usmc_chris

I completely understand. NYS follows both the NREMT I/85 and I/99 standard, calling the 85's EMT-Intermediates and the 99's EMT-Critical Care. Up until our latest protocol revision in our region, there was extremely little difference between the CC's and the P's, except that the CC's had to call for orders for a lot of medications that the P's could give on standing orders. I don't think there was anything that P's could do that CC's couldn't except maybe surgical airways. Then the I's could do IV, NS, and ET intubation, but no IV medications - just what we call "BLS" medications here - Epi-Pens, Oral Glucose, ASA, Albuterol, Activated Charcoal, and assisting with pre-prescribed NTG. I put "BLS" in quotes because, as a thread I read a while back on here said, some of the things we allow EMT-B's to do are, technically, advanced procedures, that is, beyond the scope of a layperson. Fortunately, we've started to curtail this. Our I's can no longer intubate at all, can start peripheral IV's and use alternative advanced airways. The changes that were put in place for CC's were much broader. They can no longer intubate pediatric patients. Any medication that require a medical control order for a Paramedic is now prohibited for the CC's, they can't even request an order for it. And they are required to call for orders in more cases as well. I think the next time around, they will take intubation away from CC's altogether, so they will no longer be recognized as an ALS provider in their own right. But that's my region. There's other regions that they've given the I/85's some IV medications, and there is no difference in protocol between a CC and Paramedic. There's no incentive whatsoever to become a Paramedic, especially when there is no difference in protocol and they pay difference is something like 50 cents an hour. Of course, these are very rural areas of the state. And knowing some of the mistakes I've made, and knowing that I would certainly have liked longer and more in-depth education in Paramedic school ... the thought of some of these people practicing at the level they are permitted to... SCARES me. As for Zofran, we don't carry it at all. Only Phenergan. Wish we had the option though.

As to the theft of AED's, they make cabinets to hold them that, when opened, sound an audible and visual warning, as well as placing a 911 call indicating that the AED has been accessed. I know this may not help figuring out who took it, but it certainly indicates that somebody took it. And the audio/visual alarm may be enough to scare off the would-be theft. There are several schools and other facilities in my area that have their AED's linked into 911 in this way. Whenever a cabinet with an alarm likes this is opened in my area, it generates an Echo level 911 call, with PD, Fire, and EMS all dispatched for the potential cardiac arrest, the run card notates that is the cabinet that has been opened, no call yet to confirm. Another cost, I know, but maybe a deterrent to "misappropriation" of the devices?

You know what's worse than not having AED's at adult care facilities? I have been told by staff at several of these facilities that are formally designated as Adult Homes rather than SNF's that they could actually get in trouble for doing CPR from the state. We've all seen our share of shitty adult care facilities, but the ones I reference are ones that I would generally be willing to put my own relatives in, should the need arise. I tried to find the law, but just found endless confusing regulations. Knowing the state, however, since in none of the laws/regulations that I found are resuscitative efforts specifically permitted, they would be default be prohibited. I truly hope this isn't actually true, please, somebody point me in the correct direction (so I can provide supporting documentation to these folks if I run into them again) that shows that assisted living staff in NYS can provide CPR to residents. Certainly by the time that the staff even find the patients, they're often beyond help, but if they have to wait for EMS to show up, we can be assured that there's nothing can be done.

We essentially do this on every call. I work for a commercial agency with our own dedicated dispatch channel, we respond with another agency on almost every call we go on, unless it is a scheduled IFT or an emergency call originating from one of our SNF or adult care facility contracts. We have multiple 911 contracts, some of which are full transporting ALS/BLS contracts, responding with a BLSFR or ALSFR fire department, some of which are intercept ALS contracts with volunteer fire or non-fire based BLS transporting agencies. We typically send a full ALS/BLS ambulance on most of these responses as those agencies fail to "crew up" often enough that we feel the need to already have the transporting vehicle enroute; in addition, it gets us back in service quicker as my partner can drive my ambulance behind the volly rig. So, after acknowledging the call, we have to change frequencies and say "ALS 22 to the fire [or EMS, or XYZ FD] dispatcher, responding with XYZ FD to the call on Main St, starting from Rt 1 and Rt 2" or something similar. 99 times out of 100, the only transmissions on the county fire or EMS frequencies that we make are "enroute" and "on scene." In nearly 4 years at this agency, over a year of which as a Paramedic, I think I've actually been updated by units on scene about twice. Of course, that's because our response times are typically excellent to the point where we're pulling up within 30 seconds of the FR unit in the more urban areas, and many times BEFORE the BLS truck on the intercept contracts. Since they show up before we're ready to transport, we'll go on their truck anyways. So, in theory, it's a great idea. In practice... seems like a waste of time, at least where I'm working. The only times I could see it REALLY being useful, in MY RESPONSE AREA, is if a BLS unit on scene is requesting ALS for a call not initially dispatched as an ALS priority, and more importantly, if they're transporting towards you and you're attempting to make an actual on-the-side-of-the-road-somewhere-between-the-scene-and-the-hospital ALS intercept. I think the primary reason we continue with this protocol is so we're actually monitoring the fire/EMS channel instead of our primary dispatch channel, on the off chance that somebody actually lets us know something useful prior to arrival.

They run with whoever shows up, on a scramble system. They may or may not "assign" crews to respond at night. There was also a full ALS/BLS ambulance responding from another agency as this agency is BLS only...

It's only the lubricating jelly they supply in the package that's being recalled. According the the recall notice, there is a potential risk of infection from the lubricating jelly. The device itself is fine. What our agency has been instructed to do, until replacements can be obtained, is simply to tape a new packet of surgilube or other lubricant to the package, and warn providers to use the new packet of lubricant, not the one supplied with the King.

I'm not a pharmacist, but based on a quick Google search, I think I can give you a general idea of the difference. True Racemic Epinephrine is a 50:50 mixture of the "left" (active) and "right" forms of the epinephrine isomer. Some of the pages I looked at stated that simply givng L-Epinephrine (what we ordinarily carry), at 1/2 the strength of what you would give Racemic Epi at, is equivalently effective in the treatment of croup. I THINK, and somebody please correct me if I'm wrong, that the benefit of true Racemic Epi is that there is minimal systemic absorption - we get the relaxation of smooth muscles in the airway that we are looking for, without the systemic alpha and beta effects (increased heart rate, increased BP, etc). Somebody with a better understanding of pharmacology please chip in here! I'm just as curious - I don't really truly understand the difference well, I just know there IS a difference.

Not to change the subject, but a minor educational point. Racemic epinephrine is NOT simply nebulized 1:1000 epinephrine. They are different drugs. Closely chemically related, but not the same pharmaceutical. What you describe is ordinary 1:1000 epinephrine placed in a nebulizer. There is some benefit to doing this as well, but it is not technically racemic epinephrine.

I completely agree with you, chbare! However, I understand what NYCEMS is saying... there is very little that is more frustrating than being presented with a signed, legal, complete living will in which the patient EXPLICITLY states that he/she would not want CPR, intubation, ventilation, etc. BUT because NYS only permits EMS to honor the DOH DNR form and the MOLST form, in the event that patient went into cardiac arrest, we would legally be bound to resuscitate. One could certainly contact medical control for guidance in this event, however, they would most likely instruct you to initiate resuscitative efforts, at least to the point of field termination, if not insisting that we transport (we must have medical control authorization to cease resuscitative efforts in the field in my area).

Thorough documentation is absolutely essential. In my system, even visually "looking" at a patient is considered "patient contact." For example, if I walk into a scene, and another unit is on scene in the process of obtaining a signed release (All agencies that provide EMS are required to complete a full PCR on every run, regardless of whether they are BLS first response, FD based, or whatever) and they "cancel" me at the door, I am still required to at the very least complete a "visual" assessment. Ex: Dispatched for NAEMD 17A1 fall, caller requesting lift assist only. Arrived on scene with FD Engine XXX. Entered residence, arrived to find approximately 60 y/o male pt, appears conscious and alert. FD unit state that pt has no complaints, had slipped from his chair and they picked him back up. They state that pt is adamantly refusing care, denies any head/neck/back pain, they have completed full assessment and are in the process of obtaining a signed refusal from the pt. FD state that pt has denied any chest pain/pressure, shortness of breath, or loss of consciousness. No need for full ALS assessment at this time. Pt is in no apparent distress, skin appears normal, is speaking in full sentences to FD crew with no apparent exertion. FD states that ambulance can cancel as they will complete signed refusal. Returned to service without further pt contact. There are plenty of people out there that would pretend they didn't make it in the door and document this as "cancelled on scene by FD, no patient contact." However this isn't acceptable. Furthermore, assuming that the first unit on scene was a BLS unit (we do have one agency that we respond with that provides ALS FR), if the call came in as a NAEMD C, D, or E, the ALS provider has to do a full assessment and complete any refusal documentation, regardless of what the FD unit states. The level of documentation is annoying sometimes, but in the end, it will CYA. Society today is far too litigious to risk not fully documenting any encounter with any person.

Thanks for all the replies. You pretty much have all said what I was already thinking. Unfortunately for the company, they must do what they are told or risk losing the contract on the next go-around... in my state, legally, the fire departments are responsible for EMS. If they choose not to run their own ambulance service, then they contract for a service to provide the ambulances within their district. There are at least two other services in the county (one is another for-profit, the other a non-profit 3rd service) that would bend over backwards to take this business from the company I work for, so quite literally, the management does whatever the fire chief tells them to do. If he wanted our ambulances to be painted solid purple, then they probably would get painted that way. Furthering the problem is that this is one of the biggest money-makers for the company - it's not a response area that management would make a moral stand over. Fortunately for me, I no longer work in this response area, so don't really have to "deal" with the problem. Furthermore, I don't really expect to be in the area for much more than another 6 months. I truly don't believe that this department wants to run transporting EMS - at least until this state allows fire districts/departments to bill for services. However, they do want to maximize their run numbers in order to justify additional firefighter jobs and a higher tax rate. If that's what they want to do, whatever... but I think that there are better ways to ensure "adequate patient contact" time for their firefighters. Unfortunately, in any for-profit business, "the customer is always right." I can't wait to go to a state that's a little less screwed up than this one...

I personally tend to agree with you, but this is the way the system is. As for the Omega category, I personally have only seen one or two calls ever actually coded that way, I believe they upgrade all of them to Alpha responses - but yes, we do frequently get a dual response for a call that gets entered as a "lift assist request." But to the question at hand... considering that all of these firefighters are in fact "medically" certified (let's debate the merits of the EMT-B certification another day), how do we ensure that they get adequate "patient contact" time so they don't choke in the event that the ambulance/ALS response gets delayed for some reason (without purposefully delaying the ambulance response on a routine basis)?

Edit: I posted this in the wrong forum somehow, I apologize, I have no idea how to put it in the correct forum. I'm an occasional lurker on the forums, but haven't really contributed much. A little bit about me first - I began in volunteer EMS since 2003, been an EMT since 2004, began working professionally in 2007, and finished my Paramedic degree this Spring. In addition to my A.A.S. in Paramedicine I also have a B.S. in software engineering (don't ask) and an M.P.A. My goal is ultimately to become an EMS manager. I generally agree with the "consensus" among the most active posters - that the Fire Service may not be the best way to run EMS. That being said, I had an interesting discussion with an individual at my part-time job the other day. His full time job is in the Fire Service, with an agency that does BLS first response only. Now, I don't want this to turn into a fire service bashing thread, regardless of how any of us might feel about that method of delivery. The way the system works is that this fire department "first responds" to all medical "emergencies" within their district - regardless of severity or origin - they respond to the doctor's offices, to low-priority psychiatric complaints, etc - everything except for scheduled interfacility transports. A private service (my full-time job) responds for the ALS and transport components. I personally believe that they don't need to respond to everything in their district, I would advocate for no more than NAEMD-coded "Delta" and "Echo" level responses, as well as special assists (known severely morbidly obese patients, MVA's, etc.). However, their position is that as they are tax-supported, they have a responsibility to respond for every fire, medical, or rescue request within their district. Let us assume, for the purposes of this discussion, that this is the way the system is set up. Let us also assume that for the foreseeable future this arrangement cannot be changed - we will have a minimum of 2 firefighters trained to the EMT-B level or higher (but only capable of practicing with this agency at the EMT-B level) responding on an engine, truck, or light rescue, with an ALS or BLS transporting ambulance, depending on the EMD coding of the response. Recently, the "posting scheme" (the private service uses system status management) was changed within the service area at the request of the fire department. The ultimate purpose of this, it seems, was actually to DELAY responses within the district. The assumption among many employees of the private service was that the department wanted to "look good" by "showing up first." I must confess, from our perspective, this is exactly what it looks like. Now, response times for the ambulances are still well within contracted targets, and well within NFPA standards (contracted targets are 7:59 for NAEMD Echo, Delta, Charlie, and Bravo responses; 11;59 for Alpha and Omega responses). The reason for the change, it was explained to me, was not to "look good." Rather, this department was experiencing a problem. Their EMT's were becoming too reliant on the ambulance crews and the Paramedics. Due to the ambulance being less than thirty seconds behind the fire apparatus in many cases, and often even being first on scene, the BLS assessment and treatment skills of the firefighters were being degraded. The concern of the department that should the ambulance service be experiencing higher-than-normal call volumes, or a delayed response for whatever reason, the EMT's on board the fire apparatus would simply not know what to do if they had, say, 10 minutes with a patient rather than between 30 seconds and a minute as is often the case. The solution, of course, was to shift the starting locations of the ambulances so that the firefighters would have on average 2-3 minutes with the patient, allowing them to complete their initial assessments including vital signs and begin "routine" BLS interventions - ASA, O2, etc. - prior to the ambulance crew's arrival and beginning of ALS assessments and interventions. I personally don't agree with the solution that was presented and in effect. However, I came to fully understand the fire department's point of view - assuming the firefighters will in fact respond, how do we ensure that they have adequate "patient contact" time to maintain their skill levels? Should it be required that they complete mandatory monthly ride-alongs with the ambulance crews? Should it be required that they maintain part-time employment with an ambulance service? Your comments and suggestions would be appreciated. I'm not really in a position to change anything, but as someday I hope to be in a position where I would have an impact and a decision-making role in an EMS system, it is, I think, a useful discussion. Again, I would appreciate if this doesn't devolve into yet another fire-service EMS bashing thread - rather a genuine thoughtful discussion of our identified problem. Thank you all for your input.

Doczilla, I definitely agree with what you're saying - immobilize, but use an alternative method. Is there any system where this would be considered acceptable? Within my regional protocols, once a c-collar has been applied, you MUST use a long back board - there is no "alternative" immobilization permitted. I "might" be able to get away with using a c-collar and a scoop stretcher to secure the spine. I would love to be permitted to do exactly what you describe for elderly patients with a potential for a c-spine injury but no major indicators (obvious trauma, pain to spine, etc would still get the "works") - the only reason they get immobilized is I can't use our selective spinal immobilization protocol due to their age. Is there any way anybody here can think of to get this to be permissible? Thanks

Not to stir the pot too much here, but don't forget that our entire legal system was based on Christian mores. The founding fathers were, for the most part, deeply religious men, and their values are reflected in our government and legal system. That being said, I certainly don't believe that any one religion, or group of religions should dictate social policy. While I may believe in God, and attend church, I don't believe that my beliefs should be thrust onto others. Just because I choose do to something or not to do something based on my personal beliefs doesn't mean that I can dictate that others can or cannot do that. That being said, I agree that this incident is a little ridiculous. To be removed from school for wearing a t-shirt depicting the flag of the United States of America, while within the borders of the United States of America, is completely unacceptable in my opinion.

Of course, then you have agencies where the Emergency Button does nothing other than make the portable make loud annoying noises...

Employers should be careful about making their employees pay for damages to equipment. Doing a quick search on the internet, I found my state, New York, and at least one other, California, prohibit any payroll deductions other than mandated federal and state taxes/fees that the employee does not authorize. Furthermore, deductions for damaged company equipment are expressly prohibited, except in the case of intent and/or gross negligence - which from what I read is very narrowly interpreted, most at-fault accidents would not qualify. I would imagine that other states have similar regulations. Like another poster stated, damage to equipment is a cost of doing business. While employees shouldn't be purposely reckless with the equipment, or careless, there is the fact that accidents are called accidents for a reason. Mistakes happen, and unfortunately sometimes those mistakes cost money - it is the nature of the business. Just my two cents.

I have an interesting take on this. I have always been around young EMS providers. I started out in college-based vounteer EMS, where everybody was 18-23. With my current employer, at age 24, I'm above the median age range. I'm one of the younger Paramedics, but we have a lot of very young, inexperienced EMT's. I don't have an issue with most of them, but some of them have a bit of an attitude. For example, I worked with one of them a couple months ago (about a week before I took my Paramedic certification exam), who was too young to even drive, so in effect I was an "ambulance driver" for the day. We got sent on a call, categorized as ALS criteria, with no responding ALS unit. Our agency has a habit of sending BLS units on ALS criteria calls when we are busy, and instructed to "advise on ALS" rather than securing an ALS unit, whether it be a supervisor from our quarters, or, god forbid, actually requesting another agency to help us out. She took great offense that I wanted to assess the pt more thoroughly than she did. Her idea was to put the pt on the stretcher, go to the ambulance, and only then perform an assessment on the way to the hospital. She complained to me "the supervisors have told me I do just fine by myself, you're not a Paramedic yet, so don't think you can assess MY patient!" While I know I didn't have the "P" formally yet, it was as if the year and a half of education didn't matter. I know that I, for one, when I was a newer EMT, would greatly value a partner with more experience and more education. This is by no means a common problem at this company, but this is the kind of person I don't want to work with - regardless of their age or experience level. One who has too big of a chip on their shoulders to take advice or additional input from everybody. I worked with a basic the other day who likes to perform his own assessment, without getting in the way, even on clearly ALS criteria patients - I'm glad of this! Maybe he might catch something I somehow missed. Even if he finds the exact same thing I did, it gives him additional experience and confidence assessing patients. Regardless of the age or experience level, I just want a partner who is confident in their own abilities, and also recognizes the limitations of their education - and more importantly seeks more. I know Paramedics who belittle basics for seeking more knowledge, for attending CME lectures, for reading articles, etc. This is exactly the wrong attitude! Age is not the issue - I know 50 year olds who act like 3 year olds, and some very young, very competent Paramedics with whom I would trust my life. As long as you take your job seriously, and seek to improve yourself, I have no issue working with you.

I'm glad that they had an AED available, and the gentleman survived, but that has to be one of the most poorly written articles I've ever seen! I know some AED's do display the ECG, but what are the chances of a community organization purchasing one? How is this guy actually going to know what his friend was in? The likelihood that he was in a very fine VF and therefore "almost" in asystole, based on the story here, seems relatively unlikely, especially with first shock success. Furthermore, these guys most likely wouldn't have known whether he was in VF or VT until somebody downloaded the code summary later. I'm glad trained people were there, but methinks they are trying to sound smarter than they are. Of course, then apparently he had to attach the pads twice. And an "electronic" shock was delivered. I sure hope that if I go into cardiac arrest I get an "electrical" shock. Seems much more effective.

I know it's completely unrelated to the OP, but I LOVE your c-spine protocol! I can't wait for us to get something like that in the States (or at least where I work) - I've long thought that we are most likely doing much more harm than good by immobilizing somebody on a backboard. Glad to see somebody somewhere is slightly more forward thinking.

I don't know if this has been mentioned before, because I haven't been monitoring these threads as last night was the first time I watched (and then only the second half...) But... I want those triage times!! Where somebody greets me at the door and takes my patient and MY STRETCHER away from me... so I have time to flirt with all the nurses!! (When do they get their stretchers back, anyways?) Yay for no more 3+ hour waits with your patient in the triage line... Wishful thinking... (Yes, I know it's TV and they can't drag it out, but geez, make it a little more like real life!)

Everybody learns differently, but the way I learning pharmacology was to learn the drug classes. By understanding the way a certain class works, you then understand how, with subtle variations, all the drugs in that class work. Once you know the class, many drug classes have hints built into the generic names at least indicating the class (i.e. "olol" = beta blocker; "pril" = ACE Inhibitor). Of course, this is the way my paramedic instructor introduced the material anyways. I found it nice, because not only do you learn about the drugs you carry, but then you know about common medications your patients might be on as well. A silly example, perhaps, but one that illustrates the point - you might need to know all about Metoprolol, because you carry it, but by learning about the beta blocker class, you now also know the effects of Atenolol, or any other beta blocker that your patient is on - very useful stuff for your overall patient assessment. I too, agree that pharmacology should be a stand alone course. The whole concept of placing a paramedic program as essentially a single class with X amount of hours, X amount of nights per week, for X amount of months, to me, is silly. I would MUCH rather see a paramedic program be put together as a degree program, with general education requirements, cognate requirements, and core requirements. Put people through Biology, Chemistry, A&P, then move on to separate Pharmacology, Cardiology, etc. classes - taught by experts in those fields. Meanwhile have your "core" classes be more of a "bringing it all together" approach that shows you how to bring everything you learned everywhere else together to be an effective health care provider, rather than trying to teach you all of this content a little at at time embedded in the overall course. Anyhow, good luck with learning your meds!

I tend to agree with the last two posters, however, I also agree that the OP is definitely asking the wrong questions as his first ones. I'm kinda sorta familiar with the region he is from, as I worked near there for a time. I believe he is referring to the greater Adirondack region. It's no joke, a HEMS system would be great for this region. I don't know what's available way up in the North Country, but for at least the southern portion your options are Mercy Flight Central out of Syracuse, a service out of Albany, or MAST from Ft. Drum (I'm not sure if they still do medevacs, but if they do, the Army gives you a helicopter and a pilot - you provide a medic and a way to get them home - not the greatest option). A closer HEMS service would be an asset to the area and beneficial to patients, if run properly - one local "hospital" is all of four beds, one ED and three inpatient, and has no physician at most times - I think an RN is most often in charge. To answer one of your questions - You may need to consider multiple radios. That being said, the State EMS frequency of 155.340 is NOT an EMS communications frequency. It is primarily used throughout the state in lieu of the national MED 1-10 UHF frequencies - for ambulance to hospital radio reports or orders. EMS 340, as it's commonly referred to, at least in the counties I have worked, is almost never used for vehicle to vehicle communications. If you need a patch from high band VHF to low band VHF, UHF, or 800/900 MHz frequencies then the most common channel is the alternate frequency, 155.175. Most county dispatch centers can set a patch up so you can use your high band VHF radio and talk to county agencies regardless of the frequencies they are using. I honestly have no clue about your other question. The first thing you would need, if you and your friend are serious about this, would be, of course, a helicopter, and a LOT of money. While HEMS does pay a lot per transport, in the area you are thinking of serving, they patient population simply isn't high enough to keep your volume sufficient to keep this kind of operation afloat. Some kind of subsidy would most likely be necessary in order to stay in business. If you really are serious, I would check out the State EMS website at http://www.health.state.ny.us/nysdoh/ems/main.htm. They have most of the information about starting an ambulance service in New York State, with some references to HEMS. You would need, in your helicoptor, for example, a siren. No kidding... EVERY ambulance in NYS has lights and a siren. So, quite literally, the certified state HEMS services literally put sirens in the helicopters (at least some of the ones I am familiar with do - others may actually fill out the waiver paperwork with the state). Good luck in your venture...

I wholeheartedly agree that there is something amiss with our healthcare system in the United States. We have many people who are uninsured, and skyrocketing medical costs and health insurance premiums. I would not be able to afford insurance if I weren't in the military, so I can get Tricare for a reasonable monthly premium as a reservist. My premium, as a single person, through my employer, even with an employer contribution, would be over four times what I pay now per month - I simply could not afford it. That being said, I honestly don't believe that extending government benefits to additional people in the name of insurance coverage is the answer. Medicare payment rates, while not ideal, are not, from what I understand, to be horrendous. In fact, many ambulance services, my own included, uses Medicare allowable rates as our "usual and customary" rates. However, Medicaid payment rates are atrocious. For a typical BLS non-emergency transport, for which I believe we bill $465 + $9.65/mile, of which we would normally see payment in full from Medicare or a private insurer, we see less than $60 from Medicaid. I understand that ambulance transport only accounts for substantially less than 5% of total healthcare costs, however, I can only imagine how these kinds of payments extrapolate to the healthcare setting as a whole. In my honest opinion, with this kind of "insurance" costs will only go up for individuals with private insurance. If we were guaranteed payment in full for EVERY transport, we could probably afford to only bill $300 for a BLS transport instead of nearly $500. However, increased costs are passed on to those who can afford them, because we still must provide the care and transport to Medicaid patients and patients with no insurance whatsoever. Coupled with this, rampant lawsuits and medical malpractice insurance costs keep physician's costs very high, which are in turn passed on to patients. Universal healthcare coverage, I believe, is an admirable ultimate goal - everybody should have access to affordable, high quality coverage. However, in practice, the sense of entitlement that certain modes of coverage brings with it as I see in my patients leads them to abuse the 911 system and the emergency department for problems that would better be handled elsewhere (and cost less). I honestly don't know what to do to fix the system - no one thing, even a 2,300 page legislative bill, can fix the system. I don't think that this legislation will fix the problem - it may very well worsen it. I also truly believe that the bill is NOT what the general public wanted, and I really hope that our elected leaders can eliminate this partisan BS and actually listen to the public rather than vote purely based on political ideology, especially when the vast majority of the populace doesn't wholeheartedly agree with either party's platform - but I'm not holding my breath.

I do believe that "medical control" as we know it here in the US is an outmoded concept. That being said, I STRONGLY agree that some sort of online "medical consultation" SHOULD be available, whether it be with an agency medical director, an attending physician at the receiving hospital, or even, depending on the system, a more experienced/educated Paramedic with your agency such as a supervisor. I would suggest that as long as the education of Paramedics, especially in the US, is as it is, this is absolutely necessary. That being said, I also agree with all of you that greatly increased educational standards are necessary - I forsee three levels. I am speaking with reference to US educational credentials as I have experienced them, as this is what I know best. 1. An EMT/EMR/CFR (whatever you want to call it) - these personnel would have a greatly expanded coursework (minimum 3 times the number of didactic hours with about 5 times clinical hours - if you're going to measure that way), and would be permitted to work either in a first response capacity, such as with a fire department, or with an IFT agency. I don't believe that many of our BLS IFT transfers require more highly educated Paramedics, or do I believe that 911 ambulances should be performing these transports. While "grandma" absolutely deserves to be transported home from the hospital with dignity, her non-ambulatory status and being oxygen dependent do not, in my opinion, justify taking an ambulance out of service. This practice both decreases the number of ambulances available for emergencies, and decreases the number of emergency patients Paramedics are in contact with, because they are too busy performing these transports, especially in so-called "high-performance" systems. 2. A Paramedic/Primary Care Paramedic - these personnel would have, at minimum, an Associate's degree. Every 911 ambulance would have a minimum of two Paramedics. I believe that a more traditional educational setting, and requiring degreed Paramedics, would lead to better practitioners. I don't believe that the standard Paramedic course, of whatever length, is adequate education. I don't think you can have a single instructor teaching every subject, with class 2-3 nights a week for 10 weeks - 18 months+, depending on the program, and produce providers of the level that we really need to have in prehospital medicine, unless these providers are willing to educate themselves further, on their own initiative, to achieve excellence. We need to provide Paramedics with the tools to succeed while they are still in the educational loop. Paramedics, in my opinion, may have less of a "skill set" than what we typically think of as a Paramedic in the US, but would still be able to handle 75% + of our typical "ALS criteria" calls - i.e. chest pain, shortness of breath, seizures, diabetic emergencies, etc. 3. An Advanced Care Paramedic/Intensive Care Paramedic - these personnel would have, at minimum, a Baccalaureate degree, and would have more advanced pharmocological interventions and advanced airway management. Some of the more rare conditions that we respond to would be the realm of the more "advanced" provider. I feel that by limiting the not necessarily more difficult, but are easier to "screw up," leading to poor patient outcomes, to a much fewer number of providers, we will greatly reduce the chance for error. Using the 80/20 rule that several people in my system, whom I believe to be reliable, have said does apply - 80% of our major medical errors, system-wide, come from 20% of the interventions performed - often the medications we use more infrequently. I know I have deviated from the topic at hand slightly, but I had a reason for doing so (in my mind). By increasing the standards, whether it be as defined above or otherwise, we will reduce the need for online contact. In the current system in the US, from what I have read and heard from other people, most systems that require two Paramedics on an ambulance do so not because they feel it is in the best interests of the patient, but because they feel that their Paramedics aren't good enough to practice on their own. This is not to say that Paramedics necessarily should be working on their own with an under-educated "technician" as their partner, but it is a sad state of affairs. This is typically in the systems with 10 week Paramedic courses. These providers absolutely NEED somebody else, with a higher level of education, to contact, even if they do have a second Paramedic standing next to them. For the systems who run ALS/BLS ambulances, their partner is somebody who has a 120-hour "education" behind them, and in many instances the ink is still damp on their certification/license. This is not somebody who will usually be terribly helpful when attempting to discuss a differential diagnosis on a difficult patient. By increasing educational standards, and making it so that only more highly educated Paramedics are responding to "emergencies," however you define those, you ensure that two highly educated personnel are available, and they have each other as resources. Online medical CONSULTATION may still be useful in very limited circumstances, but it is much less of an absolute NEED that I see, in my honest opinion, medical control being in many areas of the US today. For those not familiar with the educational credentials I refer to, an Associate's degree is usually about 2 years in length with 60-70 credit hours required (a credit hour being defined, typically, as a unit measurement of a course, in which you would be expected to spend one hour per week, for a 15-week semester, in lecture, and one hour per week on homework/studying - a typical course, such as Anatomy & Physiology I, would award 3-4 credit hours). A Baccalaureate/Bachelor's degree would typically take 4 years to complete, with 120-130 credit hours required for completion. Sorry for my long-winded post - thanks for listening.