# Would you like to be a Primary Care Paramedic?



## SeeNoMore (Mar 19, 2011)

While I am new to EMS, and not yet a Paramedic, it seems clear to me that the role of Paramedics, at least for the near future, will have to be totally different than it is today. 

While I think there is still a place for Paramedics in Urban Systems, I think the number of Paramedics needed will be very small, limited to highly experienced providers who can intervene in the very few situations where ALS is shown to improve patient outcomes. In addiiton I am sure there is still a place for Parmedics in inter facility and critical care transport. 

I think this will be especially true if most BLS units are able to carry and administer epi pens,CPAP,  nitro and asa for chest pain and transmit EKGs. This will require an increase in education, but I think it makes more sense that large numbers of Paramedics in any given system. 

Does an urban system need Paramedics for the vast majority of trauma calls and cardiac arrests? Do we need intubation by most Paramedics, fluid resucitation in most trauma calls, ACLS drugs etc? It seems unlikely. Unless of course RSI and artificial blood producs are shown to notably improve patient outcomes and even then, the number of Parmamedics will still be smalll. 

And so Primary Care Paramedecine is being discussed more often. But I wonder, is this something you would want to do? Especially if it means operating in mostly rural systems? I think a lot of medics are attached to the idea of being part of a urban or semi-urban system and I think the future will be tough for many providers. Personally it's not something I am interested in, and is a primary reason I plan on pursuing nursing insead of prehospital work. 

Here is an interesting link that puts together the issue well I think, sort of an overview of the death knell of paramedecine as we know it. 

http://rescuemonkey.wordpress.com/2009/04/08/do-we-need-paramedics/


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## CAOX3 (Mar 19, 2011)

CAOX3<----Gets popcorn and pulls up chair in anticipation of the fireworks.


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## SeeNoMore (Mar 19, 2011)

Actually you know what, I am really curious about how people feel about this field. Never mind the rest as most of it is in other threads. Not that i am not interested, in fact I would much prefer there to be some compelling proof to the contrary given I am about to enter the field. But there you have it. 

Simply, is this a field that appeals to you? Either the rural primary care paramedic or perhaps a type of community primary care paramedic that did not typically deal with emergent situaions. Would this work for you? Excite you? Bore you?


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## 18G (Mar 19, 2011)

I respect your position but largely disagree with your suggestions. I feel very safe in saying that there will always be a need for the Paramedic level provider. And even more so in a rural setting versus the urban one that you mention. 

Paramedics (and EMS in general) provides care. It's not measured solely by the number of lives saved. EMS triages and is the entry point for so many people into the healthcare system. 

ALS does have great effect on many patient conditions that we are called to treat. 

- Anaphylaxis
- COPD/Asthma Exacerbations
- Drug Overdoses (opiate and others)
- Head Injuries (preventing hypoxia and hypotension and triages these patients appropriately)
- Post-Resuscitation Care (hypothermia, maintaining B/P, airway control). 
- Diabetes (tx of hypo and hyper and patient education)
- Seizures (status)
- Pain Management
- Nausea & Vomiting Control
- CHF / ACS & MI
- And many more conditions.

Think of all the above conditions and take Paramedics out of the picture. The majority of the above groups will have very negative outcomes if you were to take ALS care out of the loop. 

Imagine yourself not being able to breathe due to COPD, your also dehydrated, febrile, severely hypoxic, and nauseous. Do you really want to wait 20mins or longer to get to a hospital to get relief? What can a Paramedic do you ask?

Dyspnea = beta-2 agonists and anticholinergic meds. (same as ED)
Severe Hypoxia Refractory to Meds = CPAP or intubation (same as ED).
Dehydration = fluid bolus (same as ED). 
Fever = fluids and depending on dyspnea level, acetaminophen (same as ED).
Nausea = ondansetron (same as ED)  
Underlying Pathology = Solu-Medrol (same as ED). 

The above treatments are very crucial and the earlier delivered the better. This is just one example of what we do in the field that has direct impact on patient condition and outcome. 

Your ordinary, everyday Paramedic does play a vital role in patients care and outcomes. Primary Care Paramedicine is an interesting concept and one some EMS systems have explored. Personally, I am not opposed to it and like the idea of expanded scope and dealing with patients that have chronic health problems. I am well passed the all 911, lights and sirens phase. I enjoy taking care of people and making them feel better and allowing them to live their lives as independently and deficit free as possible.


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## medicRob (Mar 19, 2011)

Paramedics in the US refuse to get with the rest of us and get a bachelors education with a proper background in the sciences, mathematics, and humanities. The last thing we need to focus on right now is giving them more skills. First, education. Then, skills.


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## 18G (Mar 19, 2011)

Agree with MedicRob. It would be many, many years before you would see a wide-spread deployment of the Primary Care Paramedic model. 

What you may see is more specific, alternate care programs being delivered by EMS. For example, DC Fire & EMS have instituted a program where they have crews that routinely check in on certain patients and help the patient in the management of their long-term care which helps avoid taxing 911 response for a non-emergency issue.


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## SeeNoMore (Mar 19, 2011)

I don't disagree overall 18g, but I think the future will see far less Paramedics in a more targeted role. I think that many paramedics will be out of a job, or new medics will have no jobs if we can not find other ways of utilizing our skill set. 

But I could not agree more about education.


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## medicRob (Mar 19, 2011)

SeeNoMore said:


> I don't disagree overall 18g, but I think the future will see far less Paramedics in a more targeted role. I think that many paramedics will be out of a job, or new medics will have no jobs if we can not find other ways of utilizing our skill set.
> 
> But I could not agree more about education.



How do you intend to bill this? Sure, you can look toward urgent care billing, but we are in a system where Paramedics are billed by mileage because they are not seen as licensed professionals by the insurance companies. The first step here would be education as well. Once you are seen as licensed professionals by the insurance companies, your services can then be billed as "Paramedic skill hours", not only opening the door to more revenue and higher salaries, but also to the possibility of urgent care billing. In our current system, if you don't transport, you get $0. 

I am doing a write up on just such a thing for EMS World Magazine where I outline several benefits of Degree versus certification programs in EMS as a whole. Skill hour billing is one of the points I make. I also speak with regard to making "Community Paramedicine" a specialty choice for 4th year BS, Paramedicine students.


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## 18G (Mar 19, 2011)

SeeNoMore said:


> I don't disagree overall 18g, but I think the future will see far less Paramedics in a more targeted role. I think that many paramedics will be out of a job, or new medics will have no jobs if we can not find other ways of utilizing our skill set.



I'm curious to hear your basis for thinking that Paramedic's will be in less demand. 

Communities will always need and desire the ALS level of care. People are not going to stop experiencing medical and traumatic emergencies. People will continue to have MI's, COPD, Seizures, hypoglycemia, crash their cars, etc. The US population has a high number of elderly and that population group is still rising. 

I would not worry about Paramedic jobs being in short supply.


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## MrBrown (Mar 19, 2011)

You mean Extended Care Paramedic, a Primary Care Paramedic is what Canada calls thier BLS person 

Brown is just going to come right out and say it, American Paramedics are way too undereducated to even have half the tricks they have now, let alone any more.


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## bigbaldguy (Mar 19, 2011)

18G said:


> I'm curious to hear your basis for thinking that Paramedic's will be in less demand.



Just to play devils advocate what about the idea that as technology advances skilled providers will be less needed or at least require less skill training? Think attach a patch and push a button, follow prompts type stuff. There was a time when a pair of shoes had to be made by hand and only a skilled craftsman could make a decent pair but these days you would be hard pressed to find a master cobbler. Just a thought.


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## medicRob (Mar 19, 2011)

18G said:


> I'm curious to hear your basis for thinking that Paramedic's will be in less demand. .



RN's getting so tired of Paramedics whining over the time it takes them to complete what little education they do have, and throwing fits about what education they need, that we take over the profession, changing CTRN from a certification to a specialty area. 

/sarcasm <-- kinda


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## SeeNoMore (Mar 19, 2011)

Well for arguments sake, I can not imagine the public has any idea by in large what Paramedics do VS EMT's. As long as someone is showing up in a lighted up truck and taking them to the hospital, well, I imagine that will be enough. 

And you could be quite right that there will no be a shortage of need for Paramedics, but perhaps there should be! It would be beyond foolish for me to match my knowledge of EMS with the majority of posters here,but I do know that every single doctor I have ever spoken with, as well as most leading EMS bloggers/writers etc all seem to agree that one of the primary problems with EMS today is the frontloading of Paramedics where EMTs will often suffice, especially if you want to coldy examine the difference in mortality based on ALS vs BLS response.


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## medicRob (Mar 19, 2011)

SeeNoMore said:


> Well for arguments sake, I can not imagine the public has any idea by in large what Paramedics do VS EMT's. As long as someone is showing up in a lighted up truck and taking them to the hospital, well, I imagine that will be enough.
> 
> And you could be quite right that there will no be a shortage of need for Paramedics, but perhaps there should be! It would be beyond foolish for me to match my knowledge of EMS with the majority of posters here,but I do know that every single doctor I have ever spoken with, as well as most leading EMS bloggers/writers etc all seem to agree that one of the primary problems with EMS today is the frontloading of Paramedics where EMTs will often suffice, especially if you want to coldy examine the difference in mortality based on ALS vs BLS response.



Veneficus and Brown, brought up a very valid point. In Western medicine, we haven't really done much for Chronic Disease sufferers other than make them comfortable or do something to take care of the symptoms, but not the underlying condition. Medicine is almost, dare I say... stunted in this area.


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## 18G (Mar 20, 2011)

SeeNoMore said:


> Well for arguments sake, I can not imagine the public has any idea by in large what Paramedics do VS EMT's. As long as someone is showing up in a lighted up truck and taking them to the hospital, well, I imagine that will be enough.
> 
> And you could be quite right that there will no be a shortage of need for Paramedics, but perhaps there should be! It would be beyond foolish for me to match my knowledge of EMS with the majority of posters here,but I do know that every single doctor I have ever spoken with, as well as most leading EMS bloggers/writers etc all seem to agree that one of the primary problems with EMS today is the frontloading of Paramedics where EMTs will often suffice, especially if you want to coldy examine the difference in mortality based on ALS vs BLS response.



I agree that the public mostly has no idea about the differences between ALS and BLS. I think if they did they would demand ALS. I strongly disagree that there should be a reduction of ALS. Paramedic should be the minimum level care provider rolling out the door on an ambulance in the US and then build from there. 

One can use research and statistics to prove their point and justify their position but decisions should not always be based on a certain statistic or single study. The Paramedic program coordinator at the school I attended (he has since passed away, RIP), worked as a researcher in infectious diseases and one statement he made was, "statistics don't lie, but liars use statistics". So true. 

Where are the statistics and research that show overall improvement rates and rates of relieving pain and suffering with ALS care? Again, EMS is not measured solely on mortality rates.

Just because a arm fracture won't kill you, should you be subjected to BLS care only in a bumpy ambulance without pain and nausea management? Since when did making people comfortable become unimportant? An EMT-Basic cannot and should not be administering narcotics. 

What about a nausea and vomiting patient? Can they be transported by BLS without any risk of increasing mortality? Of course. But what about the patient's misery. Nausea is one of the worst feelings ever. Why should people not be entitled to relief as early as possible?

Consider the timeline. N&V for a day. 911 gets called.... say 5mins to get to the house. 10-12mins on-scene. Average transport time in sub-urban/rural area about 20mins. Take patient into ED, transfer care, wait for nurse evaluation and then physician orders... depending on ED census... anywhere from 10-20mins or longer. So if BLS transported both patients from above, they would not receive pain meds or an antiemetic and IV fluids for at least an hour from the time 911 is called. That is a long time to be in pain and/or be suffering from severe nausea. Compare that to pain management in say 15mins? Big difference. 

It's not all about mortality rates. EMS provides care for the human being as a whole.


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## Goofy (Mar 20, 2011)

medicRob said:


> Paramedics in the US refuse to get with the rest of us and get a bachelors education with a proper background in the sciences, mathematics, and humanities. The last thing we need to focus on right now is giving them more skills. First, education. Then, skills.



What were you first: a paramedic or an RN?


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## medicRob (Mar 20, 2011)

goofy said:


> what were you first: A paramedic or an rn?



rn, bsn


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## Goofy (Mar 20, 2011)

medicRob said:


> rn, bsn



Cool. So why did you become a paramedic then?


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## 18G (Mar 20, 2011)

medicRob said:


> In Western medicine, we haven't really done much for Chronic Disease sufferers other than make them comfortable or do something to take care of the symptoms



If it's a chronic disease then all you can do is make patients comfortable and make them as symptom free as possible. Until cures are found what more can you do for chronic disease suffers?


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## 8jimi8 (Mar 20, 2011)

SeeNoMore said:


> While I am new to EMS, and not yet a Paramedic, it seems clear to me that the role of Paramedics, at least for the near future, will have to be totally different than it is today.
> 
> While I think there is still a place for Paramedics in Urban Systems, I think the number of Paramedics needed will be very small, limited to highly experienced providers who can intervene in the very few situations where ALS is shown to improve patient outcomes. In addiiton I am sure there is still a place for Parmedics in inter facility and critical care transport.
> 
> ...



I wonder how many people are really going to be in to these "b.s." calls that you will be treating as primary care. 

2nd If a patient needs "ALS" then they need a hospital.  Not many calls are treat and street from an EMS ALS standpoint are there?


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## bigbaldguy (Mar 20, 2011)

Another devils advocate question. Let's assume that a patient does understand the difference between ALS and BLS and is given a choice, they can ride with ALS and be comfy with lovely drugs delivered through an IV for 1400 dollars or they can ride with BLS and gut it out for an hour or so and take a 700 dollar hit. Now assuming the patient actually cared about paying the bill himself, wasn't rich, and doesn't have insurance what do you think people would choose ALS or BLS.


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## Tommerag (Mar 20, 2011)

bigbaldguy said:


> Another devils advocate question. Let's assume that a patient does understand the difference between ALS and BLS and is given a choice, they can ride with ALS and be comfy with lovely drugs delivered through an IV for 1400 dollars or they can ride with BLS and gut it out for an hour or so and take a 700 dollar hit. Now assuming the patient actually cared about paying the bill himself, wasn't rich, and doesn't have insurance what do you think people would choose ALS or BLS.



Valid point, assuming nothing changes from what it is now for transporting, the patient wouldn't get that choice. The ALS would be there and would have the higher level of training, they can't release to someone else with a lower level of care.

If that were to happen you would have to have more forms for patients to sign, to cover your rear end.


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## Veneficus (Mar 20, 2011)

18G said:


> I'm curious to hear your basis for thinking that Paramedic's will be in less demand.
> 
> Communities will always need and desire the ALS level of care. People are not going to stop experiencing medical and traumatic emergencies. People will continue to have MI's, COPD, Seizures, hypoglycemia, crash their cars, etc. The US population has a high number of elderly and that population group is still rising.
> 
> I would not worry about Paramedic jobs being in short supply.



Just to point out, why pay a paramedic $20/hour when you could pay a Basic with an extended scope $8/hour?

As for the OP. 

If I was still working as a paramedic, I would be all for this type of career description. 

MedicRob is exactly right. More education= more ability for diversification= more compelling argument for higher wages. 

I am convinced there is no need for a paramedic in an urban environment with less than 15 minute transport times. Any treatment performed short of pain releif can be done by a basic. 

Train them how to transmit a 12 lead, start an IV, and write a protocol for pain management and there is no longer any purpose for an urban paramedic.


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## medicRob (Mar 20, 2011)

Goofy said:


> Cool. So why did you become a paramedic then?



Requirement for my position in flight.


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## medicRob (Mar 20, 2011)

18G said:


> If it's a chronic disease then all you can do is make patients comfortable and make them as symptom free as possible. Until cures are found what more can you do for chronic disease suffers?



I am speaking with regard to the individuals responsible for finding cures, not EMS.


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## 18G (Mar 20, 2011)

Veneficus said:


> I am convinced there is no need for a paramedic in an urban environment with less than 15 minute transport times. Any treatment performed short of pain releif can be done by a basic.
> 
> Train them how to transmit a 12 lead, start an IV, and write a protocol for pain management and there is no longer any purpose for an urban paramedic.



You can't (or shouldn't) build an EMS system based on minimal requirements. 

And I disagree that a basic (even with an expanded scope) can replace a Paramedic in an urban environment. There are too many variables when looked at on a deeper level. Again, its a contradiction. The same people who advocate increased standards now advocate for minimal standards. Regardless of system type people need to be in the field that can handle the typical day to day calls in addition to the complex calls without using short hospital transport times as an excuse to stay minimal.

I've been involved in several EMS systems and EMT's are not suitable for giving drugs, injections, and managing a patients total care pre-hospital. It's not that they don't have the ability, it's that the EMT programs do not allow for it and are way too minimal. Even with expanded scope we all know the educational foundation is gonna be severely lacking and the focus is gonna be on skill delivery only.


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## medicRob (Mar 20, 2011)

18G said:


> You can't (or shouldn't) build an EMS system based on minimal requirements.
> 
> And I disagree that a basic (even with an expanded scope) can replace a Paramedic in an urban environment. There are too many variables when looked at on a deeper level. Again, its a contradiction. The same people who advocate increased standards now advocate for minimal standards. Regardless of system type people need to be in the field that can handle the typical day to day calls in addition to the complex calls without using short hospital transport times as an excuse to stay minimal.
> 
> I've been involved in several EMS systems and EMT's are not suitable for giving drugs, injections, and managing a patients total care pre-hospital. It's not that they don't have the ability, it's that the EMT programs do not allow for it and are way too minimal. Even with expanded scope we all know the educational foundation is gonna be severely lacking and the focus is gonna be on skill delivery only.



A basic can most certainly replace a paramedic in any environment if we up their education, send them to school for 2 years, and give them the proper training in their program + a general education. After all, people seem to forget, Paramedic is just a continuation of basic, and only a year at that. Of course we can teach that in 2 years, that is how every other paramedic is trained. 

In the perfect world, there would be: 

Paramedic (Associates), Paramedic Specialist (Bachelors), and maybe even Paramedic Practitioner (Masters). 

Paramedic would be the basic of this system, Specialist would have more education to deviate into specialty areas such as doctors offices, ICUs, ERs, Trauma Units, Community Health, etc. Paramedic practitioner would have an emphasis on research and education as well as clinical practice (continuing development of scopes of practice from evidence based findings in the literature, expanded skill set to include certificate of fitness to prescribe)

However, this will never happen til the current EMS Mindset and EMS as a whole dies. It needs rebirth, stop putting a bandaid on it and come up with a whole new system, one that emphasizes education, not skill set. Then, you have your bargaining chips for a salary  like Registered Nurses.


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## 18G (Mar 20, 2011)

medicRob said:


> A basic can most certainly replace a paramedic in any environment if we up their education, send them to school for 2 years, and give them the proper training in their program + a general education. After all, people seem to forget, Paramedic is just a continuation of basic, and only a year at that. Of course we can teach that in 2 years, that is how every other paramedic is trained.



If we send them to school for two years then they are not a Basic. 

I agree the minimum level EMS provider on an ambulance should be a two year, degreed Paramedic and then have levels on top of that. 140hrs is just not enough to serve as a primary care provider on an ambulance. Over many years I  have witnessed many EMT's and maybe one or two in almost 20yrs really knew the why behind what they were doing. In short, they were scary and I would not trust them taking care of my kids so I would not be in favor of giving them more of an arsenal to actually do harm. 

If you want to provide medical care on a professional level then it is a requirement to go to College for at least two years and put in the work. If you don't want to do that then find something else to do. 

And also along the lines of substituting urban Paramedic's with EMT's due to short transport times, then why not substitute RN's with LPN's in a hospital setting and just give them expanded scope? There are physicians present to give their orders and within arms reach so why pay an RN $30/hr when you can pay an LPN much less? It's all about standards and having people in the position that can adjust to the demand and not fizzle out when the system throws in a roadblock.


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## medicRob (Mar 20, 2011)

18G said:


> If we send them to school for two years then they are not a Basic.
> 
> I agree the minimum level EMS provider on an ambulance should be a two year, degreed Paramedic and then have levels on top of that. 140hrs is just not enough to serve as a primary care provider on an ambulance. Over many years I  have witnessed many EMT's and maybe one or two in almost 20yrs really knew the why behind what they were doing. In short, they were scary and I would not trust them taking care of my kids so I would not be in favor of giving them more of an arsenal to actually do harm.
> 
> ...



Because LPN is a technical level provider, RN is has a general education background along with an advanced skill set. EMT's are technical trades, and for the time being, so is Paramedicine.


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## Veneficus (Mar 20, 2011)

18G said:


> You can't (or shouldn't) build an EMS system based on minimal requirements.



We've been doing it for 40 years! What's changed?

Even many paramedics on this forum revolve around a skilled trade mentality. Why not just give them what they want?

The fire service, which is the largest provider of EMS in the US actually lobbies for this.   



18G said:


> And I disagree that a basic (even with an expanded scope) can replace a Paramedic in an urban environment. There are too many variables when looked at on a deeper level.



I could say the same thing about paramedics. 




18G said:


> its a contradiction. The same people who advocate increased standards now advocate for minimal standards.



I don't see it as a contradiction. I agrue that increased standards is to the benefit of all. 

If people don't want to make things better, then it is only reasonable to make the current system as efficent and inexpensive as possible. The people who pay the price will be the EMS workers who thought they would get no benefit from increased education. 

They will receive all that they wished for. In abundance. Because most are too lazy, greedy, or stubborn to look 10 years down the road is not my problem.




18G said:


> Regardless of system type people need to be in the ield that can handle the typical day to day calls in addition to the complex calls without using short hospital transport times as an excuse to stay minimal.



Why?

As EMS stands right now they cannot handle the typical day to day patient care and just bring the people to the hospital anyway.

When was the last time any EMS provider in the US administered childrens' tylenol to a kid with a fever, gave them some pedialyte and left them at home?

When was the last time a US paramedic decided somebody "just had heart burn" told them to take some antacids and left them to die of a MI?

You see the point? Starting an IV, hooking up a heart monitor, and driving every patient to the hospital whether they need it or not is just as useless as just driving them to the hospital and doing nothing. Except it is more expensive.

Overtreatment is a medical error. "What if" is just another way to say "I have no idea."

Just like the difference between "hinding" and "taking cover" one just sounds more heroic.  



18G said:


> I've been involved in several EMS systems and EMT's are not suitable for giving drugs, injections, and managing a patients total care pre-hospital.



I can also say the very same thing for many "high performance" ALS only systems. I am just too kind to name and shame them here.




18G said:


> It's not that they don't have the ability, it's that the EMT programs do not allow for it and are way too minimal. Even with expanded scope we all know the educational foundation is gonna be severely lacking and the focus is gonna be on skill delivery only.



How is this any different from the current paramedic programs?


It is not that I don't want paramedics to be more. It is not that they can't be more. They choose not to be. I can't help that. So I think since we are going on the cheap for providers and service we need to start going on the cheap what we are willing to spend for it.

I think it sucks. But it is what it is.


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## medicRob (Mar 20, 2011)

Veneficus said:


> It is not that I don't want paramedics to be more. It is not that they can't be more. They choose not to be. I can't help that.



This is the very reason I have chosen to let my EMT-P go after the next renewal cycle. I only needed it for flight, now that I have completed my Nurse Prac, I will be able to fly as an ACNP in my specific system.


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## 18G (Mar 20, 2011)

To hear a few on the forum talk one would get the impression that Paramedics and EMS in general is a sham. And that certainly is not the truth. Yes, there are areas in need of improvement as there are in all fields. Perhaps more so in EMS but you have to look at the original intention of EMS. EMS expectations and delivery has evolved. It's just unfortunate that the "smart" people who have advanced degrees and designed EMS didn't see the need to set the stage for modern day EMS by incorporating a strong educational foundation. They maintained the skills driven mentality. So again, why are the field providers getting the brunt of all the criticism when it was the so-called advanced degree smart people who caused it!

And I strongly disagree that EMS is just an expensive ride to the hospital. So your saying that our treatment of the common day to day medical ailments is useless and has no effect? Your saying we can't save a COPD patient from resp failure and give them relief? Or turn around an asthma patient? Or keep a seizure patient from arresting? Or save an anaphylaxis patient? Or extricate a patient from their vehicle and triage them to appropriate care? Or keep an MI from worsening with early ASA and triage to a PCI center in addition to pain relief? Or fixing a hypoglycemic patient that would otherwise die or have long-term neurological consequence if it wasn't for EMS? Or giving the cardiac arrest victim the best chance of survival? Or managing the patients IV drip medications, cardiac monitor, chest tube monitoring, ETT and ventilation monitoring, and hemodynamic monitoring for a safe transport during inter-facility transfer? How about triaging CVA to primary stroke centers to avoid delay of intervention? How about pre-hospital management of TBI which as shown to decrease mortality? What about the fire victim who can be treated for CO and cyanide toxicity and saved? This is stuff I do as part of my everyday job and I know other Paramedics do as well. 

The list is endless. 

Yet people want to micro-analyze and portray EMS as a sham and waste of money. BS. Take away 911 and EMS and see how many people actually die and suffer because of its lack. Perhaps someone can do a research study on that. Maybe that is what it would take for certain people to realize the necessity of modern day EMS and the role of the Paramedic. You will always have crappy EMS providers just the same as you have crappy nurses and physicians. But don't label all because of a few. There are many more great Paramedics then there are not.  

I've had many patients that have benefited greatly from the care I gave them and who would have been harmed if transported 30mins POV. If you want to advocate for change... fine... that is a great thing... but the slamming of current Paramedic care needs to stop. Improvement can always be made but that is no reason to down effective Paramedicine as it is right now. But if you are, then start with the advanced degree people (including physicians) who set all of this into motion long ago. The blame game starts there, not with the field provider .


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## Veneficus (Mar 20, 2011)

18G said:


> To hear a few on the forum talk one would get the impression that Paramedics and EMS in general is a sham.



That is exactly what I am saying. It is a sham. With its effectiveness measured by response times, "life saving" medications, and other "life saving." If it was moe than a patch to put on one's arm to show you have a few more clinical skills, I would think otherwise.



18G said:


> and that certainly is not the truth.



But what is truth?

Is truth a changing law?

We both have truths, are mine the same as yours?




18G said:


> Perhaps more so in EMS but you have to look at the original intention of EMS.



So the intentions of 50 years ago justify the attitude of a vast majority of EMS providers today?



18G said:


> EMS expectations and delivery has evolved.



As far as I can see only a few skills were added and technology has changed.



18G said:


> It's just unfortunate that the "smart" people who have advanced degrees and designed EMS didn't see the need to set the stage for modern day EMS by incorporating a strong educational foundation. They maintained the skills driven mentality. So again, why are the field providers getting the brunt of all the criticism when it was the so-called advanced degree smart people who caused it!



How many so called smart people have to tell EMS providers they need a modern education before they catch on and do it? 

Who told Nursing to do it? 

Who told other ancillary providers?

Blaming people from the 1960s for not having the ability to look into the future and see what would make a valuable EMS provider in 2011 is a very poor excuse and trying to assign blame for it on somebody other than the providers who inspite of a whole modern world demonstrating what modern EMS is, the US providers are still locked into the laborer mentality and think everyone else should do all the work and take all the responsibility for them. They even want a pay raise for their "efforts" up front. Fat Chance. 




18G said:


> And I strongly disagree that EMS is just an expensive ride to the hospital.



Really? How much does your service charge? Where are your service's studies demonstrating their medical effectiveness? Does your service even keep track of that? Nobody is going to take your word you save lives except an ignorant public.

Every other worker in any industry has to prove their worth. Why should others be required to disprove the worth of EMS?



18G said:


> So your saying that our treatment of the common day to day medical ailments is useless and has no effect? Your saying we can't save a COPD patient from resp failure and give them relief?


So can a Basic EMT.



18G said:


> Or turn around an asthma patient?Or save an anaphylaxis patient?



So can a Basic EMT and now even Police officers in some places.



18G said:


> Or keep a seizure patient from arresting?


 


18G said:


> Or extricate a patient from their vehicle and triage them to appropriate care?



Really? YOu do that? Or do you just spine board them and find the nearest trauma center?



18G said:


> Or keep an MI from worsening with early ASA and triage to a PCI center in addition to pain relief?



So can a basic, but they would need extra training and i mindless protocol for the morphine.



18G said:


> Or fixing a hypoglycemic patient that would otherwise die or have long-term neurological consequence if it wasn't for EMS?



Basic.



18G said:


> Or giving the cardiac arrest victim the best chance of survival?



Oh I'm game for that.

How many free community cpr classes does your organization provide?

Public access AEDs your service monitors?

Or do you just show up in less than 8:59 90% of the time and flog a corpse and pour some useless chemicals into it?



18G said:


> Or managing the patients IV drip medications, cardiac monitor, chest tube monitoring, ETT and ventilation monitoring, and hemodynamic monitoring for a safe transport during inter-facility transfer?



Do nurses not do this? With more knowledge?



18G said:


> How about triaging CVA to primary stroke centers to avoid delay of intervention?



A basic EMT doesn't do this?



18G said:


> How about pre-hospital management of TBI which as shown to decrease mortality?



When they put the tube in the right hole?




18G said:


> What about the fire victim who can be treated for CO and cyanide toxicity and saved? This is stuff I do as part of my everyday job and I know other Paramedics do as well.



Everyday huh? Somehow I doubt you see a fire victim everyday.  



18G said:


> The list is endless.



Perhaps in your mind. 



18G said:


> Yet people want to micro-analyze and portray EMS as a sham and waste of money. BS.



Yea? Compare yourself to every other First World Nation's EMS. You got nothing. 



18G said:


> Take away 911 and EMS and see how many people actually die and suffer because of its lack.



That was a nice strawman attempt, but I don't see what the call for the defense of an EMS system has to do with replacing ALS with more up skilled basics at a cheaper rate.




18G said:


> Perhaps someone can do a research study on that.



Every physician specialty does research on their effectiveness and outcomes.

The same for nursing. 

Where is the EMS research demonstrating their effectiveness?

Smoke and mirrors and making others responsible to prove the dogma wrong is not the level of a professional. It is that of a con artist.



18G said:


> Maybe that is what it would take for certain people to realize the necessity of modern day EMS and the role of the Paramedic. You will always have crappy EMS providers just the same as you have crappy nurses and physicians. But don't label all because of a few. There are many more great Paramedics then there are not..



The only thing I have seen is your word an anecdotes that paramedics are necessary. MOdern EMS I agree is required. Capable EMS providers like the British or Austrailians. The Slovaks or the Polish. Ther Germans or the French. Spaniards, Dutch, Even Russians. US paramedics shame the very title of EMS compared to these people.

Not im my experience, most are protocol monkeys incapable of clinical thought, too irresponsible to take credit and consequences for making their own decisions. Overtreating every patient doesn't make a great provider. Any idiot can run every test in the hospital.  



18G said:


> I've had many patients that have benefited greatly from the care I gave them and who would have been harmed if transported 30mins POV.



You have proof?



18G said:


> If you want to advocate for change... fine... that is a great thing... but the slamming of current Paramedic care needs to stop.



So does pretending it is anything but a sham.



18G said:


> Improvement can always be made but that is no reason to down effective Paramedicine as it is right now.



Look how pathetic US paramedicine is. Improvement. That is like an alcoholic touting success for cutting down from 5 drinks a day to 4. 



18G said:


> But if you are, then start with the advanced degree people (including physicians) who set all of this into motion long ago. The blame game starts there, not with the field provider .



So your solution is blaming the physicians of yesterday despite calls for change from physicians of today and the absolute refusal of the providers to make any effort?

Yea that'll get things done.

This is not specifically directed at you personally. I think every paramedic in the US should take a hard look at this.


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## 18G (Mar 20, 2011)

Once more, EMS is not a sham. And a research study is not needed to justify every single action a health care provider takes. Yes, studies are very important but people get carried away. 

- When a patient is in pain and a Paramedic reduces it from a 9 to a 1. Is that not benefit? Do we really need research to tell us pain management is effective and necessary? 

- A nausea rating from an 8 to a 2 and an obviously more comfortable patient? Do we really need research to tell us antiemetics make people feel better?

-A resp distress patient who is having a severe exacerbation of their disease, an SpO2 of 84%, EtCO2 of 50mmHg, and tachypneic. A Paramedic arrives and on arrival at the ED, the patient now has a normal SpO2, ventilation improved with EtCO2 showing 38mmHg, and resp rate of 20min, and steroids onboard at the very early onset of symptoms. Do we really need research to tell us we made a difference with this patient type?

- A patient is stung by a bee with a severe anaphylactic reaction. Pt. needs IV epi due to circulatory collapse, benedryl, albuterol, solu-medrol, and advanced airway management. Is BLS and an epi-pen really gonna suffice? Do we really need a research study to tell us that these interventions are highly time sensitive, effective, and mandatory?

- A seizure patient is status. Closest hospital is say 15mins away. Do we really need a research study to show that this patient type needs intervention now with benzos and airway and not over 15mins later?

When does intelligence start to become like ignorance and common sense gets left out of the equation. Your honestly going to argue with the above examples and claim that Paramedic care is a sham in those instances and the many more like it? Would ED care not consist of the same thing? 

And no the intentions of the leaders 50yrs ago should not solely influence the attitude of providers today. But it does play a strong part. You cant instill a certain mind set and embed it into everyday practice and then all of a sudden turn around and say your all wrong, why are you being a minimalist, etc, etc like it's their fault to begin with. You act like its totally up to us field providers and its not. 

Trust me, more then a few skills and technology has been added over the years. I went to school for two years, took A&P, etc... in fact the Paramedic program at my College is almost identical to the RN program. The only difference is the obvious core courses. The general education track is the same except for like two classes. 

And please enlighten me how an EMT-Basic is gonna fix a severe COPD exacerbation with only oxygen and a BVM? I guess trying to ventilate lungs with such poor compliance and with such high pressure that it causes gastric distention and aspiration is considered equal care to you? No inhaled or IV bronchodilators, CPAP, or steroids is okay? No way to measure ventilation and response to treatment with EtCO2 is acceptable? And the probable dehydration and fever should be ignored as well? Your argument for substituting ALS with BLS is very weak and very flawed. 

I think your getting confused. An EMT-Basic as is standard today is not able to provide ALS. You keep talking about adding this and adding that which eventually leads to an ALS type provider with nothing but skills which I always hear you argue against. So why would you advocate in this debate what you normally argue against?

I don't profess to know everything and health care is a never ending journey with something new to learn and improve everyday. But I am not so jaded as to realize when Paramedic care makes a difference. 

I guess if you were the one at this moment who couldn't breathe and a Paramedic showed up in your living room with his jump bag and started to alleviate your dyspnea and lessen your anxiety you would feel a bit different. Would you as a patient not be smart enough to figure out A) hmmmm... I cant breathe, B) Paramedic showed up and gave me medicine and made me breathe better and improved me all around. C) hmmm... did Paramedicine really work or is it just placebo effect? Do we really need research to show that putting black paint on a wall really does make the wall black? 

And before you say just give albuterol to Basics problem solved, we both know that is lame and a ignorant approach. I'm all for Basics having albuterol but not to replace a Paramedic response. Patient's on constant nebs especially with age need cardiac monitoring along with EtCO2 monitoring to gauge current resp status and trajectory. A Basic is not able to do this nor do they understand the pathophysiology well enough. 

It's obvious your very jaded which I can understand.... but I too, am finding many flaws with your perception and thinking.


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## 18G (Mar 20, 2011)

I wanted to say that I am liking the engagement and expression of different views. Hope others join in as well.


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## Veneficus (Mar 20, 2011)

18G said:


> Once more, EMS is not a sham. And a research study is not needed to justify every single action a health care provider takes. Yes, studies are very important but people get carried away.



Please if you could answer the question why other healthcare providers do studies on their value and effectiveness and all EMS presents is anecdotes and smoke and mirrors. (aka lies and cons) 



18G said:


> - When a patient is in pain and a Paramedic reduces it from a 9 to a 1. Is that not benefit? Do we really need research to tell us pain management is effective and necessary?
> 
> - A nausea rating from an 8 to a 2 and an obviously more comfortable patient? Do we really need research to tell us antiemetics make people feel better?
> 
> ...



You can type up individual circumstances and what if's until your fingers fall off. But you have not demonstrated any reason why an skills based provider at less than 1/2 the cost of a modern US paramedic cannot follow the same skills based approach as is common in a majority US based paramedics.

You have offered no rebuttal of my inqusition other than to retype your original statement in different words.  

I am most interested in hearing my points addressed, not just your reciting of self serving dogma. 




18G said:


> -When does intelligence start to become like ignorance and common sense gets left out of the equation. Your honestly going to argue with the above examples and claim that Paramedic care is a sham in those instances and the many more like it? Would ED care not consist of the same thing?



It was once common sense to bleed the bad blood out of wounds. It is still common sense apparently to put people on long spine boards. It was even once common sense to burn witches to avoid offending God.

Common sense is a weak academic argument.

I will argue that those instances are the 5-10% of all emergency calls and that it is not cost effective to maintain ALS services for them. If we are going to pay providers for 5-10% then we should value it accordingly. I also argue that in those same instances, protocol driven medicine allowing the same treatments is likely to provide equal benefit. 

After all in every instance you spelled out the exact treatment you thought indicated without regard to any variables and then stated how much it helped as "common sense."




18G said:


> -And no the intentions of the leaders 50yrs ago should not solely influence the attitude of providers today. But it does play a strong part. You cant instill a certain mind set and embed it into everyday practice and then all of a sudden turn around and say your all wrong, why are you being a minimalist, etc, etc like it's their fault to begin with. You act like its totally up to us field providers and its not.



But it is up to providers. LIke it is has been up to all other providers. Nursing etc. did not advance because a group of physicians pushed them. They took responsibility for their own destiny. 

You expect physicans to decend from on high and sudenly improve paramedicine like magic or divine power?

Why should an established profession be responsible for helping another? 

The only answer is that EMS isn't a profession. Without the high level of knowledge and responsibility, it is a skill. Skills can be taught for less than the cost/benefit of maintaining ALS for the rare instances where they actually make a difference following preset instructions. 



18G said:


> -Trust me, more then a few skills and technology has been added over the years. I went to school for two years, took A&P, etc... in fact the Paramedic program at my College is almost identical to the RN program. The only difference is the obvious core courses. The general education track is the same except for like two classes.



Becase you went to a superior program that translates into advancement for all or even a majority of EMS providers in the US? 

Does your edcation permit you anymore clinical latitude than that of a 6 week medic mill graduate?

Is the Education you went through a minimm requirement for medics around the country? 

You may have went to one of the few exceptional programs, but your program is an outlier, not the norm.




18G said:


> -And please enlighten me how an EMT-Basic is gonna fix a severe COPD exacerbation with only oxygen and a BVM? I guess trying to ventilate lungs with such poor compliance and with such high pressure that it causes gastric distention and aspiration is considered equal care to you? No inhaled or IV bronchodilators, CPAP, or steroids is okay? No way to measure ventilation and response to treatment with EtCO2 is acceptable? And the probable dehydration and fever should be ignored as well? Your argument for substituting ALS with BLS is very weak and very flawed.



Teaching basics to perform the same interventions as an ALS provider is flawed when you just listed everything that needs to be done in an itemized less in less than 30 words?

Doesn't sound that hard. I'll bet I could do it in a few weeks. Trying to exclude providers from rendering treatment based on your current system and not modification of it is where the flaw in argument is. 

I have a PA paramedic card too. Without an expiration date. I am also well aware of what constitutes ALS and its requirements in a majority of PA. Just because your service exceeds that and has a specific way of operating does not make it the only way.  



18G said:


> -I think your getting confused. An EMT-Basic as is standard today is not able to provide ALS.



Says who? We have had many providers here detail the expanded scope of Basic EMTs in various parts of the US. If it can be done there. It can be done anywhere. It is also much easier to get people to agree to when you show them how few instances all those expensive ALS providers cost to maintain and how much money they would save. 



18G said:


> -You keep talking about adding this and adding that which eventually leads to an ALS type provider with nothing but skills which I always hear you argue against. So why would you advocate in this debate what you normally argue against?



Taking the hardline as the Devil's Advocate.

Your argument has been measured and is found wanting. 

You provided nothing but unproven EMS dogma in your response. Maybe if you say it enough it will become true.



18G said:


> -I don't profess to know everything and health care is a never ending journey with something new to learn and improve everyday. But I am not so jaded as to realize when Paramedic care makes a difference.



The original argument was that it doesn't make a difference in a short transport environment, not that it doesn't make a difference at all. But when I challenged to idea it made a difference the only reponse I have seen is the party line and "common sense."  



18G said:


> -I guess if you were the one at this moment who couldn't breathe and a Paramedic showed up in your living room with his jump bag and started to alleviate your dyspnea and lessen your anxiety you would feel a bit different..



Would I care if that person was a paramedic, a nurse, an EMT-B or a doctor?

I think not.



18G said:


> -Would you as a patient not be smart enough to figure out A) hmmmm... I cant breathe, B) *Somebody* showed up and gave me medicine and made me breathe better and improved me all around. C) hmmm...The *EMS system really works*



Where I sit today I am just as likely to get a doctor. Who may even decide after my treatment I don't need an ALS ambulance bill and a Emergency room bill, because he was able to help me without automatically transporting me to the hospital. In many nations a paramedic can do the same thing. What makes you worth more than double the cost of an EMT with the same skills and treatments you possess again?

My point bolded.




18G said:


> -Do we really need research to show that putting black paint on a wall really does make the wall black?



We are not disputing what treatment helps. Only Who is capable of providing it and at what cost. 



18G said:


> And before you say just give albuterol to Basics problem solved, we both know that is lame and a ignorant approach.



It sure is. But it is cheaper than having a paramedic do it.

If Paramedics can not or will not diversify their education and practice, why pay more when you could get the same for less?




18G said:


> Patient's on constant nebs especially with age need cardiac monitoring along with EtCO2 monitoring to gauge current resp status and trajectory. A Basic is not able to do this nor do they understand the pathophysiology well enough.



Neither do most paramedics. Anyway the problem is solved by simply calling a medical control physician on a webcam with a wireless internet connection. Which is still cheaper than training and maintaining paramedics. 



18G said:


> It's obvious your very jaded which I can understand.... but I too, am finding many flaws with your perception and thinking.



Yes, I am jaded.

Yes, I do support expanding the value of US paramedics.

But if my argument, as the devil's advocate, cannot be refuted, how do you plan to convince the people who truly do see EMS as a waste of money that can be reduced?

Shout dogma at them and tell them they have no common sense?

They will bury your argument with an OPALS study and a host of expert physician opinion. Including with multiple anti-EMS physicians who are former paramedics.

As friendly advice, I would start putting together some studies and gathering some evidence as well as diversifying the value of your service.

"EMS is not a sham" says the guy who makes his living at it and as proof cites "common sense,"
and no other evidence.


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## thegreypilgrim (Mar 20, 2011)

Veneficus said:


> I am convinced there is no need for a paramedic in an urban environment with less than 15 minute transport times. Any treatment performed short of pain releif can be done by a basic.
> 
> Train them how to transmit a 12 lead, start an IV, and write a protocol for pain management and there is no longer any purpose for an urban paramedic.



Unless you want to implement something like the Community Paramedicine program that Rob was talking about and work toward deflating local ED census.

Educated paramedics --> Treat and Release & Referral --> reduction in cumulative health expenditures and better career options for paramedics themselves.

Something like that could certainly benefit an urban area and could not be performed by Basics.


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## medicRob (Mar 20, 2011)

thegreypilgrim said:


> Unless you want to implement something like the Community Paramedicine program that Rob was talking about and work toward deflating local ED census.
> 
> Educated paramedics --> Treat and Release & Referral --> reduction in cumulative health expenditures and better career options for paramedics themselves.
> 
> Something like that could certainly benefit an urban area and could not be performed by Basics.



The community health paramedic that I speak of in my article has a 4 year BS, Paramedicine degree who has chosen in his/her 4th year to specialize in Community Health Paramedicine. He would be one of many specialists paramedics. Just like my previous posts, when I refer to basic level paramedics, I am talking about a situation where education is rebuilt completely making Associates the minimal level where the associate programs themselves are recreated to have more of a clinical component than they currently instead of just a focus on research and management. 

AAS, Clinical Paramedicine would be a term I would not dismiss. 

-----
In the ideal world, I would love to see several 4th year Paramedic specialty areas:

1. CCT Transport & Aeromedicine
2. Emergency Care Paramedic (ER Medic)
2. Critical Care (Specialty in ICU, not the current cc-p you are used too) 
3. Community Health Paramedic (Works in Docs offices, in community health   treat and release programs on ambulances, etc)

4. Trauma Medic (Trauma unit based)

----
The prefix 'para' is a greek term meaning "Alongside, or aside from".  Therefore, the Paramedic acts 'aside from, alongside' the medic or physician. 

My idea is to no longer limit paramedics to the ambulance. Let's give them the proper training to utilize them in a whole host of situations besides just ERs and Ambulances. This isn't a crazy idea at all, after all.. we train nurses in 4 years to enter into a whole host of specialties. I didn't specialize until my 4th year of BSN school. We will just need to redefine the roles of the paramedic and set into place laws and languages which would allow them to function in these capacities and how medical control is to be addressed (My thought is to ditch the medical control system in hospital for a chain of command system like we have in nursing. The Nurse answers to superiors, charge nurse, ADON, DON, etc..) 

Let's use education to build bridges and to negotiate higher salaries.


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## thegreypilgrim (Mar 20, 2011)

medicRob said:


> The community health paramedic that I speak of in my article has a 4 year BS, Paramedicine degree who has chosen in his/her 4th year to specialize in Community Health Paramedicine. He would be one of many specialists paramedics. Just like my previous posts, when I refer to basic level paramedics, I am talking about a situation where education is rebuilt completely making Associates the minimal level where the associate programs themselves are recreated to have more of a clinical component than they currently instead of just a focus on research and management.
> 
> AAS, Clinical Paramedicine would be a term I would not dismiss.
> 
> ...


I would be behind this 100%.

How would paramedics function in an actual ICU environment though? I foresee the ANA expending all political capital they have to prevent something like that from happening. Not against the idea of course, but just want to see how you'd get around carving out a role for paramedics in the ICU that didn't step on nursing's toes.

Interestingly, San Mateo County here in California has instituted what they refer to as the SMART Program which utilizes paramedics to assess and triage patients suffering from behavioral emergencies to appropriate facilities.

Perhaps mental health and substance abuse could be another area for medics to specialize in.


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## medicRob (Mar 20, 2011)

thegreypilgrim said:


> I would be behind this 100%.
> 
> How would paramedics function in an actual ICU environment though? I foresee the ANA expending all political capital they have to prevent something like that from happening. Not against the idea of course, but just want to see how you'd get around carving out a role for paramedics in the ICU that didn't step on nursing's toes.
> 
> ...




Psychiatric is a good idea. Why can't we add things like Pulmonary Artery caths, Intracranial Pressure Monitoring, IV Pumps, and other ICU skills to the specialty part? That is the best part about a 4th year specialty, you have an entire year to train them in a specialty area. 

1st and 2nd year = General Education
3rd year = Paramedic Curriculum for NREMT purposes and testing
4th year = Specialty Year and Internship in specialty area


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## 18G (Mar 20, 2011)

Vene...
You know, it is a great tactic in a debate to try and passively reduce the other persons position as an attempt to highlight and make your own position sound superior. You do a great job of using that tactic. 

All I have heard you spew is your own jaded opinion on why Paramedic care is worthless and a waste of money. Where are your statistics and research to support your position? I have not provided any in this informal debate because I am shooting off replies while sitting on the couch with my laptop. If this were a "real" debate in a Community then I would have statistics to support everything I have said. 

I have read the recent studies that show pre-hospital pain management is highly effective and needs to become more aggressive. And the studies that show pre-hospital Zofran use is highly beneficial at reducing patient suffering. And the studies that show early pre-hospital steriod use lowers hospital admission for asthma. And many more. I really don't have the time to search for them all and paste the links. 

What I have promoted is not dogma or feel good speak. A degreed, Paramedic level EMS provider should be considered the new "basic" level provider with levels going up from there. EMT's should be what First Responders are now.

One last point I wanted to touch on is the comparison of nursing to Paramedicine. That is a really unfair comparison. Nursing evolution only had what... a 100 year or so jump on EMS? If EMS evolution had a 100 year jump start I'm sure we would be much further ahead. Considering EMS started in about 1968 and its now only 2011 I would say EMS has come much further in that short amount of time then what nursing did. But then again, nursing is a completely different field with a much different set of variables to overcome.

I'll give you some kind advice as well. If your gonna convince me and others that EMS and Paramedicine is a sham, then your going to have to provide some proof of that. Your gonna have to show me that my interventions are ineffective and my level of knowledge as a Paramedic makes no difference in comparison to a EMT-Basic. Prove to me that my two years of education is equal to 140hr EMT program. Prove to me my capabilities are no more then the EMT-Basics. Prove to me that my drugs and equipment make no difference in pain and suffering and life and death. 

I had a larger reply typed and this stupid laptop closed the tab somehow.


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## 18G (Mar 20, 2011)

MedicRob... I would love to see EMS education programs like you describe! That is what I am kinda talking about. The current Paramedic today would be entry level into the EMS field and go up from there. I would love to have a bachelors option for Paramedicine and not one that is focused on EMS Management.


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## thegreypilgrim (Mar 20, 2011)

medicRob said:


> Psychiatric is a good idea. Why can't we add things like Pulmonary Artery caths, Intracranial Pressure Monitoring, IV Pumps, and other ICU skills to the specialty part? That is the best part about a 4th year specialty, you have an entire year to train them in a specialty area.
> 
> 1st and 2nd year = General Education
> 3rd year = Paramedic Curriculum for NREMT purposes and testing
> 4th year = Specialty Year and Internship in specialty area


Again, I don't see any reason why we couldn't. I'm interested to know what role the paramedic could play in the ICU as it's not something I've thought of: and I assume you mean the actual ICU since you have CCT/Aeromedical listed as separate specialties. What would that mean for nursing?

PS - did you get my last PM?


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## jrm818 (Mar 20, 2011)

Just to cast some perspective on the importance of demonstrating improved outcomes as a result of EMS.

I stumbled over this article yesterday, and low and behold its relevant today: http://www.boston.com/lifestyle/hea...ill_chasing_in_the_era_of_health_care_reform/

It's sort of an interesting report on the ridiculousness that is medical billing in the lovely US of A, but the most important part I think is this: It's a BCBS rep. speaking about why insurance companies are trying to reduce compensation for ambulance transport: "According to spokesman Jay McQuaide, the state’s Blue Cross customers spend about $80 million a year for services that do not “improve the quality or effectiveness of the care” – $60 million of that total goes toward ambulances."

Individual examples of a subset of patients that seem to obviously benefit from EMS, even if accepted, don’t gain much ground to combating attitudes like that.  We need to be able to provide real evidence (patient-relevant outcome oriented data) that we improve the overall quality of care for our patients.  Thus far the evidence is spotty (and, as Vene noted, some of the better evidence is OPALS, which is not flattering)

Even demonstrating survival to hospital is probably insufficient.  If temporarily alive patients ungratefully die without regard the quality of their EMS care, it's all for naught.  You don’t get brownie points for storing corpses in an ED or ICU.

It's clear that we don't need (and couldn't obtain anyways) evidence of a benefit for every possible intervention for every possible patient presentation.  At some point it is of course time to admit that parachutes improve fall survival  (http://www.ncbi.nlm.nih.gov/pubmed/14684649).  However, EMS isn’t about parachutes versus no parachute (medical care or no medical care): it’s often about parachute now or later (in field or in the hospital).  

It’s not just a matter of carrying out the research that will demonstrate once and for all that EMS/Paramedics provides better outcomes.  It’s not at all certain that the research will show that.  Before we can prove that paramedics are better, they need to actually be better.  With the current state of protocol driven “medicine” (medicine by numbers, I think Vene has called it medicine by epidemiology) I have to wonder….

Edit: I can think of a rather short list of conditions with good evidence of improval with ALS level prehospital care.  As noted pain control, perhaps early interventions for very severe CHF/COPD, primarily by staving off intubation, trauma and MI only by virtue of transport to a proper facility and early notification, and thats...about it.  I'm sure there are several more, but really if we're hanging our hat on pain control and receiving hospital destination, we may have issues with cost justification.


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## medicRob (Mar 20, 2011)

jrm818 said:


> It's sort of an interesting report on the ridiculousness that is medical billing in the lovely US of A, but the most important part I think is this: It's a BCBS rep. speaking about why insurance companies are trying to reduce compensation for ambulance transport: "According to spokesman Jay McQuaide, the state’s Blue Cross customers spend about $80 million a year for services that do not “improve the quality or effectiveness of the care” – $60 million of that total goes toward ambulances."



Insurance will be one of, if not the biggest hurdle that paramedicine will face in its rise toward profession. This is why we need to look to new revenue streams such as "Urgent Care Billing" instead of just "Emergent", and we need to give paramedics the education to be seen NATIONALLY in the language of the law as "licensed providers" (This is different than just having a license). Once we do this, maybe we can start billing Paramedic skill hours instead of mileage. It is hard for a profession to step away from the ambulance when their only basis for billing at the moment is based upon mileage. 

Whenever I perform a skill as an RN, there is a certain $ amount attached to that equipment and a certain time that is attached to that skill (It is the reasonable amount of time the insurance company feels I should be able to perform that skill in), those are called skill hours. As a licensed professional, when I perform a skill, revenue earned on the basis of those skill hours and various other factors (Time of stay, ancillary services rendered, etc). If we could bill Paramedics in hospitals as skill hours (which would require them to be recognized nationally by the letter of the law as 'licensed professionals' <-- This is where I bring in the idea of Bachelors programs, we can do this). New revenue streams will be generated, hospitals will think more of hiring paramedics at expanded salaries, etc. 

The medical center that I work at has kind of blinded me to what is going on nationally. We are so far ahead of the curve that each patient in the ER not only has an RN, but also a Paramedic. The RN and the Paramedic work together with the MD and APRNs to care for this patient. The Paramedic not only just carries out skills like IV Starts and med pushes, but he/she also plays an active role in care planning. It is an amazing system. 

Unfortunately, it seems that my hospital is one of those rare exceptions.


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## 18G (Mar 20, 2011)

I would love to see a breakdown of that $60 million the insurance rep speaks of. Routine, non-emergency transports are big business for ambulance companies and I would venture to say that much of the $60 million goes for these type of transports and not 911, ALS level services. 

A routine ambulance transport from ED back to nursing home is quite a bill! Same way with doctors office transport that are most often BS certified medically necessary. So I would also venture to say the reps statement of, "...that do not “improve the quality or effectiveness of the care" refers to these non-emergency transports that mostly could go by other means. 



> I can think of a rather short list of conditions with good evidence of improval with ALS level prehospital care. As noted pain control, perhaps early interventions for very severe CHF/COPD, primarily by staving off intubation, trauma and MI only by virtue of transport to a proper facility and early notification, and thats...about it. I'm sure there are several more, but really if we're hanging our hat on pain control and receiving hospital destination, we may have issues with cost justification.



I can think of many more examples. EMS is dynamic and patients get themselves in a slew of unpredicted situations. What about the patient who is riding a tractor that overturns, patient is pinned with severe trauma and face down in the mud.. (real call btw). The Paramedic performed a digital intubation successfully. How do you account for this level of skill and these situations? Should this patient not have had this level of provider in his Community? BLS would have sufficed in this situatioin?


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## 18G (Mar 20, 2011)

A great article and interesting read I saw posted on JEMS Connect.... outlines how research is not a "tell all" and can be flawed and rigged to show the researchers desired outcome.

Lies, Damned Lies, and Medical Science

http://www.theatlantic.com/magazine/archive/2010/11/lies-damned-lies-and-medical-science/8269/#

It's not always about the research.


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## Veneficus (Mar 20, 2011)

thegreypilgrim said:


> Unless you want to implement something like the Community Paramedicine program that Rob was talking about and work toward deflating local ED census.
> 
> Educated paramedics --> Treat and Release & Referral --> reduction in cumulative health expenditures and better career options for paramedics themselves.
> 
> Something like that could certainly benefit an urban area and could not be performed by Basics.



That would be ideal, but with most major cities using FD based EMS as the primary source of prehospital providers, they would first have to embrace health prevention as they did fire prevention and I really don't see that as being the culture anytime soon.

It doesn't make economic sense to have a seperate 911 service from it because at that point you could just use a home health nurse and that would totally defeat the purpose of having paramedics diversify to that role.

If yo create overlap, not only do you not reduce costs, but you put the nursing lobby in direct conflict with EMS. From a political standpoint, it is a losing position. The power that nursing has is quite solidified for a small group of disorganized EMS people to overcome. Especially with the current educational standards.


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## usalsfyre (Mar 20, 2011)

18G said:


> What I have promoted is not dogma or feel good speak. A degreed, Paramedic level EMS provider should be considered the new "basic" level provider with levels going up from there. EMT's should be what First Responders are now.


I think the point Vene is trying to make is the majority of prehospital providers DON'T WANT this. They are too tied up in "hey look at this cool stuff I can do" to be bothered with the science behind it. Unless you dangle money in front of them, there's no drive to improve. I see this in about 90% of paramedics, but only 30 or 40% of other health care providers I speak with. 



18G said:


> One last point I wanted to touch on is the comparison of nursing to Paramedicine. That is a really unfair comparison. Nursing evolution only had what... a 100 year or so jump on EMS? If EMS evolution had a 100 year jump start I'm sure we would be much further ahead. Considering EMS started in about 1968 and its now only 2011 I would say EMS has come much further in that short amount of time then what nursing did. But then again, nursing is a completely different field with a much different set of variables to overcome.


Other allied health fields (lab, radiography((sorta)), respiratory, pharmacy, PT and OT, and many other I'm forgetting) have managed to impose higher education as entry. Why? Because the members of their respective fields weren't short-sighted. Meanwhile, paramedics have eschewed education in favor of things like labor unions to raise wages. 



18G said:


> I'll give you some kind advice as well. If your gonna convince me and others that EMS and Paramedicine is a sham, then your going to have to provide some proof of that. Your gonna have to show me that my interventions are ineffective and my level of knowledge as a Paramedic makes no difference in comparison to a EMT-Basic. Prove to me that my two years of education is equal to 140hr EMT program. Prove to me my capabilities are no more then the EMT-Basics. Prove to me that my drugs and equipment make no difference in pain and suffering and life and death.


I understand what your saying. The problem is, 18G, usalsfyre, medicRob, and many others on this forum aren't the norm in the US, we're the outliers. The norm is the guy who doesn't know an alpha receptor from an alpha cell in the pancreas, thinks giving narcotics to anyone is "feeding drug seekers",  and thinks paramedics "do the same job as ER doctors with half the pay" (I kid you not, I was on an employee retention commitee and saw this in more than one survey) and above all, protocol is king because "we're not doctors!" As long as this is the predominate person in our profession (and right now it is, I've talked to a lot of folks) then we don't stand a chance at real change. The impetus won't come from above, they're happy making money and justifying manpower/budget. The force for change has to come from providers. Right now, I don't see that happening, before EMS crashes and burns completely.


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## thegreypilgrim (Mar 20, 2011)

Veneficus said:


> That would be ideal, but with most major cities using FD based EMS as the primary source of prehospital providers, they would first have to embrace health prevention as they did fire prevention and I really don't see that as being the culture anytime soon.


There lies the rub, of course, but I thought we were talking about an ideal 



> It doesn't make economic sense to have a seperate 911 service from it because at that point you could just use a home health nurse and that would totally defeat the purpose of having paramedics diversify to that role.


I'm not entirely sure about this. From what I understand you have to be referred to a home health service and it's all part of a pre-scheduled arrangement. Not available on the fly. Furthermore, home health nursing has been around for years and thus far does not seem to have substantially reduced otherwise unnecessary 911 activations. Paramedics could fill the void here. 



> If yo create overlap, not only do you not reduce costs, but you put the nursing lobby in direct conflict with EMS. From a political standpoint, it is a losing position. The power that nursing has is quite solidified for a small group of disorganized EMS people to overcome. Especially with the current educational standards.


Much bigger problem here. In any instance where the nursing lobby comes in conflict with EMS, EMS is going to lose. Hence the vicious circularity and compounded nature of barriers to the professionalization of EMS. Once you think you have one problem solved (or, at the very least, a strategy for solving it) you come up against another impenetrable barrier.


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## medicRob (Mar 20, 2011)

Veneficus said:


> If yo create overlap, not only do you not reduce costs, but you put the nursing lobby in direct conflict with EMS. From a political standpoint, it is a losing position. The power that nursing has is quite solidified for a small group of disorganized EMS people to overcome. Especially with the current educational standards.










..and what's bad for nursing is bad for business, and we know that none of you want that. bwahahahah


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## Veneficus (Mar 20, 2011)

18G said:


> Vene...
> You know, it is a great tactic in a debate to try and passively reduce the other persons position as an attempt to highlight and make your own position sound superior. You do a great job of using that tactic.
> 
> All I have heard you spew is your own jaded opinion on why Paramedic care is worthless and a waste of money. Where are your statistics and research to support your position? I have not provided any in this informal debate because I am shooting off replies while sitting on the couch with my laptop. If this were a "real" debate in a Community then I would have statistics to support everything I have said.
> ...



In a pubmed search of:

EMS

EMS effectiveness

Emergency medical services

Emergency medical services effectiveness

paramedics

The only relevant study I found was:

Performance and skill retention of intubation by paramedics using seven different airway devices-A manikin study.
Ruetzler K, Roessler B, Potura L, Priemayr A, Robak O, Schuster E, Frass M.

Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Medical University of Vienna, Austria.

Aside from the OPALS study I can find nothing else.


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## jrm818 (Mar 20, 2011)

18G said:


> I would love to see a breakdown of that $60 million the insurance rep speaks of. Routine, non-emergency transports are big business for ambulance companies and I would venture to say that much of the $60 million goes for these type of transports and not 911, ALS level services.
> 
> A routine ambulance transport from ED back to nursing home is quite a bill! Same way with doctors office transport that are most often BS certified medically necessary. So I would also venture to say the reps statement of, "...that do not “improve the quality or effectiveness of the care" refers to these non-emergency transports that mostly could go by other means.



I suspect that you're right about the cost including a large amount of non-emergency transport.  It doesn't seem like the insurance companies really distinguish the between emergency and routine ALS service, and really neither do ambulance services.  Everywhere I've worked the billing (to my knowledge) is the same for an interfacilty as for emergency transport: the only price differences have been based on the number of "advanced" skills that were performed.  It doesn’t seem like BCBS thinks they get very much for the procedures they pay for, be they in emergency or non-emergency situations.

I think part of the issue is that EMS tries to distinguish between "ALS" and "BLS" by the skills that each level of provider is entitled to perform.  Thus "ALS care"  is care in which at least one ALS skill is provided.  There is no credit, for example, for an advanced evaluation that determines that no ALS procedure is required.

When physicians bill for service, their reimbursement level is tied not only to the interventions they perform, but to the complexity of the medical situation and the critical thinking required.  Their billing system has its own problems, but I think its relevant to think about the idea behind the two billing mechanisms: EMS is all about what skill was performed, but there is relatively little attention given to medical decision making.  I think that reflects pretty accurately the training attitude I've seen and the thought process of medics in the field, and that seems like a huge problem.

If we insist on valuing (literally, with money) EMS according to the procedures it is able to perform, we're missing the boat.  Yes, some procedures that paramedics perform can be demonstrated to improve outcomes.  It doesn't take a paramedic to follow a cookbook and perform a psychomotor skill, however.  We can get procedures with relatively uneducated and poorly paid providers.  

However, in most systems its unlikely that there will be more than a small subset of patients who benefit from receiving any specific intervention at t=0 rather than t=20 minutes, and that benefit diminishes with decreasing time differences.  There is only so much good EMS can do by providing "early" treatment.  

Instead we need to focus on creating a system where providers are equipped to make educated decisions about the best way to care for individual patients in a way that those decisions either reduce healthcare costs, improve efficiency, or improve patient outcomes.



18G said:


> I can think of many more examples. EMS is dynamic and patients get themselves in a slew of unpredicted situations. What about the patient who is riding a tractor that overturns, patient is pinned with severe trauma and face down in the mud.. (real call btw). The Paramedic performed a digital intubation successfully. How do you account for this level of skill and these situations? Should this patient not have had this level of provider in his Community? BLS would have sufficed in this situatioin?



Honestly, we can play with any number of examples, but the issue is the idea of picking a few select patients who benefit, versus addressing the overall needs of the population and designing a system to meet the needs of a lot of them, more than a select group of very ill patients.

I won't dispute that for this individual patient their respiratory status was possibly improved by the presence of a paramedic (although, a basic with a blind insertion device may have accomplished a similar feat without risking his digits...).  That isn't the issue.  The problem is that there isn't any compelling evidence that the "ALS" care improved this patients _outcome_.  There is of course now a great study indicating that RSI can improve TBI outcomes down under, but that certianly does not prove that American "ALS" is capable of the same benefits given the differences in philosophy.

Conditions for which "ALS" is clearly demonstrated to improve relevant outcomes are few and far between.  National EMS Advisory Council put out a position paper about the demonstrated benefits of EMS in December 09 (http://www.ems.gov/pdf/nemsac-dec2009.pdf).  It's great that the group is advocating for EMS, but the list of situations in which ALS has demonstrated benefits was rather sparce.  It was essentially my list: MI/Stroke/trauma due to transport decisions, respiratory failure due largely due to CPAP (A “basic skill” in PA), perhaps TBI due to overall management, and that’s about it.

It would be nice to add some conditions to the list, and we probably can, but that's a bit of missing the forest for the trees.  

Crafting a huge paramedic based EMS system based on a list of the small subset of patients with extremely time sensitive complaints is not likely to yield large returns.  Many of these patients will die nomatter what we do, there aren’t very many of them, and basics with protocols including a few advanced tools (and on-line medical direction Rampart style) are likely to provide just as good care as our current paramedics.  

The goal really ought to be creating a system that can bring real long term solutions (rather than temporizing measures)  to the sorts of problems that cause people to call 911.  This may involve things like alternate clinical pathways, treat and release, etc., as well as more advanced thinking when dealing with very ill patients, rather than current protocolized treatments.  That will require a level of knowledge and critical thinking that is currently beyond the design parameters of current paramedics, but it seems like a good way to achieve enough benefit with EMS to justify the expense.  The current idea of charging a thousand bucks for a few “advanced” skills will not cut it.


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## jrm818 (Mar 20, 2011)

18G said:


> A great article and interesting read I saw posted on JEMS Connect.... outlines how research is not a "tell all" and can be flawed and rigged to show the researchers desired outcome.
> 
> Lies, Damned Lies, and Medical Science
> 
> ...



Of course if we had some more EMS grown research, we could have some flaws in favor of EMS for once....

 Did you take a peak at my parachute link?  I don't think anyone here (if I dare speak for all those here smarter than I) is trying to claim that research is everything, but it is part of the equation of changing the impression of others.  The other part of changing beliefs about the inadequacy of EMS is actually making it adequate (well, really, that's the first part).


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## 18G (Mar 20, 2011)

I don't need a research study to tell me that what I do makes a difference in a persons life. I know when I make someone breathe better, take their pain away, relieve their nausea, reverse an allergic reaction, etc, etc, etc. 

If people need a research study to validate every single thing they do then they need to go to Burger King and work where its clear the hot grill cooks the meat and makes a delicious double cheeseburger. 

I love the work I do and I see how it benefits peoples lives. I don't dismiss research as I love reading the data and I think its very much needed. But I don't get carried away with it and assume just because a study isn't found that a certain modality isn't valid or makes any difference. And a single study isn't totally persuasive either.

I've stated my position and have no more to comment at this time. I'm all for Paramedic care being entry level and hopefully one day it is.


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## medicRob (Mar 20, 2011)

usalsfyre said:


> The problem is, 18G, usalsfyre, medicRob, and many others on this forum aren't the norm in the US, we're the outliers.



That's right... I'm an outlier. I am 2 standard deviations from the mean, I am 85% sure of that..   /statistics joke


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## usalsfyre (Mar 20, 2011)

18G said:


> I don't need a research study to tell me that what I do makes a difference in a persons life. I know when I make someone breathe better, take their pain away, relieve their nausea, reverse an allergic reaction, etc, etc, etc.
> 
> If people need a research study to validate every single thing they do then they need to go to Burger King and work where its clear the hot grill cooks the meat and makes a delicious double cheeseburger.
> 
> ...



It's not that YOU understand that value, it's selling your worth to others. You need research to do this. We fail miserably at this, and the majority of providers show no interest in changing it.


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## medicRob (Mar 20, 2011)

thegreypilgrim said:


> How would paramedics function in an actual ICU environment though? I foresee the ANA expending all political capital they have to prevent something like that from happening. Not against the idea of course, but just want to see how you'd get around carving out a role for paramedics in the ICU that didn't step on nursing's toes.



In the same way they function in our ER currently, right alongside nurses. Are nurses gonna be pissed? You bet ya, but aren't we already pissed that you are pushing drugs and intubating with a 1 year education? We'll get over it. 

RN / Paramedic Patient Care Team Model
http://www.mc.vanderbilt.edu/root/sbworddocs/er_services/patient_care_team_model.ppt

For more info:

http://www.mc.vanderbilt.edu/root/vumc.php?site=adulted&doc=828


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## bigbaldguy (Mar 21, 2011)

18G said:


> I don't need a research study to tell me that what I do makes a difference in a persons life. I know when I make someone breathe better, take their pain away, relieve their nausea, reverse an allergic reaction, etc, etc, etc.
> 
> If people need a research study to validate every single thing they do then they need to go to Burger King and work where its clear the hot grill cooks the meat and makes a delicious double cheeseburger.
> 
> ...



 Well put. Numbers don't mean everything but they certainly shouldn't be ignored.


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## medicRob (Mar 21, 2011)

bigbaldguy said:


> Well put. Numbers don't mean everything but they certainly shouldn't be ignored.



Numbers may not mean everything, but numbers talk. There is a reason the evolution of medicine relies so heavily on research. Also, as far as research being 'rigged', etc. Anyone with a proper education in research evaluation can spot a so called 'rigged' study from a mile away. Just take a look at the "Prehospital Fluids increases mortality in trauma patients" post in the Advanced Medical forum. When evaluating research, you must learn to look for inconsistencies.. Does this mean all research is bad? Nope. 

I am with Vene on this one. EMS in the US is going to have to crash and burn before it learns its lesson. The fact is, in medicine when you make a claim that something is effective, you are typically expected to have solid research backing you. Unfortunately, EMS suffers from 2 situations. 

1. Lack of a proper research base for the profession. 
2. It is just not that effective, not when you compare it to systems like New Zealand, Australia, and Canada.


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## KELRAG (Mar 21, 2011)

To jrm818... Besides the obvious ami/cva/asthma pts you mentioned, look at ARDS net and surviving sepsis campaign. These are two that recognize the benefits of early interventions and suggested their role in prehospital care. When it comes to trauma, I don't fully agree with Bledsoe's recent stance on "the golden hour" which arrived from the controversial article dismissing the role of aeromedical services,it seems a little extreme but one of the underlying ideas was that a good portion of stabilization can occur on scene. Too often medics are falling back on the old standard of throwing the pt "in the back" and do all the interventions en route.  This is an opinion held by many Pro-ems EM docs.

Addressing the commonly held belief by the international paramedics that pay attention; ems education in the us needs to be improved but it is heading in the right direction. At least in Texas, we now have the pathophys/a&p/bio etc... requirements. I went to a relatively well respected school that takes their  science majors a little too seriously and did decently. To be honest, I don't think the years with test tubes, behind microscopes and buried in text books were overly helpful with being a medic. I know for sure my world lit hasn't done a damn thing. I work with medics that went to community college who are amazing! I can give u an exhaustive explanation on the multiple modulators of dopamine but the best medics know how to work on their feet. As hard as this may hurt. Our job isn't all the theoretically difficult. Common sense in a significant amount of situations will trump "extensive" knowledge of disease processes.


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## Bieber (Mar 21, 2011)

I've been lurking here in the conversation and I've got to say, Veneficus and medicRob, you hit the nail straight on the head.  It's the sad unfortunate truth that you're right, a trained EMT-B who knows how to do the skills could do my job.  My protocols are literally step by step cookbook medicine, and what's even sadder is that this rigid structure still persists even in my state where paramedic requires an Associate's degree.

18g, I get what you're saying, but you've got to recognize that Veneficus is right, there's nothing about paramedics that is special as long as are protocols are rigid step-by-step instructions that tell us what to do, as opposed to guidelines that suggest the standard of care to be deviated from per our own discretion and clinical judgment.  As long as you can do a basic assessment and are trained in the skills, you don't even hardly need to be an EMT--a first responder could do what we do.  It's sad to admit it, and I think that's where you're coming from, but it degrades the paramedic and waters it down to nothing but a skill monkey (see, warm body).

And that is exactly why we absolutely HAVE to increase educational standards.  I'm right there with medicRob, an Associate's HAS to be the MINIMUM.  And I'll tell you, as an Associate's paramedic, I still don't feel like I know jack :censored::censored::censored::censored:.  I'll be getting the shiny degree this spring, and let me tell you, I struggle every day to try and feel like I am capable of caring for patients.  So how in the world is a six month paramedic mill graduate going to be competent to take care of critical patients?

There's three basic steps to making paramedic something valuable: step 1, increase educational standards (i.e. make us a true recognized profession), step 2, lobby to change the medicare scheduling so we can bill for service as opposed to transport (BLS, ALS 1, ALS 2, etc), and step 3, convince the physician community that we know what the hell we're doing (as evidenced by step 1), and get them to toss the cookbook protocols in the trash and give us clinical guidelines.

Until we can do step 1 and 3, we're nothing but EMTs with a couple of cool tricks, and until we can do step 2, you might as well kiss the dream of community paramedicine goodbye.

I want to be a great paramedic, I'm not one yet.  I want to be able to use my clinical judgment and really be able make a difference for my patients and be able to provide them with a unique service that nobody but a paramedic could offer, but I can't yet.  And it sucks to admit it, but it's the sad, unfortunate truth of American EMS.  There's something very noble about EMS, I think, but we've got a long way to go before we can really step into the role we all so desperately want to play.

Instead of fighting against the truth, we need to be working to make this dream a reality.  Call up your board of EMS today, and DEMAND that they raise educational standards.  DEMAND that they pursue higher level education for paramedics as the standard and that they provide options for increasing your education in EMS besides more alphabet certs.  THAT's going to do a lot more for EMS than arguing the reality with people online.


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## jrm818 (Mar 21, 2011)

KELRAG said:


> To jrm818... Besides the obvious ami/cva/asthma pts you mentioned, look at ARDS net and surviving sepsis campaign. These are two that recognize the benefits of early interventions and suggested their role in prehospital care.



I didn't mean to suggest that EMS is worthless or that there is no benefit whatsoever of advanced prehospital care.  I was trying to agree with the other criticisms of the idea that "ALS" (as currently practiced in the US) is a justified healthcare expense because of all the cool skills that paramedics can perform that basics cannot. 

As far as adding to the list: as far as I'm aware (correct me if I'm wrong), there is not yet any good evidence that starting early goal directed therapy in the field or that implementing ARDS care in the field improves outcomes.  It may well prove to be an area of great potential, however it also may turn out that it doesn't matter if we dump fluids into septic patients 15 minutes early. 

 If we want EMS to grow we can't keep hanging our hat on a short list of specific conditions that benefit from early intervention: the list is short, and unskilled poorly paid cookbook providers can perform interventions just as well.  There needs to be increased value in the form of educated providers who can address the needs of a wide variety of patients in a meaningful way.

ARDSnet and Surviving Sepsis are really great (for patients, and maybe for EMS), and may be a push in the right direction: since there's no prehospital tests for recognizing ARDS or Sepsis, diagnosis might require a bit of clinical understanding and good history/physical skills.  Honestly, I'm not certain a lot of the paramedics I see would do very well at this; I'm not certain that I've been educated well enough myself.  




KELRAG said:


> When it comes to trauma, I don't fully agree with Bledsoe's recent stance on "the golden hour" which arrived from the controversial article dismissing the role of aeromedical services,it seems a little extreme but one of the underlying ideas was that a good portion of stabilization can occur on scene. Too often medics are falling back on the old standard of throwing the pt "in the back" and do all the interventions en route.  This is an opinion held by many Pro-ems EM docs.



I haven't read any comment by Bledsoe, but are you referring to this article?: http://www.ncbi.nlm.nih.gov.ezproxy.uvm.edu/pubmed/19783323 



KELRAG said:


> Addressing the commonly held belief by the international paramedics that pay attention; ems education in the us needs to be improved but it is heading in the right direction. At least in Texas, we now have the pathophys/a&p/bio etc... requirements. I went to a relatively well respected school that takes their  science majors a little too seriously and did decently. To be honest, I don't think the years with test tubes, behind microscopes and buried in text books were overly helpful with being a medic. I know for sure my world lit hasn't done a damn thing. I work with medics that went to community college who are amazing! I can give u an exhaustive explanation on the multiple modulators of dopamine but the best medics know how to work on their feet. As hard as this may hurt. Our job isn't all the theoretically difficult. Common sense in a significant amount of situations will trump "extensive" knowledge of disease processes.



I obviously don't know you, so I can't speak for your experience, but I can say I'm skeptical that you haven't been aided by more education.  I think if I asked most medics I know about "sepsis" "early goal directed therapy" "ARDS" or anything like that I'd get blank stares, some reference to protocols, or "we're not doctors."  You seem to have a rather different view, and I can't help but wonder if your education has something to do with it.

As someone else said: in he US, there is no difference in practice between well educated and poorly educated providers.  In _most _jurisdictions, both versions of "paramedic" practice the same algorithmic approach, which certianly does not require the sorts of thinking skills you practiced in school.  I have no doubt that even most medic mill paramedics are capable of hanging a bag of dopamine according to the recipe.  In the current practice environment it indeed doesn't matter that you understand how it works and they don't.  

That's my point really: I think the sort of education you completed has the potential to increase the value of EMS given the right practice models.  I think this potential is far more than the potential gain in "value" from adding some cooler skills or doing some studies to prove that we can improve outcomes for 6 specific conditions instead of 4.  

That's what I want: I don't want to be in a field that challenges me by seeing how many recipes I can memorize and how long I can spend working long hours for poor pay.  I want to be in a field which challenges me by requiring critical thinking and judgment, gives me tools to meet the needs of my patients, and respects me as a professional.  As Beiber notes, I doubt I'm even qualified to ask for those things, and that's a problem.


And, a defense of lit (I did a lit minor just for fun so I may be a _bit _biased): Lit is great for making you cultured and working on writing skills so you can sound wicked smart, but that's not even the real value.  Analyzing literature (perhaps not in your specific class, there are many crappy lit classes, but in general) requires looking closely at a text, evaluating the authors perspective, biases, and goals, comparing and weighing different bits of information, and ultimately making a judgment about "so, what does this mean?"  The critical thinking skills you practice can be applied to a wide range of environments, including *gasp* EMS: dealing with patients and co-workers, evaluating research or practice advisories, etc.


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## jrm818 (Mar 21, 2011)

medicRob said:


> Numbers may not mean everything, but numbers talk. There is a reason the evolution of medicine relies so heavily on research. Also, as far as research being 'rigged', etc. Anyone with a proper education in research evaluation can spot a so called 'rigged' study from a mile away.



Tell that to the people who took Vioxx...

Sorry, agree with everything else, but have to take issue with this.  There are well recognized problems with attempting to sort the wheat from the chaff in research: it's much harder than you suggest.  There is a good amount of documentation about the failure of peer review to adequately control the quality of studies, the quality of post-publicaiton criticism, the role of buisness and advertising in literature, and the sheer volume of low quality studies that are published.  The editor of the Lancet has said something to the tune of: "we've become nothing but an advertisement for drug companies," and several other editors have made similar statements.  

For a EM perspective,from one of the editors of Annals (just to prove I'm not off my rocker): http://www.ncbi.nlm.nih.gov/pubmed/20702543


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## Veneficus (Mar 21, 2011)

jrm818 said:


> Tell that to the people who took Vioxx...
> 
> Sorry, agree with everything else, but have to take issue with this.  There are well recognized problems with attempting to sort the wheat from the chaff in research: it's much harder than you suggest.  There is a good amount of documentation about the failure of peer review to adequately control the quality of studies, the quality of post-publicaiton criticism, the role of buisness and advertising in literature, and the sheer volume of low quality studies that are published.  The editor of the Lancet has said something to the tune of: "we've become nothing but an advertisement for drug companies," and several other editors have made similar statements.
> 
> For a EM perspective,from one of the editors of Annals (just to prove I'm not off my rocker): http://www.ncbi.nlm.nih.gov/pubmed/20702543



I think what medic rob is trying to say is that a provider must be skilled enough to evaluate the studies and evidence on their own. 

Based not only in statistical analysis which is a must, but also with competent knowledge of known scientific theory as well as experience in clinical medicine.

I read many studies every day and I can agree, it takes me no time at all to recognize garbage when I see it.


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## 18G (Mar 21, 2011)

Bieber said:


> "It's the sad unfortunate truth that you're right, a trained EMT-B who knows how to do the skills could do my job.  My protocols are literally step by step cookbook medicine..."
> 
> 18g, I get what you're saying, but you've got to recognize that Veneficus is right, there's nothing about paramedics that is special as long as are protocols are rigid step-by-step instructions that tell us what to do, as opposed to guidelines that suggest the standard of care to be deviated from per our own discretion and clinical judgment.  As long as you can do a basic assessment and are trained in the skills, you don't even hardly need to be an EMT--a first responder could do what we do.  It's sad to admit it, and I think that's where you're coming from, but it degrades the paramedic and waters it down to nothing but a skill monkey (see, warm body).



I know I said I was done commenting but wanted to comment on this... 

Unless you have some super EMT-Basics where your at (not a slam towards Basics) I would never want them performing high acuity ALS skills! That is way too scary. I recently helped out with a First Responder program and they had a hard enough time remembering their CPR sequence... so you really think a First Responder could learn much higher acuity skills?... ummm.. no. 

Regardless of protocols, you always have discretion and the ability to deviate. Some protocols are much more strict in how you go about doing this, but you can easily do it by consulting with Medical Command. I follow protocols but I also treat my patient with my own clinical judgement. For example, a COPD exacerbation I had who was febrile with highly probable resp infection and dehydrated. Did my COPD/Asthma protocol mention about giving this patient a fluid bolus? No it didn't.... but its called treating your patient, common sense, and being a good practitioner! and no I didnt call MC... there was no need too. Just because something isn't explicity defined in medical protocol does not mean it can not be done. It sounds like I am more fortunate then you here in PA and actually have some decent protocols that treat Paramedics as though they are educated to make clinical decisions.   

I have seen providers use the "its not in protocol" excuse and the too lazy to call command to get their patient what they need. 



> As someone else said: in he US, there is no difference in practice between well educated and poorly educated providers.



Strongly disagree. If a poorly educated provider is not able to formulate the proper general impression or diagnosis, then how are they going to be able to execute the appropriate treatment plan or institute the proper modalities under protocol? Why treat a severe pneumonia patient as CHF when we shouldn't be? So there is a huge difference between a educated and poorly educated provider. I been around long enough to know the difference. 

And I have to ask the question, if nobody believes in ALS then what are you even doing here? Why are you even working as a Medic? With your attitudes, your the last people I would want taking care of someone I know and surely aren't people I would want to work with in the field. 

There is validity to some of what has been said but its not the extreme that is being portrayed.


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## Veneficus (Mar 21, 2011)

18G said:


> And I have to ask the question, if nobody believes in ALS then what are you even doing here? Why are you even working as a Medic? With your attitudes, your the last people I would want taking care of someone I know and surely aren't people I would want to work with in the field.



In many instances in history, the reluctant participant often makes a greater diiference for the better than the zealot.


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## MrBrown (Mar 21, 2011)

jrm818 said:


> As someone else said: in the US, there is no difference in practice between well educated and poorly educated providers.



There is no discernible difference on the outside, and that is how the Fire Service and all the barely homeotasasing loser Parathinktheyare's with poor cerebral perfusion who carry round a cookbook for retarded idiots get away with it.


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## SeeNoMore (Mar 21, 2011)

I am sorry you are offended 18G, I think there are certainly very good paramedics and I agree with you that some of what Paramedics do makes a differene and I think your point about relaving suffering being a wothy goal in and of itself is valid. 

I really do think there should be Paramedics, just less and more focused. But I don't hold much hope for EMS improving, mainly because few seem to expect it. 


I was working a code today at an ER and the person came in with the ET tube misplaced with here distended belly rising with every bvm squeeze. I don't know the medic in question, and I am not saying they were not good overall, but in this case it seemed like quite an oversight as even I , not the brightest bulb nor having ever done an intubation could see the belly rising and how distended it was. 

I was talking to folks after in the ER and they did not seem that bothered, the general impression seemed to be that this sort of thing just happend when medics intubated. Its troubling that we are regarded as barely compent in many areas, and even worse that many in EMS se generally unconcerned with making things bette, even if it means drastic changes.


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## 18G (Mar 21, 2011)

It's cool... I'm not offended. I just don't totally believe all that is being said from three voices out of a million. The situation in EMS needs improvement and that has already been recognized on a National level with changes being made as we type. 

It's not appropriate that only one side of an issue gets heard and stated as absolute. Hopefully, others are able to understand that the EMS system is not as severely broken as is portrayed on this forum and realize that we have many, many great pre-hospital practitioners in our Country that provide very professional, competent, and high quality care everyday. EMS, and ALS specifically, does make a difference and there will always be a desire to have and need Advanced Life Support care in our Communities. 

I support the initiative to raise the educational standards very much and am all for it. In fact I am a huge supporter of it. But at the same time do not belittle the majority of EMS professionals that take their role very serious and provide great care every single day and who already have a solid educational and clinical background. 

Having RN, MSN, and whatever else behind your name doesn't automatically make you the best person for the job either. Education is vital but isn't the end-all of what makes a great EMS provider. 

So take both sides into consideration and think of your own field experience and formulate your own opinion. I highly encourage ALL regardless of cert level to always strive to learn more and prove to certain people in the world that you aren't a bunch of idiots and are very capable and do in fact provide awesome EMS care.


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## Veneficus (Mar 22, 2011)

18G said:


> Hopefully, others are able to understand that the EMS system is not as severely broken as is portrayed on this forum and realize that we have many, many great pre-hospital practitioners in our Country that provide very professional, competent, and high quality care everyday.




If there were so many great providers being a paramedic would be a reputable healthcare profession that could stand on its own.

Not a bunch of protocol driven laborers who have held EMS back in the stone ages with their saving lives lights and sirens response time matters mentality while the rest of the world advanced.

If that is the measure of great, we could all do without it.

Have a look at a majority of protocols and practicioners around the country.

Congratulations on a job not done hero.


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## 18G (Mar 22, 2011)

Veneficus said:


> If there were so many great providers being a paramedic would be a reputable healthcare profession that could stand on its own.
> 
> Not a bunch of protocol driven laborers who have held EMS back in the stone ages with their saving lives lights and sirens response time matters mentality while the rest of the world advanced.
> 
> ...



Now your task is to make your face known and make your statements in a very public forum, in person Nationally. If you have all the answers and have this thing figured out and everyone else is wrong then step up and let it be known. I mean if millions of people who have much more experience then you who actually are doctors are all wrong, then please... be our EMS savior and get us out of this horrible, horrible mess. Please save us all from these thousands of horrendous monsters called Paramedics.  

Write for JEMS, EMS World, and other Publications and let the world know your position and how you can solve the problem. You will be lauded as a real hero then. As I already stated I never claimed to have all the answers and am a willing participant to make the system better. Your obviously not. So get out and stop complaining since you obviously lost the desire.  

It's quite easy with anonymity to put down a group of people. You already admitted you say what you do because your jaded. Your biased which is obvious.


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## boingo (Mar 22, 2011)

I remember an RRT that had a similar outlook....


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## 18G (Mar 22, 2011)

Vene and VentMedic would make a great couple...lol.


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## 8jimi8 (Mar 22, 2011)

18G said:


> Now your task is to make your face known and make your statements in a very public forum, in person Nationally. If you have all the answers and have this thing figured out and everyone else is wrong then step up and let it be known. I mean if millions of people who have much more experience then you who actually are doctors are all wrong, then please... be our EMS savior and get us out of this horrible, horrible mess. Please save us all from these thousands of horrendous monsters called Paramedics.
> 
> Write for JEMS, EMS World, and other Publications and let the world know your position and how you can solve the problem. You will be lauded as a real hero then. As I already stated I never claimed to have all the answers and am a willing participant to make the system better. Your obviously not. So get out and stop complaining since you obviously lost the desire.
> 
> It's quite easy with anonymity to put down a group of people. You already admitted you say what you do because your jaded. Your biased which is obvious.




You haven't been reading close enough obviously.  Every Week he posts part of the solution to the problems in EMS.  Part of that is recognizing the weaknesses.

You keep shouting about how great care paramedics are providing, when you don't realize that.  the Paramedic "INITIATES" care.  Vene is trying to get you to realize the potential of "DEFINITIVE" care.

Get off your high horse and help him.


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## 18G (Mar 22, 2011)

8jimi8 said:


> You haven't been reading close enough obviously.  Every Week he posts part of the solution to the problems in EMS.  Part of that is recognizing the weaknesses.
> 
> You keep shouting about how great care paramedics are providing, when you don't realize that.  the Paramedic "INITIATES" care.  Vene is trying to get you to realize the potential of "DEFINITIVE" care.
> 
> Get off your high horse and help him.



I more then get it. 

Paramedics providing definitive care was never the intention of EMS which makes it not appropriate to be slamming Paramedicine for performing its original mission. A new and expanded role for the Paramedic is certainly a great thing and an area I see great potential as well. But again, don't portray what Paramedics currently do as falsely as possible in hopes of achieving the new expanded role more quickly.   

An expanded role is a whole NEW territory. So why expect it to happen over night? Your gonna get much better response and initiative of providers by encouraging and supporting current Paramedics then you will by belittling them and filling them with animosity which naturally leads to resistance. That's what I'm saying. 

By its very nature field care is "initial" care and is a very important phase to dedicate ones self too. Your mentioning "initial" care as if its of lesser importance.

And during this entire thread I haven't heard anyone else offer suggestions. All I have heard is that all Paramedics suck and are worthless pretty much.


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## 8jimi8 (Mar 22, 2011)

18G said:


> I more then get it.
> 
> Paramedics providing definitive care was never the intention of EMS which makes it not appropriate to be slamming Paramedicine for performing its original mission. A new and expanded role for the Paramedic is certainly a great thing and an area I see great potential as well. But again, don't portray what Paramedics currently do as falsely as possible in hopes of achieving the new expanded role more quickly.
> 
> ...



I haven't seen anyone say paramedics suck. quit acting all butthurt and step up and drag the industry forward.  Quit crying about yesteryear's mission.  The mission is evolving.  Sorry i really have no more to add to this.  i'm checking out.


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## usalsfyre (Mar 22, 2011)

18G said:


> Paramedics providing definitive care was never the intention of EMS which makes it not appropriate to be slamming Paramedicine for performing its original mission.


But it is appropriate to slam EMS for not recognizing or being willing to step up and take care of the need at hand.  



18G said:


> A new and expanded role for the Paramedic is certainly a great thing and an area I see great potential as well. But again, don't portray what Paramedics currently do as falsely as possible in hopes of achieving the new expanded role more quickly.


You, I and probably most others on this forum understand the absence of evidence does not equal the evidence of absence. Unfortunately, this isn't an easy sell to legislators who allocate the money. At some point, these people are going to start asking some very uncomfortable, hard to answer questions about what their money is getting them. Without evidence, it's not going to be easy to sell our role.    



18G said:


> An expanded role is a whole NEW territory. So why expect it to happen over night? Your gonna get much better response and initiative of providers by encouraging and supporting current Paramedics then you will by belittling them and filling them with animosity which naturally leads to resistance. That's what I'm saying.


I don't disagree with you here BUT....any mention of requiring paramedics in my area to do more education is met with screaming, threats, calls for the union to get involved where applicable, ect. This is not a few lo level providers, this is from most providers, and a lot of the service administrators here. 



18G said:


> By its very nature field care is "initial" care and is a very important phase to dedicate ones self too. Your mentioning "initial" care as if its of lesser importance.


It's initial but never definitive. It's expensive, and refers patients to a more expensive area of medicine because we've decided we can't trust providers. Expensive=bad in the current healthcare environment.



18G said:


> And during this entire thread I haven't heard anyone else offer suggestions. All I have heard is that all Paramedics suck and are worthless pretty much.


Honestly, I'm more and more getting to the attitude that most paramedics DO suck. Because they refuse to get with the program and realize they can offer a lot more to the average patient. They suck because they want more money to do what is right by most patients. They suck because they don't realize how limited their knowledge really is. I'm not referring to most of the paramedics who read and post here regularly, I'm talking about the "just average" guy at your service. I'm sick of hearing the complaining and the desire for respect without wanting to do the work to achieve it. I'm sick of hearing paramedics tell patient's "we're not a taxi" despite having nothing more to offer than transport in the majority of cases. 

There's alot of leaders on here who could lead EMS out of the dark age it's in. But the low to average level providers are liable to lynch them first.


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## Veneficus (Mar 22, 2011)

18G said:


> Now your task is to make your face known and make your statements in a very public forum, in person Nationally. If you have all the answers and have this thing figured out and everyone else is wrong then step up and let it be known.



It is not that I have all the answers and everyone else is wrong.

I have my own perspective on what the answers are and what is wrong. 

Do you really think that my opinion that EMS needs not only more education but to diversify hasn't been said by anyone else for the last 20 years?

Do you think Industry leaders in Places like Wake County haven't figured it out? 

Even the current writers for many of your esteemed industry magazines have said the exact same thing. If I thought adding my name to it would help, I would do so. But all it would buy is "Who the hell is he to say these things?"

Even titles are not respected. There is a medical director in Naples Florida who is a real doctor who tried to do what he feels is best for patients by EMS. Did you follow how far that worked out?

I have signed my name to some direct accusations to some internationally recognized doctors in EMS that it was their neglect and impotence that allowed this to happen. 

You know the response?

"We are impotent because services we demand more of have us replaced by somebody more willing to play ball."

That is a direct statement demnstrating it is providers holding it back. Not physicans. 

You are doing the samething every mediocre parathinkyaare around the nation is doing. Claiming to be good enough and making excuses to not actually do anything for yourself. 

Your life saving ability doesn't even qualify you to work on a truck in any other modern nation. You have simply effectively sold your snake oil to the American public and politicians.




18G said:


> I mean if millions of people who have much more experience then you who actually are doctors are all wrong,



Are you suggesting that millions of doctors are actually advocating what the modern US EMS system is vs. simply making it that way because they are not currently capable of more? 

Are you suggesting that protocols are not written for the least common denominator of practicioner?

Are you suggesting that EMS effectiveness is measured in response times because doctors who know think it should be?

Do you think high flow o2 as protocol saves lives because an EMS director signed off on it. Because in the first days of medical school we were told that was poor medicine. If doctors are teaching future doctors things like this, why are the great life saving EMS providers still doing it?

Why does every doctor which much more knowledge and experience than I may ever hope to possess tell me to quit wasting time with EMS?

Becuase it is effective?

You may have helped a handful of patients in your career simply because you were better than nothing, but it certainly doesn't make it great.



18G said:


> then please... be our EMS savior and get us out of this horrible, horrible mess. Please save us all from these thousands of horrendous monsters called Paramedics.


 



18G said:


> Write for JEMS, EMS World, and other Publications and let the world know your position and how you can solve the problem.



First off, I would never write for that utter trash of a magazine called JEMS. I would be forever contaminated. 

One of the editors of EMS world posts here, if he wanted an article, he has but to ask. 




18G said:


> You will be lauded as a real hero then.



Like every other person who has said similar things in different ways? 

Pearls before swine... 




18G said:


> As I already stated I never claimed to have all the answers and am a willing participant to make the system better. Your obviously not. So get out and stop complaining since you obviously lost the desire.



If you are willing to make the system better, why instead of actually doing some research to provide something concrete, or lobbying to make a degree a requirement to be a "life saving paramedic," do you simply supply anecdotes of when you are valuable? Especially when those make up probably 5% of your total work load.

What if paramedics were only paid when their care made a demonstratable difference in outcome?

If you haven't noticed, in the US, there is a growing effort to only pay for medicine that actually makes a demonstratable difference at all levels.   



18G said:


> It's quite easy with anonymity to put down a group of people. You already admitted you say what you do because your jaded. Your biased which is obvious.



Am I any more biased than you are?

Despite having no demonstratable evidence to your effectiveness, despite not being qualified to touch a patient in any other modern country. Despite all your treatments end with "transport to the ED." Despite the fact there are major published studies demonstrating EMS is not cost effective. Despite a plethora of studies demonstrating paramedics have trouble with everything from intubation to destination selection based on out dated concepts, you seem to think paramedics are worth what they are paid because they save lives, occasionally, when the patient falls into your treatment algorythm, not because they have the tools and knowledge to select what is best.

Tell me, if paramedics are so smart and capable, keeping in mind that I not only worked as a medic but teach them also:

Why do they have to be told to take trauma patients to a trauma center?

Why do they have to be told to take cardiac patients to a cardiac center?

Why do they have to be told to take stroke patients to a neuro center?

Why are those things not only in education but written into protocols?

Why do paramedics tell people how great the local hospital is by saying it is a level I? Level one what? Trauma center? Because if I was having an MI, or a CVA, or even COPD exacerbation, I wouldn't give a crap what kind of trauma service a place had.

Incidentally, if being a paramedic is so effective, why do all the upper end ones seem to move on to other healthcare fields? How many doctors, nurses, RTs, etc are simply using that profession as a stepping stone?

Why does the average EMS provider quit after 5 years?


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## 18G (Mar 22, 2011)

I'm not gonna buy into the stance that every US Paramedic is a complete idiot and moron with no sense about them and who cannot manage patients effectively and appropriately.

Take a bunch of RN's and put em in the field and your still gonna need a framework of policies, directives, and protocols. Perhaps a bit different then what is written now, but its not gonna be unlimited practice and decision making. 

Unfortunately, I have to work full and part-time and will be going back to school next semester to finish some classes and also have kids, so I don't have the time or energy to lead a charge for EMS reform. Put the changes in place and I'm there. Force of hand is probably what its going to take. EMS providers will step up or move over... Union or no Union. Sometimes that is what it takes. States or perhaps the EMS movement in the Federal government is gonna have to say this is the way its gonna be, this is the new stage for EMS... learn the lines or get off the stage and allow the pieces to fall into place from there. 

I don't like the excuses anymore then the next person but at the same time I don't dismiss and overlook the many Paramedics who do a great job everyday. 

It's been a nice discussion but I'm gonna have to agree to disagree. Vene, you do pose some valid question and point out issues that need attention and I do agree with those. But the overall tone is what I am disagreeing with. Paramedics as a whole are not worthless... some, definitely... but not the majority. I appreciate you (and everyone else) taking the time to share your position and I do respect your knowledge and experiences that seem to be considerable and certainly more then my own. I am a hard headed person and am passionate about my field and believe in what we do (obviously, right?). So naturally I am going to pull from my almost two decades of EMS service and oppose insults to my profession and peers when they are unwarranted.


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## SeeNoMore (Mar 22, 2011)

I agree that force is necessary, and I think some states and systems will force change, and others will just sort of wallow for a while slowly watching their scope of practice diminish. 

For systems that want to improve, I think there is a future. Some states are moving towards associates degrees, not enough but a step better than becomming a paramedic with no formal anatomy and physiology etc. 

These systems will have to reduce the number of medics and the burden will be on us to prove that what we do can be useful. I think EMT's can handle a lot of prehosptial work, but you shoud have paramedics for interfacility transfers, flight crews, tiered responses to certain calls, and hopefully community paramedecine. I also think that Paramedics can probably make a bigger difference in rural areas, though I can not find many studies on this. 

But  If study after study shows a particular intervention or way of doing things is not working, it should go. This goes for Emergency medecine in general, for all the studies about paramedics not helping particular groups of patients, often I know the ED will do very similar interventions or make similar mistakes, like using ACLS drugs or stopping compressions for several minutes while they fiddle with a tube instead of placing another adjunct. And no I am not one of those folks that does not respect Dr's or in any way feel I am as smart or educated, all I am saying is that there are problems in many areas of medecine. 


But I have gotten a lot from this discussion.


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