Serious Question: Why Does Fire-based EMS sometimes produce such low results?

[E tank]

The only way this issue (FD v. dedicated medic) would ever be settled is with adequately powered outcome studies looking at specific elements of care. Good luck ever getting those studies done (sorry if someone else already pointed that out...didn't read the whole topic).

This is nothing new, but I thought the source was interesting:

http://www.governing.com/columns/sm...hink-delivery-emergency-medical-services.html

 

[FiremanMike]

I can’t but help grin, and shake my head at this. I don’t recall ever saying I wanted to be some lone-wolf paramedic coming to save the day from the clutches of improper BLS care.

Again, do your own research into this thread and wait for what I am saying to click. Furthermore, if you think my entire position on this debate is about cool skills, and being the only one to perform them, then again you have no idea who you’re talking to.

There are nuances of communication that are missed over the internet. I did re-read my statement and understand why it came across that way, and it was unintentional. I was merely trying to humanize and personalize your position on "fewer medics are better", I did not intend to come across that way.

I think it’s safe to say we’re just not going to see eye to eye here, and that’s ok. Thanks for adding your two fire cents, and thanks for vaguely dancing around all of the questions directed at why an over saturated fire-based EMS system is anything but effective. Have a good one, Mike.

My entire entry into this thread was to challenge the notion that fire based medics that are bad are bad simply because they're fire based medics. From there, we have gone back and forth and jumped from one tangent to the other and I have done my very best to offer reasonable and objective debate into the ever changing focus of this thread, which was originally that FD medics that suck only suck because they're FD medics which moved into FD EMS is under funded, then poorly trained, then poor protocols, then that they lie to the public, suppress EMS education, and finally we landed on the fact that there were too many paramedics in the system as a whole and then whittled it down to the notion that there were too many paramedics in the fire service.

I very clearly answered your question about the effectiveness of fire-based EMS, over the course of several posts within this thread and tried to show you that there was another side to fire-based EMS than your corner of the world. I have danced around nothing, I have answered your questions to the best of my ability.

You want to talk about "vaguely dancing around all the questions", I directly asked within the in this thread to objectively quantify how FD based medics provide a lower level of service (because at it's true core, that is the sum total of the thread). Stop posting anecdotes, stop posting war stories, show me outcome based studies that show FD EMS has a higher rate of morbidity and mortality than non FD based EMS.

If we want to just back off and say "you know what, this was really just a thread to ***** about the FD", I'm ok with that.. Truly I am.. But we continue to go back and forth with "no, it really is bad because of (insert anecdote)".

 

[EpiEMS]

Show me hard numbers that morbidity and mortality are higher in areas with fire based EMS.

show me outcome based studies that show FD EMS has a higher rate of morbidity and mortality than non FD based EMS.

I don't think - and correct me if I am wrong - that such studies exist. In the absence of this, all we have is anecdote & studies that are tangentially related. Experience, we know, matters (e.g. more codes/provider). So does the number of providers on scene (too many paramedics is bad, and EMT/Medic configurations are best for cardiac arrest). Cost (seen & unseen) matters, too (and fire trucks are expensive). I'll freely admit all this. Since we cannot run true controlled trials - and I have yet to see good data comparing fire-based systems to third service to private, we don't have a great way to "conclude" that fire-based EMS is better, worse, or equal to those other models.

 

[Ensihoitaja]

I do wonder, however, how far we go down this rabbit hole? So too many paramedics causes a diffusion in the exposure to skills and acuity, sounds good, and honestly it's probably even able to be statistically quantified. What about trauma docs. If there was just one trauma center in the entire region and they saw ALL the trauma, would they be 50% better than they would be if there was 2 trauma hospitals? 4? If 2 is ok but not 10, what's the cutoff, how does one even study where that cutoff should be? This could be applied to law enforcement, legal aide, primary care, car making, you

There's actually a recent study on this for trauma centers:
https://www.sciencedaily.com/releases/2016/07/160721151447.htm

"So, the study suggests the negative impact of declining patient volume is significantly greater than that of the positive impact of increasing patient volume," said senior author Jason Sperry, M.D., M.P.H., associate professor in the Pitt School of Medicine Departments of Surgery and Critical Care Medicine. "Granting unnecessary designation to a trauma center in a region that doesn't have the patient volume to support it not only hurts patient outcomes at that new center, but it will likely lead to a decline in patient outcomes at other nearby centers."

 

[DrParasite]

*I* only do training once per week, the crews do training on their own on top of that, and on top of that we are running ~7500 call out of our station (2 ambulances and an engine). There's only so much time for EMS training, but before I have to put my foot in my mouth, let me get you an accurate count of how many hours of fire/ems training we do each year. I'm inclined to say it's equal if not skewed towards EMS, but I will happily admit if I am wrong on that one. I'll let you know tomorrow

I look forward to seeing the results of your training numbers. Assuming you run 2 on each ambulance and 4 on the engine, and everyone rotates on a regular basis, and you hold people to appropriate standards, than I think your department is doing it right.... and is in the minority among fire based EMS systems across the nation.

My entire entry into this thread was to challenge the notion that fire based medics that are bad are bad simply because they're fire based medics. From there, we have gone back and forth and jumped from one tangent to the other and I have done my very best to offer reasonable and objective debate into the ever changing focus of this thread, which was originally that FD medics that suck only suck because they're FD medics which moved into FD EMS is under funded, then poorly trained, then poor protocols, then that they lie to the public, suppress EMS education, and finally we landed on the fact that there were too many paramedics in the system as a whole and then whittled it down to the notion that there were too many paramedics in the fire service....

If we want to just back off and say "you know what, this was really just a thread to ***** about the FD", I'm ok with that.. Truly I am.. But we continue to go back and forth with "no, it really is bad because of (insert anecdote)".

You know what? you're right. Seriously. We (everyone who posted here, myself included) generalized that Fire based EMS produces low results. We painted everyone with a broad brush. And yes, we grouped all fire department based EMS under the same poor provider stereotype.

I happen to think that your department is the n=1, the exception to the rule, instead of the norm. Think of all the departments that were already listed.... Detroit fire ems, FDNY, phillidelphia, & DC FEMS..... need I go on?

So your right, not every fire dept based EMS system sucks.... but a lot of them do..... your department just happens to be one that is doing it right.

 

[gonefishing]

But this isn't true. The NEJM published a study about an increase in ED utilization in one state (oh, I want to say either Colorado or Washington) that saw increased ED usage after generous medicaid expansion. It is going to take a whole lot more than educating the public.

No kidding!? Do you have a link? I would love to read it. You can pm me so this thread stays on topic.

 

[akflightmedic]

As for the IAFF holding back education, I mean how do you even qualify that.

If you care to invest the time and energy, research which group of people were the most resistant and lobbied against National Registry becoming a standard across the nation. While the process has its flaws, it IS something, it IS a start and many states adopt it. But get on a state level and find out why some have refused to accept it as the one and only or adopt any of it in part. Find out which states adopted it, dropped it then adopted different parts of it.

Then find out which Collective group of individuals was against making a two year degree for Paramedic mandatory and why,

Florida is a very interesting case study for that.

I do wonder, however, how far we go down this rabbit hole? So too many paramedics causes a diffusion in the exposure to skills and acuity, sounds good, and honestly it's probably even able to be statistically quantified. What about trauma docs. If there was just one trauma center in the entire region and they saw ALL the trauma, would they be 50% better than they would be if there was 2 trauma hospitals? 4? If 2 is ok but not 10, what's the cutoff, how does one even study where that cutoff should be? This could be applied to law enforcement, legal aide, primary care, car making, you get the picture.

It is interesting you mention the Trauma Centers and how many are enough. I can only speak for three states personally and my assumption was a similar process took place across the others. But in the states I know, including FL you cannot just open a trauma center. You must apply for and justify the need for a Certificate of Need. If you do not have the data to support your position, then there is no CoN issued thus no saturation of hospitals or trauma centers.

This same process is applied to ambulance services as well.

Law Enforcement is regulated by the numbers.

Legal Aides...well the market regulates those. Many of them sit at home staring at their degrees.

Seems like they are on to something and should streamline the paramedic pool....

I don't think you had solid logic in this example.

 

[FiremanMike]

If you care to invest the time and energy, research which group of people were the most resistant and lobbied against National Registry becoming a standard across the nation. While the process has its flaws, it IS something, it IS a start and many states adopt it. But get on a state level and find out why some have refused to accept it as the one and only or adopt any of it in part. Find out which states adopted it, dropped it then adopted different parts of it.

Then find out which Collective group of individuals was against making a two year degree for Paramedic mandatory and why,

Florida is a very interesting case study for that.

That does seem interesting to me and I will be looking into it, thanks for pointing me in the right direction! I would say, though, that this would only be a fair piece of evidence that FDs hate/devalue EMS if they were opposed to standardized EMS training and increased EMS education requirements, while at the same time promoting standardized fire training and increased fire education requirements.0

It is interesting you mention the Trauma Centers and how many are enough. I can only speak for three states personally and my assumption was a similar process took place across the others. But in the states I know, including FL you cannot just open a trauma center. You must apply for and justify the need for a Certificate of Need. If you do not have the data to support your position, then there is no CoN issued thus no saturation of hospitals or trauma centers.

This same process is applied to ambulance services as well.

Law Enforcement is regulated by the numbers.

Legal Aides...well the market regulates those. Many of them sit at home staring at their degrees.

Seems like they are on to something and should streamline the paramedic pool....

I don't think you had solid logic in this example.

Actually, you're right.. Trauma centers are a bad analogy. I think cath labs and stroke labs would be a more appropriate comparison?

I don't think law enforcement is regulated by numbers, what are you referring to?

 

[akflightmedic]

I cannot just add a police department nilly willy....nor can I just add 20 police officers to the budget just because. They are regulated again by showing an increase in crime, growth of population or stats which show having X number of cops reduces Y.

I think your examples support the other side of the debate. Less is More and Yes, regulation should be in play and there are existing systems....except within the FD.

 

[FiremanMike]

So I looked at my training file, here's what I found. Now this data is incomplete because I didn't comb through to factor in folks going to conferences and I also didn't check my secondary online CE site because datamining it is a pain in the butt, but here's what I have..

Department developed and led training - 54.75hrs EMS, 79.5hrs Fire
Online (self initiated) training - 511.5 hrs EMS, 227.0hrs Fire - This is credits given

So internally we do more fire training than EMS training, but not necessarily by an alarming amount IMHO.


Overall, I think this conversation still contains some good information and I'm sorry for any escalation that may have been caused by me. Sounds like I'm getting the chance to go to Eagles this year, so if anyone else will be there, I'd love to discuss further ways to solve all the world's problems over an adult beverage!

 

[akflightmedic]

So take the number of training hours in one area versus another and then compare the following:

Call volume Fire Versus EMS --Would you agree that the greater need is getting the lessor training/education?

And if you want to make it a life safety issue....analyze the fire runs. What type of fire versus life at risk. Do the same for the EMS runs.
Which ones had greater impact on the population at risk (the tax payers), which one yielded the best return?

And once you get done crunching all that data, you will see dollar for dollar that EMS, even within your own stellar FD (not sarcasm) is still treated/viewed as the 2nd class citizen.

I am a guy who has done both sides of the argument and then some...I am not a crunchy paramedic with an ax to grind.

 

[EpiEMS]

Which ones had greater impact on the population at risk (the tax payers), which one yielded the best return?

The only problem with this is that in some places (densely populated areas, mainly), there is a very strong case to be made for lots and lots of fire training. To generalize, one ambulance crew can only really make a difference for one patient...but one fire truck responding to a small kitchen fire in an apartment building can make a difference for a lot of people

 

[Summit]

Actually, you're right.. Trauma centers are a bad analogy. I think cath labs and stroke labs would be a more appropriate comparison?

Cath lab facilities have some very quantifiable and reportable quality metrics. Spend some time in a cath lab that has low volume. Unless you have extraordinarily experienced and dedicated staff working a well supported system, you can see some bad results. Hospitals carefully consider their potential volumes and the availability of qualified employees before they consider investing millions in a cath lab+personnel+training.

What is your point? Do you just not believe in skill dilution in EMS? Do you think it is a non-issue? How do you believe the issue should be determined? In Fire/EMS systems, it is seemingly determined by IAFF political goals and how much money taxpayers can be convinced to cough up. In private systems, it is determined by the market vs government contract requirements. 3rd services run the gamut from KCM1 to double-medic-every-bus (which is still less dilution than 6 FF/medics on every BLS call).

 

[FiremanMike]

So take the number of training hours in one area versus another and then compare the following:

Call volume Fire Versus EMS --Would you agree that the greater need is getting the lessor training/education?

And if you want to make it a life safety issue....analyze the fire runs. What type of fire versus life at risk. Do the same for the EMS runs.
Which ones had greater impact on the population at risk (the tax payers), which one yielded the best return?

And once you get done crunching all that data, you will see dollar for dollar that EMS, even within your own stellar FD (not sarcasm) is still treated/viewed as the 2nd class citizen.

I am a guy who has done both sides of the argument and then some...I am not a crunchy paramedic with an ax to grind.

I'm not sure it's quite as simple as proportionally comparing the amount of hours spent on EMS runs vs Fire runs to EMS training and Fire Training. I think one could actually make a small argument that because there are less fires, we are less experienced at fighting fires, and we should spend more time training on that. This obviously only works if you have someone paying attention to EMS deficiencies and addressing those deficiencies as they arise through education.

I will definitely admit the disparity between fire/ems training in my own wasn't what I was expecting to see, but I certainly don't think it's as horrible as it is at other places.

Cath lab facilities have some very quantifiable and reportable quality metrics. Spend some time in a cath lab that has low volume. Unless you have extraordinarily experienced and dedicated staff working a well supported system, you can see some bad results. Hospitals carefully consider their potential volumes and the availability of qualified employees before they consider investing millions in a cath lab+personnel+training.

What is your point? Do you just not believe in skill dilution in EMS? Do you think it is a non-issue? How do you believe the issue should be determined? In Fire/EMS systems, it is seemingly determined by IAFF political goals and how much money taxpayers can be convinced to cough up. In private systems, it is determined by the market vs government contract requirements. 3rd services run the gamut from KCM1 to double-medic-every-bus (which is still less dilution than 6 FF/medics on every BLS call).

I do believe in skill dilution, but I believe the issue is far more complicated than "FiremanMike takes 10 ALS runs per shift and Summit takes 30 ALS runs per shift, so obviously Summit is better.."

Clearly, there is a breaking point, past which there is no appreciable difference. 25ish years ago in this area, there were only 6 ALS Ambulances in the entire county and 20 or so BLS squads. Those ALS trucks got their absolute balls smashed with a hammer every single shift they came to work, taking 20+ runs per 24 hour shift. I hope we can all agree that likely isn't safe for the patients or the mental health of the providers, so clearly more paramedics are needed, which circles us back to the original point; at what point do we decide "that's the right amount of skill/acuity exposure" which I would take even further to say "at what point are we blaming lack of accountability on skill dilution".

Which I suppose brings me to what has motivated me to stay so fervently engaged in this thread. There is a lot of "I've experienced this setup not work, so that means it is unlikely to ever work". 6 paramedics on a cardiac arrest isn't a bad thing just because there are 6 paramedics, but it can be a bad thing if 3 of those paramedics never take EMS runs and the team leader lacks crew resource management skills to direct the cardiac arrest. FD based EMS isn't bad because the guys wear fire department tee-shirts and have a red ambulance, but it can be a bad thing if the department doesn't show value to EMS and EMS leadership.

I have very much moved my mindset into one that truly wants to move beyond just identifying problems, I want to know the mitigating factors and start working through the potential solutions.

 

[EpiEMS]

6 paramedics on a cardiac arrest isn't a bad thing just because there are 6 paramedics,

I don't agree with that - in simulation settings, more medics has not been shown to be better (in fact, it's worse). Furthermore, when those medics are doing BLS skills during the resuscitation - as three of them should be (BVM, chest compressions, getting a history/preparing to move/recording events) - they aren't doing the ALS skills that they ought to be practicing (ECG, medication administration, advanced airway placement).

Those ALS trucks got their absolute balls smashed with a hammer every single shift they came to work, taking 20+ runs per 24 hour shift.

Definitely not a good thing - but this is unlikely to be a "too few paramedics" problem, this is a "not good enough EMTs" or "overuse of paramedics" problem, I'd wager.

 

[FiremanMike]

I don't agree with that - in simulation settings, more medics has not been shown to be better (in fact, it's worse). Furthermore, when those medics are doing BLS skills during the resuscitation - as three of them should be (BVM, chest compressions, getting a history/preparing to move/recording events) - they aren't doing the ALS skills that they ought to be practicing (ECG, medication administration, advanced airway placement).

So I'd say 4 paramedics would be ideal for the way we roll. 1 to be the team lead, 1 for the intubation/airway management, 1 to mind the monitor, and one to get the IV/IO and push the drugs. This way every one of those roles is filled by someone who is trained and legally able to carry out what needs to be done in their assignment. So the other two guys will be the chest compressors, at least until its time to move to the autopulse/lucas. Sure, it's overkill that the chest pushers are paramedics? Sure, I suppose, but is it enough to get up in arms about over saturation? Nah.

Definitely not a good thing - but this is unlikely to be a "too few paramedics" problem, this is a "not good enough EMTs" or "overuse of paramedics" problem, I'd wager.

Well I wasn't there, but the guys insist they were running from ALS call to ALS call..

 

[DrParasite]

Department developed and led training - 54.75hrs EMS, 79.5hrs Fire
Online (self initiated) training - 511.5 hrs EMS, 227.0hrs Fire - This is credits given

So internally we do more fire training than EMS training, but not necessarily by an alarming amount IMHO.

Respectfully disagree. your department does more fire training that EMS training (which is what I said earlier). But it's actually a lot closer than I expected to see

Online (self initiated) training is more for EMS, but that is a HUGE amount of training (almost a 10:1 ratio of online training to departmental training), and, depending on the caliber of the training, can also determine how beneficial it is. I will also reiterate, it seems like your department is doing it well, and not the norm

I cannot just add a police department nilly willy....nor can I just add 20 police officers to the budget just because. They are regulated again by showing an increase in crime, growth of population or stats which show having X number of cops reduces Y.

why not?

If you are located at Penn Station in NYC, within a 2 block radius, you have NYPD, Amtrak PD, USPS PD, Port Authority PD, NJTransit PD, and all but USPS PD have their own ESU units. And citywide, you ave all of these: https://en.wikipedia.org/wiki/Law_enforcement_in_New_York_City

Where I am currently located, within a 4 block radius of my current seat, I have City PD, the state Highway patrol, General Assembly PD, State capital pd, and the county Sheriff's deputies, and they all have have been here in an official capacity.

If you have the money to do it, you can do it.

And if you want to make it a life safety issue....analyze the fire runs. What type of fire versus life at risk. Do the same for the EMS runs.
Which ones had greater impact on the population at risk (the tax payers), which one yielded the best return?

And once you get done crunching all that data, you will see dollar for dollar that EMS, even within your own stellar FD (not sarcasm) is still treated/viewed as the 2nd class citizen.

agreed.

I think one could actually make a small argument that because there are less fires, we are less experienced at fighting fires, and we should spend more time training on that. This obviously only works if you have someone paying attention to EMS deficiencies and addressing those deficiencies as they arise through education.

I think that's a fair argument to make, especially in your department. I don't think that applies elsewhere, but it's a valid point.

Clearly, there is a breaking point, past which there is no appreciable difference. 25ish years ago in this area, there were only 6 ALS Ambulances in the entire county and 20 or so BLS squads. Those ALS trucks got their absolute balls smashed with a hammer every single shift they came to work, taking 20+ runs per 24 hour shift. I hope we can all agree that likely isn't safe for the patients or the mental health of the providers, so clearly more paramedics are needed, which circles us back to the original point; at what point do we decide "that's the right amount of skill/acuity exposure" which I would take even further to say "at what point are we blaming lack of accountability on skill dilution".

maybe they should have switched to 12 hour shifts? maybe a better question is were those 6 ALS ambulances going on ALS calls, or BLS calls? were they transporting every patient? and more accurately, were they transporting patients that could have gone with the BLS crew without any negative patient outcomes? Are BLS squads transport capable ambulances, or non- transport first responder vehicles?

You brought it up. Assuming your entire county is fire based EMS (and without getting into specifics, it's hard to know), and made a claim about the past. All of NJ is a few paramedic trucks and a lot of BLS ambulances. All of DE is a few paramedics and a lot of BLS ambulances. NYC is a bunch of paramedics and a whole lot of BLS ambulances. Maryland has a mix of BLS and ALS Ambulances. Currently. With few exceptions, I don't see people getting run into the ground (and those that do switched to 12 hour shifts), nor do I see or read about dead bodies lining the streets because they aren't enough paramedics to save them.

 

[FiremanMike]

Respectfully disagree. your department does more fire training that EMS training (which is what I said earlier). But it's actually a lot closer than I expected to see

Online (self initiated) training is more for EMS, but that is a HUGE amount of training (almost a 10:1 ratio of online training to departmental training), and, depending on the caliber of the training, can also determine how beneficial it is. I will also reiterate, it seems like your department is doing it well, and not the norm

So the comparison between online and in person training isn't really accurate and I'm too lazy to really break it down. It would have been more accurate for me to actually multiply the number of hours per in-class training offered by the attendees for each class to then compare it to the online training total, does that make sense?

I think that's a fair argument to make, especially in your department. I don't think that applies elsewhere, but it's a valid point.
maybe they should have switched to 12 hour shifts? maybe a better question is were those 6 ALS ambulances going on ALS calls, or BLS calls? were they transporting every patient? and more accurately, were they transporting patients that could have gone with the BLS crew without any negative patient outcomes? Are BLS squads transport capable ambulances, or non- transport first responder vehicles?

You brought it up. Assuming your entire county is fire based EMS (and without getting into specifics, it's hard to know), and made a claim about the past. All of NJ is a few paramedic trucks and a lot of BLS ambulances. All of DE is a few paramedics and a lot of BLS ambulances. NYC is a bunch of paramedics and a whole lot of BLS ambulances. Maryland has a mix of BLS and ALS Ambulances. Currently. With few exceptions, I don't see people getting run into the ground (and those that do switched to 12 hour shifts), nor do I see or read about dead bodies lining the streets because they aren't enough paramedics to save them.

Again, I wasn't there, so I can only go off the lamentations of our dinosaurs who talk about the good old days. Should they have gone to 12s? Increased the number of medics by 50%? Gone to fly cars? Increased BLS education? Who knows, all of those solutions were likely considered and it was ultimately decided that they would just make all of the ambulances ALS trucks and staff them with 2-3 paramedics and all of the engines (and some of the ladders) ALS capable and staff it with at least 1 paramedic.

I'm not necessarily implying that our current system is the best, and if we are doing the true penny pinching money crunching, it clearly isn't the most financially efficient means, but that's the system we're in and it seems to be working for us.

 

[EpiEMS]

So I'd say 4 paramedics would be ideal for the way we roll. 1 to be the team lead, 1 for the intubation/airway management, 1 to mind the monitor, and one to get the IV/IO and push the drugs.

I don't see the benefit in having an ALS team lead, myself, and why do you need a medic for airway & for access + drugs? Can't the medic get access (via IO, probably), then throw a rescue airway in? BVM should be more than adequate initially. Heck, you could probably just throw on an NRB in most adult arrests of cardiac origin for the first couple minutes.

 

[Summit]

I don't see the benefit in having an ALS team lead, myself, and why do you need a medic for airway & for access + drugs? Can't the medic get access (via IO, probably), then throw a rescue airway in? BVM should be more than adequate initially. Heck, you could probably just throw on an NRB in most adult arrests of cardiac origin for the first couple minutes.

I'll go ahead and play devils advocate and present a model (of many) that you ideally get for an in-hospital code.
1-2 docs
1-2 nurses
0-1 RT
Maybe 1 pharmacist to mix up TPA (usual etiology and response times are different in a hospital vs field)
Several bodies to do compression, hold mask, record, lab courier

You have a RN running the monitor/IO/drugs.
You have a MD running the code often with a RN copilot. Their job is to stand back, manage, and think.
You have the RT or another doc (anesthesia) on airway or establishing central access, a-lines.
You have ancillary personnel for compressions, bagging, recording, run labs

Prehospital is different.

In the field you aren't dropping femoral lines, alines, running labs... you are more likely to have lucas devices (although I work at one hospital that has these for in hospital use), EMR/EMT can compress, hold mask seal, drill an IO (if your locale lets them...and they should... a mentally challenged lemur could start an IO and an IO takes much of the stress out of a code).

I think 3 ALS providers and a couple EMTs are a good thing for a prehospital code... but that does NOT mean you need 3 ALS providers on every engine. Fly cars! Command cars!

It is really easy to jump on to whether much of ACLS is useful... or whether ALS does more good than bad... when you start looking at the data you stop asking about how many paramedics you need on each engine and start asking if you want any at all vs whether to heavily reform what and how ALS does ALS care.