# Question to the experienced



## LongTranspot (Jan 26, 2019)

I’m 36 and a freshly minted EMT. I ran my first trauma today, a single vehicle MVA. The PT was obviously injured: deformed nose, bleeding and compromising his airway, crepitus in the chest, decreased lung sounds on R, and deformation to the R femur. Our service area is ~1hr from anywhere, so we called for a helicopter. We did what we could for a guy that was having one of the top five worst days of his life. 

When the flight medics arrived, one of them was, well, salty at best. We had made good progress with the PT by simple communication, e.g. “I have to suction your mouth, man. It’s not going to be pleasant.”  He didn’t seem particularly combative to my inexperienced eye. The flight fella took a different tact, barking, demanding, and complaining under his breath. 

I’m not trying to judge the medic; I just want to understand his position and I can’t exactly ask him. I know he’s in a hurry and I believe he knows what he is doing, but is this necessary? Heck, maybe he was just having bad day. Any insight anyone has would be useful. 

Thanks in advance.


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## StCEMT (Jan 26, 2019)

I mean without seeing it or knowing what he said, it's kind of hard to tell you anything. It falls on anyone running the call to make decisions and give people their roles. Maybe it's your perception? Maybe he was having a bad day? Maybe he is just a ****? Can't really tell ya anything beyond that.


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## LongTranspot (Jan 26, 2019)

That’s fair. I can’t adequately illustrate the tone and timbre of the situation. Honestly, I’m not sure what I was asking for when I started this thread, unobtainable insight, or trying to get the burr out from under my saddle, perhaps. 
Thanks for the reply, I’ll just see how it goes in the future.


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## mgr22 (Jan 26, 2019)

LongTransport, I see you're 36, so I'm assuming you've had a few jobs and worked a few places. Although I like to think the mission of EMS is distinctive, people in our industry are pretty much like anywhere else -- maybe a bit more assertive and a bit less compliant with pettiness, but basically what you're already used to. As StCEMT said, it's hard for anyone who wasn't there to know what you were dealing with. No matter how you size up the people around you, though, if you treat patients the way you'd want to be treated, know your job, show up ready to do it well, meet commitments, stay ahead of changes in your field and make time for life outside EMS, you should do fine.


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## NomadicMedic (Jan 26, 2019)

One of the hardest lessons to learn in EMS is, “not everyone is nice”. 

 Sounds like you got a pretty good example of that today.


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## DesertMedic66 (Jan 26, 2019)

Without knowing the system or what actually happened on the call it is hard to say why. Maybe he was being salty or maybe you understood it that way without that being the actual intent. Without being on scene as an objective 3rd party it is very hard to say what actually happened and not may have just been  perceived. 

For the flight side, depending on company, we try to adhere by company policies/guidelines. For my company the ideal scene call has a patient bedside time of 10 minutes so things have to move pretty quickly which means I am going to be direct and say exactly what I need. Depending on what aircraft I am in is also going to play a huge part into my decisions on the ground. If I’m in a 407 then there is very limited space to do anything at all for the patient so I need to make sure I have done everything I need to on the ground and also have a plan on how I want things situated inside the helicopter. If I’m in a 412 or 145 then that is not a huge concern since I can access much more of my patient. 

Add into all of that and the flight crew was probably highly considering to RSI this patient due to the fact you have to keep suctioning, the high potential for airway compromise, the patients clinical course, and the injuries sustained. Also add in that they are possibly thinking about doing a needle decompression or inserting a chest tube. It’s a lot of stuff to do while trying to limit our on scene time as much as physically possible.


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## VFlutter (Jan 26, 2019)

Always try to be as pleasant and professional as possible even in stressful situations however a lot of times people come off curt or demanding unintentionally when they are trying to be expeditious. As mentioned they are quickly thinking about the multiple interventions that need to be done, in what order, what needs to be done now vs in the helicopter, etc with a patient that has AMS, facial trauma, airway bleeding, pneumo, possible internal bleeding, etc. That patient would stress out most providers and presents a lot of challenges that need to be quickly addressed.


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## SpecialK (Jan 26, 2019)

Suctioning is over-rated and overused.  Most patients you can turn on their side and they will actively keep blood or fluid out of their own airway by spitting it into a vomit bag.  If there's a lot or the pt has a decreased level of consciousness then a bit of suctioning the mouth is usually all that is required.

Helicopters are very overrated and overused.  If you are one hour by road from hospital, then think of it this way: it'll take 5 minutes for the helicopter to get airborne (assuming the crew are immediately with the helicopter and this is not always the case), sounds like about 15 minutes for the helicopter to fly to the scene, another 5 minutes for it to land, personnel to get out, and do a handover, another 10-15 minutes to assess and do anything to the patient (e.g. pain relief), 5 minutes to load, 5 minutes to take off, 15 minutes to fly to hospital, and 5-10 minutes to offload the patient.

So, in this scenario, it sounds like you were no closer to hospital by just putting the patient in the ambulance and taking him there v using a helicopter and you've potentially severely limited the treatment the patient can receive because helicopters are cramped and noisy.  The exception to this is obviously if the patient needs something (for example RSI) which you cannot do and the fastest way is to get it there by helicopter.


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## VFlutter (Jan 26, 2019)

SpecialK said:


> Helicopters are very overrated and overused.
> 
> So, in this scenario, it sounds like you were no closer to hospital by just putting the patient in the ambulance and taking him there v using a helicopter and you've potentially severely limited the treatment the patient can receive because helicopters are cramped and noisy.  The exception to this is obviously if the patient needs something (for example RSI) which you cannot do and the fastest way is to get it there by helicopter.



Rapid transport is only one consideration for utilizing air transport. HEMS is more than just a fast ride. Many times it is quick access to critical care that is otherwise not available. Many ground ambulances in the US do not have RSI and even fewer have blood products, TXA, etc. Not to mention the overall level of care provided.

I agree there are places that overuse helicopters and in some regards can be considered overrated however the argument that the patient will get the hospital about the same time Ground vs Air does not necessarily mean they will be in the same condition on arrival. In most places the quality of resuscitation is a benefit.

A similar argument would be an officer tossing his partner in the back of the cruiser and booking it to the ER because he will get there about the same time the ambulance would even though he very well might be dead from an arterial bleed that needed a tourniquet on scene that the ambulance could have provided.


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## SpecialK (Jan 27, 2019)

VFlutter said:


> I agree there are places that overuse helicopters and in some regards can be considered overrated however the argument that the patient will get the hospital about the same time Ground vs Air does not necessarily mean they will be in the same condition on arrival. In most places the quality of resuscitation is a benefit.



Agreed.  If the fastest way to get a specific skill which the patient needs is by helicopter then use the helicopter, if it's by backup coming on road then use that.  Of course remembering to factor in the time to get to the helicopter, get airborne (assuming crew are immediately with the helicopter, not always the case), fly, land, etc.

Helicopters are super badass; the problem is they're often a bit of a white elephant when it comes to not being as super badass as people think.


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## akflightmedic (Jan 27, 2019)

VFlutter said:


> A similar argument would be an officer tossing his partner in the back of the cruiser and booking it to the ER because he will get there about the same time the ambulance would even though he very well might be dead from an arterial bleed that needed a tourniquet on scene that the ambulance could have provided.



Actually your comparison is accurate, yet proven to be of benefit. I was reading an article the other day where I think it is Pittsburgh police often transport before EMS even arrives. It is part of their Scope of Work, they train for it and are expected to do it...throw them in and transport. I think this also has to do with a trauma center being on every corner, however they have been doing this practice for well over a decade. Other police departments follow similar protocols...so there is tremendous merit in the police just throwing them in and transporting and not waiting.

This is just a JEMS article on it, however there are plenty of other studies on the practice.

https://www.jems.com/articles/print...tients-be-transported-by-police-officers.html


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## Gurby (Jan 27, 2019)

SpecialK said:


> Helicopters are very overrated and overused.  If you are one hour by road from hospital, then think of it this way: it'll take 5 minutes for the helicopter to get airborne (assuming the crew are immediately with the helicopter and this is not always the case), sounds like about 15 minutes for the helicopter to fly to the scene, another 5 minutes for it to land, personnel to get out, and do a handover, another 10-15 minutes to assess and do anything to the patient (e.g. pain relief), 5 minutes to load, 5 minutes to take off, 15 minutes to fly to hospital, and 5-10 minutes to offload the patient.
> 
> So, in this scenario, it sounds like you were no closer to hospital by just putting the patient in the ambulance and taking him there v using a helicopter and you've potentially severely limited the treatment the patient can receive because helicopters are cramped and noisy.  The exception to this is obviously if the patient needs something (for example RSI) which you cannot do and the fastest way is to get it there by helicopter.



I forget if you're in the UK or Canada or something where the entry level to EMS is like a bachelor degree.  OP is "a freshly minted EMT" which in the USA means he recently finshed a 120-hour high school level course, and was thrown out into the wild with no experience and no ability to perform any interventions beyond external bleeding control, O2 and transport.  This is not the person you want sitting in the back for an hour with a potentially very sick patient.  It sounds to me like given the circumstances OP did a great job just to recognize he was in over his head here and call for help.

Your point is well taken though.


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## kaisardog (Feb 28, 2019)

just  curious:  would  you  'turn  this  pt  on  his  side ' to  keep  his  airway   clear  with those sx:  " deformed nose, bleeding and compromising his airway, crepitus in the chest, decreased lung sounds on R, and deformation to the R femur..."


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## CCCSD (Feb 28, 2019)

Cops carry tourniquets.


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## DrParasite (Feb 28, 2019)

Gurby said:


> I forget if you're in the UK or Canada or something where the entry level to EMS is like a bachelor degree.  OP is "a freshly minted EMT" which in the USA means he recently finshed a 120-hour high school level course, and was thrown out into the wild with no experience and no ability to perform any interventions beyond external bleeding control, O2 and transport.  This is not the person you want sitting in the back for an hour with a potentially very sick patient.  It sounds to me like given the circumstances OP did a great job just to recognize he was in over his head here and call for help.
> 
> Your point is well taken though.


OK, your statement is insulting for many reasons:

1) EMT classes haven't been 120 hours since the 90s.  Most classes are closer to 180 hours; my current classes is 240, and is technically a hybrid, so includes a lot of work that is completed at home.  It's still could use a lot more, and should have more hands on practical/clinical time, but that's an above my paygrade decision.

2) What would you, Mr super paramedic, have done that is so much different than the freshly minted EMT?  started a line?  maybe a needle decompression if you thought it was a pnemo?  Even on this trauma there is very little a paramedic can do, and the studies show that these people need surgeon, not a paramedic.  Don't get me wrong, paramedics can do more stuff than EMTs; but an EMT can do the stare of life with a hep lock started just as good as an EMT. In all cases, we are doing the best we can with the tools at our disposal.  Stop being so judgmental

3) I've been in the back with very sick patients.  No paramedics.  If I wasn't there, than it's likely the patient would still be laying on the ground.  or in bed.  or in the doctors office.  it sucks, but it's better than nothing.  Even if there were paramedics with those sick patients, guess what: the patient might still end up dying.   So paramedics don't always save the day, despite what fire departments out west seem to think.  Most places don't operate with an all ALS system; in fact, the studies showed that tiers systems are often better, because the EMTs learn to identify sick patients, and manage them, vs always have a paramedic deal with sick patients, and the paramedics only see sick patients, so they aren't tied up on BLS calls all day.

This new EMT had a sick patient, who needed a surgeon to fix the damage, with a (potentially) compromised airway and decreased lung sounds, and when he called for a helicopter, the flight medic was grumpy that he actually had to do his job.

@LongTranspot, it sounds like you did your job, did exactly what anyone else would have done (heck likely would have done what a medic would have done), and he was just an ***.   Don't lose sleep over someone else who was cranky because they had to do the job that they were being paid to do.


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## StCEMT (Feb 28, 2019)

How is it insulting? 120 hours or 180 hours, it's still gonna be a potentially overwhelming situation, especially with long transport times.

You're right a surgeon is needed, but in a rural environment you can't expect entirely equal outcomes. Being able to decompress a pneumo is better. Being able to give blood is better. Like Vflutter said, there is a difference in resus abilities and that can be significant down the road. That's not to detract from their work on this call, but it's realistic.


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## DesertMedic66 (Feb 28, 2019)

DrParasite said:


> OK, your statement is insulting for many reasons:
> 
> 1) EMT classes haven't been 120 hours since the 90s.  Most classes are closer to 180 hours; my current classes is 240, and is technically a hybrid, so includes a lot of work that is completed at home.  It's still could use a lot more, and should have more hands on practical/clinical time, but that's an above my paygrade decision.
> 
> ...


Your brand new EMTs must be completely different than ours are out here. Yes they both (new and veteran) have the same exact skills they can preform however their assessments are probably going to vastly different and the veteran will probably feel a heck of a lot more comfortable and will possibly be even more competent. 

Now that that is said I would rather have a medic taking care of me in that situation and if it was a rural area I would much rather have a HEMS unit for both higher level of care and faster transport.


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## DrParasite (Mar 1, 2019)

StCEMT said:


> How is it insulting? 120 hours or 180 hours, it's still gonna be a potentially overwhelming situation, especially with long transport times.


it's insulting because the information is wrong.  Show me an EMT class that is only 120 hours.  I mean, a paramedic class is only 800 hours, so while it's more because they can do so much more, but it's still no where near enough.





StCEMT said:


> You're right a surgeon is needed, but in a rural environment you can't expect entirely equal outcomes.


 so we agree, whether you have an EMT or medic, what the patient really needs is a surgeon.





StCEMT said:


> Being able to decompress a pneumo is better. Being able to give blood is better.


what they really need is a chest tube. but we will agree that a needle decompression is better than nothing.  I've read about helicopters that were carrying blood, but very very few ground units.... how common is it for ground paramedics to be carrying and administering blood to trauma patients?  


DesertMedic66 said:


> Your brand new EMTs must be completely different than ours are out here.


based on what I have heard on here about pay rates, competency  levels, job descriptions and working conditions, I would be inclined to agree with you.





DesertMedic66 said:


> Yes they both (new and veteran) have the same exact skills they can preform however their assessments are probably going to vastly different and the veteran will probably feel a heck of a lot more comfortable and will possibly be even more competent.


no arguments there.  any experienced provider will feel more comfortable doing anything.  the same could be said for a 1st year resident MD compared to a 20 year attending MD.





DesertMedic66 said:


> Now that that is said I would rather have a medic taking care of me in that situation and if it was a rural area I would much rather have a HEMS unit for both higher level of care and faster transport.


me too.  a medic can give pain meds, which would make me not hurt as much.  But the sooner I get to the trauma surgeon, the better my chances of survival.


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## StCEMT (Mar 1, 2019)

I found two universities on the first page of Google that say to expect 120-150, one of them being UCLA....ok....and I don't disagree nor do I find that insulting. The bars for both should be set higher.

Yes I agree. However, you need someone who has tools to help get that person to a surgeon alive. Surgeons can't do anything if a patient tensioned to the point of arrest and nobody was there to (temporarily) fix it for a significantly prolonged time.

Wasn't specifying ground, more so just ALS capabilities in general when in the right hands.


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## DrParasite (Mar 1, 2019)

StCEMT said:


> I found two universities on the first page of Google that say to expect 120-150, one of them being UCLA....ok....and I don't disagree nor do I find that insulting. The bars for both should be set higher.


Wow.  @DesertMedic66 , I was wrong, I guess that does explain the differences between the east coast and the west coast.  I'm surprised UCLA's is that short.

Just for comparison, my local community college's course in NC is 190 hours.  Neighboring county is 204 hrs.  If I look back at NJ, it's 220 hours through Atlantic Ambulance.  My former employer in NJ (who has since been absorbed by a major conglomerate) runs a class that is a minimum of 190 hours


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## Tigger (Mar 2, 2019)

Boy, where to begin. 



NomadicMedic said:


> One of the hardest lessons to learn in EMS is, “not everyone is nice”.


This is probably the most important takeaway. Ideally, quality care is delivered in a personable manner. Not everyone can do that. Working with those people can be a drag. 


akflightmedic said:


> Actually your comparison is accurate, yet proven to be of benefit. I was reading an article the other day where I think it is Pittsburgh police often transport before EMS even arrives. It is part of their Scope of Work, they train for it and are expected to do it...throw them in and transport. I think this also has to do with a trauma center being on every corner, however they have been doing this practice for well over a decade. Other police departments follow similar protocols...so there is tremendous merit in the police just throwing them in and transporting and not waiting.


I think this is a bit apples and oranges to the OP's situation. The reason this "method" works (and by god I hope they issue tourniquets now), is that there are so many hospitals available. If the cops just through some mangled dude in the back of the squad car and had to drive an hour, I don't think the outcomes would be very good...


DrParasite said:


> it's insulting because the information is wrong.  Show me an EMT class that is only 120 hours.  I mean, a paramedic class is only 800 hours, so while it's more because they can do so much more, but it's still no where near enough.


Show me a paramedic that is 800 hours... My clinical and internship time was longer than that. 



> so we agree, whether you have an EMT or medic, what the patient really needs is a surgeon.what they really need is a chest tube. but we will agree that a needle decompression is better than nothing.  I've read about helicopters that were carrying blood, but very very few ground units.... how common is it for ground paramedics to be carrying and administering blood to trauma patients?


Things that keep from dying from tension pneumos: needle decompressions. Things that BLS does: not needle decompressions. If the helicopter is not flying, I can slide into the local critical access hospital and get a chest tube placed, and then continue on my way. Can grab some blood too. On the way I might give some TXA. Probably some pain medications. Maybe even RSI him. Could this patient go BLS? I suppose. But having these patients for more than say 15 minutes ? Time to bring some tools to the table. I am not disputing that rapid access to surgical care is what will best improve outcomes for this patients. But to discredit all the other things that could be done on a long transport is short sighted at best.

Also, let's just call a spade a spade here. The delivery of your commentary is totally off-putting and does nothing to strengthen your points or overall quality of discussion. There is no reason to deliver your message in such an aggressive way and it's disheartening to watch an "experienced provider" talk to providers in such a way.


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## johnrsemt (Mar 2, 2019)

Back to the patient and transport;  right now it would be 85 miles to our level I's,  and about 80 miles to Level II;  and that would be ground.  and probably 3 plus hours if we were lucky.  No chance of getting a helicopter.  Snowing like crazy all over the area.
   My PT job is 120-130 miles to the same hospitals.   A few years ago they transported an active MI to a Level I via ground 128 miles, took them 5hrs 25 minutes due to heavy snow and ice,  they got the flight crew and their gear  delivered by a State Trooper.  Helped the patient, he survived.  But it wasn't fun for the patient or the crews.
  Sometimes the response time at both FT and PT job can be over 2 hours from station to the scene then back past station, then to the hospital
Sometimes the Golden hour can be up to 6 hours.


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## gotbeerz001 (Mar 3, 2019)

NomadicMedic said:


> One of the hardest lessons to learn in EMS is, “not everyone is nice”.
> 
> Sounds like you got a pretty good example of that today.



My “pep talk” when I work with a new partner usually starts with:
“Our job is to solve problems and be nice; if you find yourself doing things that are not moving toward these ends, you’re probably wrong.”


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## DrParasite (Mar 4, 2019)

Tigger said:


> Show me a paramedic that is 800 hours... My clinical and internship time was longer than that.


Since you asked: http://www.mpcc.edu/health-and-medical-occupations/accelerated-paramedic-training-(emt) This one was 1,000 hours, but the didactic is only 480 hours, while the EMT basic didactic (outside of California) is around 200.  I do wish the EMT curriculum had a longer and better clinical time, but that's above my pay grade.





Tigger said:


> Things that keep from dying from tension pneumos: needle decompressions. Things that BLS does: not needle decompressions. If the helicopter is not flying, I can slide into the local critical access hospital and get a chest tube placed, and then continue on my way. Can grab some blood too. On the way I might give some TXA. Probably some pain medications. Maybe even RSI him. Could this patient go BLS? I suppose. But having these patients for more than say 15 minutes ? Time to bring some tools to the table. I am not disputing that rapid access to surgical care is what will best improve outcomes for this patients. But to discredit all the other things that could be done on a long transport is short sighted at best.


I'll give you credit for the needle decomp (esp since I already said it).  the other stuff you are taking credit for by having the ER perform, so it's not like you are doing it.  And I am waiting for more places to give TXA, I've heard its a wonder drug in trauma, just not around here.  pain meds are great, and RSI has it's place.  But at least we agree that this patient needs a doctor and a surgeon.


Tigger said:


> Also, let's just call a spade a spade here. The delivery of your commentary is totally off-putting and does nothing to strengthen your points or overall quality of discussion. There is no reason to deliver your message in such an aggressive way and it's disheartening to watch an "experienced provider" talk to providers in such a way.


So you're offended that I called paramedics out on what they can't do?  Or that I attempted to correct old information, only to be told that California is running classes that are stuck in the 90s?  I think you should review that post I was referring to.  No one disputes that paramedics can do more than EMTs, but to completely disregard them as being anything is insulting at best; It's kinda like how paramedics feel when they are talked down to by doctors and nurses.

Would you feel better if I showed you the studies that showed that paramedics don't affect mortality in traumas?  Maybe they are too old, so I'd even ask you to provide studies that show that paramedics do impact mortality in a good way.

Listen, I'm sorry you are so offended.... please provide some studies based on evidence based medicine that shows the contrary.


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## Tigger (Mar 7, 2019)

DrParasite said:


> Since you asked: http://www.mpcc.edu/health-and-medical-occupations/accelerated-paramedic-training-(emt) This one was 1,000 hours, but the didactic is only 480 hours, while the EMT basic didactic (outside of California) is around 200.  I do wish the EMT curriculum had a longer and better clinical time, but that's above my pay grade.I'll give you credit for the needle decomp (esp since I already said it).  the other stuff you are taking credit for by having the ER perform, so it's not like you are doing it.  And I am waiting for more places to give TXA, I've heard its a wonder drug in trauma, just not around here.  pain meds are great, and RSI has it's place.  But at least we agree that this patient needs a doctor and a surgeon.


We don't have trauma surgery available. The hospital gives us the blood and we continue on our way. Which is something BLS crews cannot do. Same with transporting a patient with a chest tube in, although honestly our hospital is not going to do that and just tell us to keep needle decompressing the patient (awesome). 



> So you're offended that I called paramedics out on what they can't do?  Or that I attempted to correct old information, only to be told that California is running classes that are stuck in the 90s?  I think you should review that post I was referring to.  No one disputes that paramedics can do more than EMTs, but to completely disregard them as being anything is insulting at best; It's kinda like how paramedics feel when they are talked down to by doctors and nurses.
> 
> Would you feel better if I showed you the studies that showed that paramedics don't affect mortality in traumas?  Maybe they are too old, so I'd even ask you to provide studies that show that paramedics do impact mortality in a good way.
> 
> Listen, I'm sorry you are so offended.... please provide some studies based on evidence based medicine that shows the contrary.


Far from offended. It just be nice to see professionals discuss things like...professionals. 
[/QUOTE]


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