fan of BC's system)


----------



## Ridryder911 (Nov 27, 2008)

traumateam1 said:


> lol! Nooooo. No we can't. (haha sorry, just not a very big fan of BC's system)



Come down South and you would really hate it....

R/r 911


----------



## rchristi (Nov 28, 2008)

It looks to me as though the Canadian government is much more involved in the funding of EMS. The question then becomes one of trading autonomy for secure funding. This may be oversimplifying the situation, but it does look that way from afar.
At the same time, I do like the level of training that Canada requires even at their most basic level.


----------



## John E (Nov 28, 2008)

*What good is autonomy...*

if you're training people to the lowest possible common denominator and pts. suffer accordingly?

John E.


----------



## mycrofft (Nov 29, 2008)

*Good points even the uncomfortable ones.*

Can we even define OUR "system"?


Maybe we need to look at this from another angle:

1. What is the problem? Describe it.

2. What is the history and current situation? Use hard figures such as _per capita_ descriptions of outcomes, types of calls, survival, accidents, costs, _etc_.

3. Does #2 support #1? If so, go to #4. If not, take a break.

4. What are our _outcome_ goals? Express them in quantifiable terms addressing the problem definition. Brainstorm first. Don't get caught in means/goals (i.e., your goal is "Over 90% of witnessed arrest cases will reach the hospital with viable blood pressure and pulse", not "Over 90% will get there with an IV" or "Line the current bunch of nincompoops against the wall").

5. Then how do we affect the situation (#1, #2) to effect change? (Ok, NOW, line your nincompoops against the wall).


----------



## emtlady76877 (Nov 29, 2008)

In my opinion some of these volunteer groups need to wake up & realize that they need to run paramedics on their trucks even if they have to pay them. I am not trying to step on anybodies toes by saying this I am a volunteer basic & a paramedic student. However, I think they need to realize things have changed & change with them. We need to use paramedics & pay them & for them to be able to use the paramedic drugs when they need to. If the volunteer organizations are going to act professional then let them be professional & not a mickey mouse club.


----------



## ffemt8978 (Nov 29, 2008)

emtlady76877 said:


> In my opinion some of these volunteer groups need to wake up & realize that they need to run paramedics on their trucks even if they have to pay them. I am not trying to step on anybodies toes by saying this I am a volunteer basic & a paramedic student. However, I think they need to realize things have changed & change with them. We need to use paramedics & pay them & for them to be able to use the paramedic drugs when they need to. If the volunteer organizations are going to act professional then let them be professional & not a mickey mouse club.



Are you willing to pay for it, because somebody has to?  Take my area, for example.  We cover 240 sq. miles of remote desert (nearest hospital is an hour away in any direction), with a population of about 2000 tax paying residents.  In addition, we probably have another 2000 or so non-tax paying people in our area.  On average, we run 300-400 EMS calls a year.

So lets look at this.  To provide 24/7 ALS coverage, we would need to hire a minimum of 3 full time and one part time paramedic.  At a low end wage of $20,000/yr that would be in excess of $60,000 just for wages.  This does not include the part timer's salary, benefits, or equipment and drugs to make them a true ALS unit.  So let's say it would cost our dept. $100,000/year for everything.  Divided amongst our 2000 tax paying residents, that would be an additional $50/year on their taxes.  That is a tough sell around here for a department that averages one call per day especially if you consider that over 75% of our calls come from those 2000 non-tax paying residents.  Add the fact that we run 3 stations, and everyone's taxes just jumped $150/year.

This does not even address the issue of skills maintenance.  How proficient are you going to remain with your ALS skills if you average 1 call a day?

I agree that we need to progress towards a medic on every rig, but making blanket statements like yours and calling vollie agencies mickey mouse clubs does nothing to further your arguement.


----------



## BLSBoy (Nov 29, 2008)

ffemt8978 said:


> I agree that we need to progress towards a medic on every rig, but making blanket statements like yours and calling vollie agencies mickey mouse clubs does nothing to further your arguement.



Grab stick, remove from rectum. 

I do believe that she made the statement regarding Mickey Mouse type agencies.

In situations such as yours, making a FT career ALS agency is very had to justify. However, there are TICKS in my area of the country that take jobs away, recall Medics because they are paid, and drive like assclowns to get to a job, just cause they can.


----------



## ffemt8978 (Nov 29, 2008)

BLSBoy said:


> Grab stick, remove from rectum.
> 
> I do believe that she made the statement regarding Mickey Mouse type agencies.
> 
> In situations such as yours, making a FT career ALS agency is very had to justify. However, there are TICKS in my area of the country that take jobs away, recall Medics because they are paid, and drive like assclowns to get to a job, just cause they can.



Done, now where would you like me to put it?  

Maybe I misunderstood her post, and for that I apologize.  However, my point remains.  Making generalized and blanket statements does nothing to further the argument because there is always an exception, and a lot of times they are wrong to start with.


----------



## BLSBoy (Nov 29, 2008)

Well, its rather chilly out, so chop it up for firewood!B)

I do respect vollies if they are in it for the right reasons.....to serve the community, and help their fellow man in a time of need. 

However, it had been my first hand experience, that that is, for the most part, not the case, and that is one of the reasons why I have little to no respect for volunteers, at least in my state. 


Not to mention that the First Grade Council has kept NJ EMS in the dark ages....<_<


----------



## John E (Nov 29, 2008)

*Another mistake...*

this time it's thinking that the only way to pay for remote/rural ALS is strictly thru the taxes of those served.

It's like schools being funded by local property taxes, why? Cause that's the way we've always done it? Rubbish. Education benefits the entire community/county/state/country, let all who benefit fund it.

Why not set up a system whereby the state funds EMS for the entire population of the state? Why should those who live in rural areas suffer from a lack of health care when it is in our power to change? Why do we have to do things county by county? Answer, we don't but we always have and god forbid we broach the idea of spreading the cost of EMS/health care around. "Looks like socialism to me..."

John E.


----------



## mycrofft (Nov 29, 2008)

*There are hidden and high costs missed here by many...insurance, and employee benefit*

Insuring a medical practice and the vehicles which run for it is not cheap, and there will be a number of suits annually, so figure that in as well. Plus employees don't just need a paid job, they need time off, sick leave, insurance, malpractice coverage (see above). What would the cost of an employee turnover be in advertising/recruiting, orientation, etc?,


----------



## ffemt8978 (Nov 29, 2008)

John E said:


> this time it's thinking that the only way to pay for remote/rural ALS is strictly thru the taxes of those served.
> 
> It's like schools being funded by local property taxes, why? Cause that's the way we've always done it? Rubbish. Education benefits the entire community/county/state/country, let all who benefit fund it.
> 
> ...



While you may be able to spread the costs around the rest of the state, how do you distribute the funding fairly?  The agencies that run the most calls and have the most overhead (i.e. the more populated areas) are going to need a larger percentage of that money to maintain their operations.  And where do you think the state would get it's money to pay for this?  TAXES.

As to your county by county comment, we can't even get statewide protocols because all of our medical directors have their own county wide protocols.  The reason for this is simple...what works and is appropriate in, say, Seattle is not always appropriate for here due to transport times and receiving facility capabilities.


----------



## Ridryder911 (Nov 29, 2008)

It can be and is done throughout many areas of the country and international. It is dependent upon how important EMS is to the community. There is ad valorem taxes that can be added to land, tag taxes that can be added specific to EMS, cigarette/liquor (sin tax) that can be specific. 

It takes interest, it takes hard work, and legislation. Something that most EMT's do not want to work upon; rather they have someone else do it for them. Then when there is no funding, no respect, no benefits or longevity we wonder why?

We are now suffering to cover for communities that do not have or inadequate EMS increasing the costs for those that do provide. In other words services similar to mine having to cover communities that do not have (because they cannot afford). This is a new heated debate. 

Our State EMS has decided that the "nearest" EMS _must_ respond. In other words one unit may have to respond frequently to a community 30-50 miles away, although that may cause the primary area to be without coverage and as well the local community responsible for funding the EMS. So what does one do? Not respond, or keep responding to communities and areas where they are not in the original district and do not offer funding? I

So here is the dilemma: Not to answer to cries for help or for a community be responsible to provide care for another? Then why should a community ever think of supporting EMS if another will do it for them?


----------



## Medic9 (Nov 30, 2008)

I agree with everything you have posted. I had most of that written earlier today but I was logged out ???? and couldn't post. Another thing EMS needs is to be recognized like Fire and Police. Ya know the Hero factor. People don't think about EMS being in the same catagory, most have a vague idea of what we do. When I am taking a pt to another facility and they ask about my job and I tell them the training involved and the conditions we encounter they are amazed. 
Someone said to keep the training at a minimum for volunteers. No, we need to keep our skills sharp and continue our training. We are professionals and should be able to give the best pre-hospital treatment possible. 
Knocking on our goverment official's doors asking for their help is alot of work but grass roots movements can get the ball rolling!


----------



## John E (Dec 1, 2008)

*There's nothing wrong with...*

taxes. As someone famous once said, and I paraphrase, "taxes are the costs to live in a civilised society".

As for protocols changing from county to county, all it takes is the will to make it work instead of an acceptance of mediocrity. Never said it would be easy, nothing worth attaining is easy to come by.

Again and again one hears arguments about why things won't work almost exclusively based on the fact that it hasn't been tried in the past. That's not just faulty logic, it's horrible public policy. "It won't work cause we just know it won't work" is a stupid way to go thru life.

Regardless of the logistical issues, the simple facts are the same, people need emergency medical care no matter where they live. Saying that we can't provide it because of where they live or what their tax base is, is an acceptance of mediocrity as the norm. All one need do is ask oneself, do I accept being mediocre in what I do and extend that to public policy. If the answer is yes, I do accept being mediocre, then get out of EMS and go find something else to do with your life where living life at the bottom is more acceptable.

John E.


----------



## medic5740 (Dec 1, 2008)

*You CAN make it happen*

If you are patient enough, if you want it enough, you can make EMS happen almost anywhere.  Twenty years ago, this island off the coast of the mainland by 32 miles of water decided that the medical provider needed some help.  It took twenty years of hard work to go from a basic life support ambulance that was worn out to a brand new ambulance with advanced life support.  The difference between not having any EMS and ALS service would not have been possible without dedicated people who wanted to make it happen.  It just doesn't get any more rural than this community.  The year round population is under 450 people, yet demonstrating the positive effects of having this EMS service in the community has been the reason it has progressed.

Yes, we have geographical constraints, much longer transport times, and are quite used to being with our patients for hours, not minutes.  Yes, we know the national scope of practice is important for a baseline to be established, but we also know that a patient with a pulseless limb, and fourteen hours of waiting time before the weather allows transport, needs to have this issue resolved.  Any set of protocols or scope of practice are general guidelines and not the laws of Moses engraved in stone.  Every situation in EMS requires a thinking EMS provider whose talents are known and trusted by the medical control physician.  Will you find shoulder relocation in the national scope of practice for the paramedic?  Probably not, but rural paramedics have been entrusted to accomplish this type of task while in full radio contact with a medical control physician.  

This type of trust of paramedics will not happen without many, many positive clinical experiences with the same physician, but it can and will happen with dedicated, willing EMS providers.  Do I want to relocate shoulders or straighten grossly deformed, pulseless limbs every day?  No, but I will do what is necessary to help the patients in my community under the direct orders of a medical control physician.


----------

