The OP asked a reasonable question: Why aren't EMT's more widely utilized? (paraphrased)
The real answer - and I don't think anyone has mentioned this yet - is billing.
An EMS agency can charge much more for an ALS transport than it can for a BLS transport. Take a patient with belly pain 10 minutes from the hospital who could easily be transported BLS, and put him in an ALS ambulance. The paramedic will put the patient on the monitor or pop in an IV because the ED nurses have come to expect it, and there you go.....the extra money you make in that one transport by billing ALS vs. BLS is likely more than enough to cover the extra $60 or $80 that it costs you to have a paramedic on that ambulance for the shift instead of a second EMT. The actual difference in reimbursement depends on which payor is being billed, of course, and if the payor agrees that ALS was medically necessary. But on average, over a handful of transports, the ALS unit will make more money than a BLS one, even transporting the same exact patients, and no matter how unhelpful the ALS care was.
Everything else - improved assessment skills, improved ability to recognize "sick" vs. "not sick", ability to give drugs, yada yada.....it just doesn't matter in most cases. It seems like it should - I agree - but the research is pretty consistent on this. If you are having a refractory asthma attack or a prolonged seizure, then being treated and transported by a paramedic vs. an EMT might improve your chances of a positive outcome. But that's about it. If you have long transport times, then the advantages of a paramedic are probably magnified. But for most busy systems, it's a small percentage of transports where paramedics help. In most systems, all you need is decent triage and a couple ALS units to cover those few calls where ALS really matters, and system-wide, your patients will do just as well as if every ambulance had a paramedic on it.
Perhaps they'd actually do better with fewer paramedics. There's not much research on this that I know of, but I strongly suspect that skills dilution in systems where there are lots of paramedics is a bigger problem than we realize. It's shown to be true among physicians. Being really good at managing a crashing patient takes experience and practice. And there are only so many crashing patients to go around in the field.
The analgesia thing is a little tricky. But in all honesty, I think the pendulum has swung a little too far here. I think we make a bigger deal about it than it really is. We've gone from when I was a young paramedic, in most systems someone had to be screaming bloody murder in the background before OLMC would give you orders for 2mg of morphine, to these days where paramedics compete with each other over who can give the most fentanyl in a shift. People who are really hurting deserve our best efforts at making them comfortable, of course. But I don't think that means everybody who is in any amount of pain has a right to opioids, which is how many seem to interpret the recent emphasis on patient comfort.
Measurable metrics are what we are stuck with. Most of the non-measurable ones have nothing to do with ALS vs. BLS anyway, they have to do with professionalism and common sense.
