kristo

From what I can gather, this is a global thing. In short, even though large fires are rare, when they do happen, we need a lot of people very fast. That's why we have all those fire houses, engines, hoses and fire-primates (let's all just decide for ourselves which primate...). Now, we've got all those responders, and nothing for them to do. This is very expensive. So we try to find something else for them to do. At some point someone asked themselves, hey, we have all those people available 24/7, and we need something like that to take sick people to the hospital. Yay. Without a lot of extra cost, we have EMS, and it's less difficult to justify all that rarely used, expensive, fire response. Maybe not the best EMS, but I bet the people who make those decisions don't know (or even care?). A good example of this (and one that I know perhaps best) is Iceland. How that system basically works, for better or worse, is that the government is responsible for basic healthcare . That includes EMS. Fire suppression, however, is the responsibility of the municipalities. Now, the government has money. They contract EMS out to a local agency of some sort at each place, give them ambulances and a negotiated amount of money each year to take care of EMS. The municipalities, well, not all of them can afford a good fire department. A town with a population of maybe 500 really can't have that big of a fire dept. just for putting out fire. So the end result: We have no volunteer EMS. Doesn't exist. I'm not saying it's perfect, in fact, it's far from it, but at least it's not volunteer. Fire however, outside the major urban areas, varies. In some areas, it's just one (maybe even part-time) firechief that has some people he can call, they will come, if they can (they usually have semi-understanding employers), and get paid by the hour during calls and training. In some areas, there's a good fire dept. with full-time employees. The difference between the two usually lies in whether or not they have the EMS contract. In areas where the fire dept. does EMS, the extra money from that supports having a professional fire dept. Small, but functional. In other areas, usually not. So, what I'm trying to say is that fire needs EMS. Not vice versa. We can try to justify this from the EMS side, but we would probably not be successful. Looking at the big picture, I think it may be tolerable to have professional fire suppression, though.

Ehemm - my mistake, I have no idea how the word "beta" got in there. :shock: It is, as you said, an anticholinergic drug, an antagonist for muscarinic, cholinergic receptors of the parasympathetic nervous system. The word "beta" doesn't even make sense in my post, especially given the rest of the sentence about increased heart rate (how would a beta antagonist raise heart rate? ). My post was in response to a question from mobey on anticholinergic drugs, so I wasn't really thinking of the sympathetic nervous system, although 5% of the sympathetic nervous system does use acetylcholine as a neurotransmitter (post-ganglionic).

Just came on the news - the hospital wants to save money by ceasing this practise, justifying the decision with the rising number of paramedics we have (as opposed to EMT-I). I think the final decision hasn't been made yet, but it doesn't look good. The EMS medical director has expressed serious concerns about this idea. What this means is that if you're going to have a heart attack in Reykjavik, please do it before January 15, 2008.

It would act as an antagonist for muscarinic cholinergic receptors (mAchR), such as those on the heart and lungs. It binds to the receptors and stops the neurotransmitter (Ach) from getting to the receptor. Atrovent is usually used for chronic lung diseases, but atropine, a very similar drug, for temorarily negating the effects of the parasympathetic nervous system on the heart (i.e. get the heart to beat faster). I believe Atrovent is not specific enough to the beta receptors in the lung not to be able to cause some other beta antagonist effects, so don't be surprised if it increases heart rate, cardiac output and even blood pressure.

Okay, I don't really have anything better to do right now, so I'll take a shot at this... First of all, the concept of a receptor. A receptor is basically a protein in a cell (usually in a cell membrane, but doesn't have to be (eg. NO and steroid receptors). When a ligand (an agonist) meets the receptor, the protein changes its physical conformation, making it more or less likely to do something else, eg. catalyze something, open an ion channel. Antagonists bind to receptors like agonists, but without doing anything, effectively blocking them. In the discussion of the receptors of the autonomic nervous system, we have a few types, classified by 1) their innervation (sympathetic vs. parasympathetic) and 2) their neurotransmitter. A neurotransmitter is the chemical material a nerve secretes and serves as a ligand for the receptor on the innervated organ. In short, the sympathetic nervous system is the gas pedal, the parasympathetic nervous system is the break (not universal*). For (extreme) simplification, we can say that the neurotransmitter for the parasympathetic nervous system is acetylcholine, but epinephrine/norepinephrine for the sympathetic nervous system. So, to the actual question, the receptors. I won't waste time on the biochemical properties, as they are irrelevant to the question (if you want, I can make another post on those): Sympathetic. Alpha and beta. Norepinephrine and epinephrine work on both, but norepinephrine works much better on alfa and epinephrine on beta. Most actual sympathetic nerve fibers secrete norepinephrine, but the adrenal glands, which are classified as a part of the sympathetic nervous system, secrete mainly epinephrine. I'm skipping sympathetic cholinergic receptors on purpose. Alfa1: Stimulatory. Think smooth muscle contraction to contract arteries almost everywhere (except in skeletal muscle). Alfa2: Found on nerves in the GI tract, inhibit the release of their neurotransmitter, acetylcholine. I.e. inhibit the parasympathetic nervous system in the GI tract, as mobey said. Beta1: Stimulatory. Found in the heart. See above post from mobey. Beta2: Relaxant, most importantly in the lungs (bronchodilation), coronary arteries (vasodilation) and arteries skeletal muscle (also vasodilation). Beta3: Stimulates the release of stored energy in fat cells. Parasympathetic. All cholinergic, meaning, their ligand is acetylcholine. Divided into two, nicotinic and muscarinic. What's important here is that the muscarinic ones are sensitive to atropine as an antagonist (one will usually not try to block nicotinic receptors). Heart and smooth muscle have muscarinic receptors. Skeletal muscle nicotinic. We usually don't administer acetylcholine (for similar reasons as we don't like to block nicotinic receptors), but we can make the acetylcholine stay a little longer with estigmin (physostigmine - spelling?). An example of how this whole thing works together is the fight or flight response. Epinephrine (adrenaline) is secreted as a response to danger. The heart races (beta1), the coronary arteries dilate to supply the heart muscle (beta2), the bronchii dilate (beta2), the fat cells release energy (beta3), the arteries in skeletal muscle dilate to get energy there (beta2), arteries elsewhere constrict to focus blood flow (and energy) to skeletal muscle and the heart. So, we can stimulate or block those receptors by administrating the same chemicals the body uses as neurotransmitters. An example would be when we want to get the heart going, we administer epinephrine (stimulate the beta1 receptors on the heart, step on the gas pedal) and atropine (block the effect of the parasympathetic nervous system on the muscarinic, cholinergic receptors, take the foot of the break). So, yeah. Hope this post is not too confusing. I was trying to give a good picture without going into too much detail... *The GI tract for example, is stimulated by the parasympathetic nervous system and its activity decreased by the sympathetic one - makes sense in a fight or flight response to divert energy from things like that and to more important things).

I think I've mentioned this before, but this is actually how it is done in Iceland. In the capital city (Reykjavík), the physician acting as medical command is actually on a special ambulance. That ambulance usually does not transfer, but in all calls fitting certain criteria, it is dispatched along with a "regular" one. In some cases, the doctor will join the patient in the transporting ambulance and "his" car will follow. The doctor provides online medical command through his/her cell phone and if he/she deems necessary, he/she will come to the scene, even if not dispatched originally. The ambulance that has the doctor is equipped just like the other ones, plus a heatbox for neonatals and some extra meds. It is usually staffed with (in addition to the doctor) two paramedics. The paramedics (and maybe EMT-I's?) take turns in doing shifts on this one, as it gives good experience (always go to the "good" calls). All students on ambulance rotations are put on this one (I hear the student seat is almost never empty...). The doctors who perform those duties are provided by the ER. They get some training, complete with ride alongs, before they are put out there, obviously.

In your case, maybe because you have less education than a real estate agent? *duck*

Hehehe - I gotta remember that, I may have to do some more nursing practise...if a patient gets annoying, I'll send him for a trip.

Yeah, I see what you mean. I should clarify. In this case, the EMTs were convinced of their superiority over the nurse because of their glorious EMS status, and because they are EMS, and the nurse is "just a nurse at a nursing home", they felt they were superior. All I'm saying on the education in this case is that if there would be a disagreement between an EMT and a nurse at a NH on whether a patient from said NH needed an ambulance transport or not, I think I would under most circumstances be inclined to trust the nurse's judgement - they know their patients and I think we can at least agree that their education is much more relevant in that setting. The unprofessional behaviour was, as you mentioned, unacceptable in it self, regardless of education levels or any disagreement on what kind of transport method was warranted.

I second that comment about EMTs acting like jackasses when they come to nursing homes. Having completed the 4 week "nursing practise" required for 2nd year medical students here, I have witnessed and heard of some eye-opening scenerios, like a nurse (nursing here is 4 years of education post-college) taking shit from an EMS crew for calling them to transport a patient that, in their opinion, could have gone by taxi. An educated, licensed healthcare provider should NOT have to take that from the EMT-I in the yellow jumpsuit, OR his EMT-B partner, especially if they willingly took that extra shift on the designated interfacility transport ambulance to make some extra cash.

Yes, I know, but that attack was what changed the public opinion in the US about internationalism.

Really, dust? Please read the PM I just sent you - I really am trying to mend things here, I'm not interested in taking part in a flame war*. * For those who don't know: flame war: n. [common] (var.: flamewar) An acrimonious dispute, especially when conducted on a public electronic forum such as Usenet.

First of all, I'll put in a "disclaimer" of sorts. Laughing I have no interest in making this some kind of weird anti-America campaign. I'm sorry this thread got so ugly, let's try and clean it up, shall we? In this post, I've neglected answering a few points for the very purpose of keeping the peace...

First of all, I'll put in a "disclaimer" of sorts. Laughing I have no interest in making this some kind of weird anti-America campaign. I'm sorry this thread got so ugly, let's try and clean it up, shall we? American participation in WW1 was heavily criticised. It began in 1917 (one year left of the war) and some say it was just done for their own gain. Regardless of whether or not that is true, the American public was quite convinced that this was not the way to go, until the attack on Pearl Harbour in 1941, of course. Prior to that, president Roosevelt had tried to get congress to allow him to interfere with the war in Europe, but unsuccessfully. Instead, he supported Britain financially (Lend-lease program). When Japan declared war on the US, so did Germany. In this case, the Americans were asked to help (by Churchill, who was actually a personal friend of Roosevelt's and half-American, his mother was born in Brooklyn, NY). It is interesting to note, however, that Germany did declare war on the US, not the opposite way. I'm fairly glad the US came and helped the UK out there, though. You did play a crucial role in actually liberating a lot of countries in continental Europe, France for example (didn't you kind of owe the French one, though, after their help in the Revolutionary war? That help nearly bankrupted the French state and led to a bloody revolution there, as the king was unable to feed his citizens). The Marshall plan was well received here. In fact, I would go as far as saying it made Iceland what it is today. Prior to that, we lived in houses made of stones and grass and really had nothing. So that worked out well for us. However. It must be noted that the Marshall plan was not charity. It was a genius plan to repel communism. Also, it wasn't exactly direct money. It was more like store-credit with American companies, which helped make new markets for American export after a devastating war (markets that kept on buying after the Marshall plan expired). It was a win-win plan, everyone won. Except the commies, of course, but that's their loss. True (but are you sure there's not a part of those numbers that come from the US-Japan part, in which European nations also helped? The UK, Australia, and even my native New Zealand lost a lot of people in India, Singapore, etc., fighting the Japs, which could, under the same reasoning, be called helping the US out...

First of all, I'll put in a "disclaimer" of sorts. I have no interest in making this some kind of weird anti-America campaign. I'm sorry this thread got so ugly, let's try and clean it up, shall we? Aren't your borders semi-closed now, anyway? 8) We really don't need you to fight "our" wars, but it would still be a pity if you closed yourself off. You've got a lot to offer the world. It's just that not everything that comes out of the US is as good for the world. And because you're the last remaining superpower, you have the power to piss a lot of people off when you do something, especially if it involves military actions.

Same here. :wink: Isn't that just the consequence of too many patients, too few doctors? Get more doctors. There's no shortage of very competent people who want to become doctors. Medical schools could probably accept twice as many without taking anyone in I wouldn't trust to treat me or my family. How about a mixed system? Some doctors accept the "poor man's insurance" and some don't. Those who do don't provide as good service (longer waits, lack of room service, etc.) How poor do you have to be to get Medicaid? I'm not too familiar with it, but it is my understanding that, like ERDoc mentioned, there are a lot of people who earn too much to get Medicaid and too little to be able to afford their own insurance. How about something like this: The individual states will have companies pay a tax every month by the following scheme (for each employee paid over $1,500 that calendar month): If the employer provides 3rd party insurance for the employee and his family: $0 If the employer provides 3rd party insurance for the employee: $80 If the employee already has 3rd party insurance: $100 If the employee does not have any kind of insurance: $320 The state will collect this money and use it to buy insurance from a private company (or simply provide the service itself, which may be more cost-effective in some cases). If they do business with a private insurance company, they should re-negotiate at least every second year, the offers from the insurance companies should be public and the state should publically release its reasons for choosing one over another. This insurance would cover anyone not insured by anyone else. Don't most companies already provide health insurance for their employees? The $80 would, at most, be like paying the employees an extra day at work. That's nothing. They could look at it as a 5% pay rise for everyone. Only problem here is that many companies would probably simply not hire people who don't have their own insurance. Haven't quite figured out how to bypass that. :roll: Another thing. Both you (reaper) and Dust specifically mentioned that this is something that you do not want. Why is that? If it's not for financial reasons, we could find a way to do this for free and it still wouldn't happen, so there's no real point in doing it. If it is for financial reasons, maybe you would change your mind if it was made very cost-effective? If you're worried about the government taking control, then maybe the best implementation would be on state or even county/municipality level? At least I'm pretty sure you absolutely do not want the government to actually provide the healthcare, but would you be fine with them paying for it (given that it would be made very, very cost-effective)? Are you perhaps worried that it will make people less motivated to earn their own living? I personally believe that most of the lazy bums are already on welfare and maybe even Medicaid, so that change will be negligible...

Do the Iraqi people feel liberated? I don't think the Icelanders that were killed or imprisoned by the allied occupation in WW2 did. And why, exactly, would I not have a country to call home if the US hadn't occupied it? I do and will feel free to participate in an open forum political discussion, while, of course, trying not to offend anyone (tricky sometimes) and obeying the forum rules. You should (and I'm sure you do) feel free to ignore me. You can relax, though. My opinion won't be a factor when the decision is made - just like your opinions don't (or shouldn't) matter over here. Is it just me, or isn't it a little strange, considering your stance on current US foreign policy, that you should criticise Europeans for meddling in other countries internal affairs? Edit: The actual reason there are a few Europeans posting on this topic is simply to tell you about our experience with the system you are discussing. One would think such input would be welcomed, after all, it's relatively cheap to learn from other people's mistakes or successes.

Okay, I've cooled a little bit, I was pretty rash in my previous post. What ticked me off were Dust and reaper's posts, which both seem to assume that the US is the best thing that happened to the world since sliced bread. Hasn't the rest of the world made it quite clear, that we do not want or need the American "big daddy"? This "we do what we want" is just anarchy, but if you want it like that, that is of course your business. I realise we shouldn't force other cultures to evolve. What really ticked me off here was the assumption that the US had succeeded and everyone else failed - and that everyone wants to go to America...while that is true for Mexico, that is not true for the rest of the world. And the US foreign policy is everything but PC right now. Finally; JPINFV, why do you think the EU doesn't want you out of Eastern Europe? From what I can gather, it is the general consensus in Europe that your actions there are a serious threat to political stability in the region, especially recent developments in the US installing long-range missile launchers there. Don't know about Korea, if the Koreans want you there, by all means stay. So, as a European, and as a citizen of a country occupied by the US military for over 50 years, I may be a little sensitive to the good ol' American arrogance.

I thought we could have an intelligent discussion here. I was obviously wrong. I won't be posting more to this thread.

Maybe it's time to decide if you want to be a country or if you want to be a bunch of loosely connected, kind-of-friendly, independent countries. If you can all join together in wars all around the world, one would think you could all join together on a minor issue like the implementation of universal healthcare (again, I must emphasize that the US is the only country I know of that is considered to be in the first world despite not having universal health care). Another idea would be for the federal government to make a plan and for the states to join it on a voluntary bases. I actually think it wouldn't even have to mean more taxes if you implemented this. How about just skipping the invasion of Iran this time and implement universal healthcare instead? Surely, there is nothing "unconstitutional" about the federal government spending money it already has to buy health insurance for its citizens? Anyway, if your constitution is such a problem, just amend it. That's how the best parts got in. 8)

Great. I wish we had those - in fact, that's exactly why I think we should build private hospitals for patients prepared to pay for those kind of services. Somehow, I doubt this is the case in every hospital in the US, though. Yeah, we actually have those, too...except we've already paid for it with our taxes. I understand ours are pretty good, too, but I haven't been there, so I wouldn't know. That's not really the point, though. The point is that we *can* provide at least basic health care (or not that bad health care) for those who don't have it today for a minimal cost - and the health care industry, especially EMS, would even benefit financially. You're probably right about many Europeans - the strongest argument over here against private hospitals and private anything related to health care is "Do you want things to be like they are in the US?", to which the private-advocates reply "No, of course not, but...". I realise, however, that medicaid and medicare cover millions. How about extending those programs to those who don't have anything else? It might be crappy, and people might want more (and most will be prepared to pay for more), but at least it's something for those who can't pay for more. Are you saying that every American who is not insured is that way by his/her own choice? I find that very hard to believe. I know hospitals can't turn away emergency patients. That, combined with the fact that so many have no insurance, is one of the reasons EMS can't afford to pay it's staff a decent wage, and thus contributing to the lack of professionalism we have discussed so in-depth on this website. You keep saying you take care of your own, but yet, I keep seeing people complaining on this very website that EMS doesn't get paid for its transfers, and hence can't have paid staff, can't afford properly educated people, etc. I've seen lots of people advocate having municipalities pay for local EMS, presumably with tax dollars, but yet, when the idea of actually implementing such a system is discussed, everyone is convinced it's going to doom you all.

Yes, we fund our universal health care system with taxes. Shouldn't be a big surprise. That's also the way we fund our roads, education systems, etc. Did you know that I can go anywhere in Europe with my little blue card and get access to their universal health care? My fiancée was on a vacation with her parents in London two years ago and got acute appendicitis. She was immediately rushed to surgery in the same hospital the royal births are. She had a private phone by her bed and got top-notch service. When they discharged her, they gave her a bunch of medicine to take for the first few days afterwards. How much, you may ask. Well, we'll never know. Due to co-operation of countries in the European Union / European Economic Area, the bill was sent directly to the Icelandic Insurance Agency (Tryggingstofnun Ríkisins - TR), where it was dealt with. The way we have it is that we have the above mentioned Insurance Agency (TR), which insures all Icelandic citizens and foreigners that have a work permit or a permanent residence permit in Iceland. When we go to a doctor, he charges TR for the majority, and we pay the rest ourselves (eg. $10 for seeing a family physician). When we go to a specialist (any other doctor than a family physician), we go to their own privately owned clinic. That clinic simply charges TR as any American clinic would charge your insurance company. Of course, this influences how much the doctors can get for each procedure, but no more than the insurance companies in the US do. We only have state-run hospitals, but they also charge TR for any services rendered, and I would actually like to see a private hospital here, it would give patients more options. I am considered very liberal in advocating a private hospitals, as most people are too conservative for that... According to the US Census Bureau, 47 million Americans were without health insurance in 2006 (http://www.census.gov/hhes/www/hlthins/hlthin06/hlth06asc.html). According to the NCHC, the average premium paid for health insurance for a four-person family in 2006 was $11,500 (http://www.nchc.org/facts/cost.shtml). Now, divide that by four, and we have on average $2,875 per person per year. According to the CIA World Factbook (https://www.cia.gov/library/publications/the-world-factbook/geos/us.html), you have a working force of 151,8 million people, of which 95.2% are working. That makes just over 144 million working Americans. If those people would buy health insurance for the 47 million uninsured people, that would mean them paying extra $2.6 per day per every working person. Now, what would you, normal, hard-working Americans get for your $2.6? Well, first of all, you would know that everyone could get basic healthcare (and maybe even more than basic, I don't know what "average" American health insurance gives you). Second of all, our industry, the health care industry, would get just over 135 billion dollars more annually. Of course, you'd have to split that with the insurance companies, but still, you could use the money, couldn't you? No more unpaid transfers, no more ER frequent flyers that just come there because they can't afford to go see the "correct" doctor for their problem. Would you get more bullshit calls? I don't know. I don't think they are a problem anywhere in the world, except the US. Maybe you would get fewer, as people could now go see their family physician with their problems. Maybe some chronic problems would go away. This may sound communist, "un-American" (whatever that means) or anti-capitalist to you, but let me tell you this: Capitalism is what keeps the first world going. It gives us initiative to do great things that benefit our society, it keeps us on our toes, and it makes us want to do better, work harder. It's a system where you can get to incredible heights if you're smart, lucky, or just plain hard working. But there's a flaw. It only works perfectly for one generation. The children of the hard workers now have more possibilities. They can get better education, better jobs, better healthcare. Now, that's all fine. Really. But how about the potential achievers that die because they don't get proper healthcare? What about the geniuses that never do great things because they can't get any education? In my opinion, our society loses by not utilizing those people. That's one of the biggest reasons for universal health care. Let's give everybody at least a chance to achieve - for our own benefit.

First of all, let's compare the US system to the rest of the civilized world. Please show me *any* other 1st world country that does not have universal health care. Second of all, universal health care is not equal to communism. It does not have to mean that all healthcare providers work for the government. One could think of a lot of other ways, eg. state-sponsored minimal health insurance for the unemployed, in addition to medicare/medicaid (which, from what I've heard, is not that good, but at least it's something), and make employers buy an insurance for their employees from private insurance companies. A legislature would probably be needed to define the minumum coverage. This does not even have to be that expensive, if the largest reason for high medical costs in the US is removed: frivolous law suits. It may be time to put a maximum amount of damages that can be awarded in malpractice cases. The "I take care of me and my family" argument is moot, unless you also plan to build your own roads for your car, grammar school for your children, and hire your own police officers to take care of law enforcement around your house. Even the discussion of removing universal health care would be considered ridiculous anywhere else in the world. Health care is not a luxury.

Universal health care. That way, every transport, IFT or emergency, will be paid, EMS provider income will skyrocket (real EMS providers, especially, since emergency transports seem to have the lowest payment vs. non-payment ratio?) and there will be money to increase paramedic salary, luring more people in the field, which means EMS providers can be choosy. Then they will hire better (i.e. more educated) providers over the others, the profession advances, more money will be paid to more educated staff. Voila, you have a completely new profession. No more financial reasons for volunteer EMS. Look at Iceland. I'm not saying we have the best EMS system in the world. Quite the opposite. But we have *very* rural areas. Yet, there is no place in Iceland where there is not professional EMS. The people who come get you may not be top-notch (that is material for a whole-new thread in itself), but at least they are not volunteers. Our country is roughly the size of Kentucky, but only 300,000 people. You do the math. Yet, full, paid EMS coverage, including outstanding medevac (large, well equipped coast guard helicopters that can carry 10+ patients, staffed with a MD (an ER doc) and an EMT- (Reykjavík), and fixed-wing well-equipped planes staffed with a paramedic and a MD (Akureyri and a few more places).