I laugh at SoCal EMS protocols (especially LACo) because they don't allow you to actually treat your patient effectively in many cases. No matter who you are (fire or private), you're not actually able to take care of your patients anywhere near as effectively as most of the rest of us can, and you don't really have revolutionary research, new ground or much of anything other than an overpriced, undertrained, disinterested squad of firefighters that can ask permission for some common treatments if they're so inclined (*which they are likely not) and a herd of BLS transports. Even in a state like CA, where we're subordinated to nurses and the whims of the nursing unions, LA County has terribly inadequate protocols.
Are patients harmed by being minimally treated? I don't know, to be honest, and there's not a lot of data in the wild for us field medics in Texas to get our teeth into yet regarding the long-term effects on morbidity, mortality and patient experience of screamingly advanced care vs minimalistic BLS care or "an IV" yet. To be honest, I don't know if the stable A-fib RVR I converted with diltiazem yesterday would have been harmed by waiting until we got to the hospital, or if her outcome would have been any different had I had to ask a nurse or a physician. I don't think she would have died on the ten-minute ride to the ED, and even a LACo medic can start a line, so in some ways, I can't directly claim the protocols I operate under are any
better. People don't seem to drop dead in LACo that frequently for lack of fentanyl, and a lot of the more 'exotic' things we do are both really rare and
can be diverted or otherwise done, and some of the most important things we do are basic, fundamentals that don't really need protocol wars to dictate. Frankly, I suspect that the vast majority of patient outcomes would look identical when compared between LACo and anywhere else.
However
Ours are a
lot more accepting of perceived risk, in that we do a lot of things that would get my card shredded in CA/LACo (like field blood transfusions). Sure, risk might not be your cup of tea, but accepting risk
also allows us to do helpful things for people, like provide effective pain management or more lifesaving things like emergent airway management via RSI. We can
also do things more safely and are far faster to adapt to changes in medicine, especially because many of us can be actively engaged and involved in what we do without having to rassle with nursing and fire unions and all of that madness. It
also allows us to
try and do a lot more good work for our patients, which adds value to our services and provides us with a whole lot of new opportunities for patient care, professional personal and industrial development, and gets us paid more, better and treated as professional paramedics, not the hired help. Look at the fire departments in CA. Yes, they've got tradition and great marketing and American Heroes and all, but they're
also the product of diversification of services into EMS. Their leadership saw the wave, started paddling, and they're at least pretending to surf it. If it wasn't for the EMS services that LACoFD / other FD provides the community (as weak as they are from my perspective), they would likely look a lot like CalFire or a Fire-only department like Kern County FD if they
didn't provide those services, which are generally paid less, staffed at lower levels and face far more budgetary scrutiny than their larger, more mission-diverse siblings.
From a patient perspective, I'd way rather be in Texas, in a system that lets medics 'swing for the fences', than LACo for the vast majority of what I need. I want to be in a system/treated by a culture where paramedics understand 12-leads, where I can get ketamine and a tube to breathe for me, and where they can put in blood to replace the blood I've misplaced. I'd way rather get pain meds than not if I am hurting. From the patient/clinical perspective of a paramedic, it is way better to work in aggressive, progressive systems than archaic 1970s-land EMS.
Lastly, the culture. There's really no comparison. I have literally gone years before calling for orders.
@ParamedicStudent
If you're interested, download the PPP app (Paramedic Protocol Provider) and check out some protocols from other places. You'll be very surprised at the differences and similarities. For example, Houston Fire is pretty much exactly like LACo, with a few differences, but practically the same...but immediately to their north/west are four extremely progressive services where we do things like RSI, field blood transfusions, etc.
That's right. We put blood back into people. In ambulances. Without nurses, doctors, or a crusty MICN. On standing orders. #lifechanging
Also, our EMS culture is
way more demanding and professional.
