In these other systems, not including the physician based providers, what kind of pt is being "referred" to someplace other than the ED?
I think we agree that patient outcome is very important. We base tx plans around EBM. If the U.S. medic sucks so bad, where is the evidence?
I am not interested in debating education, I'm on board, it is woefully insufficient in most places in the U.S., however I fail to see where the EU/Aus/NZ patients are enjoying significantly reduced M&M.
All of the EU systems I am familiar with are physician based.
However, I don't think you will be able to compare M&M anyway. That is defined as the incidence of disease and death.
Even death isn't that easy to figure out. If you transport a terminal cancer patient to the ED in the US, they still die. Nothing EMS does will change that. At the same time, if you have an EMS system that provides palliative service in house, the patient still dies. Are they counted as Mortality for both, not counted at all, or some combination there of? How do you decide?
Morbitity gets even more complex.
One of the big things education allows for is independant decision making. If you require a 4 or 6 year degree but still run cookbook medicine, what could possibly cause the numbers to look different?
On the other hand, if you view a patient who meets an exception to standard guidlines, and perform a medically reasonable treatment, the outcome should sometimes be better. But that "better" may or may not be 3% or more.
How do you even go about measuring treat and release or alternative destination?
There is also the issues of different resuscitation guidlines, general health of the population, and efficency of delivery. (let's face it, if you have basic AHA guidlines, a large percent of morbidly obese patients with a host of comorbid conditions and a 9 minute ALS response 90% of the time, you could not hope to compare outcomes to a guidlines with a degree of deviation, on a largely fit society, with an ALS response time of 5 minutes)
The only way I can think of to objectively measure is by cost and the US always falls way short in that measurement.
Like I have said many times, I know that many providers attempt to use EBM as the panecea of medical care. It simply is not. It is merely a tool in the box. Some studies can never be carried out. (You will never get a randomized study of people who EMS makes an effort to resuscitate vs. showing up and doing nothing to see the effectiveness) You will never be able to quantify the effectiveness of a treatment modality when a sub population responds to treatment that is outside of that being looked at. So you might see a number like: 70% of the study population responded to treatment X. But you never see that perhaps 20% of the remainder responded to Y. Are you planning to do nothing for the people who are not in the 70%?
Always remember, the studies we set up are designed to be as good as possible, I have not seen one yet that isn't far from perfect.
Really, arguing that there is no demonstrated evidence of difference in M&M looks like demanding evidence that cannot possibly be procured and then holding it as a demonstratable measure of effectiveness for the system you favor looks like a very overt bias.
It is almost as absurd as claiming parachutes don't improve survival.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC300808/
