# What is it a paramedic does?



## firetender (Jan 21, 2010)

(This was part of another thread, was probably a bit off-topic, so I figured it'd be a good thing to put it at the center of its own bulls-eye!)

Depending on the call area, the paramedic has different percentages of emergency, non-emergency, evaluation of medical status, routine transport, critical calls, trauma, basic intervention, triage and on and on. Every area is different, but only in the proportions.

In some areas, it appears all about serious medical cases. In others, mostly about the horizontal taxi game. But regardless, in MOST areas a disproportionate amount of calls involve providing the kinds of reassurance or medical guidance that the people once had available to them through connections with relatives, the family doctor, or extended families who provided folk wisdom and intervention.

It's not their fault; medical care has been institutionalized and human beings are dispensed drugs when what their humanness calls out for is connection. Our society has relegated the burden of care for the sick and injured to a cadre of professionals where once the burdens were more evenly spread out amongst the citizenry as a whole. 

Ambulance personnel are at the bottom of the food chain, getting eaten up by the assault of desperate people seeking help for what ails them, NOT by those needing emergency treatment.

What is not being acknowledged is that more and more, the ambulance delivers the hope of human compassion and technical skill to someone's scene of unbearable stress.

In reality, rather than being a Specialist, the paramedic is called on to be a Generalist who sometimes uses his/her specialist skills. The bottom line is paramedics deal with people in distress who do not have access to, cannot afford, or are not aware of other options in meeting their (perceived) immediate health care needs. As a sideline, sometimes medics intervene in serious medical emergencies.

The educational, technical, emotional, spiritual, interpersonal, moral and philosophical territory a medic must traverse is far more broad than is covered in manuals of emergency care.

_*It is my position that if the field is going to develop as a profession, it is going to have to broaden its perspective of itself and base it on reality. It is not and never has been strictly about the delivery of emergency medical care in much the same way as Nursing was never about bedpans. *_

In the real world it involves mastery of multiple modes of communication; extensive observation; multi-level discernments (where does this person best belong?), tact, diplomacy, and, if the job is to be done right, extensive knowledge of available local resources.

In an ideal world, the ambulance would be a triage unit, arriving at the scene and handling any immediate emergencies while mobilizing back-up services to follow, like EMT transport, social services evaluation teams, or psychiatric referral. As the EMS system stands, there are few services supporting IT; paramedics are flying without a net and then end up feeling guilty and somewhat ineffectual because most of the time, there are few whom they can really help.

*WHY NOT TRAIN PARAMEDICS TO ACTUALLY HELP THE PEOPLE THEY SERVE?*

So in looking over what I just wrote I'd have to conclude paramedics need to broaden their perspectives of themselves and the role they play in this society. They need to design a curricula for themselves that honestly prepares them for the reality, not the fantasy, of the job. 

That means legitimization through a degree program (Read it and weep!) and that means a longer commitment to the profession. EMS is predominately a relatively young, transient's profession because it prepares its practitioners for only one-tenth of what they do. 

Any hiring authority will tell you it is accepted that burnout is the major cause of medics leaving the field. It is a numbers game designed to keep fresh meat coming in.

Of course it is accepted as such, it's designed that way. If there will be change it's got to come from the personnel that can actually understand the role they really play in our society.


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## Veneficus (Jan 21, 2010)

I have been trying to champion that idea for years, nobody in the US wants to hear it except Skip Kirkwood. (who probably came up with the idea long before me) 

I would like to discuss ideas on how to realistically make this happen.


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## ExpatMedic0 (Jan 21, 2010)

Does anyone else feel a lot of the time its almost like your an actor? I feel like the mere presence of someone in a uniform with any medical training reassures people and often times the presence and right choice of words is all thats needed.

I do a lot of event stand by at sporting events. When I run out onto the field when someone does not get back up, I do what I am suppose to and check pulse, motor, sensation, pupils, get a GCS ect ect Most of the time I feel like its just a show for everyone .I often just have the athlete give a thumbs up so everyone knows there ok.

But that little presence and just going threw the motions turns people FROM screaming "MEDIC!", crying, and the whole crowd freaking out, into everything is ok... but nothing was really ever wrong.


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## firetender (Jan 21, 2010)

schulz said:


> Does anyone else feel a lot of the time its almost like your an actor? I feel like the mere presence of someone in a uniform with any medical training reassures people and often times the presence and right choice of words is all thats needed.



Taking it to its most basic level, we represent to people that, even though death will overcome us all, somebody's trying to do something! We preside over many more deaths than we prevent.


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## firecoins (Jan 22, 2010)

after several years of training in sense memory, i do feel like an actor.


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## Melclin (Jan 22, 2010)

I feel that we are moving towards that sort of model here. Small steps, but at least we're taking them.

Probably 60% of our degree doesn't have anything to with emergency medical education. Relative to some of our American counterparts, we learn a great deal about chronic social issues, mental health and ways we can be of help to our pts when they don't need anything from our bags (referral to GP, advice etc), although I'm not sure how much of it sticks in the minds of the students. Everyone still wants to get out an see "wicked road trauma".

I've spoken at length with Mr Brown about 'extended' roles for paramedics related to this issue. I think we should have some officially recognized and supported ability to refer pts to specialists, not necessarily of the strictly medical variety, but to social workers, psychologists, OT. This does however need to be significantly supported by our education, which at present it is not. 

One of my areas of interest is the management of mental health crisis, which is shamefully inadequate here. The attitude that many paramedics take to the mentally ill is equally deplorable. With any luck (if the money gods smile upon us) I will have the privilege of being involved in the development of an inter-professional education program for all health care providers in the hopes of smoothing out the cracks (differences in knowledge and attitudes to other HCPs) between different providers in regards to mental health crisis management. I think this is a good first step to providing the education necessary to allow paramedics to interact with and activate the services of many health and social care providers with respect to mental health issues.

Largely, I think the issue of extended roles will largely depend on the politics of the state services and the universities. If the dilution of the curriculum to raise pass rates in response to dwindling paramedic numbers, and other such changes continue, we will end up taking a significant backward step.


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## JPINFV (Jan 22, 2010)

Veneficus said:


> I have been trying to champion that idea for years, nobody in the US wants to hear it except Skip Kirkwood. (who probably came up with the idea long before me)
> 
> I would like to discuss ideas on how to realistically make this happen.



Chief Kirkwood is one of the more active posters on EMS Connect. To be honest, if I lived near or went to undergrad near Wake County, it would be a hard choice between medicine and EMS. It's one of the few areas where it looks like they do EMS correctly. However, making career choices based off of working at only one place is extremely dangerous.


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## claytondirk (Jan 22, 2010)

great post and made some good points but as i have herd in many of my classes a lot of people don't consider our profession as a necessity such as fire and police which any body who works in ems knows that's not true we . EMS has made a lot of progress from the old days where ambulance were actually ran by furnal homes and really did no treatment you either went to the hospital or the furnal home but now we have mobile icu's and flight teams which always has a paramedic on board. and even some special paramedics on like off shore drilling rigs are being thought to suture until more help arrives but in most places were paid bad and work long hours and that's not going to change until somebody realizes how much we really do and how much care is really given in the field


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## Veneficus (Jan 22, 2010)

claytondirk said:


> great post and made some good points but as i have herd in many of my classes a lot of *people don't consider our profession as a necessity*



Maybe because the service US provides is not what the public needs? You don't go to the fuel station to fill up on diesel and simply accept gasoline when the place doesn't have what you needed.

The idea the US needs EMS in its current form is not true. Consequently they are not willing to pay for what it is now. 



claytondirk said:


> EMS has made a lot of progress from the old days where ambulance were actually ran by furnal homes and *really did no treatment* you either went to the hospital or the furnal home but now we have mobile icu's and flight teams which always has a paramedic on board.



Many places have not changed treatment despite evidence, advances in science and medicine. Yes we have improved since funeral homes but not since the 1980s. Our major steps forward are actually more like a jump than a climb. I could type for ages on the ineffective or harmful treatments still mainstream in EMS. Who needs an ineffective or harmful medical treatment?




claytondirk said:


> and even some special paramedics on like off shore drilling rigs are being *thought to suture* until more help arrives but in most places were paid bad and work long hours and that's not going to change *until somebody realizes how much we really do and how much care is really given in the field*



How much is that exactly?

Without trying to be overly critical, measuring EMS value based on a set of skills and beating our chests with how important we are is why EMS fails.

A surgeon is not better than a primary care doc because he cuts people. A cardiologist not better than a neurologist because of the amount of caridac medications available. All of these people are equally needed that is why they are paid what they are.

In the 21st century it is education and knowledge that defines anyone's value to society. The days of earning a middle class living with a tech cert. are over. The job markets for "public safety" forces are on the chopping blocks. The US doesn't need somebody to drive people to the hospital. They need somebody to address the peoples needs.

Anyone who cannot demonstrate their value everyday is not worth paying for. The public knws this, even if they don't know exactly what EMS does.

Anyone who has been a paramedic for any length of time should recognize these needs.(not a comprehensive list by any stretch of imagination)

1.Somebody to help navigate the healthcare system. How to find a doctor, where, how to get there, what programs are available to help pay.

2. Education, when to call for help. (identifying MI for example) how various OTC meds are used for. When and who they are appropriate for.

3. Social support. Everything from psych support to finding resources for alcoholics. Welfare checks for the elderly. Making sure they are getting their medications refilled on time. 

I could go on. Just like in the hospital, most patients are not emergencies. But the service the hospital provides reflects peoples needs. Having a bunch of people sitting around waiting to help "with the big one" while people march hopelessly towards it without prior aid and intervention is just foolish. 

Every year I ask new paramedic students why they want to be paramedics. Every year they lie to me.

They tell me they want to "help people." Going to pick up the drunk for the 40th time this month helps him. Carrying the 10 bags of belongings of the homeless person on the way to the hospital helps them. Going on a lift assist so an elderly person can find comfort living their last days at home instead of an institution helps people. 

I have met very few paramedics that want to "help" people. But many who can tell me how indespensible they are.

Many fight with everything they have to avoid expanding their education and scope of responsibilities that would help people. As always the ones who are willing to go the distance find themselves moving on from EMS.


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## claytondirk (Jan 22, 2010)

I understand what your saying but most people are not going to go above and beyond to be a great pt *advocate*.and i highly doubt it will ever be that stressed in the school part of the paramedic programs because there is a lot to learn already and i guarantee the schools don't care because the more people they can run thru there program at a faster rate the more money they are going to make and that's the bottom line.


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## EMT (Jan 22, 2010)

EMT-P= ALS. Thats all their is to it.


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## Veneficus (Jan 22, 2010)

claytondirk said:


> I understand what your saying but most people are not going to go above and beyond to be a great pt *advocate*.and i highly doubt it will ever be that stressed in the school part of the paramedic programs because there is a lot to learn already and i guarantee the schools don't care because the more people they can run thru there program at a faster rate the more money they are going to make and that's the bottom line.



That looks like a straw man argument to me. 

The student decides which school they attend.
The student decides what education they are paying for.
The student decides how motivated they are to join the profession.
The student lives with the poor job prospects and pay if their education is substandard.
The student decides if they want to obtain an education in a saturated field where supply is high and demand is low. 

"educational" institutions that rush people through to make money are not ripping off patients. They are rippping off students. It is the student with the power to stop this practice.

The solution is simple, don't give these places any money.Demand a proper education both in depth and length. 

The purpose of educational institutions is not to get people to pass their certification test. The purpose is to give people the knowledge and skills needed to perform a function in society.

It is society that determines your value, not your certifications, morals, values, or hero fantasies. 

I could certify you to be omnipotent and omniscient but clearly that certification would not confer upon you such abilities. There are many certified paramedics without the knowledge or ability to be of value to society. That is not the fault of the school. It is the fault of the student.

If your school teaches you that "patient advocacy" is merely a behavior, that teaching what consumers want or need from you takes up too much time, or that it is your skills that matter most. I would demand my money back. In fact I would sue them for it back if need be.

If there is too much to know in too little time, it is the student that has the power and responsibility to demand more time.


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## MrBrown (Jan 22, 2010)

People call an ambulance for help, not necessarily an ambulance.  All that is provided seems to be an ambulance.

The ambo of the future needs be a public or mental health nurse/paramedic/social worker/GP.

Words like "prehospital", "emergency" and "life support" need to stop being used.

Total intergration is required here; no more take people to the hospital but rather help people get to the right people for help and/or care.  That might mean putting somebody in the car and dropping them off at a community care centre with thier broken arm or Rx'ing somebody some panadol and using thier tablet PC to make an appointment with the pts GP after entering in some notes thier doctor can see into the system.

After that thier next job might be a cardiac arrest or an anaphylaxis, then they might have lunch and go to check on somebody who thier computer tells them they went to two days and missed a doctor's appointment that was made for them at that time.

A model of care such as this has no place for traditional advanced life support and demands a radical shift in education to a ~70/30 balance between assessment and management of patients with a small emphasis on emergency care rather than the sort of 90/10 mix we have now in favour of emergency care.


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## Veneficus (Jan 22, 2010)

MrBrown said:


> People call an ambulance for help, not necessarily an ambulance.  All that is provided seems to be an ambulance.
> 
> The ambo of the future needs be a public or mental health nurse/paramedic/social worker/GP.
> 
> ...



You should get some kind of award for this post in fact it should be a sticky. Absolutely inspired.


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## Aidey (Jan 22, 2010)

In the US though usually our "help" is limited to transporting to the ER. Sometimes people call 911 because they don't know what else to do, and for various reasons we can't do anything but transport them to the ER, even if that isn't really what they need. 

For example, in my area a homeless person called 911 recently because he got too cold and was worried he wasn't going to stay warm enough through the night. We go and respond, and determine he isn't sick/injured, he hasn't developed hypothermia yet, he just doesn't think he can stay out all night. There were several shelters available, but all were at least a few miles away. 

This guy flat out admitted that he didn't know what else to do but call 911 and go hang out in the waiting room until morning. Now, what this guy really needed was a ride to one of the shelters, not an ambulance and the ER. The problem we ran into was that there wasn't anyone who could drive him over there. There is no system set up to handle situations like that, leaving us with transporting the patient to the ER. 

Luckily in this case one of the LEOs who wasn't doing anything gave him a ride over to the shelter, but only after a lot of grumbling and being promised coffee. It wasn't even that the LEO didn't want to help, but that technically he wasn't really supposed to be doing it in the first place. 

I agree that we need to have additional options to help patients. I'm not sure that it is going to happen anytime soon though. 

Aside from all the roadblocks within the medical community, I can see a potential problem from the patients themselves. American's have become accustomed to instant gratification. They want medication NOW. They want to feel better NOW. They don't want to wait, even if there is no reason they can't.


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## Shishkabob (Jan 22, 2010)

EMT said:


> EMT-P= ALS. Thats all their is to it.



Hmmm...


/grabs popcorn


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## Veneficus (Jan 22, 2010)

Linuss said:


> Hmmm...
> 
> 
> /grabs popcorn



I am not feeding the troll.


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## EMSLaw (Jan 22, 2010)

EMT said:


> EMT-P= ALS. Thats all their is to it.





Linuss said:


> Hmmm...
> 
> 
> /grabs popcorn



Are you grabbing *their* popcorn?  Okay, I won't go *there*.

Sorry, I didn't get much sleep last night.  I must be in a mood.


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## Smash (Jan 22, 2010)

MrBrown said:


> People call an ambulance for help, not necessarily an ambulance.  All that is provided seems to be an ambulance.
> 
> The ambo of the future needs be a public or mental health nurse/paramedic/social worker/GP.
> 
> ...



This model has already been considered and is in place in a number of places, most notably I believe in the London Ambulance Service.  Paramedics have further training in assessment, diagnosis, wound care and suturing and have limited prescribing rights as well as the ability to order further testing or refer to other providers.


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## MrBrown (Jan 22, 2010)

Smash said:


> This model has already been considered and is in place in a number of places, most notably I believe in the London Ambulance Service.  Paramedics have further training in assessment, diagnosis, wound care and suturing and have limited prescribing rights as well as the ability to order further testing or refer to other providers.



I recently had the pleasure of listening to Malcom Wollard who is a professor of paramedicine in the UK and one of five consultant (attending) level paramedics within the NHS.  

He said the Emergency Care Practitioner model in the UK had the right sort of aim but was totally and utterly flawed in its implementation and has become a joke internationally.  While it may not have all the things you describe, it should have, and that is what a system that is going to meet future demand needs.

People do not necessarily call ambo because they have a medical emergency, they call because they have an inability to cope with some sort of crisis which may be slightly medical in nature.  

Until we figure that out and implement a system to deal with it, we are going to get nowhere.


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## Melclin (Jan 22, 2010)

The extended care model is a good step, and we would do well to move in that direction here. 

The frustrating thing here is that we are actually allowed to do things like refer to a GP etc, its just that very few if any seem to bother doing it. Either they don't seem to have to the confidence in their own ability to decide on an appropriate course of action for the pt's treatment beyond our guidelines, or they simply don't want to have to put up with the possibility that a complaint is made and they have to justify their actions. Its simply easier to transport to the ED.

Eg, I went to a bloke about 60 who'd tripped over and skinned his knee the day before and his wife had convinced him to call an ambulance. He could drive, he had in fact driven home from where he tripped with no difficulty.  He was in no particular pain except some discomfort putting weight on it. There was no reason why we simply could not have said, you don't need to go to the ED with us, how about we make an appointment with your GP. But we transported with the rationale later explained to me as being that he seemed like the type to complain to the service and he (the medic, didn't wanna get yelled at). There must be a million jobs like that, that don't need to clog up the ED.


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## Veneficus (Jan 22, 2010)

Melclin said:


> The extended care model is a good step, and we would do well to move in that direction here.
> 
> The frustrating thing here is that we are actually allowed to do things like refer to a GP etc, its just that very few if any seem to bother doing it. Either they don't seem to have to the confidence in their own ability to decide on an appropriate course of action for the pt's treatment beyond our guidelines, or they simply don't want to have to put up with the possibility that a complaint is made and they have to justify their actions. Its simply easier to transport to the ED.
> 
> Eg, I went to a bloke about 60 who'd tripped over and skinned his knee the day before and his wife had convinced him to call an ambulance. He could drive, he had in fact driven home from where he tripped with no difficulty.  He was in no particular pain except some discomfort putting weight on it. There was no reason why we simply could not have said, you don't need to go to the ED with us, how about we make an appointment with your GP. But we transported with the rationale later explained to me as being that he seemed like the type to complain to the service and he (the medic, didn't wanna get yelled at). There must be a million jobs like that, that don't need to clog up the ED.



Sounds like the simple solution is for the ED to yell at you more and louder. Then it isn't the path of least resistance. 

I worked for a US service that could deny transport, we rarely did for the same reason you described.


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## Melclin (Jan 22, 2010)

I think officially recognizing the ability of a paramedic to be able to be guided in clinical decision making about minor issues of injury, illness and social care but guidelines like those published by the Westcountry Ambulance Service trust that brown put me onto a little while back, would be a good start. 

http://www.swast.nhs.uk/clinical/pdf/ECPGuidelines.pdf --I think this is it but I can't open the document on account of being capped. 

What do people think about this kind of approach being extended to all paramedics? Keeping in mind the different levels of education around the place.


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## Jeffrey_169 (Jan 22, 2010)

Veneficus said:


> I have been trying to champion that idea for years, nobody in the US wants to hear it except Skip Kirkwood. (who probably came up with the idea long before me)
> 
> I would like to discuss ideas on how to realistically make this happen.



I agree, totally. The modern EMT-P needs to diversify like the nurses did, and in reality this is will be the only way we survive as a viable and respected profession. We need to fight for more education, a higher standard of care, and and a far more diversified scope of practice. It is important for us to write our congressman and representatives and other elected and non elected officials the same way the other lobbyists do. We need to stand up and break our silence. 

We are the only ones responsible for our profession, and we need to take action to improve it.


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## MrBrown (Jan 23, 2010)

Veneficus said:


> I have been trying to champion that idea for years, nobody in the US wants to hear it except Skip Kirkwood. (who probably came up with the idea long before me)
> 
> I would like to discuss ideas on how to realistically make this happen.



Skip is a very smart man I've talked to him a few times.

The biggest problem in the US that I can see is lack of insurance, so lack of access to healthcare services.  Nations with universal healthcare do not have this problem so implementation may be much easier.

A lot of the problem could also be attritubed to inadequate education and overly laborinthien medicolegal problems as well as disparity between states in that each state will have a different standard and "nationalisiation" is a very bad word it seems in the US.

The following seems to be needed to make this plan work

- Disestablishment of BLS/ILS/ALS as it currently exists
- One new level with most focus on public health but with emergency care skills included
- Electronic linkage of patient records into a single system
- Total intergration into the public health system
- Independant rights to prescribe certian drugs and tests
- Registration of ambos as a health practitioner

I forsee a Bachelors Degree being the entry requirement for this sort of person who would have to operate with another practitioner while going through some sort of post-Degree internship to earn a Masters Degree which would enable independant practice.

Basically, if you put a PA in a 4WD with an ALS bag and MRx that is what I am proclaiming needs to be done.


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## JPINFV (Jan 23, 2010)

MrBrown said:


> The biggest problem in the US that I can see is lack of insurance, so lack of access to healthcare services.  Nations with universal healthcare do not have this problem so implementation may be much easier.



That's patently false. The difference is lack of access due to monetary reasons to lack of access due to demand outstripping supply. If you're waiting years for a procedure, there's a problem with access. If some place with more universal care (e.g. Massachusetts in the US) is considering (or implemented) a law requiring physicians to see patients on a specific insurance (small business health insurance in this case) as a condition of licensure, then there's a problem with access. Access problems don't go away just because the government decides to pay for everything while setting a price that is fair to the government. Just because you give the gas station attendant a 10 dollar bill doesn't mean you get a full tank of gas.


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## Melclin (Jan 24, 2010)

MrBrown said:


> The following seems to be needed to make this plan work
> 
> - Disestablishment of BLS/ILS/ALS as it currently exists
> - One new level with most focus on public health but with emergency care skills included
> ...



I don't know about saying "most focus on public health with emergency care skills included". I think that's going too far. Public health is largely policy and education based and it is never going to be our primary role. I think the more appropriate term is Primary care. 

I don't think is necessary of realistic to have us try to be an every-professional. This going and checking why granny smith didn't make her doctors appointment is more the domain of Royal District Nursing service or community health/social workers. I don't think we should try to become GP/District nurse/community psych workers. I think we should be streamlined EM physicians/nurses - primarily concerned with emergency medical issues but with an extensive capacity to refer to/consult with, more appropriate healthcare professionals. 

Making us an every-professional is unnecessary because professionals in the various fields already exist - we just need to learn how to refer too, and work with, them better. It will also dilute the knowledge and expertise of our specific field - Imagine spending 3 years checking on grannies and counseling smokers to quit in between RSIs.

EG: Call to granny smith who can't get out of her chair. O/S She's basically fine. Now I'm not going to spend the next few weeks with her setting goals, changing the plan of her house and adjusting chair settings - its not my field and I have other things to be doing. I would however, like to be able to activate the services of an OT who could, and to consult with her GP/national electronic health records to be able to better make a decision about whether or not I should leave her at home, have a family member come and watch her for an hour, take her to her GP or rush her to a tertiary referral center.

Removing the term emergency completely from descriptions of our profession is perhaps ill-advised - we will always maintain an emergency role. However, I very much agree with you about the term pre-hospital etc. This is why the fashionable term of choice at the moment, at Monash at least, is Community Based Emergency Health. I personally like the slightly modified Community Based Acute Health, just because it feels like it takes into account things like granny smith not being able to get up - it is an acute issue, its happening now and needs to be assessed/dealt with now, but it is not an emergency in the medical sense. 

Even with my extreme lack of experience I have already walked out of quite a few jobs thinking, we could do so much more for that person if we were simply taught how to use/provided with a system of inter-professional communication, consultation and activation, it wouldn't take up much more of our time, and our trip out here wouldn't have been time wasted.


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## Shishkabob (Jan 24, 2010)

MrBrown said:


> The biggest problem in the US that I can see is lack of insurance, so lack of access to healthcare services.  Nations with universal healthcare do not have this problem so implementation may be much easier.



Fallacy, and one that I am quite tired of seeing spewed about.  The vast majority of Americans have insurance,  so the problem cannot be associated with that.

Now, overuse and abuse?  Sure.


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## CAOX3 (Jan 24, 2010)

MrBrown said:


> People call an ambulance for help, not necessarily an ambulance.  All that is provided seems to be an ambulance.
> 
> The ambo of the future needs be a public or mental health nurse/paramedic/social worker/GP.
> 
> ...



We have community visiting nurses and social workers that handle what you described above and their already educated and their services actually get reimbursed. Why muddy the waters with the paramedic.

If you ask me it would be more cost effective to further educate them to handle the medical emergencies then it would be to re educate every paramedic and EMT.


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## Melclin (Jan 24, 2010)

I would think the 15 or so percent of Americans who don't have insurance would be more than enough to account for a lot of those problems. 

The point though is that its a lack of a single unified system and a culture of government mandated health care that make changes like universal electronic health records or shifts in standards and the roles of services such as integrating more of a primary care role into EMS, far more difficult. When you have a mess of competing services and financiers, a million ways for people to fall through the cracks, you are going to have problems keeping up with the standards of better funded, better integrated services for whom the primary goal is not profit, but better standards of care for the community.


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## MrBrown (Jan 24, 2010)

Perhaps i was a bit unclear.  As Melclin said, community based acute (or emergency) health is basically what we need.  

We should not attempt to be every professional and do away with our specific emergency skillset however it should be more balanced in favour of having specific ability to be first point of contact out there in the community when called, sort of like a super triage system.

Let's immagine say somebody calls up at 1am coz thier nana has been sick for a week but waited until now to ring up.  Rather than sending two ambo's in a flash truck with all the bells and whistles to pop her on the gurney and take her up to ED you get a solo responder in a 4WD.  This ambo can tap into nana's electronic health care record on his tablet PC and see she has a history as long as my arm but nothing recent but does see her allergies and that she sometimes falls down a lot and has the falls person come over once a month to check on her.  After he does an assessment he gives her some panadol and has a cup of tea, hops back on that magic tablet PC and makes an appointment with her GP for two days later and enters in some notes.  I would also immagine with Bluetooth he can link up to the monitor and put in a 12 lead ECG too.

Case number two is somebody who has an infection in ther indwelling cathether.  Super ambo rolls up in his beasty looking 4WD and tells the eight firefighters who are on scene doing nothing to pop back to the station and watch telly, wait, never mind they didn't show up because we have more sense here (<tongue in cheek>).  He could replace the cathether, prescribe several days worth of anti-biotics and make a followup for this patient with the community health team on his tablet PC as well as enter some notes.

Case three, cardiac chest pain so super ambo is just a first responder here until the transport ambo comes along.  Nothing would change.

Case four could be a kid who broke his arm falling out a tree.  Super ambo rocks up and excludes any major internal injuries, gives the kid some methoxyflurane to suck on, splints the arm and can either put mum and kid in the car and take them to the urgent care (having told them he was coming on the cellphone) or get mum to take the kid herself, low clinical risk.

Case five might be somebody who this super ambo went to two days ago but missed thier GP appointment.  Not sure if it'd be better to have super ambo pop in and check out why or have somebody else go and do it in some other way e.g the doctors surgery giving him a phone call.

Such a system like this demands very high levels of knowledge and skill, far in advance of what I believe most ALS providers have.  That is why I said it would be inappropriate to try and build this sort of knowledge into a traditional Paramedic education as most of the focus there is on simple assessment and treatment for urgent, life threatning jobs.

I envisage something like an RN/PA/ALS hybrid would be needed and would be at least at a Bachelors level, probably a Masters degree qualification.

Something like what I immagine is being piloted by the ASNSW http://www.changechampions.com.au/resource/Katie-ODonnell.pdf


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## Melclin (Jan 24, 2010)

I believe Queensland has had an extended care program for a while too. Victoria have trialed the idea, but I don't know where its going from there.

The CARE program and ideas like it, separate to the idea of a fully fledged Extended Care Provider, is a good idea because it gives legitimacy to what we are already told we are *ALL* _supposed_ to do at uni but never seem to once we graduate.

Having a masters level program for paramedics allowing them to get all the "s**t jobs and none of the good ones" is going to present problems. 
The CARE program is a great idea because it can be rolled out to just about everyone, and its only needs to involve minimal training because it deals with clinical scenarios that we already have the education (in theory) to deal with, but for whatever reason (some mentioned in my earlier post), we are still referring to ED. The CARE training package should probably just be integrated with the degree (maybe as a compulsory follow up to the internship). Its not exactly overwhelmingly complex as it stands, and as I say you wouldn't really be adding anything, just putting a greater emphasis on certain 'minor' issues.


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## MrBrown (Jan 24, 2010)

I agree however I think we need to go beyond the education which is presently offered to much more focus on assessment and clinical decision making.

Are you taught to differentiate between the zillion possible types of abdo pain, probably not, am I, not really.  

Whatever training is included in the Extended Care scope around assessment, clinical decision making and referral options should really be part of the core ambo degree.


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## Jeffrey_169 (Jan 24, 2010)

Originally Posted by claytondirk  View Post
I understand what you’re saying but most people are not going to go above and beyond to be a great pt advocate and I highly doubt it will ever be that stressed in the school part of the paramedic programs because there is a lot to learn already and I guarantee the schools don't care because the more people they can run thru their program at a faster rate the more money they are going to make and that's the bottom line.

First off I would like to state if the paramedic is not willing to go the extra mile for pt advocacy, then perhaps another occupational selection should be considered. 

Paramedics and EMT's do far more then "scope of practice" entails, at least in my experience. I cannot speak for paid services, as I have never been paid (this is NOT an argument of paid vs. volunteer, I just don't want to speak out of turn), but as a volunteer I have responded to everything from a pt. assist from falling, to the older and/ or disabled who are simply lonely and need someone to talk to. Patient advocacy is not always as cut and dry as some might like to think, but it is important and pivotal to what we do. I have never refused to be a counselor, a friend, an ear, or a rescuer to anyone who calls, and I have never had the displeasure of knowing someone who has. As medics we are often second only to the dispatcher who sends us of who the public relates and judges the entire system by. I agree, we do need more medics and EMT's who are willing to do what is best for the patient, even if it is only for the lonely person who has no family, and is lonely. Loneliness is a killer of our old, and when we lose them we lose our history and our experience. 

I would like to say also pt. advocacy, common sense, and compassion are not something which can be taught in a simple 2 year degree program. You either care about people or you don't. I have been told emotional reactions are not conducive to the professional, and to this I strongly disagree. Caring and compassion are direct results of emotional responses, and we as medics need to understand this. There are far too many of us who feel emotions have no place in what we do and anyone who thinks a patient can't sense our biases need to strongly reconsider their position. 

When I went to my first EMT class several years ago I was taught if you have biases and you are not willing to stand up and do what is best for your patient, ALL of them, then you are in the wrong class. I have ben to several classes and seminars sense, and there too this is/ was strongly emphasized. 

People come into this profession with a Hollywood mentality, and this is another cause of our issues. As someone else already stated, we are the liaison between the care the patient and definitive care, whether it be social, psychiatric/ psychological, medical, or surgical; if we are to provide the proper and necessary interventions we need to be more educated in multiple disciplines. It has been proven in several studies all around the world the psychology plays a major role in the health of a people; sunlight exposure, diet, exercise, etc. also play a major role in both treatment and preventive care. Most medics, and therefore EMTs do not get a proper education on the ENTIRE person, and so there treatments and referrals are limited to the ER protocols.  
As the ones on the front lines of EMS we are the ones who need to press for more education, higher scope of practice, and more jurisdictions to make better decisions for our patients. No one is going to just give it to us unless we fight for it. There need to be more involvement in our own occupation from within if we are to improve our public image and our ever increasing educational demands. We need to do more, we need to be better educated,   and we needs vast improvements in our scope of practice, but it will not come unless we fight for it and receive the proper education.


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## Veneficus (Jan 24, 2010)

“You either care about people or you don't. I have been told emotional reactions are not conducive to the professional, and to this I strongly disagree.”

Emotional attachment or reactions can lead to poor judgments, missed findings and overlooked considerations. It is why Doctors do not treat family members. The emotional and sometimes physical distance helps maintain objectivity. It can also make a patient feel more comfortable at times by removing a perception of expectation, disappointment or judgment.

“Caring and compassion are direct results of emotional responses,”
I don’t agree. I care about my patients, I want do my very best to take care of them. Not because I have an emotional connection, because it is my personal value set. 

 “and we as medics need to understand this. There are far too many of us who feel emotions have no place in what we do and anyone who thinks a patient can't sense our biases need to strongly reconsider their position.”

By training yourself to remain objective and distanced, you can put aside your biases.

I always like my patients to feel they will get the very best I can provide, no matter what circumstances brought them. That they can be honest and forthcoming without my disapproval. That all are treated equally.


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## reaper (Jan 24, 2010)

Bravo my man, Bravo!


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## Jeffrey_169 (Jan 24, 2010)

Veneficus said:


> “You either care about people or you don't. I have been told emotional reactions are not conducive to the professional, and to this I strongly disagree.”
> 
> Emotional attachment or reactions can lead to poor judgments, missed findings and overlooked considerations. It is why Doctors do not treat family members. The emotional and sometimes physical distance helps maintain objectivity. It can also make a patient feel more comfortable at times by removing a perception of expectation, disappointment or judgment.
> 
> ...





reaper said:


> Bravo my man, Bravo!



Veneficus, you are someone I highly respect and admire. I have learned greatly from you in my time here on this site, and although we do not always agree, we can disagree in a respectful and professional manner. 

This is one of those times I simply cannot agree with you, but why remains a mystery. Allow me to elaborate; how can someone risk their life to save someone they have never met? How can someone take such a low paying job, in some cases no pay at all, risk their health in a variety of ways, and not care about and have some degree of concern for their patients? I understand objectivity is essential to what we do, and I understand we need to have a certain degree of distance from the ones we encounter; however, there has to be some compassion and concern for our patients if we are to perform adequately and remain in this line of work for any length of time. 

Compassion for someone is not unprofessional, nor is completely avoidable as we as a race are by nature social creatures. We are more complicated in our social stratification, but we are not unlike most other creatures in how we deal with the loss of another person. We are, as a matter of survival, social and endearing creatures. Any anthropologists will agree to this (as I am an anthropology and psychology student, as well as a biology major). 

One more point I would like to make. To say one can hide their personal biases, especially when dealing with those who already have complex issues and to those who are naturally intuitive, it can be seen. Children are especially insightful. To separate ourselves in the manner which you stated would result in us being robots, and no one wants to deal with a concrete slab as a clinician. Bed side manner is an important factor, especially when dealing with those who are lonely and disconnected. 

In my studies and experiences I have learned a great deal of the human condition. We are all people if we try to train ourselves to be robots acting upon pure academics we will not only see a lack in bed side manner, but also a much higher burn out rate as we will be expected to bottle up the grief we feel and dismiss it as simply unprofessional. It is not possible, in my opinion, to be as objective without desensitization. A certain degree of separation and objectivity is paramount, but where does one draw the line in the sand? 

I am only disagreeing because it makes no sense to me, but as I have learned about you already you have a way of explaining things that normally do. I am simply asking for more definition.


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## sdadam (Jan 25, 2010)

There are many things that we as paramedics would need to do in order to bring about change in Paramedicine as a whole. The way I see it it would take education, paramedic leadership, individual identity, public awareness, and higher pay.

Education, a BS program in Paramedicine is the only way that we have a future as anything but gurney transport technicians. Once established, state and city governments must legislate that the bachelors program is the minimum education required to work as a paramedic. Similar to the increase in scope from EMT-B to EMT-P. As long as the basic education beyond a paramedic license is a high-school diploma, or a GED no one is going to consider allowing paramedics to give medical advice, make decisions about definitive care, and act independently of medical direction. And I don't blame them.

Paramedic Leadership, this is something we do very poorly in my opinion. In most systems I encounter nurses run Paramedicine. From base hospital radios, to paramedic school director positions, to "nurse educator" positions at EMS and fire services. I understand how this happened, when EMS started there was no one to supervise it, the only logical choice was the nurses. For the past 30 years they have done a great job, but now it's time that paramedics started leading Paramedicine, there should be base hospital paramedics on the radio (after all who is in a better position to give you advice in the field, someone who has been there, or not?), paramedic directors of paramedic school, and so forth. However this will never happen unless paramedics match the educational level of nurses, the choice between a licensed paramedic with a bachelors in Paramedicine, and an RN with a two year RN program is much easier to make in favor of the paramedic.

Individual identity, If you were on duty and asked 100 people what they though you did just looking at you in uniform, what responses would you get? Here are the most common I get; Firefighter, EMT, Security Guard, Ambulance Driver, Medic or Paramedic. Do the same for a police officer, or firefighter and you don't get the same range of responses. EMS needs to cut it's ties to the fire service. I know that this is a highly debated topic, but if we want our profession to reflect the statements in this thread, it is mandatory. The fire service is incredible at what they do, and I am thankful for them, but they will never accept fire service personell spending a half an hour on scene talking to an elderly woman about the trouble she has refilling her prescription medications then another half hour making calls and finding a solution (having the freedom to help people in this way is, after all what we are talking about right? Not just the emergencies, but responding to the need of the patient whatever that may be). Paramedics must stand alone in order to grow as a profession, Paramedicine can't be the job that firefighters do when they aren't fighting fires.

Tying in to the above point the public must be educated, they must be aware of the services that paramedics provide. Educated when it is appropriate to call 911 for a paramedic and when not to. They must be presented the idea that a paramedic is a pinacle of medical knowledge and care, that whatever their problem is, a paramedic will be able to help them either directly or by setting up a plan of action which will change their circumstance. This is not the image the "Ambulance Driver" brings to mind. Though we can only tell them this if we give paramedics the education to make it true.

The last issue, and always one of the central ones is pay. Paramedics must be paid well. Paramedicine must be a profession that one can work in for a lifetime, making a good and honest living, and raising a family if they chose, not needoing to be a firefighter in order to pay their bills. However I firmly believe that like nurses, paramedic pay will not increase until two things happen. The first I have talked about at length, education. The second ties into paramedic leadership, we must unite as paramedics on a national scale, as much as I have mixed feelings about unions, a National Union of Paramedics just might do the trick.

However all of these things are closely tied together, for instance, as long as becoming a paramedic is seen as a stepping stone into the fire service, no one is going to dedicate the time to get a bachelors degree in it, so the education issue is difficult to accomplish without the individual identity, leadership is tied to education as well as stated earlier. It is a very complicated issue.

These are just my thoughts on the whole thing.


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## MrBrown (Jan 25, 2010)

sdadam said:


> Education, a BS program in Paramedicine is the only way that we have a future as anything but gurney transport technicians.



Agreed ...... but, you're preaching to the converted here mate.  

From 2012 the Bachelors Degree will be required here to be a Paramedic (super ILS ambo) and a Post Graduate Diploma will be required for Intensive Care Paramedic (ALS)



sdadam said:


> Paramedic Leadership, this is something we do very poorly in my opinion.



I agree but in some ways we need to get away form it; eg Paramedics teaching Paramedics.  While our faculty here are Paramedics they are all at Masters or PhD level.



sdadam said:


> Individual identity ... Paramedics must stand alone in order to grow as a profession, Paramedicine can't be the job that firefighters do when they aren't fighting fires.



Agreed, but again, you are preaching to the converted lol


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## Veneficus (Jan 25, 2010)

Jeffrey_169 said:


> how can someone risk their life to save someone they have never met? How can someone take such a low paying job, in some cases no pay at all, risk their health in a variety of ways, and not care about and have some degree of concern for their patients?



I nurse I know likes to say "I have empathy, not sympathy."
I think it is possible to care about people, even individuals without emotional attachment or reacting emotionally.  





Jeffrey_169 said:


> I understand objectivity is essential to what we do, and I understand we need to have a certain degree of distance from the ones we encounter; however, there has to be some compassion and concern for our patients if we are to perform adequately and remain in this line of work for any length of time.



I agree but compassion is not emotional attachment. Careers are often shortened by emotional distress. Especially carrying others emotions as your own.




Jeffrey_169 said:


> One more point I would like to make. To say one can hide their personal biases, especially when dealing with those who already have complex issues and to those who are naturally intuitive, it can be seen. Children are especially insightful. To separate ourselves in the manner which you stated would result in us being robots, and no one wants to deal with a concrete slab as a clinician. Bed side manner is an important factor, especially when dealing with those who are lonely and disconnected.



It is an acquired skill. The ability to smile, address them by name, a pat on the shoulder, the touch of a hand, making the person comfortable. addressing about non medical concerns like "how much does this cost?" "what will life be like?" "what is happening to me?" 



Jeffrey_169 said:


> In my studies and experiences I have learned a great deal of the human condition. We are all people if we try to train ourselves to be robots acting upon pure academics we will not only see a lack in bed side manner, but also a much higher burn out rate as we will be expected to bottle up the grief we feel and dismiss it as simply unprofessional. It is not possible, in my opinion, to be as objective without desensitization. A certain degree of separation and objectivity is paramount, but where does one draw the line in the sand?



A robot is not a skilled clinician. Nor is a skilled clinician a robot. However when you are called to help, whether a patient shows up to you or you go to them, as I stated before it is possible to have compassion and even empathy without personal attachment. 

The line is different with each patient. But I find starting with absolute objectivity and working towards the line to be more beneficial to both the patient and the provider than starting with connection and trying to move towards objectivity. 

It is the art of being a clinician. Bedside manner, with compassion but not emotional connection, objectivity without being cold, professional without being condescending. 

Sometimes people say "treat every patient like it was your mother." Would you ask your mother her sexual history? How many partners? Vaginal sex? Anal sex? Oral sex? Protection? What kind? Ever treated for a STD? A partner treated for an STD? Sex work? In the past? Currently? Pregnacy and deliveries may be easy. How about miscarriages and abortions?

Would you feel comfortable discussing this with your children? How about your grandmother? Would they be comfortable discussing it with you? Would they answer you honestly?

I use this example because it unnerves the most people. Some will be ok with it, most are not. But all your patients must be able to discuss these things with you. A clinician should have genuine concern for their patients, but once you get too close you lose the professional relationship. 

I guess it could be said "you can be friendly, but you cannot be friends."


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## firetender (Jan 26, 2010)

Jeffrey_169 said:


> how can someone risk their life to save someone they have never met? How can someone take such a low paying job, in some cases no pay at all, risk their health in a variety of ways, and not care about and have some degree of concern for their patients? I understand objectivity is essential to what we do, and I understand we need to have a certain degree of distance from the ones we encounter; however, there has to be some compassion and concern for our patients if we are to perform adequately and remain in this line of work for any length of time.



I would love you to take your thoughts here, tweak them a little to begin a new exploration and START A NEW THREAD, so we can give this the attention it deserves. It's a little out of context here, yet, very valuable.


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## firetender (Jan 26, 2010)

*Terrific Stuff!!!*

Responses here have been quite wise. They show lots of people understanding what they are part of. In reading them all over, however, I have a couple more things I'd like to reflect on.

Most systems of EMS, as they stand, are overburdened by people mis-using the services. Notice, _I did not say "abuse". _Once again, it's not their fault; in part because our Western medical approach has convinced us:

 * folk remedies don't work, therefore
 * connection with a relative or friend, etc. to advise/treat you is of no value
 * medical intervention begins with a drug you can buy at a store, that you've heard about through an advertisement
 * if the drug doesn't work, THEN you must seek a professional
 * professionals usually maintain Banker's hours,
 * they have a facility that you have to go to
 * want insurance or money up front
 * make you wait for attention

We have been dis-empowered as a community and trained, because economics dictate it, to go outside ourselves for medical assistance. Once we felt dis-empowered, we began to sue. That resulted in establishing a culture of "defensive medicine" which complicated treatments and limited universal access even more.

It also made each patient a puzzle to be successfully solved, rather than a human being to be responded to. Studies are showing how separation and lack of human connection appears to be at the root of most emergency room visits. People go to great extremes to get compassion. The culture of the paramedic and of emergency medicine denies this reality. This must be dealt with in order for EMS personnel to become effective.

Once medicine and medical care became an industry, people began to see they could either work around it or take advantage of its weaknesses. One of its major weaknesses is that it will send a professional to your door if you holler loud enough. The people count on the responder to be compassionate.

The most readily available "faces" of the professional medical system are Ambulance personnel. They were originally conceived as primary response units for emergency situations but evolved into primary response units for what ails you. 

*The larger SYSTEM (US) continues to nudge more and more people into the Ambulance loop. That offers their first contact with medical professionals. But it does so WITHOUT providing back up to medics so they can be freed to provide real emergency services for people in real emergencies.*

In reading these posts, and hearing how some of our compatriots in the British Empire are seeing things evolve there, I have to say I'm not all that convinced such systems as theirs will work in the US.

In terms of emergencies, I don't think we can wiggle out of sending the most qualified and specifically trained non-Physicians available -- just on liability factors alone. The "eyes and hands" of the doctor are indispensable on the scene. How long they tie themselves up on the scene, however, is something that must be controlled.

NO, I don't think an emergency paramedic should have to do the hand-holding or transporting of the non-emergent elderly, but someone should. It doesn't make sense. To get paramedics involved in that would require three times as many ambulances available, each with highly trained medics as described in the NSW system or others as identified on this thread. Tying up many more EMS personnel also lowers their exposure to emergencies, therefore reducing experience levels across the board.

The Emergency Paramedic should, however, be cross-trained well enough to quickly discern the next level of care, whether it be non-emergency transport, referral to another agency, 5150 hold, or whatever and then be able to get the next provider of care to the patient quickly while remaining available for the next call.

Based on these posts, now I'd offer a slightly different model with Two Levels:

*Level One *requires the equivalent of an Associate's Degree in Emergency Response. Training in handling physical emergencies would be to the EMT level, and beyond that would be extensive training in use of medical, psychiatric, social and community resources. The job would occasionally require transportation. The operative description would be post-stabilization referral and transport, with an emphasis on "movement" of the patient to the next appropriate level of patient care.

(As an aside, I believe EMTs can learn how to respond to patients human-to-human without losing their effectiveness. If you re-define their role to INCLUDE providing the vital human link in the healing process, THEY will find they can be more effective AND fulfilled in their jobs.)

*LEVEL TWO* builds on that knowledge to the Bachelor's Degree level, with Emergency training to the Paramedic level and an expansion of the Associate's program to promote the ability to Triage patients appropriately. The Level II Emergency Responder would primarily make the judgment call to call in Level I in the event that the call is not really an Emergency. If a true emergency, Level II should both treat AND transport.

*Perhaps we should expand the profession from the ground up, rather than the top down. The EMTs of today should be trained to be able to effectively deal with the bulk of what our calls really are: non-emergency. Entry level would be upgraded to Associate's level which still makes the profession accessible.

Paramedics should be better trained, but used appropriately so they can render and be available to offer immediate advanced emergency medical care and transportation. Other than that, their job would be to mobilize a second tier of support services.*

*Our dispatchers could be easily trained (decision-tree style) to discern whether to send Level I or Level II as first responders. Any doubt, send Level II.*

I wonder: If we were to go to the NSW system as described here in the US, wouldn't that encourage more inappropriate use of the EMS systems? Then, people would know that paramedics are there for hand holding.

When the first responder is a Level II unit (and yes, I agree, it would work best as a vital protection agency *separate *from Fire services) it sends the message *USE IN EMERGENCY ONLY!*

One way or another, the system of tomorrow is going to have to provide support for paramedics if it wants them to effectively handle real life-threatening emergencies. That support does not exist today. Rather than expect outside agencies to step up to the plate, we should better train our personnel to handle what really is.


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## Veneficus (Jan 27, 2010)

*a respectful opinion in 2 parts*

“Most systems of EMS, as they stand, are overburdened by people mis-using the services. Notice, I did not say "abuse". Once again, it's not their fault;”

I don’t think it is just because of medicine, for a long time in human existence, culture as defined in anthropology, the protection of home range resources and reproductive rights, has shifted from that of the group to that of the individual. With the loss of social support, psychological and emotional support has been lost. Community knowledge and collaboration is almost nonexistent in the US, and quickly fading in Europe. I can’t speak about the other hemisphere but I imagine it is similar. What used to be supported by communities is now supported by counseling and medications. This coupled with society’s stigma and legal ramifications, people struggling to cope have resulted in “medical care” being the only nonjudgmental help available. Moreover, there are few effective support mechanisms available unless you can pay. A bit counter intuitive as people struggling emotionally and psychologically often have already lost control of their finances or had none to begin with which led to the condition. As we discussed, the emergency system has become the safety net.

Likewise, western values of “rescue” assistance while heartwarming is extremely wasteful and ineffective.

For example, how many people gave a crap or even knew where Haiti was prior to an earthquake? How many people made every effort to supply money or aid with the fervor created by TV? This same scenario plays out every day all over the world. “Out of sight, out of mind.” How many complain about giving aid to foreign peoples offer to pray and contribute during disasters that could have been avoided had there been even a fraction of the contribution earlier. 

Especially in the US, we have lost our sense of community. “team work” “united we stand” “hang together or hang separately” are ideals lost to history. I find it ironic that a government of the people is supposed to support and provide for its people without contributions from them or as minimal contribution as one can get away with. These same people who value “helping people” then turn around and call what little there is “abuse.” More than anything they don’t want to pay another cent towards a sustainable or equitable solution. We cannot blame “medicine” for these ills.


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## Veneficus (Jan 27, 2010)

"in part because our Western medical approach has convinced us:"
(I would say culture, not medicine)

"* folk remedies don't work, therefore"

There is a whole medical specialty devoted to healthy living and practical remedies. But it is out of reach of the common mans’ ability to afford it.  A cheeseburger is a money/time  saving value than healthy food. Especially for people who need to spend more time earning income instead of preparing meals for continued survival. 

"* connection with a relative or friend, etc. to advise/treat you is of no value"

It was not medicine that destroyed these values, it was greed. (More for me without any concern for others)

"* medical intervention begins with a drug you can buy at a store, that you've heard about through an advertisement"

A tragedy for certain, but attributable to corporations with an interest, there are both legal and ethical checks to police this behavior among providers.

* if the drug doesn't work, THEN you must seek a professional"

If you can afford it. If not, you are out of luck. Then all of society will complain you are a leech when you shift from a viable producer to strictly a consumer.

"* professionals usually maintain Banker's hours,"

This I would agree is the fault of the providers. There was a time when medicine was a dedicated lifestyle. In the effort to have the prestige and money, but not the sacrifice, we have tried to have our cake and eat it too. It has cheapened provider, once a pinnacle of humanity and society, no different now than a loan shark or pimp.

"* they have a facility that you have to go to"

Unfortunately this is a product of our knowledge and technology. We simply cannot provide the level of medicine now considered acceptable in a mobile way. 

"* want insurance or money up front"

I would say this is because in America nobody feels they should pay for medicine. A perception it is a right you don’t have to pay for, from insurance companies to those considering themselves “upstanding citizens,” the purpose and value of medicine has been lost. Plus there is the problem of the cost to the provider. My debt to school alone will exceed many peoples lifetime income. The bank doesn't care about my altruism.

"* make you wait for attention"

I respectfully take issue with this statement. 
I have not met one medical provider in any country I have ever been in who made a patient wait for any reason other than lack of resources. I think this stems from a phenomenon I call “McMedicine” The idea that no matter what a patient does to themselves over however long, they will simply show up at a medical provider and order the cure off the menu to be delivered at the speed of digital media. Medicine, Western or otherwise, was never meant to work like this. I doubt it ever will. 

Many great minds have offered solutions to the resource problems. Nobody wants to fund them. From medical and nursing schools, to hospital beds, to physical therapy spots, in the US there is a gross lack of resources. 

In the US nobody wants to prevent, pay for, or wait for medicine. Modern man is extremely specialized in their knowledge. Why is there not a high school class dealing with when and what a person can do prior to calling on a professional? We can teach CPR and AEDs but cannot teach people that when you acquire an influenza infection going to the hospital hoping to get a prescription will for a bactericidal drug isn’t going to help. That you really do get pregnant when you have sex and it is not a medical emergency. The test down at the drug store is just as good as the one in the ED.  (and you do have to pay for it.)


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## ivanh3 (Feb 12, 2010)

I have to disagree with the notion of requiring a degree for medics. I wholeheartedly appreciate that there are degree options out there for medics, but to require it could decrease some patient's access to ALS response in some areas (rural, etc). I like that idea that paramedic courses are awarded college credit and could be applied towards a BS degree. With that model the public is served and EMTs are afforded the opportunity for personal and professional growth. 

In terms of what we do as a profession, for me that has always been simple. We do it all: some of it medical, some of it psychosocial, and even a wee bit of law enforcement sometimes. That is the upside of it. The downside is that our ceiling for growth is lower than other professions. Which I why I think there should at least be degree opportunities (not mandates). Having those degrees can offer other options for medics (law school, med school, research, academia, etc). 

I think the method of patient care has to be region/population/volume specific. There have been many good ideas proposed in this thread. It would be exciting to see some of the put into play.


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