systemet

I think you have a fairly unique situation there, as some of your flights are crewed BLS, right? The article seems to suggest that "paramedics" can't give sedation, but you're EMA-3 / ACP medics must have some sort of standing orders for benzos or haldol right? The flight ACPs have an expanded scope, don't they? From what I get reading the news story, it sounds like there's a blanket policy that any psych transfer requires a fairly heavy degree of sedation, regardless of the perceived risk? And also that this is being applied in some situations where the patient's being transferred for another complaint but has a history of a psychiatric disorder? Am I reading that correctly? If this is the case, I'd suggest that the policy is dysfunctional and needs to be changed to allow the transporting paramedics the discretion to decide what degree of sedation is required, and which patients should receive it? It might be worth re-designating psychiatric transfers that are judged by a PCP crew to require sedation to go ALS. Or continuing the existing policy of allowing any crew (BLS or ALS) to refuse to transport any patient they feel is not adequately sedated. But any attempt to demand that all patients with a psychiatric diagnosis, or being transferred for a psych referral be sedated into a danger zone for losing airway control, would be grossly unethical. ------------- Also, regarding the argument that benzos/antipsychotics can interfere with the receiving physicians assessment, it should be remembered that the use of chemical restraint is also to protect the patient, so that the transport is less distressing for them, and to prevent them from harming themselves! While these patients may be manageable in a clinic environment without medication, the flight environment provides a bunch of additional stressors must be anticipated. Some of the problem with longer acting agents, e.g. valium, can be mitigated by choosing agents with a shorter half-life, such as midazolam. But even accepting that this is a problem, any inconvenience to the receiving physicians should be outweighed by the risk of a catastrophe if a high risk patient is flown without proper precautions. I don't want to seem like I'm doing an about turn on my previous statements, I'm not. The crew has to have the ability to refuse a potentially dangerous transport, and the tools to mitigate any risk that is judged acceptable. But any blanket policy that removes that choice from them, and results in overaggressive sedation of low-risk patients is a problem.

P waves look a litle p mitrale. So perhaps some LAE too? Also nice rS in Lead II, predominantly negative complex, the axis must be quite rightward. No STEMI. NSTEMI possible. Could be about to see STEMI on our next ECG. Lack of any improvement with O2 and positioning isn't great. Combined with sudden onset, and prior DVT, the possibility of PE has just gone up. Do we know the last INR? Any sign of a current DVT? CHF exacerbation remains possible, especially with HTN and JVD, but seems less likely if there are no other signs of volume overload. Patient producing urine? No hx of renal insufficiency? The dyspnea is paroxysmal, just about nocturnal, but doesn't improve with positioning. ACE inhibitors aren't new? Spontaneous pneumo is possible, with diminished A/E, cyanosis, and JVD. But the patient still has a pressure. I guess I'm leaning towards COPD exacerbation, and remain suspcious of an underlying infectious cause. A few more questions: Baseline GCS? Is he normally confused? Temperature? Should probably do a neuro exam as well.

I'm going to use my crystal ball combined with an extreme distrust of nursing facilities and profound cynicism. The patient has a recent nursing-home acquired pneumonia that's caused an acute exacerbation of his CHF, manifesiting as dyspnea misdiagnosed by nursing staff as agitation, treated with po benzodiazepines and supine positioning x 30 minutes ago? Any improvement with Fowler's and O2? Level of consciousness? Accessory muscle use? Does he appear to be tiring with a RR of only 24/min? Signs of volume overload? Ascites? Sacral / pedal edema? Heart sounds? Any assymetry of chest rise? 12-lead ECG? IV access and bG. HX of recent illness / surgery / fall / catheterisation? Any recent disease outbreaks in the nursing facility? Recent med changes?

Case report in PEC about an episode of laryngospasm following intramuscular ketamine for sedation, here: http://informahealthcare.com/doi/full/10.3109/10903127.2011.640766 Short version: 97kg male patient given 5mg /kg ketamine I.M. in the field for agitation, possible drug overdose, hx of bipolar disorder, suddenly desaturates in the ER @ +15 minutes, after previously appearing dissociated but hemodynamically stable. Examining physicians report a SpO2 of 20% with good pleth, chest / abdominal motions consistent with attempted inspiration, with no A/E, and palpate spasm of the larynx. No improvement with bilateral NPAs and positioning. Sounds scarey. They tried PPV, got A/E, and restored the SpO2. But then it happened again, so they elected to RSI with succinylcholine. Transferred to ICU, but extubated and sent to psychiatry the same day. CBC / lytes normal, mUrine tox negative, noncontrast CT negative, CK normal. Discharge dx: bipolar affective disorder with acute mania and psychosis.

I actually emailed them a while back out of curiosity, and it turns out that they only offer subscriptions to organisations / agencies, not to individuals. So unless the organisation you're working for has a contract with them, you can't access the training yourself. No idea whether it's actually good quality or not, but the per user cost seems very reasonable. http://www.emsonline.net/Signup/Subscribe.aspx If anyone does have a suggestion for a decent website for CE, it would be much appreciated. But it needs to be at a decent level.

It's good that you're taking it as a compliment. That's probably how it's intended. Who do you have to go on from EMS? Well, you don't, right? That's a choice you get to make yourself. But what some of these people may be suggesting is that after you've worked in EMS for 5 or 10 years, many of the calls and situations you get placed in will seem very familiar, and perhaps a little boring, and that you may wish for more of an intellectual challenge in your daily work. Being a paramedic is very exciting at the beginning, but can become much less exciting as time goes on. Some people find an intellectual fulfillment through doing EMS management, QI, participating in research programs, teaching, or simply studying in their time off and learning something new, e.g. computer programming, or taking a correspondance degree in Anthropology. What is worth thinking about is what you want to be doing in 10 or 20 years, and what steps you can take once you've finished paramedic school to make these things happen. I don't know how old you are, or what your background is, but a lot of these things are easier to achieve before you have big financial commitments like a house, children, or being a sole income provider for a family, etc. There's a point where age and financial factors start working against you for doing things like medical school, for example. Not to say that it isn't possible, just that something difficult becomes perhaps even more difficult. I think what you need to work out (or perhaps you already have), is what being in EMS means to you, and what you need from it? If it's important for you to feel respected, or have a certain status in society, or achieve a certain income, then maybe being a lawyer or a physician, or working in the financial sector, are better fits. If being in EMS works for you because it's exciting and ever-changing, realise that in 10 years, it won't be as exciting, change may not be happening as fast as you like, and the unpredictability of a given work day may be as much an irritation as a positive. On the other hand, if you like helping people, enjoy being in dynamic situations, have an interest in how scenes and calls flow and run properly, and feel like being a paramedic is a good, positive way to contribute to your community, and perhaps you enjoy mentoring and teaching new people, then maybe a more long-term paramedic career is a good fit? Can you go to work, accept that some days it may be a little boring, but accept it for what is as a way of meeting your financial needs? I don't claim to have any answers here. I think this is a personal decision that you have to work out for yourself. True, but change comes slowly, and many of the people who enter EMS like working on a much shorter time-line. Many of us lack the patience necessary to effect change over a long period of time. It's hard to adjust your perspective, and as a result, a lot of people become frustrated and give up. If you want to effect change you need to be tenacious and unrelenting.

This also has to do with the physiology of sudden decompression. There are human populations living at altitudes of ~5,5000- 6,000m, but they've been been born into this environment and adapted to it. Visitors from lower elevations need time to adapt to gradual changes in elevation, otherwise they suffer mountain sickness, abd possibly cerebral or pulmonary edema. Obviously people have climbed Everest without supplemental O2, but they're very much dying on their way down, and even today the safety margin is very small. Having to suddenly go from around sea level to high altitude is not something our physiology can handle. I'll try and work out a little more about why.

There's a pretty good link here discussing neonatal heat regulation: http://www.neonatal-nursing.co.uk/pdf/inf_015_nor.pdf Also worth nothing re: heat packs, a case report of a 5% BSA 3rd degree burn caused by a chemical heat pack (54C) applied to a neonate: http://www.ncbi.nlm.nih.gov/pubmed?term=Brun%20C.%2C%20Stokvad%20P.%2C%20Alsbjorn%20B.F.%20Burn%20wounds%20after%20resuscitation%20of%20a%20newborn%20girl.%20Ugestrift%20for%20Laeger%201997%3B%20159%3A%206531-32 (Unfortunately in Danish).

Granted, but bear in mind they've been maintaining thermoneutrality at an ambient temperature of 37C while bathed in liquid for the last nine months. So, while I'm sure it's possible, there's much more risk of making them too cold.

Good scenario. * Obviously we need to be vigilant to assess for other injuries, or other mechanisms of self harm here. If he has a pressure and rate as reported, and we're not seeing visible external hemorrhage, he's probably not going to decompensate through hypovolemia, although it's always possible there's some sort of deep injury that we can't see. * He's described as "awake, but non-verbal". Is this suggesting that he's refusing to talk to you, but appears otherwise alert -- or is this a suggestion that he has an obvious decreased LOC? Because, if so, that's not from the knife wound, given current hemodynamics. There's always the potential of some sort of coingestion in this population, even if they're GCS 15 on presentation. * Ground, I'd restrain, sedate as required, and ride it out to the ER unless anything changes. * Flying, I think you snow with some fentanyl and ketamine, and do what the doc suggested and place a bougie through the wound, very carefully, then place the ET tube directly into the trachea. I wouldn't want to RSI this guy, because you can't bag valve mask ventilate him, and none of the alternate airways are likely to work here. At least with ket, you have a good chance of maintaining his respiratory drive.

This is great. Hopefully this attitude becomes more prevalent in other regions. I've listened to no end of people argue for scope expansion, more responsibility and better pay without actually wanting to increase the educational level. I don't know here. I mean, part of the 4-year Bachelor's versus 3-year Bachelor's is a consequence of the lack of specialisation in the final years of high school --- but this does preserve options for the high school graduates. If at age 18, they decide that maybe engineering was more their goal than nursing, often they have the prerequisite courses, or only require a short period of study to get one extra course. In the context of a Bachelor's degree, I don't know. Obviously for the North American system, you have certain prerequisite courses that the medical / dental / veterinary programs demand, as they don't typically have Bachelor's stream medical education. And you have to prepare for the MCAT. So this has lead to biology degrees tending to have a fairly similar common first two years. I think it has to depend on the aim of the degree. I don't think I know anyone who's taken nursing, for example, who didn't want to have more electives and fewer core nursing courses. Having those elective courses lets you choose areas of interest to focus on, or learn more about. I think even for an engineer, having the ability to learn a foreign language, or take some economics or financial planning might be very beneficial, both in terms of personal satisfaction, and in a long term career path. I have a science degree, with all the typical MCAT pre-requisite stuff, and a ton of cell bio, biochemistry, pharmacology, physiology, genetics, etc. I think if I could go back and do it again, I'd benefit from taking less hard science, and more arts courses. There's also a certain argument that while your strengths tend to be what makes you successful, your greatest gains are often working on your weak areas. I found this to be very true as well. With high school level courses I was always able to just sit in the room, absorb the material, do a minimal amount of studying and regurgitate it for fairly high grades. With university, I often didn't get the quality of teaching to be able to do that, or, in many more cases, I was competing against a large number of really smart people for a grade on a bell curve distribution. Much more time was spent directing my own study. This was also a major contrast with paramedic school for me. Although it also required a lot of self-study, paramedic school consisted of being in the gym from 0700-0900, and in classes solid from 0900-1700, monday to friday. A more typical university schedule would be about 3-3.5 hours of lecture a day, and maybe an hour or two of labs a couple of days of the week. But I new I was spending at least one or two hours studying myself for every lecture hour spent in the class room. While I have no direct experience of either NZ or US university programs, I think this probably just reflects being a year ahead. If they've already taken introductory courses, then they're going to need to be taking more specialised courses. I also think this is the primary difference between first-year courses and so-called "advanced courses". I don't think that the information in an advanced cell biology class is necessarily more complex --- it's just more specialised. You're dealing with material that often hasn't made the textbooks yet, and often you're learning to evaluate new research, and considering ideas in areas that lack a consensus opinion. The focus becomes more about asking "What do we think is happening?", "What evidence supports this belief?", and "What issues need to be resolved in order to have a more complete understanding?", and "What experiments would blow this theory out of the water?". Graduate studies in biomedical science tend to be more about actually doing those experiments, and investigating those areas. I think often the first-year courses are actually more difficult, because they cover such a broad range of topics that they feel disjointed, and it becomes harder to identify underlying concepts. The difficulty of the course often also depends on factors like who's in the classroom (determining how difficult it's going to be to get a difficult grade --- a neuroscience course with 75% honors degree in neuroscience students might be hard for the average English literature student to take as an elective, just as the neurosci kids might have trouble with analysing Chaucer or something). I've definitely taken graduate courses that have been easier than some undergraduate courses. Or fourth year courses that have been less challenging than first year courses. Everyone also has their weak points, things they just don't like or "don't get". Microbiology is one for me. I can't stand the "trainspotting nature", of looking at, that's a non-motile gram positive acid-fast coccus.... what species and genera could it belong to?

I can't speak to the NZ or Aussie educational systems, but in the UK it's quite common that a Bachelor's degree is only 3 years. But their last two years of "high school" typically have them focusing on 3 subjects at an advanced level. So if you have someone coming out of secondary school with Math, Biology and Chemistry, they've often covered these topics in depth equivalent to a first-year university student. This is great in terms of reducing the time spent in university getting a Bachelor's degree, but it's tough for students, as they have to make some pretty major decisions while pretty young about what courses they're going to take at "A/level". These decisions open some doors, but close many others. The advantage of the US / Canadian system is having a much broader base education and more options at graduation, and less closed doors before leaving high school. The down-side is the added cost and time of a four-year Bachelor's.

I think it can be --- but, the physician is also accepting some vicarious liability for the paramedics under his or her medical direction, and depending on local politics, may have little say over training or disciplinary matters. While they might be able to restrict protocols in a poor system ---when a mistake happens (and they happen in both good and bad systems) they're someone with liability insurance who's an easy target.

Thanks! Awesome link!

Well, seeing as you asked... At the risk of irritating some of the physicians on the forum, the title "Doctor" is not restricted to those who've completed an undergraduate or graduate M.D. There's a similar level of academic rigor and personal suffering that goes into obtaining a PhD. I can't speak to PharmDs or DNPs, but I would imagine these are also very well educated people. If someone has worked hard enough to earn one of these degrees, then they have an equal right to the respect that should or shouldn't come with it. I can understand the need to differentiate between someone who is a medical doctor, or even for individual MDs to identify what step of fellowship training they're at, or what specialty fellowships they've completed. But it seems the reasonable thing to do here, would be to require any DNP, PharmD, PhD, etc. to identify themselves clearly when conversing with patients. If someone is talking with a Genetic Counsellor with a PhD, or a psychologist, it's absolutely appropriate for that person to be identified as having completed a doctoral degree, and to be called "Dr.". But it's also vital that such people know and respect the limits of their training, and refer patients to the appropriate medical specialists when conversations enter areas where they're not qualified to dispense advice. I would argue further that the title "Dr.", or the idea of calling someone "Dr. Brown", or so forth, is antiquated and places an unnecessary barrier between the physician and the patient. I remember one of the ER doctors I respected most walking up to the wife of a STEMI and saying "Hi, I'm Andy, I'm your doctor, I just want to tell you that we've got a few things we need to do quickly, and a couple of questions I need to ask you, but if you can be patient for a few minutes, I'm going to come back and explain what's going on and answer all your questions, ok?". This left a lasting impression.

Me too. Clearly superior to homeopathy, tea-leaf reading, astrology or wild-ass guessing. Well, things aren't getting worse, and we know more about what doesn't help What's the alternative to changing the guidelines? We could do whatever currently doesn't work, and just keep doing it, forever? The fact that the approach to resuscitation changes reflects that science is an ongoing process, and not a static fixed system of rigid beleifs. Trying something, finding out that it doesn't work, and then trying something else, seems pretty reasonable. Maybe, maybe not. It's impossible to know what's going to happen in 8 years. Just because the guidelines change periodically doesn't mean all treatments are equal, or that the guidelines process, however fallible, doesn't work. It's difficult to know what's going to happen. I don't think it's been shown that intubation is bad, as much as that it doesn't help (I think ERDoc said that already in this thread). The bigger message seems to be that even brief interruptions in CPR (whatever the reasons for the interruptions) produce dramatic decreases in survival. What's more surprising to me is that we've had the ability to measure this effect in experimental animals for decades, yet no one seems to have focued on it until we realised that anti-arrhythmics weren't doing much to help. I guess everyone was too busy looking for the new super-bretylium. I also think that we should keep intubation, because it's life-saving in a limited set of circumstances, e.g. asthma, airway burns, airway trauma, anaphylaxis, etc. (I agree that RSI'ing asthmatics or patients with potentialy laryngedema is terrifying, but it is sometimes necessary). I don't think there's any evidence for ETT over BIAD in cardiac arrest. The best evidence right now is non-inferiority of BIADs. So I don't think intubation is the most important thing in cardiac arrest management, especially now that we have better tools. Given that placing an advanced airway allows asynchronous compressions, and the whole move to 30:2 and >100 compression rates is supposed to maximise "hands-on" time, and the number of compressions per minute, I'm surprised that the AHA isn't advocating an early KIng, or ETT, then asynchronous compressions. There's also little evidence that paramedic intubation has served patients well in the past. Most of us like to think that it has, and that we're working in systems that are the exception, and that the available data doesn't apply to us. But it's looking more likely that even the good systems aren't having a big impact on morbidity / mortality (see: RSI trial, Melbourne?, very well trained paramedics, intubating a lot, very small reduction in morbidity in closed head injury, no reduction in mortality). Relatively few. Pretty much everything published has to go through an ethics committee, and primary investigators almost always hold a professorship somewhere. Any reputable journal requires that conflicts of interest be disclosed. A bigger problem is that commercial companies often invest substantial amounts of money into research projects, and then delay / obstruct or refuse the publication of negative data. There's been a lot of situations recently where several drug companies have got slammed for not publishing internal data that shows that drugs under patent are dangerous. While you could argue that companies providing equipment or research drugs or training, etc. might give an incentive for researchers for find a positive result, any outright academic fraud, or even the simple appearance of it, can ruin a career quickly. I agree that a lot of physicians prescribe more expensive brand name medications when a generic may be cheaper. But they're making this judgment on the data available to them. While the drug companies should take responsibilty for situations where they've withheld data that shows their product in a negative light, they can hardly be blamed for promoting their own products. Big pharma needs to get paid -- it costs a ridiculous amount of money for 1-2 novel clinical entities / year. It just needs to be ethical about how it does it. Edit: isn't for is ! Oops.

Opinions: * None of the staff at this hospital seem very nice. * The patient didn't sound symptomatic and will probably live to fight another day. I'd remove them from my Christmas card list and politely decline invitation to any social events, unless it's some sort of delightful masquerade ball. In which case, I'd politely decline, wait until they'd left, and then laugh. Also, I'd drink a cup of coffee, with too much milk, and a lot of sugar.

Perhaps we should move this to it's own thread. I'd argue that whether it's ethical depends on why you're doing it. If you're trying to punish the patient for being schizophrenic, and don't want to listen to him rant all the way to the receiving facility, then it's unethical. If you're doing it to facilitate his safe transport, and protect the airmedical crew from him, and protect him from himself, while avoiding the potential complications of giving large amounts of sedation in the air without a definitive airway, then I'd say it's ethically permissible. Others may disagree. Weaning is more of an issue when you're intubating someone with pre-existing pulmonary disease, or you're going to have someone intubated for a long period of time. This isn't going to be the situation here. There's definitely some risk to intubation itself, especially in the hands of paramedics, but this has to be balanced against the risk to patient and crew of not having him intubated. Just an opinion. Other's opinions may vary!

Not wanting to distract from the exciting academic conversation that's going on (seeing pubmed on EMS sites makes me happy!), but this sounds like someone who might be a good candidate for RSI. He can't kill you if he's paralysed.

Really? Having capnography is going to let you know that the tube has been displaced quicker than anything else. It's going to give you some indication of developing bronchospasm. If you have a pre-transport ABG, it may allow you to estimate the PaCO2 somewhat reliably. It may warn you of a cuff leak or mucus plugging. How do you suggest assessing the adequacy of ventilation without it?

Agreed, but if I was OP, I'd consider career pathing for a new position sooner rather than later.

What medications are in-scope for EMTs in your region? po ASA is unlikely to provide effective pain relief for injuries and illnesses commonly encountered in the prehospital setting. Entonox / Nitronox systems are used in some regions in BLS centers, but they're contraindicated in bowel obstruction. I don't remember what entonox costs, but I think it's fairly inexpensive. There's some cost for buying the tanks, regulator and masks, but this is probably minimal. There may be additional costs or paperwork if you're required or see it necessary to regulate storage and usage to prevent abuse. In my opinion, either (1) this patient should have been transported ALS in the first place, or (2) an RN escort should have been provided to administer pain meds, if this is allowed in your area. There's multiple people at fault here, in no particular order: * The sending physician for not considering the need for repeat analgesia in a patient who had already been given demerol at the sending facility. * Your company, for accepting the transfer and sending a provider who couldn't provide analgesia. * The individual providers on the transfer truck for accepting a patient that they were unable to manage, and then doing nothing to seek medical care when the patient's condition changed. I don't understand how you can have an ALS "box" without opiates or benzodiazepines. How do you intubate people? How do you maintain post-intubation sedation? How do you do procedural sedation for cardioversion / pacing? What are you doing if a patient starts seizing? I realise this probably doesn't come across as very helpful, but I'd consider looking for employment with a better organisation that's more committed to taking care of its patients. I think you've made this situation more difficult by not dealing with it when it occurred. I think you need to get together with your partner and discuss how things could have been done differently in a constructive and nonjudgmental manner. This may be challenging if your partner is a supervisor. Then I would suggest submitting a proposal for some combination of (1) addition of BLS or ALS pain relief measures, and (2) a new mechanism for screening transfers and assigning the appropriate level of care, to the next tier of management and possibly the medical director, together. Recognise that this may be a career-limiting choice in this particular environment. You have an obligation to future patients to prevent this from happening again, and you have a lesser obligation to your partner not to get them into trouble without talking to them first. Then you have a very secondary obligation to not just jump of chain of management without consulting them. Edit: its versus it's

Some confusion here. I'm post #13. I didn't call anyone Mike. As an odd coincidence, my name isn't mike. Although this furthers my personal belief that everyone in EMS is actually named either Mike, Dave or Shane. I didn't refer to anyone "maturing" either. My post was directed towards runwithneedles, and wasn't intended to be offensive. All the best.

Yes, you can enjoy running a cardiac arrest or a critical call without being a psychopath. I think what's wrong, is if you feel you have to act like you don't care because it's an attitude that's been modelled for you by preceptors, instructors, class-mates or your peers. If you honestly don't care, then that's ok. There's a certain amount of emotional distance you need to cultivate to survive seeing some of the things we see in EMS. I know I can't remember even a fraction of the cardiac arrest I've worked. Although, related to this call, I can say I remember working a man in his mid-forties in front of his wife and two kids, and while it didn't bother me almost 10 years ago when I had no children of my own, it's something I think about occasionally now. I remember another I worked around Christmas time on my final practicum, where we had to move children's toys out from under the body, perhaps even younger. This call didn't bother me particularly at the time either. But I think, once you have children of your own, or you have them in your life, your feelings about this call might change. Not everything we think we've put behind us stays there. [These are far from my worst experience in EMS, but they seem relevant here.] I don't think it's wrong, either, to feel angry at this person, because they did something stupid and selfish, and traumatised their children for life. Or because they caused you to have what you may later decide was actually a very unpleasant experience. In general though, I think it's better not to go around judging people, because as you collect life experiences you may have a better insight into what they're going through, or what they've gone through. I would suggest, also, that you need to be careful about how hardened and how cold you let yourself become as a defense mechanism. It's easy to let your humanity slip away in small pieces and not realise it. Then you come home, take the streets with you, and end up treating your family and the people around you who love you with the same indifference. This does not do good things to relationships. Maybe save a little compassion for the kids. Take care.

I'm going to start from the assumption that anyone becoming an EMT is planning on one day becoming a paramedic. I know this isn't always true. The way I see it, you've got two major goals as an EMT in preparation for medic school: (1) Gain exposure to the largest possible number of patients, so that you have seen many conditions as an EMT before you encounter them as a paramedic, and develop your physical examination / assessment skills. (2) Get lots of experience managing calls. An all-BLS system, or a tiered system that has infrequently available ALS, is optimal for (2), and even better if you see a lot of patients, meeting (1). This would be ideal, in my opinion. I think the benefits of having worked with an ALS partner prior to going to paramedic school are understated, although a decent paramedic can provide a mentoring role. Your history taking / physical examination skills will (hopefully) improve during paramedic school, but if you begin with them already well-developed, you're ahead of the game. Unfortunately (or, I guess, fortunately, depending on your perspective), most of the busier services that meet (1), tend to have an ALS tier or are all ALS, either reducing your exposure to sicker patients, or limiting your opportunities to develop leadership skills on critical calls, as you'll likely be deferring to a medic. Typically these jobs also pay better, and are closer to major population centers. It's nice, for example, if you've got to run at least a couple of cardiac arrests BLS before you end up on an ALS practicum. It's nice to have run a couple of MCIs, before being thrust into a situation where not only are you the senior provider, you may be the only ALS provider, and you may have to make some very difficult decisions while balancing multiple factors.