Delete American paramedics.

[Veneficus]

Has anyone thought of who is going to pay what would likely be sky high rates for the malpractice insurance these providers would need to carry. Providers already are running as fast as they can from areas in medicine that carry high risk,this MD or PA in the field idea it seems to me would carry a huge amount of liability and risk that most MD's and PA's would not be interested in.

As always the compensation versus education and vice vera comes into play. There is no money in pre hospital EMS fire non fire or any other area of pre hospital medicine. When I think compensation I am thinking no less than 90K a year for advanced providers. People that have put in the time effort and money involved in obtaining education should expect at least something more than slightly above poverty level wages. Right now I see very poor wages that might increase if you climb the ladder into something like an FTO but who needs the stress and headache of mothering a bunch of field cowboys. Most of the fire oriented people know how that end of the industry is going,layoffs and hiring freezes nation wide and starting pay that should you be lucky enough to receive is chump change in most parts of the country.

We see this "doc on the box" idea every so often and then people come to their senses or sober up. Face the facts,it is what it is and trying to make it better by thinking advanced providers are going to come on boad in a nation wide effort to make our pre hospital ssytem look like of an EMS nirvana is just never going to happen.

I don't think you are fully appreciating the situation.

Malpractice rates or not, the transport all patients to the ED for a battery of mostly useless testing is not economically sustainable. It hasn't been for some time.

So when healthcare spending collapses, and it is just a matter of years, some sort of reasonable and sustainable alternative will have to be found.

I think that is what all the discussion on what should or needs to be done is based on.

When people start finding out that a BLS ambulance in an urban area is just as useful as ALS, which has been discovered by a major city council in OH, paramedic positions are going to go faster than fire jobs.

Some systems around the country, notably Wake County, has taken the initiative, and is actually about to present data I understand, demonstrating how much money is saved by making EMS proactive as opposed to reactive. (and I might add they had to increase education to do it)

So while it is easy to say say dinosaurs rule the earth and always will, because that is what you see today, some of us actually acknowledge the incoming meteor instead of burying our head in the sand and pretending it will go away on its own.

If you do not participate in shaping your future, then you will just have to accept whatever happens to you.

 

[EpiEMS]

When people start finding out that a BLS ambulance in an urban area is just as useful as ALS, which has been discovered by a major city council in OH, paramedic positions are going to go faster than fire jobs.

How strong is the data on this? Also, in what terms do you mean? Survival rates for, say, cardiac arrest? Trauma?

 

[Level1pedstech]

I don't think you are fully appreciating the situation.

Malpractice rates or not, the transport all patients to the ED for a battery of mostly useless testing is not economically sustainable. It hasn't been for some time.

So when healthcare spending collapses, and it is just a matter of years, some sort of reasonable and sustainable alternative will have to be found.

I think that is what all the discussion on what should or needs to be done is based on.

When people start finding out that a BLS ambulance in an urban area is just as useful as ALS, which has been discovered by a major city council in OH, paramedic positions are going to go faster than fire jobs.

Not only do I fully appreciate the situation I happen to have the perspective that comes from being involved in both the hospital and pre hospital setting. Do you have any kniwledge as to the inner workings when it comes to the business side of running a large hospital system? If you do you are in the minority,most people rely on what they hear from the media or read on the web.

The battery of useless tests is done to prevent people from trying to reach into the pockets of the hospital after laimimg they were not cared for properly. Please tell me you dont think this is because the hospital is trying to take advantage of the poor helpless patient.




Some systems around the country, notably Wake County, has taken the initiative, and is actually about to present data I understand, demonstrating how much money is saved by making EMS proactive as opposed to reactive. (and I might add they had to increase education to do it)

So while it is easy to say say dinosaurs rule the earth and always will, because that is what you see today, some of us actually acknowledge the incoming meteor instead of burying our head in the sand and pretending it will go away on its own.

If you do not participate in shaping your future, then you will just have to accept whatever happens to you.

I agree with the need to prticipate in shaping your future I have spent my life setting goals then woking towards obtaing those goals. Sady most people are more talk than action.

 

[Level1pedstech]

Obviously I dont have the multi quote thing down sorry all.

 

[Veneficus]

Obviously I dont have the multi quote thing down sorry all.

No worries,

Actually I have been involved in the conversations of healthcare costs for a number of years now. I am party to two professional associations where healthcare spending is their focus.

I understand the requirement from the organizational standpoint of defensive medicine.

However, as I said, sooner, rather than later, the level of healthcare spending will need to be drastically reduced.

Just as medicare stopped paying for treatment resulting from "preventable" complications(which I agree their definition of preventable is rather unrealistic), I forsee they will stop paying for diagnostics that are indicated to prevent monetary loss to the hospital, rather than medical necessity to dx or treat the patient condition.

Not paying for exams or treatments not related to a reasonable suspicion has been used to control the healthcare costs of several nations.

It is fair to say these nations do not have the malpractice liability issues the US does, but as that is unsustainable and driving up the cost of care to the point of pricing healthcare out of the market, eventually it will be changed.

Logically, when it takes lawyers more effort to get money than the value of spending that time, the issue will likely self resolve.

One of the major contributors to this situation is the malpractice insurance company. As long as they feel it is cheaper to settle than fight, it really benefits plantifs to bring cases.

The short sightedness of the insurance companies is that if they did regularly fight, it would remove the easy money and likely lawyers would be less likely to spend time on cases that were not likely winners.

The much simpler solution would be to remove a jury from the process in favor of an arbitor of 3 judge panel.

But the long and short is, defensive medicine is not going to pay well forever.

 

[Level1pedstech]

No worries,

Actually I have been involved in the conversations of healthcare costs for a number of years now. I am party to two professional associations where healthcare spending is their focus.

I understand the requirement from the organizational standpoint of defensive medicine.

However, as I said, sooner, rather than later, the level of healthcare spending will need to be drastically reduced.

Just as medicare stopped paying for treatment resulting from "preventable" complications(which I agree their definition of preventable is rather unrealistic), I forsee they will stop paying for diagnostics that are indicated to prevent monetary loss to the hospital, rather than medical necessity to dx or treat the patient condition.

Not paying for exams or treatments not related to a reasonable suspicion has been used to control the healthcare costs of several nations.

It is fair to say these nations do not have the malpractice liability issues the US does, but as that is unsustainable and driving up the cost of care to the point of pricing healthcare out of the market, eventually it will be changed.

Logically, when it takes lawyers more effort to get money than the value of spending that time, the issue will likely self resolve.

One of the major contributors to this situation is the malpractice insurance company. As long as they feel it is cheaper to settle than fight, it really benefits plantifs to bring cases.

The short sightedness of the insurance companies is that if they did regularly fight, it would remove the easy money and likely lawyers would be less likely to spend time on cases that were not likely winners.

The much simpler solution would be to remove a jury from the process in favor of an arbitor of 3 judge panel.

But the long and short is, defensive medicine is not going to pay well forever.

Nice to see someone that can offer a clear,concise and experience based opinion. To many people like to spew out opinions one way or the other without even taking time to learn both sides of the arguement. To be honest I have done it and now always try and post only what I can source.

There are others in this community that have inside hospital experience or a the least some first hand knowledge of what goes on behind the scenes. Howeverr the majority is made up of young less thanwell informed people who love to take a side sometimes not even knowing that sides arguement. Thats okay we all were young and less than informed at one time.

Sometimes I think the hospitals and health care sytems in general take an unfair beating.All the stories I have heard are most likely the same as you and do with out a doubt point to the need for change. On the other hand I know of millions of dollars in charity provided to those without resources by my former employer.

 

[systemet]

How strong is the data on this? Also, in what terms do you mean? Survival rates for, say, cardiac arrest? Trauma?

For cardiac arrest, and trauma, take a look for OPALS, it's a study of progressive introduction of ALS into the Ontario provincial system in Canada. It's the best data for that.

There's also a paper somewhere in Quebec comparing a pure BLS system with a physician-ALS system and a paramedic-ALS system for trauma. The BLS system had the best outcome, though I suspect there was some selection bias in there.

If I feel energetic I'll grab the references, but this should be a different thread.

--------------

I think for ALS, we know that it improves outcomes in medical patients not in arrest, specifically respiratory and cardiac patients. There's good data for 12-lead, pre-alert, and some data for prehospital thrombolysis and ER bypass to PCI.

There's not good data for pain control, but it's intuitive that ALS is beneficial here.

 

[EpiEMS]

I'd definitely buy ALS > BLS for pain control. Morphine + splints beats splints alone any day.

I just pulled up the Quebec study and your intuition is on target, they indicate quite clearly that the "injury severity scores" were higher for paramedics and MDs than for BLS. However, when you hold ISS levels constant, BLS still comes out ahead.

 

[Veneficus]

I have done it and now always try and post only what I can source..

There are not too many sources to what is discussed in private and not in public

Sometimes I think the hospitals and health care sytems in general take an unfair beating.All the stories I have heard are most likely the same as you and do with out a doubt point to the need for change. On the other hand I know of millions of dollars in charity provided to those without resources by my former employer.

Nobody should doubt hospitals provide charity. Not just in care but also community programs and support.

There will always be disaffected people.

But I see no way that a strictly for profit healthcare system can sustain itself. Particularly when it is constantly under attack by the tort system.

As I said, various factors increase cost. That cost has been unsustainable.

Because of ideology being the driving force, total collapse will likely be what it takes for meaningful reform.

I think all of the interests involved know that, but they are all hell bent on bleeding every last drop and letting it collapse, rather than make sacrifice for sustainability.

No single group bears more responsibility than the rest. That includes physicians and their professional associations.

 

[Veneficus]

sorry, missed this in all the type

How strong is the data on this? Also, in what terms do you mean? Survival rates for, say, cardiac arrest? Trauma?

OPALS was the most damning study to ALS.

However, I think the Ohio argument was because transport times were so short, ALS cost the city money and prolonged transport times.

While there are instances where ALS onscene treatment are beneficial, I think anyone who has worked in an urban system can attest that so few patients require ALS intervention, that from an economic standpoint, as well as using the response time benchmark that has so long been touted to the public by EMS agencies as the benchmark of effectiveness, how many BLS rigs could you field if you cut ALS rigs (and all the associated costs from initial training to equipment and recertification) out of the budget?

A strong case was made and it was only political lobby by the interested party (aka self serving greedy party) that stopped it.

 

[EpiEMS]

Gotta say, this sounds like a great dissertation topic for an epidemiologist or health policy/management PhD.

 

[Veneficus]

Gotta say, this sounds like a great dissertation topic for an epidemiologist or health policy/management PhD.

it's all yours, i'll stick with pathophys.

 

[EpiEMS]

I just wish a major city would let me run a controlled experiment on this. Oh man...

 

[Veneficus]

I just wish a major city would let me run a controlled experiment on this. Oh man...

I have a sneaky suspicion you would have to be put into protective custody after publishing your findings.

I also suspect the smear campaign funded by organized labor and private EMS against you and your results will reach a fever never before seen.

 

[RocketMedic]

OPALS was the most damning study to ALS.

However, I think the Ohio argument was because transport times were so short, ALS cost the city money and prolonged transport times.

While there are instances where ALS onscene treatment are beneficial, I think anyone who has worked in an urban system can attest that so few patients require ALS intervention, that from an economic standpoint, as well as using the response time benchmark that has so long been touted to the public by EMS agencies as the benchmark of effectiveness, how many BLS rigs could you field if you cut ALS rigs (and all the associated costs from initial training to equipment and recertification) out of the budget?

A strong case was made and it was only political lobby by the interested party (aka self serving greedy party) that stopped it.

The flaw with dropping ALS is that those rare patients who need it are out of luck and you place even more of a burden on the ER to triage patients.

 

[Maine iac]

How about we get rid of certain elements in our government which seem to slow down any advancements in EMS, then change the system so every truck has either dual ALS or BLS + ALS. THEN place an emphasis on quick care type locations so that the public does not have to wait 8 hours for an ear infection, or so that I can transport my ear infection that called 911 to the quick care instead of the ER.

 

[Tigger]

That being said, one could argue that its a good thing we work for peanuts. The first bog groups of "$30/HR for my bachelor's" are going to be disappointed or unemployed right quick. What power, exactly, does a degree confer over, say, military service or prior experience?

Degrees objectively quantify someone's knowledge base. A certification obviously does the same thing, but a bachelor's degree includes a knowledge base not just limited to the subject at hand. The thing with 4+ year degrees is they teach one to learn and research, not just the knowledge needed to preform a job. My upcoming political science degree has not provided me with a meaningful technical education for politics, far from it in fact. But it has provided be with the tools to be an effective researcher as well as the ability to succinctly state my findings in a compelling way. This is one way for a trade to advance into a profession, it's members need to be able to learn how to improve their profession's quality independently. It's tough for other medical professions to take any EMS providers' research seriously since they simply do not have the background in academics that lends authenticity to their findings.

 

[Tigger]

OPALS was the most damning study to ALS.

However, I think the Ohio argument was because transport times were so short, ALS cost the city money and prolonged transport times.

While there are instances where ALS onscene treatment are beneficial, I think anyone who has worked in an urban system can attest that so few patients require ALS intervention, that from an economic standpoint, as well as using the response time benchmark that has so long been touted to the public by EMS agencies as the benchmark of effectiveness, how many BLS rigs could you field if you cut ALS rigs (and all the associated costs from initial training to equipment and recertification) out of the budget?

A strong case was made and it was only political lobby by the interested party (aka self serving greedy party) that stopped it.

Using the commonly cited metric of cardiac arrest survival rates, the city of Boston's EMS system is generally rated as excellent. Yet the city is served by (on average) 19 BLS and 5 ALS trucks with a relatively small amount of calls seeing ALS on the initial dispatch. Realistically, in the Boston system non-cardiac arrests are saved by the close proximity of hospitals and cardiac arrests are saved my early CPR and AED administration. With most transports under 10 minutes, the question of whether ALS being actually needed comes into play. The patients transported by BLS may not arrive in better shape on arrival to the hospital, but they aren't dead either. It's tough to prove that ALS does lead to a decrease in mortality as far as I can see.

However, mortality rates are not the only metric of systemic effectiveness. Providing pain and nausea control will not improve patient outcomes in a measurable way but they do improve outcomes in a meaningful way. So therein lies a question, how do we measure the effectiveness of EMS systems besides on who lives and who dies? There's so much more to EMS than just saving lives.

 

[Veneficus]

However, mortality rates are not the only metric of systemic effectiveness. Providing pain and nausea control will not improve patient outcomes in a measurable way but they do improve outcomes in a meaningful way. So therein lies a question, how do we measure the effectiveness of EMS systems besides on who lives and who dies? There's so much more to EMS than just saving lives.

I agree with this, however, EMS systems in order to easily demonstrate their effectiveness to the public (erroneously and without much forethought, but look at the caliber of people who came up with it) have long spouted about saving lives and response times.

Those are therefore what the public knows and expects. It has been drilled into their heads over a decades. (easy little tag lne for the masses, saving lives/response times)

If you try to go on TV and lobby for pain/nausea control, some right wing anti tax nut job is going to counter with not wanting to pay for drug seeking ambulance abusers.

That metric will not work either.

If you want to show effectiveness, the metric needs to be cost savings. With the increase in demands for EMS service,as both the population and those with disease increases, response and a ride to the ED is not only going to be logistically impossible to keep up with, the public will demand it is done as cheap as possible.

We are left only with the alternative that in order to be of value to society, paramedics and EMS providers in general will have to provide more and more valuable service.

As I keep stating, that service is logically, education, prevention, alternate destination, and treat and release.

It will require more resources, but when the public actually sees and feels it is getting something for its money, it is more inclined to spend money on it. No reasonable person doubts that roads are a good use of tax dollars. But EMS is largely only seen when an individual needs it. That largely inhibits any quality/cost comparison outside of responsetime and lives saved.

As with any job, if you want more, you will be expected to do more and show you are worth more.

 

[Tigger]

As usual, well said Vene.