# Different angle: why basic level technicians?



## mycrofft (Jul 18, 2012)

I've suggested that Paramedics be forced to upgrade and the category be abolished, as well as other aspects of the skill/scope picture.
How about another slice at it?

Instead of fighting to graft new individual skills onto EMT-B's (and this includes everything between EMT-B and Paramedic), why not just recognize that a basic EMT, with sufficient training and protocols, makes a difference and fills a vital niche (remember more than just paid urban settings here), and propose we sharply draw the line between Basic and Paramedic...as the Feds obviously want to do but don't have the _huevos_ to carry through?

Or is this wrong, and we need to be able to graft and glue/tape on any skill set a basic wants, or create all sorts of hybrids as has been done by many EMSA's and states? 

Before we start, I recognize and respect people who want to gain more skills and knowledge, and I know theoretically that more skills OUGHT TO (but largely hasn't) translate(ed) into more pay and security. But WHY NOT a basic level tech, with decent pay and a threshold over which they become paramedics so their training and practice is not fragmented by a non-holistic/global approach? (Do you know what global/holistic approach means?). 

Thoughts?


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## EpiEMS (Jul 18, 2012)

Perhaps it's an artifact of the apprentice, journeyman, master system?

The idea of the EMT-B (i.e. the EMT, according to the new nomenclature) is to be able to reduce morbidity and mortality due to traumatic injury and acute medical problems - and to adequately triage them. We all know the basic history of EMS, and Mycrofft, you're certainly more knowledgeable than I, so I hate to "lecture."

As far as the economics and business aspect of it goes, EMTs can provide the most cost-effective life-saving and life-preserving interventions that are shown to have minimal downside risk and maximum benefit. Most of what the EMT can do is fairly uncomplicated and very effective or of such low cost (both financial, opportunity-cost, and in terms of risk to the patient) that it is judged to be appropriate. I'd go as far as to say that the addition of ALS skills, while important and sometimes efficacious (as well as very helpful for alleviating suffering), are not as cost-effective or life saving, on a purely empirical basis.

This lack of cost effectiveness of the ALS provider at the prehospital level means that it makes sense to bolt-on, as needed, ALS skills to the BLS level, both to suit research, cost, the region, and other conditions the medical director deems appropriate. For example, I would most certainly consider blind airway insertion devices to be BLS-appropriate. Not only are they quick, cheap, and fairly easy to use, they are nearly as effective (if not just as effective) as the ETT. Thus, since the cost is low and the skill fairly simple, it makes sense as a bolt-on. Similarly, consider Narcan. Yes, overdose management at the BLS level can be accomplished with a BVM. But if there is an effective way to move from BVM ventilation to solve the underlying problem, why not at least consider it, if it proves to be effective and safe? (And, far as I know, IN naloxone administration is used successfully at the BLS level in some regions).

Let's question all of our assumptions: let's start with evidence and cost efficacy and then build from there.


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## bahnrokt (Jul 18, 2012)

The lines between ALS and BLS should be flexible region to region. What works for FDNY probably isn't going to work for a rural squad in Montana. 

I am an EMT with a rural 100% volunteer BLS only squad with no ALS coverage in our CON. 30+ minutes to a hospital, 60+ to level 1 trauma. Most of our members are college educated, many hold advanced degrees...we are not idiots.   I can do a lot more with some extra tools than a city emt that rides with a medic and is never more than 10 min from an er door.

I do agree that the requirements need to be changed in general.  EMT B should be eliminated and the min to work in EMS should be should be near that of an EMT I or CCT.


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## TB 3541 (Jul 18, 2012)

bahnrokt said:


> EMT B should be eliminated and the min to work in EMS should be should be near that of an EMT I or CCT.



I think this should be the focus, instead of clarifying the lines between Basic and Paramedic. Maybe it would cause shortages of "ambulance drivers" in other parts of the country, but I know that in Southern California, we _need _for EMT-B (or whatever we will call entry-level EMS care providers) to be harder to get. 

Why not advance society and patient care by raising the bar? I'm probably going to lose my EMT-B certification with having never gotten a job, and not for lack of trying. The only thing I haven't done was start assassinating EMT's to open some positions .

All joking aside, I would gladly take a longer, more expensive, more comprehensive course if I knew that not every Joe and Jane out there who "just felt like trying it" could get hired just as easily as me.


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## EpiEMS (Jul 18, 2012)

Hold on, now. Eliminate EMT? That doesn't make sense. There is a reason we have the EMT. Cost effective life-saving (and IFT).

The AEMT is, more than anything else, an EMT with additional skills training. There's nothing wrong with that. However, most of the additional skills that the AEMT can provide should be at the EMT level to begin with -- namely administration of nitro, BiADs, inhaled beta agonists, Narcan, Nitrous (not like it's widely used), and administration ofIM and SQ epinephrine for anaphylaxis (which most EMT protocols that I've read allow). Oh, and, of course, CPAP.

Is the AEMT useful? Yes. Cost effective? I don't know.


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## TB 3541 (Jul 18, 2012)

EpiEMS said:


> Eliminate EMT?



I suppose it does say that in my post, but what I meant was something like EMT-B's would be trained at the level of AEMT, and EMT-B, as it is currently known, would cease to exist.


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## TB 3541 (Jul 18, 2012)

EpiEMS said:


> Cost effective? I don't know.



From my limited understanding of economics, (and also potentially limited to the Southern California market, and others like it) an EMT-B with more training would not cost much more to hire, if any more, than they currently do. The reason being that there are so many EMT-B's currently, that all can't possibly be hired. If you increase the standard by which EMT's are measured, many are bound to fall out. You would just have to find the spot wherein the supply of EMT-B's at the new training level matched, or slightly exceeded the demand.

But who's to say that it would be a bad thing if private EMS wages competed more closely with city or county wages?


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## the_negro_puppy (Jul 18, 2012)

Or maybe have two levels of Paramedic like in Aus?

We have Advanced Care Paramedic (ACP) and the higher Intensive Care Paramedic.

Our ACP is somewhere between your EMT-I and EMT-P

we operate ACP/ACP or ACP/ACP student and have Intensive Care Paramedics on fly cars for intercept.

Just a thought.


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## EpiEMS (Jul 18, 2012)

TB 3541 said:


> From my limited understanding of economics, (and also potentially limited to the Southern California market, and others like it) an EMT-B with more training would not cost much more to hire, if any more, than they currently do. The reason being that there are so many EMT-B's currently, that all can't possibly be hired.



Makes good sense. If you bring EMT training up to the AEMT level (for convenience, "New EMTs"), you've automatically removed a large portion of the "supply," that is, workers. So, less labor supply, given the same level of demand for their services, ceteris paribus, means higher wages for the New EMTs.

There's a problem, though. What if, by imposing this additional barrier to entry, we reduce the number of providers to a level where peoples' healthcare needs go unmet?

I'd rather have the status quo (from a system perspective).



TB 3541 said:


> But who's to say that it would be a bad thing if private EMS wages competed more closely with city or county wages?



Private companies might not be able to continue to operate, for all I know. Honestly, I don't know much about the business model of private EMS to speak intelligently on that aspect of it.


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## EpiEMS (Jul 18, 2012)

the_negro_puppy said:


> Or maybe have two levels of Paramedic like in Aus?
> 
> We have Advanced Care Paramedic (ACP) and the higher Intensive Care Paramedic.
> 
> Our ACP is somewhere between your EMT-I and EMT-P



Makes sense to me. Then again, I repeat my objection to eliminating a whole level of provider (especially because of how cost effective and efficacious the EMT level is).

I'd certainly like to see a system like that, where we're all medics (that term has so much more traction with the public, after all). Something like:

Certified Paramedic (EMT-level, with the addition of all AEMT skills except IV and IO, no degree requirement, but encouraged)

Licensed Paramedic (EMT-P level, minimum associates degree level)

Advanced Practice Paramedic (EMT-P, with more medications, more autonomy, etc., minimum bachelors degree level; a physician extender like a PA, with an independent DEA #, etc.)


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## DPM (Jul 18, 2012)

Other EMS systems that I have experience with don't really have this problem, and I think it's mainly down to EMS not being 3rd service.

Many people, especially in CA where I am, take EMT-B because it is now a requirement for Fire, and the same can be said (to a degree) about Paramedics too. And this has had two knock on effects. 

One is that the labor market is saturated with EMT-Bs. Not surprisingly, Fire doesn't hire around here very often. And with hundreds of applicants for every 1 position, and with every applicant being an EMT-B, we have a surplus.

Second is that private firms exist. Even though their 'product' is healthcare, they are also, essentially, private companies. They provide 911 and IFT ambulances because they have identified that this is a way to make money. 

The normal rules of supply and demand will show you that if you have 1,000s of people to choose from then you don't have to pay a great deal. This pay can then be decreased further when most of the employers are private firms looking to make money. And I don't think that any of this is new to anyone here, but what is a solution?

I think making the entry level harder to obtain is a start. We are currently churning out 'healthcare providers' within a period of weeks. There is a school near me that has an EMT-B school that is 15 days long. This has lead to a situation where EMT-B is not so much a job, but a certificate and something used to fill out your CV for the Fire Department.

I don't want to get rid of EMT-B. I think we all agree that we need them. But I would estimate that probably close to 50% of people in my state that are licensed EMT-Bs do not work in healthcare, be it Fire, AMR, hospital etc. I'd recommend adding more of those grey I-95 / EMT-IV areas, but on a national level. 

Basic, Intermediate, Paramedic and then CCT / Paramedic Practitioner. This would allow a county EMS coordinator to cater to the levels that they require, giving you multiple ways to combine the 4 levels of training. The rural service can run Basic / Basic ambulances with a Intermediate or Paramedic cars to supplement their coverage. Also, with degree level trained Practitioners more patients can be treated at home without requiring a lengthy and expensive trip to the ER.

This is a similar to the NHS in the UK and to the Australian model and probably a few others too. Unfortunately I don't see this shift happening in the US without a lot of change. Change in the level of training required and also in the general mentality of pre-hospital providers. EMS in itself needs to be a career choice, not some quasi half private half fire situation. I honestly feel that 3rd service EMS, with several well defined levels of experience and training would be a big step in the right direction.

An interesting JEMS article on Paramedic Practitioners / ACPs


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## firetender (Jul 19, 2012)

*What am I hearing?*

There's economic justification for providing the Lowest Common Denominator of service to our people?

What I'm looking for is an understanding that we as a society are sophisticated enough and reasonable enough to actually want an EMS system that can handle all the basics AND has the will, desire and willingness to sacrifice so that if someone needs more advanced care, they've got it available to them.

Everybody. Everywhere. At any time.

That means an EMS culture designed for upward mobility, steady continuing education and numbers large enough at every level (with safety-nets built in to protect them) so that no one is left out of receiving superior emergency care.

Anything less is cheating our populace.

This means a service and culture completely independent from other vital protection agencies.


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## DPM (Jul 19, 2012)

firetender said:


> There's economic justification for providing the Lowest Common Denominator of service to our people?



There is when the shortfall in coverage is bridged by private agencies.



firetender said:


> This means a service and culture completely independent from other vital protection agencies.



^ This is the answer. Either 3rd agency like in other countries, or left ENTIRELY up to Fire. It's the middle ground that we've fallen into that causes this trouble.


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## DrParasite (Jul 19, 2012)

oh, where to start, where to start, where to start.....

Why not just get rid of paramedics?  We are always pushing for evidenced based medicine, have any studies been done to say that paramedics save move lives than EMTs?

Or lets make everyone have to be a paramedic.... I'm sure there are studies that will say that all ALS systems have lower mortality rates than tiered systems right?

Lets also consider this, currently Paramedics are specialists (like a cardiologist, pulmonologist, or any other specialist doctor).  If you are a specialist, and only see sick people in your specialty, you will be really good at what you do.... but if I have a heart condition, and am experiencing chest pains, should I really be going to a proctologist? So if I'm a paramedic, why am I dealing with an assault victim, or back pain, or abdominal pain, or the guy with a boil on his butt????  Shouldn't I be dealing with people with complaints that I am a specialist in?

Lets also deal with the other groups: 1) volunteers, people who want to help out, are working a full time job, and now you want to send them to an even LONGER course?  what about sending them to a 6 month course, but they only go on 20 calls a year, how good will they be?  2) for profit, companies (and their employees) where the almighty dollar rules, as long as the billing paperwork is correct, you will still have a job.  not only that, but I don't need a 6 month educated EMT, a 3 month one will do; at least it has for the past 15 years. 3) firefighter, we don't want to be EMTs, we don't want to do EMS, we don't want to be on the ambulance, we are only completing it because it's a job requirements.  If it wasn't a job requirements, I wouldn't even have CPR.

I'm sure there is more, but It's 4am and I don't want to make this 3 pages long.

There are a lot of short comings in the current EMT class.  complete your 120-140 hour class.  than take another 80 hours of training (con edu).  and then have 100 patient contacts, 30 of them are sick patients who would benefit from ALS interventions.  spend 3-6 months with an FTO, who is constantly evaluating you.  Maybe by then you will be ready.

And before anyone calls me any education, I have my degree, and have completed all by one requirement to get into med school (MCATs).  Organic Chem was a :censored::censored::censored::censored::censored:, esp when taking it and Bio 2 at the same time, and working 60 hour weeks in two busy EMS systems.  

But if we want to be considered equals to others in healthcare, than we need to start playing by their rules, and that means using evidence based medicine to guide our protocols and actions, need to be active in the research area, and realize new items that have shown to be beneficial to patients can be used, not disregarded because "we didn't need them 20 years ago, and we don't need them now!"


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## mycrofft (Jul 19, 2012)

Tiered EMS was initiated so that it could penetrate areas and people who did not have what it takes to field paramedics. Have we solved that? We have areas where you can't even get a doctor much less a base hospital.

Why make job descriptions so fluid they cannot be legislated and you can train someone to within one skill short of a paramedic and pay her/him as an EMT? (The answer to the latter is that EMT's want the skills and don't realize they ought to/need to be paid much more).

If we all need coverage from BLS up through ALS, why not just require everyone doing paid prehospital EMS (PHEMS) become a paramedic? Or require a certain ratio in the smallest and most-rural services?

Can a new service ("The PHEMS Service", say) afford to be started by purchasing all new infrastructure, separate communication system (hardware and frequencies/bandwidth), and hiring (either new hired because current fire EMS don't want to lose their jobs, or pay enough to attract old hires away)?


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## EpiEMS (Jul 19, 2012)

The practice of medicine is state-regulated in this country. That's one aspect we shouldn't forget. (And, I for one, think it makes sense.)



firetender said:


> There's economic justification for providing the Lowest Common Denominator of service to our people?



That's not the idea –:censored:the idea is to do what's evidence based and efficient, especially if people are demanding something for free (or low cost).



firetender said:


> What I'm looking for is an understanding that we as a society are sophisticated enough and reasonable enough to actually want an EMS system that can handle all the basics AND has the will, desire and willingness to sacrifice so that if someone needs more advanced care, they've got it available to them.
> Everybody. Everywhere. At any time.



That's ideal, I agree, but it is both unrealistic and doesn't necessarily jive with the scientific evidence.



firetender said:


> This means a service and culture completely independent from other vital protection agencies.



Absolutely. I like the idea of PD and FD responding to life-threatening emergencies on the off chance that they arrive first, but outsourcing medicine to PD and FD is a huge mistake.


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## mycrofft (Jul 20, 2012)

Consider a parallel: get rid of nurses and staff hospitals with only MD's. Aren't there some advantages to tiered coverage ?


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## thegreypilgrim (Jul 21, 2012)

What has to happen is the EMT-B level has to be scrapped altogether and replaced with something else. It simply has no utility in a modern ambulance service (O2 and band aids are not all that useful for much). It has to be upgraded to something like a "Basic Paramedic" level which would have the education and skillset to attend the majority of calls so you can actually have a tiered response system.

*Basic Paramedic*
BS Degree
Basic airway management: supraglottic/BIAD insertion, NPA/OPA, BVM
CPAP
IV/IO Cannulation
12-lead ECG
Defibrillation/Cardioversion/TCP
Meds: O2, Adenosine, Amiodarone, Albuterol, ASA, Atrovent, Atropine, Benadryl, Dextrose, Epinephrine, Fentanyl, Glucagon, Morphine, Midazolam (or some other benzo), Narcan, NTG, Sodium Chloride, Zofran

*Advanced Paramedic*
MS Degree
Independent medical license
Advanced airway management: adult & pediatric oral and nasotracheal ET, RSI, surgical cricothyrotomy
Needle thoracostomy
EJ & Central cannulation
Execution of behavioral hold orders
Minor wound debridement and closure
On scene discharge and alternative destination referral
Meds: Calcium Gluconate, Diltiazem, Ceftriaxone, Dobutamine, Ketamine, Dexamethasone (or some other corticosteroid), Levophed, Succinylcholine, Vecuronium, Tetanus toxoid
Scope could be significantly altered for CCT and HEMS operations

There should be a federal mandate for this - no more state-level or (even worse) local determination of provider standards. 

Then you unmerge fire and EMS. Fund EMS by taxation or application of levies at state-level. EMS organization should be at state-level as well (so, no more litany of different agencies and companies providing EMS - just one statewide organization). Very important to not codify scope of practice or education into any kind of statutory law though (too difficult to change). All states should defer to a delegated practice model.


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## mycrofft (Jul 21, 2012)

Can and would rural and frontier services be able to do that? WOUld these practitioners need a base hospital? Some areas need to travel over a hundred miles to get to an accredited emergency department.


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## thegreypilgrim (Jul 21, 2012)

mycrofft said:


> Can and would rural and frontier services be able to do that? WOUld these practitioners need a base hospital? Some areas need to travel over a hundred miles to get to an accredited emergency department.


Not if funding and resources are limited to local entities. What we would have in this scenario are statewide ambulance services (eg California Ambulance Service, Wyoming Ambulance Service, North Dakota Ambulance Service, etc.). So resource allocation wouldn't be an issue. This is what Australia does with great success despite significant remote areas.

No more base hospitals either.


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## Ghostnineone (Jul 21, 2012)

It seems like requiring paras to be PA's or MD's is too much to me...because while there are some that will work as an EMT on the side, how many will choose to work as an EMT full time that might not get payed much vs PA or MD that gets payed more? Especially when they could just work in the ED. I don't think I'd want to go to med or PA school and do an internship and residency and have 100k in debt if i just want to be a paramedic.

The clinical knowledge would be helpful, but how much of it will they use on the scene or in the back of an ambulance? Would you do a chest tube insertion in an ambulance? What about a thoracotomy? Central lines? It seems like there would be a lot of "hospital only" skills that they would have to learn but never use in EMS. 

Am I not understanding something? :/


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## DPM (Jul 21, 2012)

I have to disagree with 'thegreypilgrim' on this. Every single call requires BLS. You can't argue that. However you will find that not every call requires ALS and a tiered system is absolutely necessary. Removing EMT-B and requiring a degree isn't necessary for the type of care and the skill set that your basic level needs.

EMT- Basics have a basic level of training but they are still a valuable resource. There is more to their scope than Back boards an O2, and the most commonly used interventions listed in your 'Basic Medic' scope are skills that they can perform.

I do like your Advanced Paramedic idea though. In the UK and Australia and a few other EU countries there is a very similar system in place, Paramedic Practitioners (not to be confused with critical care). They have an expanded scope but work as more of a 'traveling primary care'. Research has shown that a large proportion of ER visits are for things that can and should be seen at your GP or Dr's office. The Paramedic Practitioner will make a home visit with the aim of diagnosing and treating on scene without having to take the PT to hospital, thus freeing up ER resources and saving money in the long run.

And again, I like your last point about separating Fire and EMS. With Fire departments already providing ALS and BLS we already have government funded EMS, people just don't realize it. If we want FD to proved EMS services then we need to go all the way and have all EMS and transport provided by Fire with their own ambulances. AMR / Rural Metro / Paramedics Plus have all shown that EMS can be profitable, so I don't see how this would be a problem financially for a FD to step in. 

Or we can go the other way to a 3rd service, an Ambulance service. They will have the SOLE responsibility of providing EMS and transport, and would be managed and funded in a way comparable to local Police and Fire Departments.

Being stuck in the no man's land of half private and half public isn't the most effective and efficient use of our medical resources, and I feel that removing private EMS from the equation is the solution.


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## Tigger (Jul 21, 2012)

DPM said:


> I have to disagree with 'thegreypilgrim' on this. Every single call requires BLS. You can't argue that. However you will find that not every call requires ALS and a tiered system is absolutely necessary. Removing EMT-B and requiring a degree isn't necessary for the type of care and the skill set that your basic level needs.
> 
> EMT- Basics have a basic level of training but they are still a valuable resource. There is more to their scope than Back boards an O2, and the most commonly used interventions listed in your 'Basic Medic' scope are skills that they can perform.
> 
> ...



Yet much of the developed world operates their frontline ambulances in a manner like thegreypilgrim has described. There is no reason to differentiate between ALS and BLS, it's all medicine.

Not every call requires advanced interventions or education, but there is no reason why someone with those qualifications cannot take such a call. Our BLS providers are capable of transporting most patients without having their condition decrease in a meaningful way, but that does not make it the best practice. An extremity fracture could just be a BLS call; splint, ice, and transport. Or we could throw a better educated provider into the mix who can provide pain relief. Either way the patient is not going to die on the way to the hospital, but with a higher level provider the patient is not going to be suffering, and that is almost as important as the whole "EMS saves lives thing," if not more so.


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## JPINFV (Jul 21, 2012)

DrParasite said:


> And before anyone calls me any education, I have my degree, and have completed all by one requirement to get into med school (MCATs).  Organic Chem was a :censored::censored::censored::censored::censored:, esp when taking it and Bio 2 at the same time, and working 60 hour weeks in two busy EMS systems.


Anyone who's completed a degree in biology has achieved that. Actually, the pre-reqs for med school aren't exactly difficult. Finishing them with grades that make the student competitive is a different question altogether, and why the US med school admissions rate is something like 50%.


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## JPINFV (Jul 21, 2012)

mycrofft said:


> Consider a parallel: get rid of nurses and staff hospitals with only MD's. Aren't there some advantages to tiered coverage ?


Nursing and medicine are two different things. Heck, I've completed my first rotation and I still haven't started an IV. Physicians are educated in the diagnosis and treating disease and health maintenance. Nurses are educated in implementing the physician's treatment plan and the personal side of patient care (feeding, bathing, turning, etc). Nurses aren't physician + ___ and physicians aren't nurses + ____. Both are integral to providing good patient care even if cleaning up poop isn't as sexy as ordering Tylenol PRN for fever. 

However a paramedic is an EMT + _____, which is why an EMT can be replaced on an ambulance with a paramedic, but a physician can't replace a nurse in a hospital.


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## JPINFV (Jul 22, 2012)

DPM said:


> I have to disagree with 'thegreypilgrim' on this. Every single call requires BLS. You can't argue that. However you will find that not every call requires ALS and a tiered system is absolutely necessary. Removing EMT-B and requiring a degree isn't necessary for the type of care and the skill set that your basic level needs.



The only way that it can be argued that every call needs at least an EMT ("BLS") is if the assumption is that every call needs to be transpoted and an EMT is the lowest level allowed to staff an ambulance. If a patient could have gone by a taxi and be none the worst than the patient didn't need BLS.


> EMT- Basics have a basic level of training but they are still a valuable resource. There is more to their scope than Back boards an O2, and the most commonly used interventions listed in your 'Basic Medic' scope are skills that they can perform.



Such as? The vast majority of patients who receive a backboard or supplemental oxygen don't need them, and the handful of other interventions (e.g. ASA for ACS or oral glucose) are such that the patient should have additional treatment options available immediately anyways. The vast majority of trauma interventions (splinting, bleeding control, etc) are taught to boy scouts, which doesn't exactly make them very special in terms of interventions.


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## DPM (Jul 22, 2012)

I feel like I didn't get my point across well. I wasn't saying that all calls require BLS. Your taxi analogy is spot on, some cases don't really require any treatment. Others require a lot of specialized care, and there is everything in between. I'm just saying that I don't think we need to 'upgrade' EMT-B when our 911 ALS services already have a Paramedic on board. At a time where we are trying to reduce EMS costs, can we afford the extra pay a more advanced basic level would require? Especially when we've all pointed out that a lot of the time this extra training isn't needed, and in cases where it would be, there is already someone else there who has a higher level.

Tigger, I disagree with you on your ideas of how the rest of the world operates. One example, the London Ambulance service, has 4 Levels of EMT, 4 of Student and 2 of Paramedic. They have normal ALS ambulances, BLS PT transport, ILS Bikes, Paramedic RFVs and they also have the capability to send forward ER Drs using HEMS or a FRV. I lived for a while in Germany and they were similar. 

I'm not saying 'lets just use BLS because it'll probably be ok', and I do agree with you that having someone with the training to deliver a higher level of care is always better. I just feel that if we have our Paramedics and an existing intermediate scope in place, do our EMT-Bs need to be some kind of Intermediate-lite?

The point of what I was trying to say was that, in my opinion, the level of training that our basic level providers have is adequate and suitable for the role that they perform.


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## Tigger (Jul 22, 2012)

DPM said:


> I feel like I didn't get my point across well. I wasn't saying that all calls require BLS. Your taxi analogy is spot on, some cases don't really require any treatment. Others require a lot of specialized care, and there is everything in between. I'm just saying that I don't think we need to 'upgrade' EMT-B when our 911 ALS services already have a Paramedic on board. At a time where we are trying to reduce EMS costs, can we afford the extra pay a more advanced basic level would require? Especially when we've all pointed out that a lot of the time this extra training isn't needed, and in cases where it would be, there is already someone else there who has a higher level.
> 
> Tigger, I disagree with you on your ideas of how the rest of the world operates. One example, the London Ambulance service, has 4 Levels of EMT, 4 of Student and 2 of Paramedic. They have normal ALS ambulances, BLS PT transport, ILS Bikes, Paramedic RFVs and they also have the capability to send forward ER Drs using HEMS or a FRV. I lived for a while in Germany and they were similar.
> 
> ...



Lets leave IFT out of all of this, there is really no reason it should be included in EMS beyond the fact stretcher transport is common between the two. London's IFT ambulances aren't responding to 911 calls (ever) so that's kind of a moot point. Their 911 ambulances (or whatever number, 111?) are all some sort of ALS. In much of this country, that is not the case. It might be where you are, but I can assure you that there are many places that send 911 BLS ambulances only. That's where there is a problem, our patients deserve more than BLS care during their emergency. If it's a medic/basic truck that's one thing, but a straight BLS truck doing 911 isn't exactly 21st century medicine.


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## DPM (Jul 22, 2012)

Tigger said:


> Lets leave IFT out of all of this, there is really no reason it should be included in EMS beyond the fact stretcher transport is common between the two. London's IFT ambulances aren't responding to 911 calls (ever) so that's kind of a moot point. Their 911 ambulances (or whatever number, 111?) are all some sort of ALS. In much of this country, that is not the case. It might be where you are, but I can assure you that there are many places that send 911 BLS ambulances only. That's where there is a problem, our patients deserve more than BLS care during their emergency. If it's a medic/basic truck that's one thing, but a straight BLS truck doing 911 isn't exactly 21st century medicine.



I'm with you 100% on that point. My suggestion would be instead of improving / upgrading the existing EMT-B scope, we should properly implement the existing Intermediate scope. So in these (I'm assuming rural) communities there is an ability to provide better care while keeping costs down (EMT-B gets EMT-B pay, Intermediate gets Intermediate pay etc).

Of course I'd rather all 911 had a Paramedic on board, I just don't think that both people on the ambulance require advanced training.


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## Ghostnineone (Jul 22, 2012)

I sorta don't understand having 4 levels of EMS thing...if its a basic/para, then where do I and CC fit in? And why do you need I and CC if there is a paramedic on board anyways? I guess if it was a really bad PT then having someone with I or CC could help. What would happen if there was only ALS providers on every rig? They can all do BLS. There just seems to be way, way too many ways to do things...


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## DPM (Jul 22, 2012)

Ghostnineone said:


> I sorta don't understand having 4 levels of EMS thing...if its a basic/para, then where do I and CC fit in? And why do you need I and CC if there is a paramedic on board anyways? I guess if it was a really bad PT then having someone with I or CC could help. What would happen if there was only ALS providers on every rig? They can all do BLS. There just seems to be way, way too many ways to do things...



The issue is that some areas cannot afford to provide Paramedics / ALS ambulances. Ideally, all 911 would have at least one Paramedic on board but unfortunately that isn't the case. So having a tiered system _should_ make a higher level care available without the Paramedic price tag.


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## thegreypilgrim (Jul 22, 2012)

DPM said:


> The issue is that some areas cannot afford to provide Paramedics / ALS ambulances. Ideally, all 911 would have at least one Paramedic on board but unfortunately that isn't the case. So having a tiered system _should_ make a higher level care available without the Paramedic price tag.


This is why you fund at state-level. As long as local communities have to pay for EMS you're going to have this disparity in resource availability.


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## thegreypilgrim (Jul 22, 2012)

DPM said:


> I have to disagree with 'thegreypilgrim' on this. Every single call requires BLS. You can't argue that. However you will find that not every call requires ALS and a tiered system is absolutely necessary. Removing EMT-B and requiring a degree isn't necessary for the type of care and the skill set that your basic level needs.


 You can't have a tiered system that consists of EMT-Bs and Paramedics. To be blunt, EMT's have no real utility other than being sort of like "assistants" on scene as most areas their scope literally is O2, backboard, band-aids and for good reason. It's not a solution to just graft extra skills on a 120 hour training background. As it is "BLS" offers very little to the majority of patients that access 911 other than just transport which defeats the purpose of tiered-response. What is needed is a professional-level educated provider who can utilize some degree of clinical judgment and perhaps not transport every patient they see.

Furthermore, they should be operating without on-line medical control since that whole practice wastes time and costs hospitals hundreds of thousands of dollars every year to maintain.


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## mycrofft (Jul 22, 2012)

JPINFV said:


> Nursing and medicine are two different things. Heck, I've completed my first rotation and I still haven't started an IV. Physicians are educated in the diagnosis and treating disease and health maintenance. Nurses are educated in implementing the physician's treatment plan and the personal side of patient care (feeding, bathing, turning, etc). Nurses aren't physician + ___ and physicians aren't nurses + ____. Both are integral to providing good patient care even if cleaning up poop isn't as sexy as ordering Tylenol PRN for fever.
> 
> However a paramedic is an EMT + _____, which is why an EMT can be replaced on an ambulance with a paramedic, but a physician can't replace a nurse in a hospital.



So you would teach and require the MD's to do that sort of care. It is real healing, not just throwing knowledge out as orders and watching for a result.  The parallel I was  trying to raise and others have to a degree is that as we add tiers we delete duties from those who are "on the top"; however, what if we took thirty embryonic nurses, thirty embryonic doctors, and thirty embryonic PA's, and instead made them all generalists, doing EVERYTHING? (Same for ALS versus BLS).


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## mycrofft (Jul 22, 2012)

DPM said:


> The issue is that some areas cannot afford to provide Paramedics / ALS ambulances. Ideally, all 911 would have at least one Paramedic on board but unfortunately that isn't the case. So having a tiered system _should_ make a higher level care available without the Paramedic price tag.



Some areas cannot attract medical providers, much less afford them.


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## mycrofft (Jul 22, 2012)

thegreypilgrim said:


> You can't have a tiered system that consists of EMT-Bs and Paramedics. To be blunt, EMT's have no real utility other than being sort of like "assistants" on scene as most areas their scope literally is O2, backboard, band-aids and for good reason. It's not a solution to just graft extra skills on a 120 hour training background. As it is "BLS" offers very little to the majority of patients that access 911 other than just transport which defeats the purpose of tiered-response. What is needed is a professional-level educated provider who can utilize some degree of clinical judgment and perhaps not transport every patient they see.
> 
> Furthermore, they should be operating without on-line medical control since that whole practice wastes time and costs hospitals hundreds of thousands of dollars every year to maintain.




Haven't we established elsewhere/when that the majority of 911 calls DON'T require advanced life support? And many don't really require BLS either?
But I am sympathetic to your reconsideration of tiered responses.

Here's a rhetorical question: why is it (or IS it?) "beneath" paramedics to be called and to provide basic treatment? To revisit an earlier post of mine, if everyone was a paramedic, the wage would down, so it wold be affordable. But could enough people, or enough in a given region, pass the training to become one?


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## mycrofft (Jul 22, 2012)

thegreypilgrim said:


> This is why you fund at state-level. As long as local communities have to pay for EMS you're going to have this disparity in resource availability.



I think maybe national too, as they do or did) for Indian reservation clinics and GS positions at such places as Johnson Island, Antarctica, etc.

Hey, use the military, especially National Guard and Reserves.

But definitely, some areas deserve better than they can afford.


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## JPINFV (Jul 22, 2012)

mycrofft said:


> So you would teach and require the MD's to do that sort of care. It is real healing, not just throwing knowledge out as orders and watching for a result.  The parallel I was  trying to raise and others have to a degree is that as we add tiers we delete duties from those who are "on the top"; however, what if we took thirty embryonic nurses, thirty embryonic doctors, and thirty embryonic PA's, and instead made them all generalists, doing EVERYTHING? (Same for ALS versus BLS).




However, the problem is that for EMS we're comparing the same professional field, while for medicine vs nursing we're comparing different professional fields. However I will argue that when it comes to inpatient medical care, there is a large bit of throwing out orders and waiting for results. Obviously, the physician needs to understand the practical ramifications of his orders (i.e. vitals Q4 hours overnight...). Otherwise you're going to expect the admitting physician to be an expert in medicine, nursing PT, dietary, radiology, and numerous other fields. That's not really the same as having different tiers within the same profession. 

The closest thing when it comes to tiers would be specialties to subspecialties. A cardiology and a pulmonologist should be able to both manage regular inpatients since both are specialized in internal medicine prior to subspecializing in pulmonology or cardiology. Thus a pulmonologist or cardiologist is an internal med physician + _____, just like a paramedic is an EMT + _____ under the current system.


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## thegreypilgrim (Jul 22, 2012)

mycrofft said:


> Haven't we established elsewhere/when that the majority of 911 calls DON'T require advanced life support? And many don't really require BLS either?
> But I am sympathetic to your reconsideration of tiered responses.


 We need to abandon the whole dichotomy between "BLS" and "ALS". It's no longer a useful concept. So, while it's true that very few 911 patients actually require "life saving care" however you wish to define it, it remains true that they are going to require some level of medical intervention. That's why we need a provider who can fill that role whilst simultaneously being able to initiate resuscitative or otherwise "invasive" care. That would be the new "BLS" - an ambulance officer who can handle the majority of calls. The new "ALS" would be an intensivist who is available on retainer for those rare calls that actually do require life-saving efforts as well as being someone who can connect less acute patients with alternative resources in a systematic way.



> Here's a rhetorical question: why is it (or IS it?) "beneath" paramedics to be called and to provide basic treatment? To revisit an earlier post of mine, if everyone was a paramedic, the wage would down, so it wold be affordable. But could enough people, or enough in a given region, pass the training to become one?


 It isn't "beneath" them, but there needs to be an appropriate matching of resources. These "basic" patients deserve and require something more than a 120-hour glorified first aider, but then there needs to be a separate specialized provider for those complex and high-acuity cases who can deliver invasive and intensive care.


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## thegreypilgrim (Jul 22, 2012)

mycrofft said:


> I think maybe national too, as they do or did) for Indian reservation clinics and GS positions at such places as Johnson Island, Antarctica, etc.
> 
> Hey, use the military, especially National Guard and Reserves.
> 
> But definitely, some areas deserve better than they can afford.


 National would be even better, even if it was under the same rubric of the old 1973 EMS Act.


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## DPM (Jul 22, 2012)

I'm going to stick by my guns on this one. I agree with most of what you guys are saying but I really don't believe that increasing the training of our Basic level is the solution here.

I see you point Mycroft, but I can't help but feel that you're saying it just to stir things up a bit. I don't think that our best solution to providing affordable treatment is to engineer a situation where our workforce gets into a price war with itself and as a result everyone stands to earn less.

State or Federal funding would be brilliant, and I know I bang on about it, but if PD and FD can do it at a local level then why can't EMS?

No one likes the idea of Basic / Basic ambulances because of the chance that skills beyond their scope will be needed. So instead of driving down the wages of Paramedics nationwide, I feel that the efficient use of Paramedics or even Intermediates is what we need. Instead of a system with 6 ALS Ambulances, you have 4 BLS and 2 ALS rigs. The BLS units can do the BLS calls, and ALS is there if needed. If you then find that 4:2 doesn't work, you can change to 3:3. Or 3 BLS, 2 Intermediate and 1 ALS. If you find that ALS is needed on 10% of the time, then it doesn't make financial sense in these poorer communities to pay for it the entire time.

A Paramedic practitioner is also perfect for these situations. Instead of worrying about getting ambulances to transport all patients we can use a Practitioner to diagnose and treat the PT at home. We all agree that the majority of 911 calls do not require ALS interventions and of them many aren't true emergencies either. This concept has been in place in many modern EMS systems worldwide and is working really well.

Thoughts?


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## thegreypilgrim (Jul 22, 2012)

DPM said:


> State or Federal funding would be brilliant, and I know I bang on about it, but if PD and FD can do it at a local level then why can't EMS?


 Well, it isn't at all clear that PD and FD _can_ be efficiently operated at the local level! Cities go bankrupt all the time, and I would argue that the cause of their fiscal problems are traceable to the burdens of having to provide police & fire services to their populations. Now, for PD it's kind of unavoidable because of jurisdictional differences in legal codes, but FD is more or less in the same category as EMS. They're both money pits and pose significant economic burdens on the locality. State-level (or federal) funding and operation dilutes costs and recruits wealthier resources to subsidize depressed or isolated communities.



> No one likes the idea of Basic / Basic ambulances because of the chance that skills beyond their scope will be needed.


 It isn't really a question of probability - it's inevitable and happens every day. BLS units get called out for low priority designated call and discovers it's more serious than originally triaged, so they upgrade to ALS. What has effectively been done here other than add a layer of redundancy? Especially considering that the BLS crew basically has to just sit there unable to provide any substantial intervention while waiting for ALS who will have to start from square one when they arrive. Why not get it right the first time and send someone out to each call who is capable of providing some basic interventions?


> So instead of driving down the wages of Paramedics nationwide, I feel that the efficient use of Paramedics or even Intermediates is what we need.


 How would increasing the training and scope of BLS result in driving down wages for paramedics? If anything they'll increase. Requiring a BS degree like every other profession in the world will reduce supply of qualified medics. You also need to let go of the notion of transporting every single patient EMS comes in contact with. EMS has an opportunity to significantly impact national health expenditures and deflating hospital census by being able to either not transport or to refer to an alternate destination (e.g. urgent care, sobering center, behavioral health facility, etc.). In order to do that we have to lobby our elected officials to get them to change Medicare's ambulance reimbursement schedule to include non-transport; and, in order to do that we have to be educated professionals. 


> Instead of a system with 6 ALS Ambulances, you have 4 BLS and 2 ALS rigs. The BLS units can do the BLS calls, and ALS is there if needed. If you then find that 4:2 doesn't work, you can change to 3:3. Or 3 BLS, 2 Intermediate and 1 ALS. If you find that ALS is needed on 10% of the time, then it doesn't make financial sense in these poorer communities to pay for it the entire time.


 Just because "ALS" isn't needed does not mean no interventions are needed. Which is essentially what "BLS" means: the category of patients who can be transported with no ambulance personnel intervention.

It isn't feasible to continue to transport every patient that access 911. Can you say that a crew of EMT-B's can make such determinations?



> A Paramedic practitioner is also perfect for these situations. Instead of worrying about getting ambulances to transport all patients we can use a Practitioner to diagnose and treat the PT at home. We all agree that the majority of 911 calls do not require ALS interventions and of them many aren't true emergencies either. This concept has been in place in many modern EMS systems worldwide and is working really well.
> 
> Thoughts?


 Paramedic Practitioners are great for community health type programs and non-emergent contexts. There should be a non-emergency line that patients enrolled in such a program can call directly to have a Paramedic Practitioner come out and assess them. But people don't always do that. There will always be those who call 911 but do not require hospital admission or even evaluation in the ED. We need to have ambulance personnel who can reliably identify these patients so when an ambulance is called as opposed to a Paramedic Practitioner we don't have to lose time waiting for the Practitioner to respond.


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## DPM (Jul 22, 2012)

> How would increasing the training and scope of BLS result in driving down wages for paramedics? If anything they'll increase. Requiring a BS degree like every other profession in the world will reduce supply of qualified medics. You also need to let go of the notion of transporting every single patient EMS comes in contact with. *EMS has an opportunity to significantly impact national health expenditures and deflating hospital census by being able to either not transport or to refer to an alternate destination (e.g. urgent care, sobering center, behavioral health facility, etc.). In order to do that we have to lobby our elected officials to get them to change Medicare's ambulance reimbursement schedule to include non-transport; and, in order to do that we have to be educated professionals.*



With our 'top flight' HEMS Paramedics not requiring a degree, I just feel it's a bit of a stretch to require that as entry level. I do agree that further education is the way forward, but I don't think starting at the entry level should be the first step.

And I don't want to transport everyone, not even close. That's why I'm such a fan of practitioners. And I really agree with you on the highlighted text. I would love an EMS system that could treat and release, and have the autonomy and capability to determine who needs to go where. But is that going to be the responsibility of the everyone on the ambulance? Shouldn't this change come from the top? Enhance / Improve the Paramedic scope, and then move onto the Basics.


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## thegreypilgrim (Jul 22, 2012)

DPM said:


> With our 'top flight' HEMS Paramedics not requiring a degree, I just feel it's a bit of a stretch to require that as entry level. I do agree that further education is the way forward, but I don't think starting at the entry level should be the first step.


 Right, do HEMS paramedics make better money than their ground medic counterparts? No, not substantially. Why do paramedics only make on average around $30k/year? The answer is employers can get away with it - because the barrier to entry into the field is so low. You can become a paramedic in this country in as little as 1100 hours. Employers are happy to keep things at that level and aren't likely to be the ones to start requiring higher education. You can say you don't think a higher education is needed, but you're going to have to explain why. A bachelor's degree isn't exactly a huge burden to overcome and it is the entry-level standard for every profession in existence. Other developed nations require undergraduate degrees for paramedics as well.



> And I don't want to transport everyone, not even close. That's why I'm such a fan of practitioners. And I really agree with you on the highlighted text. I would love an EMS system that could treat and release, and have the autonomy and capability to determine who needs to go where. But is that going to be the responsibility of the everyone on the ambulance? Shouldn't this change come from the top? Enhance / Improve the Paramedic scope, and then move onto the Basics.


 So how is that going to be done with the present level of training requirements?


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## DPM (Jul 22, 2012)

I feel like we're arguing two sides of the same coin. We both want higher levels of training, I agree with you entirely there. But you have already pointed out how easy it is to make it all the way to the top of our EMS food chain, so making the first rung harder to get on doesn't solve this.

I think that making that top level more difficult first is the way ahead. Once we have our Paramedics etc educated to a decent level, then we can progress down the food chain. What happens when our Basics are degree trained but the Paramedics have an associates?

Either way, I don't think requiring a degree to be a paramedic is a bad thing. Far from it, higher levels of education across the board will only improve our current system.


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## thegreypilgrim (Jul 22, 2012)

DPM said:


> I think that making that top level more difficult first is the way ahead. Once we have our Paramedics etc educated to a decent level, then we can progress down the food chain. What happens when our Basics are degree trained but the Paramedics have an associates?


 No I mean upgrade both at the same time. 

The new EMT = BS degree
New paramedic = MS degree


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## DPM (Jul 22, 2012)

thegreypilgrim said:


> No I mean upgrade both at the same time.
> 
> The new EMT = BS degree
> New paramedic = MS degree



What happens to the fire departments that want everyone to be EMT-B qualified?

How about:

Old EMT-B = Certificate or what ever it is
New EMT -B (obviously needs a sexy new name) = Associates
New Paramedic = BS
Practitioners / CCT / HEMS = MS

It may sound like dumbing down, bur for the majority of work that our Basics actually carry out on the ambulance considering that it's the Paramedics that deliver most of the care, can we justify asking them for 4 years of education and training?


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## Level1pedstech (Jul 22, 2012)

thegreypilgrim said:


> What has to happen is the EMT-B level has to be scrapped altogether and replaced with something else. It simply has no utility in a modern ambulance service (O2 and band aids are not all that useful for much). It has to be upgraded to something like a "Basic Paramedic" level which would have the education and skillset to attend the majority of calls so you can actually have a tiered response system.
> 
> *Basic Paramedic*
> BS Degree
> ...



Oh goody another way to over educate our local providers and let them continue to earn poverty level wages by way of taxation. Please for the class could you direct us to where you find the wording in the constitution that allows the use of any federal tax dollars for determination of provider standards for state or local EMS systems. Better yet which one of the 15 enumerated powers allows for any federal involvement in state or local EMS issues?

So in your opinion when did the EMS system in Any Town,USA become subject to any intervention by the feds. Do you think those of us that actually pay federal income taxes really want to see our hard earned money going to another worthless money losing venture forced on us by the feds? By paying taxes I mean those of us sending money to the feds and not receiving 100% of it back as a refund. My guess is a large portion of you fall into the second category which means you have no skin in the game so please stop wasting my money. Fix all the other worthless,useless and bloated programs already out there there then give us back the savings.

And of course there is always that one little tiny thing you all like to leave out when you start with these fantastic fixes for EMS. Money,money and more money. There is NO more money for the feds to spend on stupid,worthless and useless fixes for state and local EMS sytems. There is NO more money at the state and local level either. Do you get it there is NO MORE MONEY! Its like talking to a five year old.

There are alot of people who will lower themselves to working in EMS with a degree for 25k a year but eventually they will sober up and realize you cant live forever on what MOST non fire EMS providers are paying. Then there are those out there that think more education is the answer and that with more education better pay and professional respect will follow,to which I say REALLY. Do you think these people ever come up out of their mothers basement and see what a complete state of financial meltdown this countries in?

Your ideas as well as the others are peachy and you go to bed at night feeling all warm and fuzzy but the american people are about fed up with the useless programs we are paying for now and here you are advocating for yet one more.


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## Tigger (Jul 22, 2012)

Level1pedstech said:


> Oh goody another way to over educate our local providers and let them continue to earn poverty level wages by way of taxation. Please for the class could you direct us to where you find the wording in the constitution that allows the use of any federal tax dollars for determination of provider standards for state or local EMS systems. Better yet which one of the 15 enumerated powers allows for any federal involvement in state or local EMS issues?
> 
> So in your opinion when did the EMS system in Any Town,USA become subject to any intervention by the feds. Do you think those of us that actually pay federal income taxes really want to see our hard earned money going to another worthless money losing venture forced on us by the feds? By paying taxes I mean those of us sending money to the feds and not receiving 100% of it back as a refund. My guess is a large portion of you fall into the second category which means you have no skin in the game so please stop wasting my money. Fix all the other worthless,useless and bloated programs already out there there then give us back the savings.
> 
> ...



Well that attitude is certainly going to fix any problems. It might also be nice if you could stop deciding who gets to have these conversations and who doesn't. We all come from different backgrounds, that's an asset to discussion and should not be a deterrent.

And if we want to play the whole "interpret the constitution game," we could go ahead and look at the very first enumerated power "the Congress has the power to lay taxes, duties, imposts, and excises to pay the debts and provide for the common defence and general welfare of the United States; but all duties, imposts, and excises shall be uniform throughout the United States."

Surely the provision of prehospital medical care could be considered as providing for the general welfare of the country.

This country will come out of the present recession eventually. There is no reason not to attempt to lay the groundwork for a dramatic improvement of this country's EMS system so that when revenues start to increase we can be ready to implement change.


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## Level1pedstech (Jul 22, 2012)

DPM said:


> What happens to the fire departments that want everyone to be EMT-B qualified?
> 
> How about:
> 
> ...



Your playing right into the delusions. Really four years of education for a medic that might make 40k a year. You would either really,really want to be a medic or your incredibly naive at how much money it takes to run even the most fugal of family budgets. Would you advise your kid to spend all that time and money and then be rewarded with compensation that would allow him to qualify for food stamps in most places in the US?

Return on investment is how you have to look at this issue if your really serious about staying on in pre hospital EMS. Remember there is barely enough money out there to cover the system as it exists now. This is bound to get worse as more and more cities start flooding the bankruptcy courts. Where do you think the money is going to come from to compensate these "super medics"?

These things that people come up with to over haul the system always seem like great ideas and they give people hope for a fix. This issue is really not (unless your in EMS) what we as a country are really focused on and really should take back seat to all the other issues we face. Sometimes I think half of this comes from people to young and inexperienced to have a clue about securing their future. The other half is made up of old farts that have already made their mark and just like to yank the newbies chains.

Go to school and come out an MD,PA or RN and then you can give back to your community and play in EMS as a hobby. There are many agencies that rely on volunteers who have full time jobs in other health care occupations. Leave the low pay and poor working conditions that most non fire EMS agencies offer to those that cant make it in school for whatever reason.


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## Level1pedstech (Jul 22, 2012)

Tigger said:


> Well that attitude is certainly going to fix any problems. It might also be nice if you could stop deciding who gets to have these conversations and who doesn't. We all come from different backgrounds, that's an asset to discussion and should not be a deterrent.
> 
> And if we want to play the whole "interpret the constitution game," we could go ahead and look at the very first enumerated power "the Congress has the power to lay taxes, duties, imposts, and excises to pay the debts and provide for the common defence and general welfare of the United States; but all duties, imposts, and excises shall be uniform throughout the United States."
> 
> ...



Not sure where our coming fom on where Im deciding who gets to have these discussions. All are welome.

Where do you get the funding for state and local EMS out of the first enumerted power? 

Are you talking about making it a federal system,if so nice try but its not high on most peoples list of priorities.


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## DPM (Jul 23, 2012)

Tigger said:


> Surely the provision of prehospital medical care could be considered as providing for the general welfare of the country.
> 
> This country will come out of the present recession eventually. There is no reason not to attempt to lay the groundwork for a dramatic improvement of this country's EMS system so that when revenues start to increase we can be ready to implement change.



That's quite right. There are already taxes in place that provide for emergency healthcare. A slight increase in that area could fund a proper EMS system, which would in turn drive down pre-hospital healthcare and insurance costs. So you may end up paying an extra .05% in taxes but you would recoup that loss in your cheaper health insurance.

And I really can't see a reason why you are arguing against the education of our healthcare providers. Every method of measuring economic development shows that the more university educated people there are in a population the higher their mean income is. More money and a better service... I don't see the down side.


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## Level1pedstech (Jul 23, 2012)

DPM said:


> That's quite right. There are already taxes in place that provide for emergency healthcare. A slight increase in that area could fund a proper EMS system, which would in turn drive down pre-hospital healthcare and insurance costs. So you may end up paying an extra .05% in taxes but you would recoup that loss in your cheaper health insurance.
> 
> And I really can't see a reason why you are arguing against the education of our healthcare providers. Every method of measuring economic development shows that the more university educated people there are in a population the higher their mean income is. More money and a better service... I don't see the down side.



 What part of I dont want to pay any more taxes for programs that are run by the government federal,state or local dont you understand. We really should turn it over to the free market and see what happens. Sadly the free market knows pre hospital healthcare for the most part is a big money wasting  loser and has chosen for the most part to stay away.

No one is aginst better educated providers I just feel its fair to offer proper compensation for your investment. If you want to spend four years in school and be compensated with poverty level wages then by ll mens have at it. Some of these young people might like to have a job that llows them to raise a family and  have some fun.


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## rescue1 (Jul 23, 2012)

Level1pedstech said:


> What part of I dont want to pay any more taxes for programs that are run by the government federal,state or local dont you understand. We really should turn it over to the free market and see what happens. Sadly the free market knows pre hospital healthcare for the most part is a big money wasting  loser and has chosen for the most part to stay away.
> 
> No one is aginst better educated providers I just feel its fair to offer proper compensation for your investment. If you want to spend four years in school and be compensated with poverty level wages then by ll mens have at it. Some of these young people might like to have a job that llows them to raise a family and  have some fun.



The way to fix a problem is not to say "Oh, there's nothing we can do about it, better get another job".

Free market economics will never fix EMS, because EMS, and all of health care, is not a profitable industry. Like the fire department, it is most efficiently run when it doesn't have to cost costs or drive up rates to turn a profit. 

I don't think anyone is advocating a massive federal tax to create the United States Ambulance Service...but suggesting that some state or federal taxes support underfunded EMS systems (Detroit, anyone?) to allow them to provide  an effective level of service.

And if we want to advance as an industry and ask for a wage comparable to police or fire, education has to part of the equation. Other countries have done it, there's no reason America can't do it too.


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## DPM (Jul 23, 2012)

Level1pedstech said:


> What part of I dont want to pay any more taxes for programs that are run by the government federal,state or local dont you understand. We really should turn it over to the free market and see what happens. Sadly the free market knows pre hospital healthcare for the most part is a big money wasting  loser and has chosen for the most part to stay away.
> 
> No one is aginst better educated providers I just feel its fair to offer proper compensation for your investment. If you want to spend four years in school and be compensated with poverty level wages then by ll mens have at it. Some of these young people might like to have a job that llows them to raise a family and  have some fun.



No matter what happens, you will be paying for your ambulance ride. You can't get around that. But from what you're saying you'd rather pay more money for an inferior service, and pay it to you insurance company. If you paid the same amount in a healthcare tax, just like the rest of the world does, then there would be a much better EMS system in this country. And I really don't see why there is opposition to this. If you are already going to be losing X% of your paycheck in healthcare costs, why are you against that amount either going down or being used more efficiently?

Edit to add: No one seems to mind when Federal money is used to help fund other 911 services (Department of Homeland Security does a good one for Fire) so why the opposition for EMS?


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## Tigger (Jul 23, 2012)

Level1pedstech said:


> Not sure where our coming fom on where Im deciding who gets to have these discussions. All are welome.
> 
> Where do you get the funding for state and local EMS out of the first enumerted power?
> 
> Are you talking about making it a federal system,if so nice try but its not high on most peoples list of priorities.



We all have skin on the game, no matter what income tax bracket we fall into. It's. It just your tax dollars that go to federal programs, it's mine too.


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## Level1pedstech (Jul 24, 2012)

DPM said:


> No matter what happens, you will be paying for your ambulance ride. You can't get around that. But from what you're saying you'd rather pay more money for an inferior service, and pay it to you insurance company. If you paid the same amount in a healthcare tax, just like the rest of the world does, then there would be a much better EMS system in this country. And I really don't see why there is opposition to this. If you are already going to be losing X% of your paycheck in healthcare costs, why are you against that amount either going down or being used more efficiently?
> 
> Edit to add: No one seems to mind when Federal money is used to help fund other 911 services (Department of Homeland Security does a good one for Fire) so why the opposition for EMS?



Please do not use the words efficiently and government (federal,state,local) in the same sentence if you want to be taken seriously.

There are plenty of us that are against the use of federal tax dollars for anything other than what is set aside in the constitution. Any federal money that returns to the states in the form of grants for local services is a misuse of federal tax revenue. Once again its done all the time but that does not make it constitutional. The federal taxes I pay in CA should not be sent to fund EMS services in your home town. You can jump up and down all you want but its not going to make it right.

Are you not sick and tired of watching government agencies piss away our hard earned money? Can you point to one entitlement program that is anywhere near solvent or stable (social security,medicare,medicaid)? Do you want to see EMS agencies run like the post office,amtrak or your local DMV?

Here is an idea if you want somewhere to stick your x%,how about we start properly compensating our men and women serving this country. When these volunteers return state side they are offered a pathetic excuse for support and thats if they are lucky enough to have not been wounded. If they have been hurt the care and support they are offered is far from what my definition of quality care is. Lets take better care of these folks before we fund one more dollar out in the form public safety grants. 

And for those that think they have some skin in the game and see no problem with just one more tax. How about you write out an extra check at the end of the year to help cover some of this debt. If your okay with sending more money down the hole then have it.

The people that come up with these ideas to improve or change the way EMS functions are well meaning but naive to say the least. They look at change on a national level before they attempt to make changes at home which is their first mistake. These ideas to make big grand changes to EMS on a national level come and go all the time. The ones with the ideas feel all warm and fuzzy thinking they have come up with the solution to a problem that really only exists in the minds of those involved in EMS. The general public really could give a rats butt.

Once again no new taxes.


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## rescue1 (Jul 24, 2012)

Are you really complaining about government run public safety systems? Because...you know...they're almost all government run, paid for through taxes. 

It's fine that you don't like taxes, nobody does, but without them we cannot operate emergency systems, except for some private ambulance companies (which often receive some tax funding) and lucky volunteer companies in areas where they can survive on donations alone.

If you think I'd be upset about tax dollars that go to funding firefighter and EMS jobs and systems, you'd be wrong.

And don't even get me started on US healthcare.


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## Level1pedstech (Jul 24, 2012)

rescue1 said:


> Are you really complaining about government run public safety systems? Because...you know...they're almost all government run, paid for through taxes.
> 
> It's fine that you don't like taxes, nobody does, but without them we cannot operate emergency systems, except for some private ambulance companies (which often receive some tax funding) and lucky volunteer companies in areas where they can survive on donations alone.
> 
> ...



Local taxes=Local services 

I would gladly pay more local taxes than I do now if I could be assured that my money was being spent to fund my local services in an efficent manner.

Having spent six years working in the ER of an inner city level one trauma center I can tell you we have the best healthcare system in the world. No waiting for weeks for procedures like you have in the UK and Canada. Why do you think the wealthy and politicaly connected flee to the US from these countries for their more complicated procedures. Yes everyone gets healthcare at some point but not the way we do here in the US.  Places that practice socialistic medicine are at present just a small step above the third world toilets they will become once they collapse in on themselves.


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## rescue1 (Jul 24, 2012)

Level1pedstech said:


> Local taxes=Local services
> 
> I would gladly pay more local taxes than I do now if I could be assured that my money was being spent to fund my local services in an efficent manner.
> 
> Having spent six years working in the ER of an inner city level one trauma center I can tell you we have the best healthcare system in the world. No waiting for weeks for procedures like you have in the UK and Canada. Why do you think the wealthy and politicaly connected flee to the US from these countries for their more complicated procedures. Yes everyone gets healthcare at some point but not the way we do here in the US.  Places that practice socialistic medicine are at present just a small step above the third world toilets they will become once they collapse in on themselves.



My issue with US healthcare is that it IS the greatest in the world...if you happen to be in the top 50% of earners (or higher), or critically injured. But then it starts to taper off rapidly. However, that is not the point of this thread, so I'll agree to disagree on that one.


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## rescue1 (Jul 24, 2012)

Level1pedstech said:


> Local taxes=Local services
> 
> I would gladly pay more local taxes than I do now if I could be assured that my money was being spent to fund my local services in an efficent manner.



What about municipalities that are in financial trouble or are just very poor? Detroit, Camden...even Philadelphia's EMS system is about 30 ambulances understaffed. 

These areas, whether due to economically depressed conditions or financial mishandling by the government, are unable to provide effective emergency services to their citizens. Would it really require punishing taxes to try and support (but not supplant) the fire/EMS/Police forces of these areas? I don't really think so. SAFER grants are such a tiny drop in the bucket for the federal government budget it isn't even funny.


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## Tigger (Jul 25, 2012)

Level1pedstech said:


> Local taxes=Local services
> 
> I would gladly pay more local taxes than I do now if I could be assured that my money was being spent to fund my local services in an efficent manner.
> 
> Having spent six years working in the ER of an inner city level one trauma center I can tell you we have the best healthcare system in the world. No waiting for weeks for procedures like you have in the UK and Canada. Why do you think the wealthy and politicaly connected flee to the US from these countries for their more complicated procedures. Yes everyone gets healthcare at some point but not the way we do here in the US.  Places that practice socialistic medicine are at present just a small step above the third world toilets they will become once they collapse in on themselves.



Have you ever actually experienced or even studied healthcare systems in developed nations outside the US?


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## Level1pedstech (Jul 25, 2012)

Tigger said:


> Have you ever actually experienced or even studied healthcare systems in developed nations outside the US?



Good friends with a fireman and his wife whos a nurse they live in Manchester UK,family friend whos a Canadian citizen that regularly travels south for medical treatment. Not sure if that counts but combined with stories I have heard over the years I can say we are with out a doubt the best.

Honestly Im not real interested in what the rest of the world does. I have been knee deep in this countrys health care system and can tell you its not perfect but I would gladly take it any day over the systems in the UK or Canada.

Now let me ask you,have you ever spent an extended period of time in one of our inner city level one trauma centers? If you have did you focus on what came thru the back door like most people do, these would be your A typical emergent health care recipients. Or did you take the time to observe the very large number of people that came in the front door,these would be your not so sick health care recipients. For those that might not know, its the not so sick health care recipients that are dragging us into the hole.

A majority of the not so sick health care recipients are at least in the inner city level one truma scenario going to fall into two groups. Group one is made up of those that could pay but they know if they work the system they can get their care for free or at a deeply discounted rate. Group two is the indigents,illegals and just plain losers in life. They have no resources and after recieving the best care available will walk out knowing they will never have to pay. Then of course there are the rest of us who have to absorb the cost of providing that first class care to every one in need.

Moral of the story is everyone gets first rate care regardless of thier ability to pay. It might be a level one full system trauma patient or your run of the mill tummy ache regardless they both recieve the same care. This care is rendered in sterile state of the art facilities by some of the brightest most educated providers the world has to offer. Funny how the best and brightest are drawn to the US when there are so many other places they could go.


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## Level1pedstech (Jul 25, 2012)

rescue1 said:


> What about municipalities that are in financial trouble or are just very poor? Detroit, Camden...even Philadelphia's EMS system is about 30 ambulances understaffed.
> 
> These areas, whether due to economically depressed conditions or financial mishandling by the government, are unable to provide effective emergency services to their citizens. Would it really require punishing taxes to try and support (but not supplant) the fire/EMS/Police forces of these areas? I don't really think so. SAFER grants are such a tiny drop in the bucket for the federal government budget it isn't even funny.


 
Why are these municipalities in financial trouble,could it be that they have no fiscal accountability or maybe its that they couldnt run a lemonade stand without screwing it up? 

I have over the years used the same arguement when tying to convince people that some areas have no choice but to rely on volunteers. Where there is no money there is no paid service but there will always be people willing to volunteer.

A tiny drop in the bucket....you truly dont get the big picture,its okay at least you have something in common with the feds.


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## the_negro_puppy (Jul 25, 2012)

Level1pedstech said:


> Local taxes=Local services
> 
> I would gladly pay more local taxes than I do now if I could be assured that my money was being spent to fund my local services in an efficent manner.
> 
> Having spent six years working in the ER of an inner city level one trauma centre I can tell you we have the best healthcare system in the world. No waiting for weeks for procedures like you have in the UK and Canada. Why do you think the wealthy and politically connected flee to the US from these countries for their more complicated procedures. Yes everyone gets healthcare at some point but not the way we do here in the US.  Places that practice socialistic medicine are at present just a small step above the third world toilets they will become once they collapse in on themselves.



Baloney. We have been practising Socialised medicine in Australia for decades. It's not without its problems but any citizen or permanent resident can receive primary or emergency care without having to worry about paying a $10,000 for a bed for 12 hours, a CT scan and a few blood tests.

We also have the option of having private health insurance like in the states to attend private hospitals for both emergencies or procedures. No waiting for weeks if you are insured.

I agree that we probably pay higher taxes than US residents, and yes, many dollars are wasted by an inefficient bureaucracy. Without health, what do you really have though?


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## rescue1 (Jul 25, 2012)

Level1pedstech said:


> Why are these municipalities in financial trouble,could it be that they have no fiscal accountability or maybe its that they couldnt run a lemonade stand without screwing it up?
> 
> I have over the years used the same arguement when tying to convince people that some areas have no choice but to rely on volunteers. Where there is no money there is no paid service but there will always be people willing to volunteer.
> 
> A tiny drop in the bucket....you truly dont get the big picture,its okay at least you have something in common with the feds.



Bro...I get the big picture. I have a college degree in the big picture. So please don't talk condescendingly to me about public finance and tax spending, I just spent four years studying it.

There are municipalities that have been run like absolute crap, no question. But there's no reason to punish the citizens inside for the actions of a few incompetent politicians. And you can't expect Detroit to be protected effectively by volunteers.

Look, we clearly disagree on this, and I don't think either of us is going to convince the other that we're right, so let's get back to talking about basic technicians as opposed to government healthcare and taxes.


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## sir.shocksalot (Jul 25, 2012)

Level1pedstech said:


> Moral of the story is everyone gets first rate care regardless of thier ability to pay. It might be a level one full system trauma patient or your run of the mill tummy ache regardless they both recieve the same care. This care is rendered in sterile state of the art facilities by some of the brightest most educated providers the world has to offer. Funny how the best and brightest are drawn to the US when there are so many other places they could go.


By every measure the US has one of the worst health care systems in the world. http://www.who.int/countries/en/ Compare Canada and the US, life expectancy is greater, and your chances of dying are smaller in Canada than the US, they also spend less of their GDP caring for themselves.
I will agree that the US probably has some of the greatest physicians in the world. Unfortunately we are measured on averages, and on average we provide poor primary health care, poor public access health, poor preventative medicine.
I also agree that if you show up sicker than :censored::censored::censored::censored: on a US hospitals door step that we probably have a better chance of saving you than maybe the UK or Canada. However the UK or Canada may have prevented that illness from occurring, or follow up care will probably be better should the pt recover.
I have worked in an inner city area with a lvl 1 safety net hospital, and yes these homeless pt's get the care they need to survive, but that's it. Also their care (while cheap compared to a non-homeless person) is still financially devastating, which is an issue that neither the US or the UK has.
Politics aside, believing that our current system is working is simply an exercise in ignorance.

Now that we have gotten sufficiently off topic I will add my 2 cents on EMTs. I think all BLS care in the US system, while not ideal, would be adequate for an urban setting. ER's are often so close that BLS skills will sustain a patient until they get to the ER. However I think ALS should be the minimum for any community, if they can afford to have cops they should also be able to pay for a paramedic.


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## Level1pedstech (Jul 25, 2012)

the_negro_puppy said:


> Baloney. We have been practising Socialised medicine in Australia for decades. It's not without its problems but any citizen or permanent resident can receive primary or emergency care without having to worry about paying a $10,000 for a bed for 12 hours, a CT scan and a few blood tests.
> 
> We also have the option of having private health insurance like in the states to attend private hospitals for both emergencies or procedures. No waiting for weeks if you are insured.
> 
> I agree that we probably pay higher taxes than US residents, and yes, many dollars are wasted by an inefficient bureaucracy. Without health, what do you really have though?



The majority of us want nothing to do with socialised or government run health care. The majority of my fellow americans were against the passing of Obama care but it was forced on us,had there been a chance to vote on a national level it would have been defeated. Many of those backing the plan are not sure what it really offers,they openly admitted to never reading the complete 2700 page bill. The house speaker stood before the american people and with a straight face(no pun intended) said "we need to pass it to see whats in it". The majority of us are of the mind that "if it aint broke dont fix it". Our system pre Obama care is not perfect but I have yet to see people fleeing to Australia,Canada or the UK to recieve quality healthcare. Glad it works for you but you can keep it.

I laid out my arguement based on years of observing people receiving high quality health care in a privately run system that served a wide demographic. One thing that I will agree with you on and that is the importance of general over all good health. Sadly we have a lack of it here in the US,this is an area where we could learn from other countries.

By far the biggest drain on my former system were those who suffered the health complications related to poor life style choices. Behind that is the tremendous strain the illegal immigrant population continues to put on almost every facility on the west coast. Facilities that should be open and available to all have been closed because their resources to operate have been pissed away in large part on people who are here illegaly or who for whatever reason could just not make good choices.

But because we turn away no one and because we treat all equally those of us that maintain good health and lifetyle choices are forced to live with what remains. Once again its not without problems but I still believe it is the best in the world.


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## mycrofft (Jul 25, 2012)

Is this because of America's health culture is aimed at rescue, and many  Americans abuse drugs and live in poverty and have rejected any sort of regulated diet and/or do not engage in anything much more strenuous than lifting the remote and rocking back their recliner?
And to sound a more sinister, eugenic but pragmatic note, we also support, accept and recuse many with lethal genes or lifestyle that pass on to their children ( and may even pass on to their neighbors).

Also, don't some countries fudge their statistics? (Such as the USSR/Eastern Bloc and many Muslim countries OFFICIALLY reporting for years there was no HIV, alcoholism, suicide, etc).


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## Level1pedstech (Jul 25, 2012)

rescue1 said:


> Bro...I get the big picture. I have a college degree in the big picture. So please don't talk condescendingly to me about public finance and tax spending, I just spent four years studying it.
> 
> There are municipalities that have been run like absolute crap, no question. But there's no reason to punish the citizens inside for the actions of a few incompetent politicians. And you can't expect Detroit to be protected effectively by volunteers.
> 
> Look, we clearly disagree on this, and I don't think either of us is going to convince the other that we're right, so let's get back to talking about basic technicians as opposed to government healthcare and taxes.



Never meant to adress you in a condescending manner,I assume we all have mutual professional respect even if we share different views. My time is valuable and I would not take the time to participate in these discussions if thought I would easily win all the battles.

Good to see you have taken the time to become educated but your four years of higher education cant touch my real life experience. In thirty years we can have a few beers and I can almost guarantee we will be closer in agreement,it just happens.


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## mycrofft (Jul 25, 2012)

*Edit to comment above" RESCUE not "recuse".*

I want my Windows XP back. Wah.:angry:


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## Level1pedstech (Jul 25, 2012)

mycrofft said:


> Is this because of America's health culture is aimed at rescue, and many  Americans abuse drugs and live in poverty and have rejected any sort of regulated diet and/or do not engage in anything much more strenuous than lifting the remote and rocking back their recliner?
> And to sound a more sinister, eugenic but pragmatic note, we also support, accept and recuse many with lethal genes or lifestyle that pass on to their children ( and may even pass on to their neighbors).
> 
> Also, don't some countries fudge their statistics? (Such as the USSR/Eastern Bloc and many Muslim countries OFFICIALLY reporting for years there was no HIV, alcoholism, suicide, etc).



Most of us who are involved in health care know that people will often wait until the last minute to seek treatment even when early treatment is readily available. This of course is why our ER's are bulging at the seams with people that would have been better treated at a doc in the box or a community clinic a few days earlier. 

The patient whos common cold or flu that could have been handeled at home with fluids,rest and some OTC meds is now leaving the ER with a big fat bill and a set of simple instructions for rest,plenty of fluids and treat the symptoms with some OTC meds ( generic motrin will be fine). I have seen this scenario play out in the pediatric emergency room on a regular basis. These simple cough,colds and sniffles patients once they enter the system usually will get a consult,chest film,fluids (IV or oral) and motrin. Most of this is CYA on the hospitals part.

I have always had a hard time buying the arguement that we offer great critical or emergent care but fall short in the area of preventitive or general care. Its been my experience that especially in the last twenty years we have made a huge effort to offer early education and have put in place safety nets to help those that cant or wont help themselves. Pre natal care,well baby check ups,early childhood immunizations are just a few things that give all new americans a fighting chance. These services are easily found and are available to all. 

We have an ever increasing number of our fellow americans that are fat and lazy. Even with the flood of available resources and information people continue to  partake in activities that will eventually kill them. Those of us that eat right and exercise regularly are far out numbered by those who dont. Life style related illness and disease are becoming common place and even after we treat and educate these people most continue on with the bad habits.


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## usalsfyre (Jul 25, 2012)

Level1peds, 

I could type a couple of pages on the issues with your arguments, but what it essentially boils down to is your far too focused on EM and not accounting the bulk of medicine. Expand your horizons a bit.


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## Tigger (Jul 25, 2012)

Level1pedstech said:


> Good to see you have taken the time to become educated but your four years of higher education cant touch my real life experience. In thirty years we can have a few beers and I can almost guarantee we will be closer in agreement,it just happens.



I too have about finished my degree in the "big picture," and it does touch your thirty years of life experience because when you study something, you have to go a bit beyond "in my experience" to see if there is a problem. You state that you believe that our healthcare system is the best in the world, yet we fall short of nearly every accepted measurement standard on healthcare performance. It just simply isn't enough to say "I've been in healthcare in thirty years, and I say it's great." That's just not a tenable position, given that you have no evidence to support such a position beyond your personal experiences, which are neither reproducible nor verifiable.

I may not have thirty years of life experience but don't think for a second that I don't know what I am talking about and that eventually will see the error in my ways. There's a lot more to medicine than just EM, and there's a lot more to studying to something than just saying "I know this is true because I have seen it."


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## Level1pedstech (Jul 25, 2012)

Tigger said:


> I too have about finished my degree in the "big picture," and it does touch your thirty years of life experience because when you study something, you have to go a bit beyond "in my experience" to see if there is a problem. You state that you believe that our healthcare system is the best in the world, yet we fall short of nearly every accepted measurement standard on healthcare performance. It just simply isn't enough to say "I've been in healthcare in thirty years, and I say it's great." That's just not a tenable position, given that you have no evidence to support such a position beyond your personal experiences, which are neither reproducible nor verifiable.
> 
> I may not have thirty years of life experience but don't think for a second that I don't know what I am talking about and that eventually will see the error in my ways. There's a lot more to medicine than just EM, and there's a lot more to studying to something than just saying "I know this is true because I have seen it."



My experience has been that as patients pass thru the emergency department its possible to get a snap shot of how our health care system is working. For example are we seeing a larger number of chronically ill patients in our inner city area due to lack of available services or is it that some people no matter how much care is available just will not help themselves and eventually end up in the ER. 

Having spent the majority of my time working in pediatric emergeny medicine I have over the years seen huge improvements in the general health of our kids. This I owe to the availability of pre natal and well baby care to those that need it regardless of their ability to pay.

I admit to not having poured over tons of research and cant throw out statistics to back my observations. Because traditional learning has always been a challenge I have tried to use the real world as my course of study. Asking questions of the advanced providers and always being available to learn something new. Maybe I am missing some pieces of the puzzle and should seek a wider perspective?

So help me out, give me the top three issues or problems that you think are negatively affecting our health care system and let me see if I truly am centered on emergency medicine. Remember that I have pointed out in most every post that our system is not perfect and there is always going to be room for some improvement. I just dont see the large scale critical failures I would expect to see if as you say we are falling short in multipile areas.


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## DPM (Jul 25, 2012)

The last few pages are very interesting, but not exactly relevant to the topic... "Why Basic level Technicians?"

Perhaps a new thread for "What's wrong with the US healthcare system?"


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## rescue1 (Jul 25, 2012)

Level1pedstech said:


> So help me out, give me the top three issues or problems that you think are negatively affecting our health care system and let me see if I truly am centered on emergency medicine. Remember that I have pointed out in most every post that our system is not perfect and there is always going to be room for some improvement. I just dont see the large scale critical failures I would expect to see if as you say we are falling short in multipile areas.



The US healthcare system isn't suffering from critical failures (though some to the far left would probably say it is), it's just an inefficient system based around older government programs that have never been changed to reflect advances in preventative care or current laws. Remember, government healthcare makes up 21% of the yearly federal budget (as of 2011), more then any other expenditure (including the military). That's like $750 billion a year. Which is a lot of money for how little coverage it provides.

Basically, my issue with US healthcare is this: We spend the most per-capita on healthcare then any other nation in the world (between insurance and government assistance, I think over $7,000 a person) and have lower life expectancy, high child mortality rates, and higher obesity then all the other western democracies. 
This is mainly because of ERs being forced to treat all patients regardless of payment ability. Now, I'm not advocating casting poor people out in the cold to die, but when the government passed the Emergency Care Act in 1986, they failed to provide a revenue stream for hospitals to compensate for all this free care they were giving out. Which drove up prices for you and me, people who have health insurance and pay our bills. So basically, we have free healthcare, funded by you and I through our pants-:censored: ingly high medical bills, in an environment meant to deal with emergencies that instead has to treat people with runny noses and constipation in addition to STEMIs and trauma.

There is also that category of income where you have too much money to qualify for Medicaid or to blow off medical bills, but not enough for insurance. Then you can face bankruptcy very quickly through medical bills if you have a sudden medical issue.

The system could be better optimized if we realized that we're already paying for other people's healthcare, and then took that money and spent it on preventative care, clinics that people could use instead of clogging the ER, and that kind of thing. There will be a trade off--the more people you incorporate into the system the longer lines will be, but there are some fixes for that (private hospitals/insurance, like Australia has).

Keep in mind I'm very tired when I wrote this, so it may be riddled with errors, but I think that basically sums up my problem.


And yeah, this should probably be a new thread...


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