Different angle: why basic level technicians?

[DPM]

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?

 

[thegreypilgrim]

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.

 

[DPM]

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.

 

[thegreypilgrim]

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?

 

[DPM]

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.

 

[thegreypilgrim]

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

 

[DPM]

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?

 

[Level1pedstech]

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
K
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.

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.

 

[Tigger]

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.

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.

 

[Level1pedstech]

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?

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.

 

[Level1pedstech]

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.

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.

 

[DPM]

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.

 

[Level1pedstech]

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.

 

[rescue1]

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.

 

[DPM]

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?

 

[Tigger]

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.

 

[Level1pedstech]

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.

 

[rescue1]

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.

 

[Level1pedstech]

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.

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.

 

[rescue1]

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.