# Do we REALLY save lives?



## rescue1 (Feb 8, 2012)

Hi all,

Maybe it's just my early semester blues hitting me, but during one of my weekly grumble sessions about one of my volunteer ambulance companies, I had a depressing thought. My college town's EMS agency is slightly old fashioned, boasting response times of around 10 minutes for calls a few miles away, and providers who barely squeak by their EMT recerts (and anyone who's taken a Maryland recert course should know you have to try very hard to fail). Yet as a friend and I were discussing the benefits of the town being served by a paid ALS service instead, I couldn't help but think...would the citizens actually be better off with a new service?

Think about it...many new studies show that with the exception of serious trauma and arrest (which is probably around 1-2% of EMS runs), response time, and even scene to hospital time, has little overall effect on patient outcomes. Other studies show that ALS may be less effective then BLS care when dealing with trauma (though some have disputed that). I've seen many patients survive serious medical issues despite the best efforts of providers to kill them with improper care. So while we sit here and talk about professionalism and increased standards for EMS, my question is...how good much do we actually do?

I know we serve as a gateway for people to enter the hospital system, serving as a triage of sorts...strokes to the stroke center, MVC victims to the trauma center, people with headaches persisting for several weeks to the local ER, etc.

There's cardiac arrest survival too...EMS is basically the only hope for out of hospital SCA victims...but they account for a handful of EMS runs.

But for the other 90% + of our calls, (discounting the headaches, the nursing home runs, and the lights and sirens to the scene at 4am to find a chronic diarrhea patient calls), do we really make a big difference? If there were no ambulance, and people were driven by family members or upstanding local police officers, how worse off would the public be?
Or if we were back in the early days of EMS, and all we have in our arsenal is a fast response time and a giant box of gauze, would our patients be worse off in areas where the hospital wasn't unreasonably far away (which by my guess is probably 80% of the country)? 

Or can someone show me how higher education and training standards will lead to significant increases in patient care outcomes? Because while I am all for increased education, it's difficult for me to think about spending large sums of cash upgrading paramedics and EMTs to new, great standards while I watch a system with slow response, minimal training and outdated equipment transport alive and stable patients to the hospital every day.

I can justify my existence as a firefighter--without the FD, city blocks would burn, people would remain trapped in cars and kittens trapped in trees. My friend can justify his existence as a cop--without police, life would be a little more exciting and dangerous for obvious reasons. But without EMS? People would have to...find someone to drive them to the hospital.

I'm not trying to bash EMS, far from it. I want someone to jump up and prove me wrong and show me that EMS is good and awesome and fantastic and that paramedics with 4 year degrees will make it better. So please, tell me how great EMS is and that I'm wrong.


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## Aprz (Feb 8, 2012)

I support increasing education hoping that it would reduce the number of people we unnecessarily transport to hospitals, and to manage their problems sooner rather than waiting for the ER to solve it. Our education standards and the system works, but it's not good; we can do better.


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## Melclin (Feb 8, 2012)

If driving people to hospital is all EMS is doing in your area then maybe it is reasonable to question it. 

To me the idea of improving education and standards is all about actually being worthwhile to the community. I think it is sometimes reasonable to question the idea of EMTs being taxi drivers with AEDs.

Its interesting, and perhaps indicative of the "company" you feel you keep, that you compare yourself to police and fire. The first people I think of when comparing paramedics to someone are other healthcare professionals. I'm not being nasty, but I think its an interesting observation. If you see yourself and being only for emergencies and life saving, CPR and car accidents and bells and whistles and blood and guts, then yeah, you might start asking questions. I'd argue that a lack of all that doesn't mean we're useless, because the bulk of work and benefit to the community can be felt in other ways (if appropriately educated).

*I did a little "study" I suppose you could call it.* Maybe personal audit might be a better word. I forget the stats exactly and I can't find the papers right now but I'll give you what I had written in my notepad from a while back. Basically what I did was that for about a month I categorised jobs into one of the following categories:

1. Those I felt a reasonable lay person would or should call an ambulance for.

2. Those that I felt a reasonable lay person would recognise needed to go the ED but could have got there via their own means or gone in their own time (things like lac requiring suture + tentnus at 0330, ?bowel obstruction with significantly distended abdo in an ambulant CA pt with family and a car).
3. Those that a reasonable person would not call an ambulance for and that could and should be managed through their GP or self care. 

Then for each job I noted whether or not an intervention was performed. I didn't include advice/referral as an intervention but I soon realised I should have given that its own category. I also didn't include cannulation where I didn't give any drugs or fluids (it was a just in case cannulation or a line for the hospital to do bloods with).

I went to 42 jobs as the attendant during "data collection" . I was surprised at the results.

-68% of jobs I classified as one for which a reasonable lay person would call 000. (I thought it would be much less, and this felt like a bad month in the regard too, so I'd wager about 3/4 in most months).
-9% should have recognised that an ambulance wasn't needed and got to the ED themselves (but notably it was often not their fault because ridiculous advice lines, like "nurse on call" that basically tell people to call an ambulance regardless of complaint, told them too. 
-23% could have been handled via GP or self care.

I performed a meaningful clinical intervention in 23% of these cases, mostly pain relief.

I got several things out of this audit:

*1.* We don't go to as much BS as I thought. You could make an argument the about 3/4 of what we went to actually required that we be there to assess a pt (a reasonable lay person, or even a HCP, would have called 000). Maybe we weren't required to medically intervene, but its not the public's job to know that in advance, and, at the very least, a decent healthcare assessment was required. So I don't see it as a waste and 3/4 ain't bad.

*2.* The intervention rate was higher than I thought - I actually got hands on with more people than I thought.  

*3.* The number of time wasting idiots who should have known better was actually quite low when I really thought about it and circumstances surround each job.

*4.* Not included in the data collection but something that kept coming up again and again, was that for every single self care/GP job and for others as well, I was educating, advising and referring. 

*Example*: To CA pt with D&V since chemo, "Oh see than Ondansetron there, that is for nausea and its better than that other one, so remember to take that next time. Now tomorrow I want you to do a couple of things. I need to you try and eat some small amounts of food. Small portions, well spaced out. Yep those ones you planned. Send husband down to the pharmacy. Get some gastrolyte, they come in icy poles too which are good if you don't feel like you can drink or eat much, and some gastrostop, and talk to the pharmacist about them, explain whats happening, they're really helpful and he'll tell how and when to take them if you need them. Now stay away from sugary drinks. I know mum always said flat lemonade when you're sick but its actually worse for your diarrhea", ***write it all down + a note to the pharmacist explaining the situation and asking for his/her advice***. "Now if you feel dizzy, or you spike a fever. Head down to the ED, but its unlikely that you'll need an ambulance. Are you happy with and do understand the plan we've made?" 

Other examples include spending time on the phone with pt's doctors, case workers etc and sorting out what kind of care pathway is best for them. I've found specialists and GPs are really helpful if you take the time to ask.

I went to a job once where a baby had been "throwing up blood". After a little detective work we found out that the antibiotic syrup she was on was red and she'd spit a little up. During the worrying, dad fainted and we looked him over too. After about an hour spent there, thoroughly assessing baby and then dad, treating dad, making care plans for both of them, reassuring them, exchanging favourite pasta bake recipes and having a bit of a laugh, we left. As gloried first aiders we could have transported baby and dad in a second ambulance, wide eyed, to hospital L/S, clogged up the system, adding to their worry. But as well educated healthcare professionals ourselves I'd like to think we brought about a better outcome for everyone involved. They wrote in several weeks later to thank us too which is always nice, but the point is that, yeah as a glorified first aider who drives people to hospital, we probably couldn't have added much more to that situation other than an unnecessary trip to hospital and a uselessly dangerous and expensive L/S drive. But as actual HCPs we did, not because we ourselves are so smart or wonderful or any of that crap, its just that its the way our system works and I think its one of the things that actually makes us useful. That's the benefit, not of ACLS or ALS or whatever, but of proper HCPs as opposed to drivers with first aid certs. 

Doing all this, I don't doubt that I make a reasonable difference (not in some heroic way but in the same sense as anyone else makes an actual contribution to the society they live in with their skills and expertise) some of the time.

I don't mean to waffle on about being better or smarter and so on. Thats not my point. Its just something to consider, a different system and some different ideas.


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## the_negro_puppy (Feb 8, 2012)

Melclin said:


> If driving people to hospital is all EMS is doing in your area then maybe it is reasonable to question it.
> 
> To me the idea of improving education and standards is all about actually being worthwhile to the community. I think it is sometimes reasonable to question the idea of EMTs being taxi drivers with AEDs.
> 
> ...









Well said. I've often thought of keeping a log of the types of jobs I go to myself. I find it good that in Australia our job inst necessarily just to drive people to hospital. We can be a social worker, counsellor , community and emergency health worker all rolled into one.


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## firecoins (Feb 8, 2012)

The goal of EMS, BLS or ALS is more than saving lives. A good number of my calls involve taking people to the hospital where other means were not practical.  Many patients needed more involved care than putting them in the back of a car.  People who required lifting over obstacles etc etc.


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## Veneficus (Feb 8, 2012)

*the myth of EMS and public safety*

As you have discovered, EMS isn't really a public safety service.

The fire and police departments serve for the benefit of society. Whether in crime/fire prevention, intervention or investigation, they serve to keep society functioning.

EMS provides a value to individual members of a society which in turn permits them to remain (hopefully productive) in society.

The first problem with US EMS is it exists for a world that no longer does. When only a handful of people had any real medical knowledge and those people were called doctors. In those days, they also knew about all there was to know about medicine.

Some doctors came to the conclusion that people would be helped on the way to the hospital with some simple interventions. So they got together and made some stuff up they thought would help.

This made up stuff had to be simple, easy to teach to people who didn't go to medical school or have any background in science. Most of all it couldn't cause a lot of harm if applied to the wrong patient.

Thus EMS came into existence in the US.

As these new providers were taught by doctors, it became apparent they could function at a higher level. The doctors were very interested in furthering this new field and with strict oversight and criteria, ALS was born.

Having given EMS its start, these doctors either died, retired, or faded from view for the most part. For decades now EMS has had no direction and very few advocates. The old guys became the instructors, teaching outdated information and skills to the younger ones. Reliving the glory days.

But the world advanced, other healthcare professions really started embracing the new knowledge, and the doctor can no longer know it all, because there is too much to know.

But rather than embrace these changes US EMS resisted change. Prefering instead to focus and master skills. 

But disease that affects people changes over time. 100 years ago if you got an infection, you would most likely die from it. In history, many of these diseases were acute in onset. Acute treatment was a valid solution.

In today's world, the diseases of our day are chronic. The largest killers develop over decades and are not responsive to acute treatment. Procedures like cardio bypass maintain function as best they can, they do not reverse disease.

So when you try to use yesterday's treatments, for yesterday's reality, you become invaluable and obsolete. As our knowledge of medicine advances, the expert opinion of yesterday is dispelled.

I can't imagine why anyone would pay for care like that. Certainly I can't imagine why anyone would respect people doing it.

If you look at EMS in other nations, they struggle to build a modern and valuable service.

They focus on what helps today. Sometimes it is the treatments of yesterday, but rarely. Sometimes they act as the gateway and direct people to the most appropriate resource. (In the US they have to make protocols to take trauma patients to the trauma center and not the nearest hospital. Why do you think those rules need to be made, seems rather intuitive doesn't it?) Sometimes these modern providers can solve the patient's problem at home, teach them how to self-care for pathologies. They are the house call, the first resort at a reasonable cost, for patients to even determine if they need to pay for higher levels of care.

These modern paramedics provide help for modern diseases in the modern world. The very money and other resources they save justifies their value to society at large.

In these modern nations, in order to provide this service, it takes years of education, not hours. It takes educated people, not skilled people. 

These nations enact laws mandating that municipalities provide these services, both for the patient and because of the money it saves society at large in everything from healthcare costs to productivity hours.

The question these nations face is not "why would anyone pay for paramedics?" The question is " How do we fund these paramedics because the money they save society is far greater than what they cost."

Who wouldn't pay for that?

It is not really a point of saving lives or reducing pain and suffering. As public health experts discovered as far back as Ancient Rome, a healthy society is a productive society. A productive society is a wealthy society. That wealth makes a better quality of life for all levels of the social spectrum. It doesn't give all levels of society the top quality lifestyle.

So to answer your question directly:

Why should you pay more for an educated provider? Because you get more.

Why should you pay more for the current level of provider? You shouldn't, because what they deliver doesn't justify the cost now.

The pain management argument is moot. Ask any working person without insurance if they would rather suffer an hour or 2 in pain or pay $600 to relieve that pain faster.

A couple hours of pain is a small price to pay when relief of that pain causes you to miss your rent, or electric bill, your ability to cloth yourself, or pay for gas to get to work.

For any population, a paramedic who can treat your ankle sprain and cost you a couple hundred dollars and send you on your way (maybe cost shared from taxes) is worth far more than a paramedic who takes you to a place where you have to pay $1000 or more for the same.    

But in order for a paramedic to do that, it doesn't take xrays or labs, etc. It takes education.


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## Ramis46 (Feb 8, 2012)

I think that you also have to look at it from not just our point of view but from a culture in general. What i mean is I wor for a small rural Hospital based system. On any given day we see alot of the "BS" the chronic headache, Back Pain, or the CP call that we all know is anxiety, or someone just needs attention. We know as EMS providers that people know the system and that they read stuff on the internet and know that we can't deny them transport to the ED. That means they can (in our system for the most part) bypass any wait time and for the most part with Iowa's health care system don't have to pay for their taxi service. 
That being said though the acutal calls we attend to that are true emergencies, I feel that our training is great. Granted some of the skills should be practiced on a more regular bases. But the thought of more educations, We have more CE than nurses by almost 3 X. As often as we have to go back to BLS, ALC, ACLS, PHTLS, PEAR, PALS, (and/or whatever other class we have to take.)


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## DrParasite (Feb 8, 2012)

rescue1 said:


> Maybe it's just my early semester blues hitting me, but during one of my weekly grumble sessions about one of my volunteer ambulance companies, I had a depressing thought. My college town's EMS agency is slightly old fashioned, boasting response times of around 10 minutes for calls a few miles away, and providers who barely squeak by their EMT recerts (and anyone who's taken a Maryland recert course should know you have to try very hard to fail). Yet as a friend and I were discussing the benefits of the town being served by a paid ALS service instead, I couldn't help but think...would the citizens actually be better off with a new service?


taking a couple things into play: college towns typically have a healthy population of aged 18-30year old people, who outside of doing something stupid (fall, injuries, minor trauma, or drunks) will be pretty healthy.  

urban/poorer cities tend to use EMS as a taxi service, since they don't want to go to the doctor or can't afford a ride.

but while I always joke about EMS is about saving lives, it's more about making a difference.  sometimes going out at 3am to check the vitals of a 70 year old lady, telling her she is going to be ok, and keeping her company for 20 minutes can make all the difference in her day.


rescue1 said:


> I can justify my existence as a firefighter--without the FD, city blocks would burn, people would remain trapped in cars and kittens trapped in trees.


really that's your argument?  what if I told you all fires go out eventually (even if they end up running out of fuel), people who remain trapped in cars is just an example of darwinism, and I have never seen a cat's skeleton in a tree?  doesn't that just blow three big holes in the justification of your existence as a firefighter?


rescue1 said:


> My friend can justify his existence as a cop--without police, life would be a little more exciting and dangerous for obvious reasons.


ask your friend how often he has drew his gun in his career.  now ask him how many times he has fired his gun in the line of duty.  bet the first number isn't that big, and the second number is less than 3.

so maybe those reasons aren't what you think?  or rather, they aren't as common as you think?


rescue1 said:


> But without EMS? People would have to...find someone to drive them to the hospital.


right.  but what if they couldn't drive?  what if they didn't have a car?  what if they didn't need a hospital, just needed someone to check them out?  or if you are 30 minutes from a hospital, and having an asthma attack and lost your inhaler, how long can you hold your breath for? 

basic things that save lives: Heimlich maneuver for choking victims, bleeding control, airway control for unconscious people, and CPR/early Defib.  much of the rest of what we do doesn't save lives, but makes for a much more comfortable existence for the patients (splinting, carry downs, even much of the ALS stuff, the patient would still survive the trip to the ER most of the time, just end up in worse shape long term without ALS care).


rescue1 said:


> I'm not trying to bash EMS, far from it. I want someone to jump up and prove me wrong and show me that EMS is good and awesome and fantastic and that paramedics with 4 year degrees will make it better. So please, tell me how great EMS is and that I'm wrong.


I think FFs do have a role in the world  I think cops do as well. EMS isn't about saving lives (but we defiantly do more than the FD, just when we save a life, it isn't cool or sexy or able to be publicized due to pt confidentiality laws) or being great, it is just a field that serves a need to help the public.

I don't know if 4 year degreed paramedics will save more lives than 2 years degree paramedics, or diploma paramedics.  or masters degree paramedics.  but while I do think more education is rarely a bad thing, I think the city needs to decide what level of service it wants for it's taxpayers.


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## EpiEMS (Feb 8, 2012)

Under the assumption[/URL] that a reasonable cost per quality adjusted life years (QALY) is anywhere from £20,000 (according to the UK's National Institute for Health and Clinical Excellence, which decides quite a bit about what treatments the NHS will pay for) up through $100,000 (see http://marginalrevolution.com/margi...lue-of-life-and-the-value-of-health-care.html), an intervention that might be reasonable to implement are public AEDs (http://www.ncbi.nlm.nih.gov/pubmed/14656838) or perhaps calling for HEMS for serious trauma cases (http://www.ncbi.nlm.nih.gov/pubmed/9326865). 

More research on cost-effectiveness is key to improving outcomes — deploying dollars properly is just as important as deploying providers. From a business of healthcare perspective and a policy one, the question isn't "Does EMS save lives" but "Is EMS saving lives in a cost effective way? If not, where should the money go?"


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## Veneficus (Feb 8, 2012)

EpiEMS said:


> More research on cost-effectiveness is key to improving outcomes — deploying dollars properly is just as important as deploying providers. From a business of healthcare perspective and a policy one, the question isn't "Does EMS save lives" but "Is EMS saving lives in a cost effective way? If not, where should the money go?"



If I could just comment on the part I didn't quote?

Compared to all of the estimates I have seen over the last 10 years, the QALY article is grossly underestimated.

Now the quote.

I don't think you can change the efficency of EMS without changing the entire US healthcare system.

That is a tremendous task that as far as I can see is going to require a total collapse of it first.

As it stands, the US is the only country I know of where spending is not tied to some measure of effectiveness. 

A very good example is the cost an quality of life studies of hemodialysis vs. peritoneal. (there are many and citing one does not do justice to the argument.) 

The long and short of it is that while peritoneal dialysis is only usuable for a short period compared to hemodialysis, the quality of life maintained is the same for both during the peritoneal dialysis effectiveness period. 

After that, the hemodialysis pt basically becomes a medical cash cow until they finally die from complications.

From the practical point, dialysis you get at home while sleeping, sounds like it allows better selectivity in spending life how you like than going to a dialysis center 3 days a week and getting a protocol based filtration. You lose at least those 3 days.

The cost difference between the 2 is also disproportionate. Guess which one costs more?


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## Shishkabob (Feb 8, 2012)

The reason why studies 'show' EMS has little overall effect on patient outcomes is because the vast majority of the calls that EMS is called for are non-emergent, not legitimate use of 911. (Note, I did not say non-legitimate medical complaints, but 911, which is intended strictly for life and limb threatening emergencies) When most of your calls are for things such as a broken toe or the flu, of course you'll have little if any impact on patient outcome.  It's not the fault of EMS, it's the fault of uneducated civilians misusing 911.  EMS is evolving to be out of hospital medical care, gaining things that can help patients more in that realm, but again, that is not the intent of 911, and should be separated as such.




However, you cannot doubt that calls that 911 was intended for, you know, true time sensitive medical emergencies, (cardiac and respiratory arrest. severe allergic reaction,  decompensating CHF, hypoglycemia. narcotic overdose, status asthmaticus), EMS either helps greatly, or is the most notable cause of survival.   Granted, it's a "team effort" for survival, but alas, without some of the prompt interventions that EMS does out in the field, without a doubt,  some of the patients would otherwise be dead.



A real, life saving call is rare, but they happen, and I can say without a doubt I've saved atleast one in the past year.


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## Mountain Res-Q (Feb 8, 2012)

I think I understand the route of your question, and while I agree with everyone's lengthy (and correct) responses, lets see if I can sum this up:

QUESTION:  Why do we need a higher level of education to provide this level of service?

ANSWER:  With a higher education, maybe you wouldn't be providing that level of (dis)service!

The same could have been asked of Civil War medicine; why does a Civil War Surgeon need any level of education to hack away limbs?  With a higher level of knowledge and education that is no longer the standard of care.  It is called progress.  In regards to EMS, the United States is often operating in a "Civil War" mindset, and maybe some portions of the States are operating in the Dark Ages.  Education is the only way to make progress; that and we kill all the bureaucrats!  EMS becomes something more when we stop trying to make it akin to Fire, Law, or the Postal Service, and a sub-specialty of the medical field; which requires a higher level of education than is presently encouraged.

You assume that the existence of EMS can only justified by the lives saved.  Reality check; lives are never saved.  Best case scenario, you can prolong a life; they still die eventually.  Worst case, you simply help in a way that can not be easily quantified; either physically, mentally, or emotionally.  How do you justify the existence of Law Enforcement?  By the number of tickets written?  The number of bullets fired?  Or the amount of crime prevented or solved?  I would say, the last!  But how do you quantify that impact?  For EMS, if the standard is "lives saved", then how do you justify the existence of many aspects of the medical field?  I think your criteria when comparing EMS to Fire, Law, or any other Medical Profession needs some modification.  Also, I think your experience in your region and with your service has jaded your perspective; a reflection of what some would call a "Civil War System" and not the reality of EMS elsewhere or the potential capability that has not been seen in much of the U.S.


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## Brandon O (Feb 8, 2012)

I see my life is 90% relieving pain and distress, 9% improving outcomes and reducing morbidity, and 1% saving lives. If you can be okay with that, this job makes much more sense.



> ... shortly after they put me to work, I began to realize that my year of training was useful in less than ten percent of the calls, and saving someone's life was a lot rarer than that. I made up for this by driving very fast, one call to another -- at least I looked like a lifesaver -- but as the years went by I grew to understand that my primary role was less about saving lives than about bearing witness. In many cases the damage was done long before I'd been called, and there was little I could do to reverse it. I was a grief mop, and much of my job was to remove, if even for a short time, the grief starter or the grief product, and mop up whatever I could. Often it was enough that I simply showed up. . . . Calling 911 is a fast and free way to be shown an order in the world much stronger than your own disorder. Within minutes, someone will show up at your door and ask you if you need help, someone who has witnessed so many worse cases than your own and will gladly tell you this. When your angst pail is full, he'll try and empty it.
> 
> Bringing Out the Dead


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## firecoins (Feb 8, 2012)

Veneficus said:


> As you have discovered, EMS isn't really a public safety service.
> 
> The fire and police departments serve for the benefit of society. Whether in crime/fire prevention, intervention or investigation, they serve to keep society functioning.
> 
> ...



I would disagree with that. What your describing is very much a public service. Many fire calls affect one house or less than that. Many Police calls that affect one person. 

We benefit society which sometimes means saving lives.  Sometimes it means other things.


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## Tigger (Feb 8, 2012)

Brandon Oto said:


> I see my life is 90% relieving pain and distress, 9% improving outcomes and reducing morbidity, and 1% saving lives. If you can be okay with that, this job makes much more sense.



I can't come up with a better way to sum up my thoughts on my job. My job is not to save lives. I am able to do so should the situation arise, but if you can't break the mindset that lives are more often than not saved by being in the right place at the right time, EMS will wear on you. If you can accept that you're job is attempt to relieve pain and suffering (and yes BLS can certainly do this), you'll be alright.


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## patput (Feb 8, 2012)

The service I am affiliated with covers an area of nearly 500 square miles, and we see anywhere from a call every 30 minutes to a call every 2 days, but generally we fall in the middle, 4 or so a day. From my limited experience and talking to the medics that have been around for a while the majority of the calls in our district are BS calls. I know for me probably about 25% of the calls we go to patients will sign off. The next 70 or so percent will go to the hospital for something they probably never needed to call 911 for in the first place, and the last 5% I feel like we actually make an impact in someones life. The use of ALS techniques here for those 5% are definitely prominent though, and I feel that if it had been only a BLS provider some of them could have turned out differently.


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## Shishkabob (Feb 8, 2012)

Tigger said:


> I can't come up with a better way to sum up my thoughts on my job. My job is not to save lives. I am able to do so should the situation arise, but if you can't break the mindset that lives are more often than not saved by being in the right place at the right time, EMS will wear on you. If you can accept that you're job is attempt to relieve pain and suffering (and yes BLS can certainly do this), you'll be alright.



I don't think anyone has an illusion otherwise... HOWEVER, the reality is:

EMS is 90% acting as a taxi for the lame and lazy, 9% helping those who truly need more than just a ride, and 1% making life or limb saving decisions.


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## Brandon O (Feb 8, 2012)

Tigger said:


> I can't come up with a better way to sum up my thoughts on my job. My job is not to save lives. I am able to do so should the situation arise, but if you can't break the mindset that lives are more often than not saved by being in the right place at the right time, EMS will wear on you. If you can accept that you're job is attempt to relieve pain and suffering (and yes BLS can certainly do this), you'll be alright.



The nice thing is, if you just figure that you're here to help people however you can, it relieve you of the constant burden of asking "_is this really a *proper* use of 911?_" Should the homeless guy really have called for an ambulance? Does it reveal some deficit in his personhood? Is it a good use of finite system resources?

I have no idea; determining that isn't my job, or at least isn't my job while I'm working the road. But will it make him any happier? Sure, it's warm and they have food there, that's probably why he called. Sounds good, let's go dude, what kind of music ya like?

("But what if he's drug seeking, Mr. Preceptor?" "Dang, then he needs this stuff _extra_ bad.")


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## Mountain Res-Q (Feb 8, 2012)

Linuss said:


> EMS is 90% acting as a taxi for the lame and lazy, 9% helping those who truly need more than just a ride, and 1% making life or limb saving decisions.



"[EMS], my dear friends, is 93% perspiration, 6% electricity,
4% evaporation, and 2% butterscotch ripple." -Willy Wonka (1971) :rofl:​


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## Tigger (Feb 8, 2012)

Linuss said:


> I don't think anyone has an illusion otherwise... HOWEVER, the reality is:
> 
> EMS is 90% acting as a taxi for the lame and lazy, 9% helping those who truly need more than just a ride, and 1% making life or limb saving decisions.



Most people that have some time in EMS don't have said illusion. But for people that are just starting out, it can be tough. I had a partner recently that would figure how far away the emergency calls that the medics were getting and then call dispatch to see if they needed "assistance." I know of a guy who carried a scanner to buff city calls while working for a private so that he could be first on scene to save a life. 

Some people will struggle to find that tiny bit of satisfaction from readjusting the sheets under a patient to make them a little comfortable or even just holding their hand.


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## rescue1 (Feb 8, 2012)

Wow, lotsa replies. Thanks guys, especially Vene and Melclin--that's the sorta stuff I was looking for.
Just as an aside, my first post was written at 2am, so if it came across a little disjointed, that's my bad. I also don't want people to get the idea that I think EMS is about nothing but life saving and danger and carrying orphans in respiratory arrest out of buildings. I think the ricky rescue live-saver culture is absurd, and I have to deal with it every single day, in the form of people swaggering around talking about how cool it will be able to intubate patients.

I think EMS has the potential to be more then the taxi service which is currently is in most areas of the US. I don't need to be convinced that community paramedicine and treat and release programs are part the future of EMS. So I guess anything with "lifesaving" in it was a poor choice of title. I should probably have said "How effective really is US EMS?"

As I said earlier, my impetus for posting this was a discussion at my volly squad where I was, as usual, discussing the various benefits of being a staffed, ALS equipped ambulance. Someone posed the question "Give me an example of someone who died because we took 10 minutes to get there with a BLS crew instead of 2 minutes with an ALS crew" (the hospital is right in town making transport times short, as an aside). I could only, off the top of my head, mutter something about witnessed cardiac arrest.
Now obviously, this is still in the mindset of EMS being a primarily lifesaving organization, but it had some validity to it. Why would a community pay more for this supposedly "better" paid service when the bumbling volunteers can still get similar outcomes? I mean, I knew US EMS had some issues, but that just seems absurd. 

(Note, this is not a bash on volunteers, I'm sure there are quite a few good volunteer ambulances in America. I just don't deal with good ones on a regular basis)





DrParasite said:


> really that's your argument?  what if I told you all fires go out eventually (even if they end up running out of fuel), people who remain trapped in cars is just an example of darwinism, and I have never seen a cat's skeleton in a tree?  doesn't that just blow three big holes in the justification of your existence as a firefighter?
> ask your friend how often he has drew his gun in his career.  now ask him how many times he has fired his gun in the line of duty.  bet the first number isn't that big, and the second number is less than 3.




Well, first, the kitten thing was just a little sarcastic. That and saying that all fires go out eventually is like saying everyone dies eventually, so why have health care?

But all those points still stand. Fire and Police are public safety agencies who impact society is very measurable and noticeable ways. If you have no firefighters, a blaze could destroy lots of buildings and cause huge economic hardship. No police, and people run around stealing stuff. You can't possibly be arguing that police and fire are unnecessary services. It's more difficult to quantify the benefits of traditional American ambulance services.




(Disclaimer, all of the above was typed while buzzed out of my mind on energy drinks)


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## Shishkabob (Feb 8, 2012)

Brandon Oto said:


> The nice thing is, if you just figure that you're here to help people however you can, it relieve you of the constant burden of asking "_is this really a *proper* use of 911?_" Should the homeless guy really have called for an ambulance? Does it reveal some deficit in his personhood? Is it a good use of finite system resources?
> 
> I have no idea; determining that isn't my job, or at least isn't my job while I'm working the road. But will it make him any happier? Sure, it's warm and they have food there, that's probably why he called. Sounds good, let's go dude, what kind of music ya like?



Yet, the issue is the opportunity cost:  Helping someone who doesn't need it is taking the resource away from someone what DOES need it.  I'd rather help a diabetic who's unconscious with a BGL of 22 then taking granny to the hospital because her legs hurt for a week and she's tired of it, but refuses to do the logical thing and see a PCP, but rather get a big ambulance and ER bill that she won't pay, or expects medicare to pay in full.


If they are willingly abusing the system, they don't need access to the system.  If they are unknowingly misusing the system, they need to be educated of this and provided with different alternatives.



We will never solve the problem if we let people think what they do is ok or acceptable, or even correct.  Nip the issue in the bud, tell them what they did is incorrect, mistaken, or just plain wrong, educated on how to fix, and ensure they follow it in the future.


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## medic417 (Feb 8, 2012)

Linuss said:


> Yet, the issue is the opportunity cost:  Helping someone who doesn't need it is taking the resource away from someone what DOES need it.  I'd rather help a diabetic who's unconscious with a BGL of 22 then taking granny to the hospital because her legs hurt for a week and she's tired of it, but refuses to do the logical thing and see a PCP, but rather get a big ambulance and ER bill that she won't pay, or expects medicare to pay in full.
> 
> 
> If they are willingly abusing the system, they don't need access to the system.  If they are unknowingly misusing the system, they need to be educated of this and provided with different alternatives.



This is why every Paramedic should have the ability to say no to people that do not need ambulances.  Sadly though we all know there are people that just have the certification yet can't even safely transport much less decide no.  So my theory is fire anyone to stupid to be able to learn to say no when appropriate.


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## Brandon O (Feb 8, 2012)

rescue1 said:


> As I said earlier, my impetus for posting this was a discussion at my volly squad where I was, as usual, discussing the various benefits of being a staffed, ALS equipped ambulance. Someone posed the question "Give me an example of someone who died because we took 10 minutes to get there with a BLS crew instead of 2 minutes with an ALS crew" (the hospital is right in town making transport times short, as an aside). I could only, off the top of my head, mutter something about witnessed cardiac arrest.



I think my response was a little too preachy to make the point I intended, which is: I feel much of the benefit of ALS, when used appropriately, is to relieve suffering. They can provide analgesia, anti-emetics, anxiolytics, sedatives; they can improve work of breathing; they can even, quite frankly, provide a better placebo effect and reassuring presence with all their interventions and blinkenlights. To me, that's big, which is why it annoys me when medics can't be arsed to push the morphine or zofran or otherwise put emphasis on palliative measures.


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## Brandon O (Feb 8, 2012)

Linuss said:


> YWe will never solve the problem if we let people think what they do is ok or acceptable, or even correct.  Nip the issue in the bud, tell them what they did is incorrect, mistaken, or just plain wrong, educated on how to fix, and ensure they follow it in the future.



If you mean this as a "how to fix EMS" solution, you may be right. But if you mean this as a recipe for "how to work in EMS as it exists today," I find it to be a fast road toward burnout. Because if you can only perceive your role as a responder to emergencies, then on most calls you will be disappointed, since they're not. (And quite frankly, this will probably remain true even in an ideal world, because people will still call when they don't _know_ whether something's an emergency -- that's why they called for a medical professional to advise them -- and in most cases, it won't be. But unless we want to start writing off large numbers of the population, that doesn't mean they were wrong to seek help, because it could have been.)

I also think that the sole perception of our emergency role attracts a far lower quality of provider than the alternative.


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## Shishkabob (Feb 8, 2012)

Brandon Oto said:


> Because if you can only perceive your role as a responder to emergencies, then on most calls you will be disappointed, since they're not.



Trust me, having been in EMS for 3 years, I know my role isn't solely emergencies.  However, my role SHOULD be solely legit medical complaints that either require, or could be helped by, my knowledge and expertise.    Having the flu for 2 weeks, with no other complaints, , while a 'legit medical complaint', doesn't count.    While leg pain could indicate an MI or PE, if you've had said leg pain for a week and nothing is different, you don't need an ambulance, you need to figure out why you didn't call for a taxi 5 days ago.  Etc etc.

Just because we CAN help with an issue, doesn't mean they are using the right resources.  Sure, FD CAN get a cat out of a tree, but would anyone argue that is correct usage of that resource, and that they should do it all the time, no questions asked, without trying to educate the people calling for it?


The issue isn't so much being called to a place when someone has a questions, it's them expecting a ride to the hospital, demanding said ride, even though they have no legal right to an ambulance, let alone a transport in one, or a transport in one to the destination they want.




You know one of the first questions I ask someone who calls for a minor complaint?  "Why don't you take the medication you're prescribed for the issue you're calling for?" or  "What made you wait so long to seek medical care?"  Sure, it's had volunteer FFs complain about me making it seem like "Their complaints are not worthwhile", but I find it's the best way to try to educate someone, by understanding their thoughts behind their actions.  Does it change how people act?  Not as much as I want, but alas, it keeps me sane knowing I am trying to help people in the best way possible, which is guiding them away from thinking of the ambulance solely as a taxi and seeking the proper help, sooner, and much more affordably.


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## Veneficus (Feb 8, 2012)

Brandon Oto said:


> If you mean this as a "how to fix EMS" solution, you may be right. But if you mean this as a recipe for "how to work in EMS as it exists today," I find it to be a fast road toward burnout. Because if you can only perceive your role as a responder to emergencies, then on most calls you will be disappointed, since they're not. (And quite frankly, this will probably remain true even in an ideal world, because people will still call when they don't _know_ whether something's an emergency -- that's why they called for a medical professional to advise them -- and in most cases, it won't be. But unless we want to start writing off large numbers of the population, that doesn't mean they were wrong to seek help, because it could have been.)
> 
> I also think that the sole perception of our emergency role attracts a far lower quality of provider than the alternative.



Well said,

I woukld just like to restate, the "emergency, life saving role" of EMS was initiated in a time when large amounts of people suffered acute events that could be acutely corrected.

If you think your job is "real emergencies" in this day, bad news, they are going to become less frequent, not more. 

For those of us that started before mandatory seatbelt usage, when cars were tanks with wheels, and even car seats were unheard of, every car accident was an emergency. There was no such thing as "no patient" and the interventions that are directed towards class III and class IV shock we used regularly. (we didn't know they didn't work then as they don't work for what they are designed for now) 

respiratory problems, diabetics, etc are all chronic problems. They are managed chronically with the occasional acute exaserbation. That is the way of the future every aspect of medicine is governed by it, not just EMS.

Death is no longer the enemy to be conquered, palliative and end of life care is back.

Trauma that 20 years ago would definitively get you an emergent laparotomy will not longer even be operated on.

Whether you are managing the chronic drug fiend, urban outdoorsman, or full code nursing home patient, the days of Johnny and Roy coming to the rescue are gone.

Even your Emergency STEMI alert is going to receive treatment based on their overall health. 

Do you really think the 90 year old lady with a complicated history is going to the OR for a hip replacement?

Do you think the 65 year old chest pain call with decades of untreated hypertension, arteriosclerosis, and renal insufficency automatically qualifies for a CABG or intravascular stent?

How about after his previous 3 stents and CABG?

Really, you think the chronic poorly controlled diabetic is saved by your interventions? They just live to die another day, often being hacked apart a piece at a time.

Your CHF patient who can't breath today, won't be able to pee in a few years. Enter in the IFT dialysis derby. For at least 3 days a week of their life wasted and complicated with compartment syndromes from volume overload, unhealing wounds, cellulitis, neuro deficits, bleeding, clotting, etc.

Well, there still are the once in a blue moon anaphylaxis patients right?

Welcome to modern medical reality heroes.

"Your feeble skills are no match for the power of the dark side."


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## titmouse (Feb 8, 2012)

that quote from "Bringing out the dead" was crazy .


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## RocketMedic (Feb 8, 2012)

Sounds like you're a bit bitter,Veneficius 

. Where are you in Europe?


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## Veneficus (Feb 8, 2012)

Rocketmedic40 said:


> Sounds like you're a bitter



It is not that I am bitter, I am realistic and very tired of hearing people put forth the same sad and outdated dogma. 

The cutting edge of medicine is all molecular and biochemical.

From genetically engineered viral treatments to blood banks created with stem cells.

Many surgical techniques are approacing perfection, from off pump bypass to 20 minute cross clamp times on aortic repairs.

Despite the lag time from academic research to clinical acceptance, treatments and thinking not 20 years old are rapidly becomming obsolete.

Can you imagine how far behind EMS is still using treatment modalities from the 60s and 70s today?

There are political leaders in the US asking why they should pay for ALS, not just people on this forum.

I have been fortunate in my time from the fire service to medicine and everything in between I have done, to be around basically when things change from an old way to a new. It gives the benefit of knowing what was and what will be.

It is frustrating when people can't keep up. It is a flaw in _homo sapien_ to desperately cling to a world they knew. But more important than mental security is not getting caught with your pants down when somebody asks you to justify why you are being paid. (the purpose of this thread)

I see trying to drag EMS into the future like trying to drag a person out of a burning building and having them resist you the entire way. The only difference is, instead of naturally selecting themselves out, they are going to take a whole industry with them.

Many industries over the years have found themselves obsolete, when that happens people find themselves unemployed or underemployed. While it doesn't affect the young people as hard, look at all the people in their 50s today who are out of work with skills no longer desired by employers who still need to work.

In another 10 years at the going rate, the people with 5-10 years in EMS today can realistically see themselves being paid worse or unemployed completely without marketable skills if they do not enact change. (the most logical being from emergency response as a primary function to emergency response as a colateral function as the predominant pathology changes)

Both the fire service and law enforcement figured out a long time ago proactive and preventive in the way to ensure a future. While I support it for EMS, it is not something I made up.

Given the avoidance of change in EMS during the past and the economic realities of today, change will have to be accelerated.

The people inhibiting it are dragging the field down and actively stopping it from becomming a proud profession with a future for its members.   

While some will doubt my altruism from my manner, ask yourself:

What do I have to gain by ensuring there is a future for EMS and spending effort getting it there?

As far as I can tell, nothing at all. 

I have benefited greatly from my time in the Fire and EMS services and I do hope to give a little back, as well as be one of the people who moved on who still look out for the people I came from.

Looking out for somebody other than yourself may not be popular in America now-a-days, but it was the ideal that dinosaurs like me lived by. Not only for our communities, but for our coworkers as well.



Rocketmedic40 said:


> Where are you in Europe?



Katowice, Poland.

But it is fair to say I travel a lot. Including to the US to teach EMS and AHA classes for months at a time.

I have also been to a few other places as a medical provider on my breaks.


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## Brandon O (Feb 8, 2012)

titmouse said:


> that quote from "Bringing out the dead" was crazy .



Great, great book for anyone in EMS. Pitch-perfect illustration of true burnout.

Movie's good too, and actually a very close adaptation. Check out both.


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## Tigger (Feb 8, 2012)

Linuss said:


> If they are willingly abusing the system, they don't need access to the system.  If they are unknowingly misusing the system, they need to be educated of this and provided with different alternatives.



Someone that is willingly abusing the system still needs access to the system. It is no one's right to say "you called EMS too many times for BS," we aren't taking you anymore. I'm not quite sure what you meant by the above point, so if I have erred I apologize but I think the rest of my point still stands.

Even patients that make our job suck by forcing us to go to their crappy homes twice a week for a BS ride to hospital might still need an ambulance for a legit issue and if you scare them out of the system, they're not getting it and then we have done that patient a huge disservice. Some will say that that's what they deserve for calling wolf so many times, I guess I just think we can do better.


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## EpiEMS (Feb 8, 2012)

Couldn't it be that the system, with all the third party payment problems, is the issue? If there's no payment, there's no way for incentives to align.


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## titmouse (Feb 8, 2012)

I know its not gonna be Epic all the time, but I personally believe that its gonna make me a better person, and being able to assist people in my community that really require help is something that I am looking forward to.


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## Shishkabob (Feb 8, 2012)

Tigger said:


> Someone that is willingly abusing the system still needs access to the system. It is no one's right to say "you called EMS too many times for BS," we aren't taking you anymore. I'm not quite sure what you meant by the above point, so if I have erred I apologize but I think the rest of my point still stands.



Probably didn't phrase it right:  2 points,

Point one:  EMS, and transport from it, is not a right.  You can demand a ride all you want, but it's not illegal to refuse it to you, hence why a few agencies can, and do, refuse transport.


Point two:  You read my thread about the MedStar article.  If someone is labelled a system abuser, they still get an APP to come and check them out.  If it's legit, an ambulance is used to transport.  If it's not legit, a medical director refusal takes place where the medical director refuses transport.  

For system abusers who are still transported, they have home hospitals.  They can ask / demand to go to any other hospital, but they can only be taken to the 'home' hospital.




If you're willingly abusing the system, there needs to be repercussions.  If I call 911 every day for police for something that is not legit, I can expect to be arrested.  If I call for a fire everyday that is actually just a candle, you can expect me to be arrested.  Why is this different?  Am I talking about arresting people?  Not necessarily.  But there needs to be something to dissuade the abuse... and monetary ones clearly aren't working since they refuse to pay the bills anyhow.


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## Melclin (Feb 8, 2012)

Tigger said:


> Someone that is willingly abusing the system still needs access to the system. It is no one's right to say "you called EMS too many times for BS," we aren't taking you anymore. I'm not quite sure what you meant by the above point, so if I have erred I apologize but I think the rest of my point still stands.
> 
> Even patients that make our job suck by forcing us to go to their crappy homes twice a week for a BS ride to hospital might still need an ambulance for a legit issue and if you scare them out of the system, they're not getting it and then we have done that patient a huge disservice. Some will say that that's what they deserve for calling wolf so many times, I guess I just think we can do better.



We have means by which problem callers are dropped down the list of priority. If it turns out badly for them well then they should have read the boy who cried wolf. I must say though, that this is in a different sort of system. These people have access to all the healthcare they want. They just chose to call us repetitively because they're lonely or not coping with life. Thats sad, but whats sadder is that someone else could die while every ambulance in town is there patting them on the head and saying there there.


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## Handsome Robb (Feb 8, 2012)

rescue1 said:


> I can justify my existence as a firefighter--without the FD, city blocks would burn, people would remain trapped in cars and kittens trapped in trees. My friend can justify his existence as a cop--without police, life would be a little more exciting and dangerous for obvious reasons. But without EMS? People would have to...find someone to drive them to the hospital.



EMS exists for a reason. Not everyone has a ride to the hospital. Sure we don't save lives all the time, but I can show up on scene and make someone much more comfortable, care for them and make their family feel better on the way to the hospital. I can show up to a diabetic problem, start a line, give them dextrose, make them a sandwich in theory "saving their life" because you can't survive without glucose as well as taking a load off the local ER system because most don't want to go to the ER after we fix em up and make them food.  That's what it's about not "saving lives". Why does everything have to be about saving lives and being a hero?

How many fires are there compared to EMS runs? "City blocks would burn?" Really?  If something needs to change the fire service needs to be cut back and EMS needs more support, but that's just me.


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## rescue1 (Feb 9, 2012)

NVRob said:


> EMS exists for a reason. Not everyone has a ride to the hospital. Sure we don't save lives all the time, but I can show up on scene and make someone much more comfortable, care for them and make their family feel better on the way to the hospital. I can show up to a diabetic problem, start a line, give them dextrose, make them a sandwich in theory "saving their life" because you can't survive without glucose as well as taking a load off the local ER system because most don't want to go to the ER after we fix em up and make them food.  That's what it's about not "saving lives". Why does everything have to be about saving lives and being a hero?
> 
> How many fires are there compared to EMS runs? "City blocks would burn?" Really?  If something needs to change the fire service needs to be cut back and EMS needs more support, but that's just me.



This has nothing to do with being a hero...it's about the effectiveness of a well run professional EMS system compared with a poorly managed EMS system in the the current US system, in which EMS exists primarily as a vehicle to transport patients rapidly to a hospital. 
How can I justify (mainly in my mind) how a professional, fast, well trained ALS service is significantly better then a volunteer squad with a slow response and minimal training, with chase ALS a ways away? Basically see my second post, where I explain my point a bit better.

I'm not a whacker wanna be who's upset that I can't save people every day like they do on Trauma, trust me.

Also, I'm not saying that fire threatens us on a hourly basis and could destroy cities at any second...I'm just saying there is a real and measurable consequence to not having fire protection.


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## DrParasite (Feb 9, 2012)

rescue1 said:


> Well, first, the kitten thing was just a little sarcastic. That and saying that all fires go out eventually is like saying everyone dies eventually, so why have health care?
> 
> But all those points still stand. Fire and Police are public safety agencies who impact society is very measurable and noticeable ways. If you have no firefighters, a blaze could destroy lots of buildings and cause huge economic hardship. No police, and people run around stealing stuff. You can't possibly be arguing that police and fire are unnecessary services. It's more difficult to quantify the benefits of traditional American ambulance services.


no its not.  I shot all your points full of holes, you just refuse to realize them.  and your not alone, the FD and PD unions are great fear mongers.   don't fund the FD, and your house will burn down.  don't fund the PD, and you will become the victim of a crime.  that's the argument.

it's very easy to quantify ambulance service.  if you don't have EMS, you have a greater chance of not recovering if you experience a medical emergency or a traumatic injury.  the difference is, most people don't think they will ever need EMS.  As such, they don't want to pay for EMS, because they don't want to pay for a service that they will never need.

the difference is, FD and PD don't have any confidentiality issues like EMS does.  FD or PD delivers a baby, and it's news.  EMS does, and it's not.  FD saves someone with a defib, and they tell the media.  if EMS does, they can't.  if someone gets shot 12 times, the PD usually has a statement about what happened.... EMS rarely speaks to the press, and has the misguided notion that no news is good news.  no one thinks they will ever need EMS, and few people (outside of those IN EMS) actually know what EMS does.

Few fires will burn city blocks, even in urban cities.  you put the tower up, surround and drown, and the city block is saved.  usually the loss is just a house, maybe an exposure if the delay is that great. but it isn't a city block unless there are other factors at play.

think of it this way:  if EMS doesn't do anything, and should need to justify their existence, why have EMS calls nation wide steadily risen in numbers in the past 40 years?  apparently someone keeps calling for EMS and more and more people are calling them.


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## ffemt8978 (Feb 9, 2012)

DrParasite said:


> think of it this way:  if EMS doesn't do anything, and should need to justify their existence, why have EMS calls nation wide steadily risen in numbers in the past 40 years?  apparently someone keeps calling for EMS and more and more people are calling them.



For discussion purposes only:
Stating that EMS can justify its existence simply because more and more people call them is not taking into consideration the nimber of people that call EMS simply for a taxi ride to the ER because they use the on duty ER staff as their GP.  Nor does it take into consideration the increase in IFT calls because nobody wants to take on the liabilty of taking granny to the nursing home or the doctors office.

Better systems than EMS can be implemented to address these issues, but EMS (like the FD and PD) is terratorial by nature and does not want to give up anything that can be used to justify its continuing existence.

Sent from my Android Tablet using Tapatalk


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## rescue1 (Feb 9, 2012)

DrParasite said:


> Few fires will burn city blocks, even in urban cities.  you put the tower up, surround and drown, and the city block is saved.  usually the loss is just a house, maybe an exposure if the delay is that great. but it isn't a city block unless there are other factors at play.




Yes...because they have a fire truck to do that. I'm not talking about "oh god, if we brownout an engine company everyone will die". I was talking about not actually having a fire department. Like, at all. 

Besides, this is a minor point to the discussion. I'm not advocating cutting EMS funding to fund new fire apparatus, I'm not suggesting that the fire department is somehow better then EMS or "saves more lives". I'm using the fire department as an example of a service that produces, for the most part, easily noticable results. When the fire engine shows up and puts out a fire, it's easy to say "This is what the firefighters did and why it's good that they did that." I can compare two departments and say that one puts out fires faster and more safely than the other. I can do the same with plumbers, electricians, and restaurants too, the example doesn't change. 

Here, lets look at it this way. Pretend that you have to sell your paid ambulance service to my town. How do you convince the Big Cheeses that your paid ALS ambulance will be worth the extra tens thousands of dollars to the town compared with an unstaffed BLS volunteer ambulance which we have now.

Forget the fire department and the cops, just answer me that.


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## Handsome Robb (Feb 9, 2012)

rescue1 said:


> This has nothing to do with being a hero...it's about the effectiveness of a well run professional EMS system compared with a poorly managed EMS system in the the current US system, in which EMS exists primarily as a vehicle to transport patients rapidly to a hospital.
> How can I justify (mainly in my mind) how a professional, fast, well trained ALS service is significantly better then a volunteer squad with a slow response and minimal training, with chase ALS a ways away? Basically see my second post, where I explain my point a bit better.
> 
> I'm not a whacker wanna be who's upset that I can't save people every day like they do on Trauma, trust me.
> ...



Sorry I shouldn't have snapped. Working 84 hours a week between clinicals and work has made me a bit ragged. 

Agreed many EMS systems are run backasswards in this country, however many run just fine. 

People might hate me on here because I always reference my agency but when we are having door to ballon times of 20-25 minutes when we call a STEMI alert we are doing something right. Do we have longer times than that? Absolutely but It is rare to have a time of greater than 45 minutes. Hell often we get Pt contact to ballon times of 45-60 minutes with routine transport rather than lights and sirens. Time is tissue. Is EMS abused, I agree and many systems need a reconstruction on their operations. My point is I don't know many volley agencies who are able to make things like this happen.


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## Veneficus (Feb 9, 2012)

*If I could point out...*

Everyone, in every industry, has to justify their value everyday.

EMS is not an exception to this.


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## rescue1 (Feb 9, 2012)

NVRob said:


> Sorry I shouldn't have snapped. Working 84 hours a week between clinicals and work has made me a bit ragged.



Hey, don't worry about it. I'm running on little sleep too and I have a medic school entrance test coming up, so I'm in the same boat.


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## RocketMedic (Feb 9, 2012)

*Points at Detroit*
Fire and EMS done correctly do a lot more prevention than response, and without a robust law-enforcement arm...



DrParasite said:


> no its not.  I shot all your points full of holes, you just refuse to realize them.  and your not alone, the FD and PD unions are great fear mongers.   don't fund the FD, and your house will burn down.  don't fund the PD, and you will become the victim of a crime.  that's the argument.
> 
> it's very easy to quantify ambulance service.  if you don't have EMS, you have a greater chance of not recovering if you experience a medical emergency or a traumatic injury.  the difference is, most people don't think they will ever need EMS.  As such, they don't want to pay for EMS, because they don't want to pay for a service that they will never need.
> 
> ...


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## RocketMedic (Feb 9, 2012)

Simply put, ALS saves lives sometimes. What's the mayor going to say when his daughter goes anaphylactic at her school or little Timmy chokes on meat or Mr. Oldrichwhiteguy spends three hours onscene with an MI because no one assesses the possibility of MI? Or Mrs All-American and family linger in horrible pain for an hour because they wrecked 30 minutes from a city at 1700?

When in doubt, copy fire and paint a bleak picture of a world without ALS while we present our best image to the public.


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## Veneficus (Feb 9, 2012)

Rocketmedic40 said:


> Simply put, ALS saves lives sometimes. What's the mayor going to say when his daughter goes anaphylactic at her school or little Timmy chokes on meat or Mr. Oldrichwhiteguy spends three hours onscene with an MI because no one assesses the possibility of MI? Or Mrs All-American and family linger in horrible pain for an hour because they wrecked 30 minutes from a city at 1700?



Well, he could say:

"While this may seem like a tragedy, your taxes are the lowwest in the Western World, so the Smith family has made a great sacrifice in the American dream of the government not taking your money."

A flag, a wreath, and a rock with an empassioned speech about being a self sacrificing hero is a lot cheaper than ALS.

Or he could say "Only in socialist countries does the government take your money and give it to your lazy good for nothing neighbor, so if Timmy chokes and dies, his family should have gotten a better job to pay for the concierge doctor to respond  like I did when my daughter was having an alergic reaction."

How about?

"If little timmy was working as the school janitor or shining shoes on the corner instead of being at school, he would be able to afford his own healthcare coverage. Since he can't, let him die." (The people at republican debates seem to think this is cool.)

"Maybe Mrs. All American and family should go to church and ask them to pay for their EMS and medical bills like they did back in the 50's. It's not the government's problem"

Will this suffice or do I need to type up a few more?


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## RocketMedic (Feb 9, 2012)

Veneficus said:


> Well, he could say:
> 
> "While this may seem like a tragedy, your taxes are the lowwest in the Western World, so the Smith family has made a great sacrifice in the American dream of the government not taking your money."
> 
> ...



Remember that for the public the system generally works, and many of us are insured. Cutting ALS service will not be seen as politically possible when fire departments and private ambulance services lobby to keep paramedics. Most American s want care, even if it means a bill. You can't paint a national system like ours that is so fragmented in one stroke.

Not having ALS drops you in the 1950s and prompts ALS.


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## Veneficus (Feb 9, 2012)

Rocketmedic40 said:


> Remember that for the public the system generally works, and many of us are insured..



:rofl:

I think you need to do way more research on Americans without insurance and underinsurance.

Additionally, in every nation throughout history, people at the lower end of the economic spectrum are sick/injured more often more severely, and can absorb less loss of production capacity. Which means your poorest people put the largest burdon on the system.

As for that insurance, as soon as you are out of work with an injury or illness for a couple of months, not only will you burn through your entire savings, you will lose your insurance, because the critical flaw in the US medical system is the only people who can afford insurance are the ones working. If you are working, you are generally not sick. (as for if you become sick, see the losing your insurance part.)

Next, when you retire or disabled, you become part of the government insurance, like medicare. Which means all the money you paid in premiums and the profits generated by such (which is how insurance works) is kept by a private company while your healthcare bills at that point get picked up by taxpayers.

In essence, in the civillian world, you pay your premium copay out of your wages, then you pay medicare tax, you are ineligible for medicare until you are disabled/past your productive work years, so you are literally paying twice for something you will only ever get once. (and as I said, never see a return on your insurance investment)

If you haven't noticed, medicare is unsustainable and every year there are new and creative ways required to cut it. Rather soon, it will require a significant reduction in benefits or tax increase. (Want to lay a wager on which it will be?)  You will one day depend on those benefits unless you are independantly wealthy enough to absorb the inflation adjusted cost of healthcare out of pocket. 

Not sure of your definition of "works" but that certainly doesn't meet mine.

Another "works" is since most people will use EMS once or twice in their life they cannot make an informed decision on whether it works or not. But in my experience, they are definately not getting what they think they are paying for. (like treatments that are harmful or do not work.) 





Rocketmedic40 said:


> Cutting ALS service will not be seen as politically possible when fire departments and private ambulance services lobby to keep paramedics. Most American s want care, even if it means a bill.



I would like 2 types of steak for dinner along with some Russian black caviar and a bottle of Dom. But I am not getting it even if it means a bill. You know why? Because I cannot afford to pay the bill. 

Now if the supplier billed me and I defaulted, then the supplier will go out of business. Which means the next person or time I would like such a fine meal, there will be nobody there to sell it to me. Medicare, private insurance, and private pay all work the same way. If the payer defaults, the supplier (EMS, hospital, Doctor, etc) all go away. 



Rocketmedic40 said:


> You can't paint a national system like ours that is so fragmented in one stroke.



Yes I can. Very accurately, watch. 

The US healthcare system is a private pay system. Money always has to change hands. Sometimes that money comes from tax payers, who share the cost of paying the care. (EMS to hospital) Private insurance companies, who not only need to maintain liquidity but ever increasing investor profit margins in order to stay in business to pay again, or it comes out of the individuals pocket.

Which means, when tax dollars alone will not cover the cost of responsive ALS ambulance, and it becomes so expensive that other payers can't either. ALS ambulance is going away or becomming strictly pay to play. (probably as a subscription service upfront) 



Rocketmedic40 said:


> Not having ALS drops you in the 1950s and prompts ALS.



I have said it many times, but here it is again. 

ALS is not a need, it is a want. It is a higher level of care with fancy bells and whistles. You may need a ride to the hospital, you may want a paramedic. But if you can't afford the later, you will settle for the former.

Starting to see how this works now?

Medicine was created to protect and preserve wealth. When medicine costs more than the loss of a certain level of wealth, it no longer benefits anyone to have it. Think of it like this:

If generation A works hard and passes down a house (shelter) and money generating resources (like investments) and even cash, Generation B does not have to work to reproduce these assets. Which means what Generation B produces increases the family standard of living. (and generation C so on down the line.)

If the good people in generation A wind up with a sickness that costs more to treat they assets they have, they lose all and generation B starts over from 0. (this perpetuates poverty.)

But let's say generation A is now 65-80 years old, and wants to break the poverty cycle. You know what that means when they get sick?

It is more beneficial for the familiy if they die than to pay for medicine.

If generation B decides they will be altruistic and take care of generation A, at some point, the cost of that care will be so high, that thier production does not match their consumption. 

Elderly, out of work, working adults, and children are all consumers. 

Working adults are the only produces.    

When consumptions outpaces production, it leads to defualt and contraction. If you are alive in the modern US, you definately should understand how that works, because it is happening to you.

Imagine that in healthcare.

People can no longer pay for the cost of cardiac bypass, so the hospital stops offering cardiac bypass. Now you need cardiac bypass and you cannot find a supplier. By chance you manage to locate one, but since so few people actually can afford it, he has to charge more for the people who can.(Regardless of outcome) So if he charges more than you can possibly pay, even if you liquidate all of your extended family assets, you can't have it.

Nobody is going to give you a loan, becuase it would be an unacceptable risk to the lender. After 40+ years of messing yourself up, you have to be returned to a level of function that you could continue in a job long enough at a high enough pay to pay back your debt. At 65+ after a CABG, that is an unacceptable gamble for a lender.

You can spout all day about altruism, doing the right thing, etc. 

But money talks and BS walks.

Show me the money.


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## rescue1 (Feb 9, 2012)

Rocketmedic40 said:


> Remember that for the public the system generally works, and many of us are insured. Cutting ALS service will not be seen as politically possible when fire departments and private ambulance services lobby to keep paramedics. Most American s want care, even if it means a bill. You can't paint a national system like ours that is so fragmented in one stroke.



Remember that you are talking about the US healthcare system--the one that spends more money per capita then most other countries while providing less overall care.


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## RocketMedic (Feb 9, 2012)

American health care is not perfect. However, I do not see the entire system collapsing into rubble where only EMT-Basics take their 1997 E350 into the wastelands of abandoned hospitals to see faith healers.

Communities invest in ALS services every day, and those services do save lives. The proliferation of ALS service since the 1960s is proof that our communities do want more care than AEDs, Epi-Pens, and Kerlex. 

By Veneficus's standards, it's too expensive to actually have or staff a complete ER when an urgent care clinic will take care of 90% of the patient population. It's not economically effective to go into pediatric oncology when the cost of care far exceeds that child's likely lifetime earnings. You could argue that 3 years of medical school is "enough" for most of what a doctor usually sees and save some money there too.

Cost is important, but some things are not solely cost-governed. As evidenced by the existence of EMS, some things are not cost-effective, but they are morally deemed necessary by their communities.

Medicine in America is expensive because we have a lot of problems, a lot of old people, and a lot of tests/procedures in our treatment pathways. A lot of those are redundant, but a lot are not. Does the average headache in the UK get a CT scan, for instance? Many hospitals here in the US do it, even as a rule-out. Sometimes it catches something, most of the time it doesn't. The only real changes I think need to be made are a massive emphasis on preventive medicine and end-of-lifespan care. 

Personally, I'd rather spend a little more and have world-class medical care when I need it than a poorly-run socialized health-care system where I'm not "productive" enough to rate ICU time. To tie care to cash directly is immoral from my perspective.


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## systemet (Feb 10, 2012)

Rocketmedic40 said:


> Medicine in America is expensive because we have a lot of problems, a lot of old people, and a lot of tests/procedures in our treatment pathways. A lot of those are redundant, but a lot are not. Does the average headache in the UK get a CT scan, for instance? Many hospitals here in the US do it, even as a rule-out. Sometimes it catches something, most of the time it doesn't. The only real changes I think need to be made are a massive emphasis on preventive medicine and end-of-lifespan care.



* Is the US population significantly older than other first world countries? This is within the realms of possibility, but seems unlikely to be a major contributor to the cost of US health care.  I'm sure a quick google around could find any number of industrialised countries with similarly old populations, with lower per capita costs.

* Is the population more sick?  I honestly don't know, but a question that needs to be asked at the same time is "Are they more sick due to a lack of timely access to primary care and preventative medicine?".  Because if that is the case, it's a fault that's directly related to the distribution of healthcare resources.  In that case, the reason the system is expensive, is because it's poorly designed.  So this might be a dependent variable.

* A lot of diagnostics?  I think this may be true.  This is where medical tort law threatens to turn the entire conversation into a side show.  If you risk a multi-million dollar settlement for a missed aneurysm, then doing a lot of unnecessary CT scans becomes economically rational.  This issue is a little more difficult, because defensive medicine saves people with atypical presentations, but it does it at the cost of injuring a lot of people with typical presentations, and making the entire system much more expensive.

I think if I was arguing your side of this, I'd be focusing on obesity and related diseases as driving the cost up, and on the effects of poverty and drug addiction.  But let's be realistic, the reason it's expensive here is that your system is run for profit by a bunch of insurance companies and privately owned hospitals and health centers.  Each of these has CEOs, and managers, and a healthy level of bureaucracy.  They have shareholders who need to see good numbers.  



> Personally, I'd rather spend a little more and have world-class medical care when I need it than a poorly-run socialized health-care system where I'm not "productive" enough to rate ICU time. To tie care to cash directly is immoral from my perspective.



Find a socialised health care system where ICU admission is based upon "productivity", in the first world. The only examples I can think of are places like China, which probably isn't a valid comparison.  For example, tell me which of the 30+ nations in Europe you feel allot ICU beds based on socioeconmomic status.  I'm not saying it doesn't happen somewhere, but if you think the German, French, English, Polish, Spanish, Italian, Czech, Slovakian, Austrian, Irish, Norwegian, Danish, Swedish, Icelandic, etc. systems work like this then you're confused.

I would suggest that the "tying cash to care" is more a characteristic of the US system.  How much personal bankruptcy occurs due to healthcare costs?  This doesn't happen in most other first world nations.  I'm saying most, because I think there must be an example I'm missing somewhere.  How much and what quality of care do the uninsured in the US get?  This just isn't an issue in most of what the right wing likes to call "socialised medicine".  To most people living in other first world countries the idea of getting sick, losing your insurance, and losing your house, savings, vehicles, etc. and descending into poverty, just isn't an issue.

I also want to spend a second asking you what "world class" care means?  There's no question that patients are cared for at a high level in the US.  But they are in lots of other countries, including many on the list above, and others that are missing, e.g. New Zealand, Australia, Japan, Canada, etc.  On the same metric, where does US care for it's uninsured rate on a world scale?  Would the average poor uninsured American be better off (from a medical perspective) in Cuba?  One thing is defined, if you're planning on delivering a baby, the infant mortality rate is better in Cuba than in the US (marginally), but it's also better in about 40 other countries.  What about life expectency?  There's a similar argument there, with about 30 countries beating out the US, including the UAE.

It could be argued that many of these differences are due to the effect of a quality system for those who are insured being diluted by poor health amongst the uninsured.  It seems likely there'd be a selection bias there anyway, that sicker people tend to become uninsured and would make the insured cohort look healthier.  But if you want to talk about the US healthcare system, I think you're compelled to include both.

Please understand I'm interested in discussing this, and happy to be shown wrong on any of the above.  None of this is intended in anger, and please don't take any of my opinions about the US healthcare system as being an attack on Americans in general, or on the USA.  It's not intended that way.  I just have a different perspective on how socialised and privately run healthcare systems work.


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## RocketMedic (Feb 10, 2012)

Definitely pop-up I'm tied to the porcelain throne LOL. Captive audience. 

American health care for the uninsured is very dependent on how sick that person is and what sort of help they seek. Acute episodes are managed as well as anywhere else, its prevention that we suffer in. Americans suck at self-preservation medicine-wise.


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## Veneficus (Feb 10, 2012)

Rocketmedic40 said:


> By Veneficus's standards, it's too expensive to actually have or staff a complete ER when an urgent care clinic will take care of 90% of the patient population.



Actually, the trend in ER service is to have an attached urgent care, which has a seperate designated staff and billing for the very reason of not requiring the actual ED resources on every patient which reduces the need for more resources and cost of them. 

Another idea is the observation units that observe chest pain pts without elevated troponins so they do not tie up monitored beds in the hospital. 

You really should look into this stuff, healthcare costs in the US are a very serious issue, as is how the emergency department  is going to meet the demands and budgets of modern care. (one more reason I don't want to go into EM, then I would have to deal with this headache as more than an observer) 



Rocketmedic40 said:


> It's not economically effective to go into pediatric oncology when the cost of care far exceeds that child's likely lifetime earnings..



This statement is absolutely erroneous, pediatric oncology has a remission/cure rate approaching 80%. It is one of the most effective medical specialties anywhere in terms of both quality of life and productivity.

Quit trying to make stuff up to pull heartstrings.



Rocketmedic40 said:


> You could argue that 3 years of medical school is "enough" for most of what a doctor usually sees and save some money there too.



You have a pssionate argument, but I don't think you are actually aware of the situation past your feelings. Any health system is required to keep costs under control. The US system has been out of control and on the verge of breakdown for many years. 

If you are working in US healthcare I would really suggest you look into the problems faced.

As for mdical school, I think it should be 6 years.  



Rocketmedic40 said:


> Cost is important, but some things are not solely cost-governed. As evidenced by the existence of EMS, some things are not cost-effective, but they are morally deemed necessary by their communities.



I get what you are trying to say, but you don't seem to get that no matter what your morals, if you can't actually pay, you can't actually have.



Rocketmedic40 said:


> Medicine in America is expensive because we have a lot of problems, a lot of old people, and a lot of tests/procedures in our treatment pathways. A lot of those are redundant, but a lot are not. Does the average headache in the UK get a CT scan, for instance? Many hospitals here in the US do it, even as a rule-out. Sometimes it catches something, most of the time it doesn't. The only real changes I think need to be made are a massive emphasis on preventive medicine and end-of-lifespan care..



:rofl:

You should ask some US medical professionals.

In any event, in no country is running every or especially expensive tests to "possibly catch" something, good medicine. Most tests in the US are not done for the patient , they are done for lawyers, it is called "defensive medicine" by trade name.



Rocketmedic40 said:


> Personally, I'd rather spend a little more and have world-class medical care when I need it than a poorly-run socialized health-care system where I'm not "productive" enough to rate ICU time. To tie care to cash directly is immoral from my perspective.



But you do not have world class care.

3 examples I can rattle off the top of my head, but I am sure there are many.

In young or active people, biological replacement heart valves are superior as they allow greater activity and do not require life long anticoagulation compared to mechanical replacements. This increases not only quality of life, but also productivity. The draw back is that they have a 5 year life span, which means they have to be replaced.

In the system here (which is insurance based) if you qualify for a biological replacement, you get one, and it gets replaced on schedule and any complications managed.

In the US, largely based on legal fears and cost, most places (including some very reputable cardiac centers) will only put in mechanical valves because it saves money and reduces hospital exposure to liability. It is actually worse for the patient. The systemic anticoagulation makes the patient sicker and reduces the normal level of activity.

Is that what you call "superior" medicine?

Cardiac bypass in the US is most often done "on pump" to say a cardio bypass machine is used during the procedure. It nearly doubles the price of the surgery.

In the rest of the modern world, and even some not so modern places, bypass is done off pump except in special circumstances.

Now to cover the cost increase a US cardio-surg group did a study comparing on pump to off pump bypass. They claimed on pump showed better results, but a flaw in the paper was that since so few US surgeons use off pump bypass operations, they included all surgeons that performed as little as 10 off pump procedures. (the mean I believe was nealry 12) 

Use your head, how many times do you think a person needs to perform a specific cardiac surgery to be good at it? (i'll give you a hint, most C/T surgeons do 3-5 operations per day) 10 is nowhere near enough to qualify the effectiveness of a procedure.

I absolutely love the hemodialysis vs. peritoneal dialysis argument. The British proved this point long ago. 

Peritoneal dialysis is cheaper (by more than 5 times), leads to a better quality of life, and is effective to maintain that quality of life just as long as hemofiltration.

How often do you see US patients on peritoneal dialysis? (let me help you, almost never, because in the US hemo is the recommended)

Do you think spending your whole life and considerable monetary costs revolving around when you can pee is a moral quality of life? One you would like?

Do you think when the effectiveness of quality sustainment on hemo is over, justifies paying to haul around and cover the complications and cost of making sure Frankenstein can pee is good medicine? Even when these people cannot remain conscious for more than afew hours a day?

No offense man, but you seriously need more time/information of medicine if you want to argue about what is good medicine and the costs relative to it outside of ethnocentric propaganda and passionate moral conviction.

As for a collapse, you don't need to be a healthcar einsider, you ever hear the word "unsustainable" on the news when talking about medicare and prescription drug benefits?

Texas is one of if not the leading state in unreimbursed healthcare costs, ask some of your local hospital administrators how well that works.

As I said, save your convictions, show me the money.

(medical tourism anyone?)


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## Veneficus (Feb 10, 2012)

Rocketmedic40 said:


> its prevention that we suffer in. Americans suck at self-preservation medicine-wise.



and rehabilitation, and chronic disease management.

All of which increase the burdon on the system.

This is part of my point.

What you call "world class health" is BS. 

Because somebody enacted an unfunded law based on moral conviction. (help the sick in time of urgent need) and neglected to care for these people after the acute crisis, instead of these people being "saved" and returned to life, they get "saved" and sent to disability. 

With chronic conditions and rehab unaccessable, they get stuck in an endless loop of acute conditions that are never managed past the emergent event.

I am not against America, but I do have both an inside and outside look at how US healthcare system doesn't work.


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## Hunter (Feb 11, 2012)

After I had been working for a few months I changed my view on what we do. Yes we do save SOME lives, but I don't think that should be our goal, I think our major goal is; to minimize the loss of quality of life.


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## RocketMedic (Feb 12, 2012)

Looks like I got told, but I do know that I don't want to live under a government-socialized medical thing like the military healthcare system. We do deeply stupid things and it's not good for patients.


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## systemet (Feb 12, 2012)

Rocketmedic40 said:


> Looks like I got told, but I do know that I don't want to live under a government-socialized medical thing like the military healthcare system. We do deeply stupid things and it's not good for patients.



For what it's worth, I'm not trying to tell anyone how it is.  I'm interested in having a discussion.

I'm just surprised at some of the opinions you hold.  I don't expect to convince you to my point of view, especially as I think both our opinions are formed by our own life experiences.

It seems that you're assuming that "socialised medicine" in other countries works in a similar manner to the healthcare offered to the US military.  I don't think that assumption is valid.  

Other countries manage to provide care that's at least equivalent, if not superior, for a much lower per capita cost, using a publicly funded system.  Myself, I could not imagine ever not being insured, or losing my insurance because of unemployment, or having this happen to a family member or someone I cared deeply about.  That must be a very difficult situation to be placed in.


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## Veneficus (Feb 12, 2012)

Rocketmedic40 said:


> Looks like I got told, but I do know that I don't want to live under a government-socialized medical thing like the military healthcare system. We do deeply stupid things and it's not good for patients.



It's not about being told, it's about educating people to what is really going on so they can make rational decisions based on knowledge.

This past Holiday I had the pleasure of dealing with US military medicine. In my not always humble opinion they are not accountable for their care in any way. So if they provide poor care, so what? It is not like they will be punished, or sued, or that most people they "help" know any better.

I also noticed they are more interested in the niceties and ego of being an officer than they are patient care. Too much being called sir and ma'am and not enough earning it.

But I really think if you actually went abroad and looked at other systems from the inside and not from the propaganda that people with special interests want you to hear on tv, you may actually decide it is not so bad.

Then again, you may, but you will have made an informed decision. Not one based on emotion. Especially fear.

It seems to me that your journey in healthcare is rather new. That you have passion and want to do the best you can for the people you serve. There is definately no shame in that.

But many of us want the same thing. The only difference is we realize that doing the very best for as many or all of the patients we see requires us to get involved with where the money comes from and how it is spent.

If you stay in the EMS job for any length of time, you will see first hand the flaws in the system. Especially when you transport the same patient for the same thing the 100 time and find out the hospital did the same thing for him as the other 99 times.

It is about then you realize that these frequent flyers are not abusing the system, the system isn't helping them. But yet we keep spending money on what the system is doing for them.

A few years ago medicare decided it wasn't going to pay for patient care resulting from "preventable" complications. The hospital would have to treat these complications at their own expense. 

In defense of the hospitals, what is considered "preventable" is extremely unfair. (some are regular and expected complications of procedures)

If you really want to see change, lobby medicare to stop paying for ED visits if the patient's condition doesn't get the required treatment and they are forced to return.


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