Rank the EMS systems of the world

[rescue99]

I realize the glaring education differences, however can anyone show me where patient outcomes are worse in the U.S. v/s anyplace else? I'm not talking about refering to PCP or GP, I'm talking patients treated and transported to a hospital?

I agree. Only those who have recently worked or work currently in a different system have anything to say worth listening to IMHO. I've had a few visitors to my classroom from other places around the globe. They don't seem to convey the same anti-American opinions as some here in our own country. Are there any legitmate statistics that compare apples to apples or are we just lemmings following the crowd?

 

[Stew]

I'm just about to head over to the USA for 3 months holiday, during which I'm heading to a few community colleges and have scored quite a bit of ride time in different services.
I'm very interested to see how the US systems compare with our own here. Will keep you guys posted!

 

[Melclin]

I am not sure that any such data exists. However, the ability to refer to an alternate destination and treat and release save a lot of money.

It may not. There is an increasing amount of research into paramedic decisions making and alternative care pathways coming out of the UK. Despite the enthusiasm of the investigators, a lot of schemes have failed to perform in quite the way they hoped.

Treat and release also doesn't take into account the oddities of many people who call the ambulance. It has often been mentioned here and I've seen it myself. One of our faculty members did her PhD on the topic. People call ambulances, not because they feel there is a medical emergency but because a situation is vaugely healthcare related and exceeds their coping ability. If you leave them at home with the appropriate clinical measures in place, most of the time you are returning them to a situation with which they cannot cope. So they ring back half an hour later despite the best efforts of the first crew to assuage concerns and build a care plan that everyone is happy with.

You of course know I'm on board with alternative care pathways, but the above is certainly a problem that needs addressing if it is to work.

It also brings new meaning to critical care for interfacility transport. I have seen units go out with a medic and 2 cardio surgeons as well as a medic with a transplant surgeon and an anesthesia intensivist. In terms of care, these docs were also the primary physicians that took care of the patient at the receiving facility.

This is often the way actually critical patients are transported here. To be honest the idea of a paramedic doing the transport doesn't make a great deal of sense to me. First of all you reduce mistakes if you have one physician handing over to another rather than trying to distill things for a paramedic. Secondly, the paramedic model (here at least, and from what I can see in the US as well) has very little to do with ongoing critical care needs. If anyone other than the sending physicians do it, it should be the nurses from the sending facility.

If the "sending facility" is a doctors surgery or a small rural hospital, that's a little different.

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.

Haven't you heard the old saying that the absence of evidence does not mean the evidence of absence?

I can't see how you could look at some of the absurd responses to scenarios here and difficulty grasping seriously simple concepts and not think that this could lead to worse outcomes. That kind of crap goes on all over the US everyday. The picture painted for the triage nurse is important. How can you paint an adequate picture when a graduate of junior year highschool biology knows more about the human body that you do?

Besides, its not just about misusing the care modalities you do have, its about not being able to use others because your medical direction rightly thinks you're too stupid to apply them. RSI is the perfect example. Pain relief. There is a reason why that BS 2mg q10 for extremity fractures only is still common. Every time a pt gets brought into the ED in unnecessary pain is a time when US EMS is worse than everyone else.

Honestly, beyond some jingoistic rubbish, and a few isolated examples of excellent EMS systems the US prehospital system is clearly a joke.

 

[MrBrown]

Honestly, beyond some jingoistic rubbish, and a few isolated examples of excellent EMS systems the US prehospital system is clearly a joke.

It doesn't stop Brown ringing up on the ambo phone and asking the medical control physician very persuasive like for some morphine + midazolam, seeing as how nobody really carries anything else eg ketamine, toradol, nubain.

 

[rhan101277]

It doesn't stop Brown ringing up on the ambo phone and asking the medical control physician very persuasive like for some morphine + midazolam, seeing as how nobody really carries anything else eg ketamine, toradol, nubain.

We have toradol (orders req.), no orders needed for morphine up 10mg or versed up to 20mg for continued sedation DAI.

 

[MrBrown]

We have toradol (orders req.), no orders needed for morphine up 10mg or versed up to 20mg for continued sedation DAI.

Can you use morphine plus midazolam for analgesia?

If you call for a morphine order are you likely to get it, eg Brown has given somebody 10mg of morphine and its done nothing to touch thier pain.

 

[cruiseforever]

Hello, just found this web site a few days ago. It looks very intresting.

We can give unlimited Morphine for anything but peds and cardiac. If that does not work we will try Dilaudid. We can also get an order for Versed.

 

[boingo]

Haven't you heard the old saying that the absence of evidence does not mean the evidence of absence?

Yeah, lack of evidence is o.k. when it supports your position.

I can't see how you could look at some of the absurd responses to scenarios here and difficulty grasping seriously simple concepts and not think that this could lead to worse outcomes. That kind of crap goes on all over the US everyday. The picture painted for the triage nurse is important. How can you paint an adequate picture when a graduate of junior year highschool biology knows more about the human body that you do?

Really? Do your triage reports include a lot of high school biology? Do you think I might have finished Junior year in high school too? Get over yourself.

Besides, its not just about misusing the care modalities you do have, its about not being able to use others because your medical direction rightly thinks you're too stupid to apply them. RSI is the perfect example. Really? Funny, I do RSI. Pain relief. There is a reason why that BS 2mg q10 for extremity fractures only is still common. Says who? Every time a pt gets brought into the ED in unnecessary pain is a time when US EMS is worse than everyone else. System failure, not U.S. failure.

Honestly, beyond some jingoistic rubbish, and a few isolated examples of excellent EMS systems the US prehospital system is clearly a joke.

Have you worked in the U.S.? Are you really convinced that your 3 years of school makes you that much better? Maybe the lack of physicians on ambulances makes EMS in Australia a joke. You think the guys in France look at you as a bunch of undereducated knuckle dragger ambulance drivers? After all, you have just enough education to hurt someone.

The U.S. EMS system is disjointed and has a lot of flaws, no doubt, but seriously, you seem to come off like you are so much better, I just haven't seen the proof.

 

[MrBrown]

Have you worked in the U.S.? Are you really convinced that your 3 years of school makes you that much better? Maybe the lack of physicians on ambulances makes EMS in Australia a joke. You think the guys in France look at you as a bunch of undereducated knuckle dragger ambulance drivers? After all, you have just enough education to hurt someone.

The U.S. EMS system is disjointed and has a lot of flaws, no doubt, but seriously, you seem to come off like you are so much better, I just haven't seen the proof.

You misunderstand. Three years of formal education is for what we call a Paramedic, in Australia thier base level and our intermediate level. To reach ALS level (what you call a Paramedic and we call an Intensive Care Paramedic) is an additional two to undefined years of experience and formal education. It's literally possible to become a Doctor quicker than an Intensive Care Paramedic here or in Oz.

Where to begin?

- Unlimited drug dosage in line with prudent professional praxis
- No medical control, no orders for anything
- Proper RSI that doesn't kill people
- Thrombolysis
- The ability to proactively leave people at home

We can also use combination analgesia (morphine + midaz and ketamine) and have scopes of practice out of the 21st century.

We're not better, just different, and it's not a bad thing.

Ambulance Officers are career healthcare professionals who should be held to the same standards as others, which here, means a Bachelors degree for entry and Advanced Degree for various subspecialties as well as appropriate professional autonomy. Note that does not mean a couple hundred course down at the back room of the local patch factory for the barely homeostasasing Firemonkeys who want to become Paramedics to get on the big red truck or siren freaks who know just enough to be dangerous, oops sounds like a bit of shortness of breath, should we give em some lasix Johnny?

 

[sir.shocksalot]

Have you worked in the U.S.? Are you really convinced that your 3 years of school makes you that much better? Maybe the lack of physicians on ambulances makes EMS in Australia a joke. You think the guys in France look at you as a bunch of undereducated knuckle dragger ambulance drivers? After all, you have just enough education to hurt someone.

The U.S. EMS system is disjointed and has a lot of flaws, no doubt, but seriously, you seem to come off like you are so much better, I just haven't seen the proof.

Well we all have enough education to hurt someone, the question is do we have enough education to know better?

I hope that when you ask if 3 years of education makes Aussies better it is purely rhetorical. Education will always create more knowledgeable providers, and knowledge is key to providing good medical care. Unless you think that you Americans are so talented that the same knowledge can be squeezed into 6 months or a year course? And I say that as an American paramedic.

 

[medichopeful]

You misunderstand. Three years of formal education is for what we call a Paramedic, in Australia thier base level and our intermediate level. To reach ALS level (what you call a Paramedic and we call an Intensive Care Paramedic) is an additional two to undefined years of experience and formal education. It's literally possible to become a Doctor quicker than an Intensive Care Paramedic here or in Oz.

Where to begin?

- Unlimited drug dosage in line with prudent professional praxis
- No medical control, no orders for anything
- Proper RSI that doesn't kill people
- Thrombolysis
- The ability to proactively leave people at home

We can also use combination analgesia (morphine + midaz and ketamine) and have scopes of practice out of the 21st century.

We're not better, just different, and it's not a bad thing.

Ambulance Officers are career healthcare professionals who should be held to the same standards as others, which here, means a Bachelors degree for entry and Advanced Degree for various subspecialties as well as appropriate professional autonomy. Note that does not mean a couple hundred course down at the back room of the local patch factory for the barely homeostasasing Firemonkeys who want to become Paramedics to get on the big red truck or siren freaks who know just enough to be dangerous, oops sounds like a bit of shortness of breath, should we give em some lasix Johnny?

Brown I'd kill to be able to work somewhere like that for my career :sad:

 

[MrBrown]

Brown I'd kill to be able to work somewhere like that for my career :sad:

Auckland Metro is hiring Qualified Ambulance Officers

 

[Veneficus]

Auckland Metro is hiring Qualified Ambulance Officers

How is the job market for doctors?

 

[MrBrown]

How is the job market for doctors?

Most of them are foreign anyway ..... so probably not bad!

 

[tazman7]

NYC 911 system is best in the world hands down!










Now thats funny. Considering one of the medics that taught my medic class was a 35 year retiree from Chicago Fire and he said that when he started teaching out where i live (an hour west of Chicago) he had to learn all of the drugs that we give because they hardly had any in their protocols due to (his exact words) "being able to fart and be at the hospital before you are done"

And we dont even give that many drugs compared to a lot of the systems in the US.


So how you can say big city departments are "the best" is beyond me...

Not sure how NYFD is but im sure its not that much different than CFD...

 

[Melclin]

Have you worked in the U.S.? Are you really convinced that your 3 years of school makes you that much better? Maybe the lack of physicians on ambulances makes EMS in Australia a joke. You think the guys in France look at you as a bunch of undereducated knuckle dragger ambulance drivers? After all, you have just enough education to hurt someone.

The U.S. EMS system is disjointed and has a lot of flaws, no doubt, but seriously, you seem to come off like you are so much better, I just haven't seen the proof.

They may well do so. I freely admit that those physician based European systems would provide better care. My argument against physician based systems is that a medical degree is largely superfluous for the majority of EMS work. I think you could achieve a great deal of the advantages of a physician based system by educating separate providers to an appropriate level. The argument against it though is mostly logistical and financial. I have no doubt that they provide better care.

Its not the three years of schooling. In fact under the old system it was a "sorta" two years (I might add that this is not for ALS, this is for ILS). Many would argue that it produced better paramedics - more practical stuff and less essays on indigenous well-being.

Its the overall attitude that makes a difference. An actual respect for knowledge. I was shocked to hear the "lets all follow the protocols and never open a book" attitude on this forum. I've never once encountered that attitude here (I'm sure it exists but its rare and people hide it from students to set a good example if they do feel that way).

I was shocked that paramedics were considered in the US to be lesser providers (less educated, looked down upon, less pay) than nurses. We're educated identically, often thought more highly of by the general public and paid considerably more than most nurses. Quite a few people who ask about my degree thought it was four years and have trouble understanding that we aren't doctors.

Our lack of medical control puts the clinical onus on us. The university model encourages paramedic led research.

Our education doesn't end after three years. That's just a baseline level of knowledge; it starts with that. I'm a good student and I make an effort to develop myself, but after three years I'm still don't consider myself ready to be making unsupervised decisions about patient care. The induction program for the service involves two weeks of intensive clinical revision, after which you are allowed on the road under varying levels direct supervision by clinical instructors, for the next year, during which time you are expected by everyone to study during your down time and free time for the end of year pannel exams. After you qualify there is still a strong (relative to what I've seen here) culture of continued learning, especially if you want to make the jump to ALS in 3-5 years.

Sure you could easily 'do the job' with less. In fact, I'd wager that you could practice a lot a of medicine with a year or two and an iPhone. But you would be unacceptably incompetent. Nobody would suggest you should. Its about where you draw the line of acceptable competence and the American line is a long way from what the rest of the world would be happy with.

Stop asking for proof. You know, or at least you should know, that it doesn't and probably can't exist.

Look at peoples responses here, "Herp Derp, when do I use a BVM, derp derp?". I see that and think f**k, and they're the ones who at least made an effort to join a forum and find out. I don't think you could honestly say that you'd be just as happy to have idiots like that turn up to your nanna as you would a well educated and trained career professional who wasn't drawn from a gaggle of basement dwelling high-school drop outs with appropriately backed cheque books.

 

[tazman7]

They may well do so. I freely admit that those physician based European systems would provide better care. My argument against physician based systems is that a medical degree is largely superfluous for the majority of EMS work. I think you could achieve a great deal of the advantages of a physician based system by educating separate providers to an appropriate level. The argument against it though is mostly logistical and financial. I have no doubt that they provide better care.

Its not the three years of schooling. In fact under the old system it was a "sorta" two years (I might add that this is not for ALS, this is for ILS). Many would argue that it produced better paramedics - more practical stuff and less essays on indigenous well-being.

Its the overall attitude that makes a difference. An actual respect for knowledge. I was shocked to hear the "lets all follow the protocols and never open a book" attitude on this forum. I've never once encountered that attitude here (I'm sure it exists but its rare and people hide it from students to set a good example if they do feel that way).

I was shocked that paramedics were considered in the US to be lesser providers (less educated, looked down upon, less pay) than nurses. We're educated identically, often thought more highly of by the general public and paid considerably more than most nurses. Quite a few people who ask about my degree thought it was four years and have trouble understanding that we aren't doctors.

Our lack of medical control puts the clinical onus on us. The university model encourages paramedic led research.

Our education doesn't end after three years. That's just a baseline level of knowledge; it starts with that. I'm a good student and I make an effort to develop myself, but after three years I'm still don't consider myself ready to be making unsupervised decisions about patient care. The induction program for the service involves two weeks of intensive clinical revision, after which you are allowed on the road under varying levels direct supervision by clinical instructors, for the next year, during which time you are expected by everyone to study during your down time and free time for the end of year pannel exams. After you qualify there is still a strong (relative to what I've seen here) culture of continued learning, especially if you want to make the jump to ALS in 3-5 years.

Sure you could easily 'do the job' with less. In fact, I'd wager that you could practice a lot a of medicine with a year or two and an iPhone. But you would be unacceptably incompetent. Nobody would suggest you should. Its about where you draw the line of acceptable competence and the American line is a long way from what the rest of the world would be happy with.

Stop asking for proof. You know, or at least you should know, that it doesn't and probably can't exist.

Look at peoples responses here, "Herp Derp, when do I use a BVM, derp derp?". I see that and think f**k, and they're the ones who at least made an effort to join a forum and find out. I don't think you could honestly say that you'd be just as happy to have idiots like that turn up to your nanna as you would a well educated and trained career professional who wasn't drawn from a gaggle of basement dwelling high-school drop outs with appropriately backed cheque books.

I personally think that the paramedic program that I went through, as well as others that I have heard about, do need to have a few more prerequisites before you get into the paramedic portion of the program. I think that it would make things a lot more clear and give people a better understanding of things.

But remember, we make darn near minimum wage. It is a job that isnt for everybody. If they want people more educated, then they need to pay us a respectable wage.

I dont know what type of care you guys give out in the land down under but we treat and transport here in the states. You kind of make it sound like you are performing heart surgery out in the field. Ya there are a lot of medics our there that dont know their bung from a hole in the ground, and I know I have a lot to learn but step off of your pedestal for a second and realize your not operating a hospital on wheels. There is only so many tools in the back of your rig to treat and fix...only so many drugs you can give and only so many hands to help, so put the person in the back of the rig, maintain their abc's, keep their heart ticking around 60-120 preferably, keep their blood sugar above death and get them to the hospital.

A facebook group called Ambulance Drivers Unite put it very clearly:

I know what you are thinking... Yes, we are Emergency Medical Technicians. Basic, Intermediate, and Paramedics. But what is it that we really do as a profession? Lets not take ourselves too seriously. We are a bunch of wise *** jokers who provide high quality care that usually goes unappreciated and unrespected. But hey, if we wanted all the glory we would have gone to medical school for 15 years. We are what we are. We provide high quality pre-hospital care with out receiving "thank you's". We dont ask for the glory, we just do what needs to be done. We are Ambulance Drivers.

 

[Melclin]

But remember, we make darn near minimum wage. It is a job that isnt for everybody. If they want people more educated, then they need to pay us a respectable wage.

Not ganna touch that. There are plenty of threads already on the which comes first? Pay or education?

I dont know what type of care you guys give out in the land down under but we treat and transport here in the states. You kind of make it sound like you are performing heart surgery out in the field. Ya there are a lot of medics our there that dont know their bung from a hole in the ground, and I know I have a lot to learn but step off of your pedestal for a second and realize your not operating a hospital on wheels. There is only so many tools in the back of your rig to treat and fix...only so many drugs you can give and only so many hands to help, so put the person in the back of the rig, maintain their abc's, keep their heart ticking around 60-120 preferably, keep their blood sugar above death and get them to the hospital.

Firstly, I don't know what you think is so simple about treating and transporting. Why is it that so many paramedics insist on judging the complexity of their role by the number of drugs they carry and the thickness of their protocol books. Secondly, not everyone gets transported. Not everyone fits the cook book.

How do I make it seem like we're doing heart surgery? I think its depressing that the mere mention of taking pride in higher education and putting a value on knowledge is seen as taking it all too seriously. Going overboard. Honestly, you mention and bloody associates degree on this board and 7 different idiots come out of the wood works to piss and moan about too much education. Like, woah dude, lets not go nuts now, I'm a professional, I memorised my protocols normal BSL range in under two days, what else could I possibly need to know?

Its not even just about "need to know". Probably 70 percent of my degree won't be directly relevant when I start. How much of a nursing degree is directly relevant to my ex-girlfriend in the first days of her nursing grad year on a cardio-thoracic ward? Couldn't she just go to a tech school for 6 months and learn everything she needed to know about that particular ward and memorise some dot points on "chests and junk"? How much of my best mate's computer science degree is relevant in his grad position drafting induction literature? Probably less than me. Nobody whinges about having to have a degree in his field though. What is it with American EMS's obsession with the bare essentials?

If in 10 years, maybe I move into teaching, other parts of my degree may be relevant, the parts on health systems and adult education. I'm thinking about an MPH, expanding into epidemiological research on acute care. Pretty hard to do a masters with a certified 6 months in the back of a fire department though. Maybe I want to move into emergency management. Do a post grad cert, maybe a masters if I'm desperate , some research, maybe publish a few papers, be seen at the right conferences, smooze the right managers, move up the ranks of the Ambulance service's emerg management department. My degree doesn't specifically prepare me for any of that, but, like any degree, it provides a good baseline level of education that can be built on in the right ways.

I believe this obsession with the bare essentials and only those directly relevant to one's current position is a quality of a technician not a professional. The continued adherence to that model really makes EMS's utility in a changing future questionable.

In subtle ways, education can raise the standards of the entire field.

I know what you are thinking... Yes, we are Emergency Medical Technicians. Basic, Intermediate, and Paramedics. But what is it that we really do as a profession? Lets not take ourselves too seriously. We are a bunch of wise *** jokers who provide high quality care that usually goes unappreciated and unrespected. But hey, if we wanted all the glory we would have gone to medical school for 15 years. We are what we are. We provide high quality pre-hospital care with out receiving "thank you's". We dont ask for the glory, we just do what needs to be done. We are Ambulance Drivers.[

This whole paragraph is a joke. Lets call ourselves professionals and but constantly resist any improvements in education or changes in practice and only memorise a few directly relevant edicts. High quality care? In many cases I doubt it. But it seems like many providers are too stupid to conceive of the idea that the blind adherence to protocol may not equal high quality care. That if you get your patient to the ED doors breathing, that's not necessarily a win.

Medical school? Yeah because every EMT out there was sitting in front of an acceptance letter from Johns Hopkins but thought, "Nah I just don't feel like all that glory, I'll get my EMT cert instead".

Come on mate, I'm willing to take the piss out of myself as much as the next bloke but that facebook group paragraph is ridiculous and this thread is a serious comparison of EMS systems.

 

[MrBrown]

But remember, we make darn near minimum wage. It is a job that isnt for everybody. If they want people more educated, then they need to pay us a respectable wage.

And you have nobody to blame but yourselves for that. The system does not want more education and we look at Fire Service based EMS, it is actively discouraged.

There is only so many tools in the back of your rig to treat and fix...only so many drugs you can give and only so many hands to help, so put the person in the back of the rig, maintain their abc's, keep their heart ticking around 60-120 preferably, keep their blood sugar above death and get them to the hospital.

We have exactly the same drugs as you and see the same pathologies the world over, well, thats not true we are given drugs it seems American Paramedics are not trusted with (ketamine, combination analgesia, suxamethonium, heparin etc).

The difference is in how we approach clinical praxis and the modalities we have at our disposal. American EMS seens obsessed with "emergencies" and "getting the patient to the hospital" and it seems you learn just enough to cover that, whereas we take a more broad view ie does this patient require treatment, do they require transport, is an ambulance the most appropriate transport mechanisim or can they be left at home?

We also seem to have different priorities; rather than craming 15LPM NRB down everybodies throat and strapping them to a longboard we see providing adequate analgesia and packaging as more important hence why we have a large number of pain relieving medicines and RSI.

We are also trusted to be a professional capable of using the tools given to us and not have to run off to the medical control physician and ask for permission to do our job.

Brown is not a university educated Paramedic but rather completed the old vocational stream.

 

[medicRob]

But remember, we make darn near minimum wage. It is a job that isnt for everybody. If they want people more educated, then they need to pay us a respectable wage.

So what you are saying is that you want to get paid more so you can at some point pursue higher education?

Formal education solidified by way of degrees are the bargaining chip for a good salary. A minimum degree requirement in EMS of Associates at a minimum (Preferably bachelors) where individuals must take college level anatomy & physiology, microbiology, pharmacology, etc is the starting place for moving EMS toward being considered a profession as opposed to a stepping stone to another allied health career. At this point, the argument for higher salaries would be more readily accepted.. However, expecting a higher salary because you attended a 6 week EMT-B course and a paramedic course that lasted a year at best just doesn't compute.

Look at the other allied health professions, most of them require an individual to complete a formal degree before being allowed to practice in the profession.