Massachusetts FAIL

[DwayneEMTP]

Yeah, I get some of that, and having reread your posts I guess I can see where you're coming from, don't completely agree, but I think I get it.

So, if no one objects, in the spirit of restarting the thread, how about if we start again here?:

But to answer your question, I believe any good EMS system requires balance. If you have two evenly trained individuals working together all the time, who are focusing on the same things and working the same treatment modalities in their heads, things get overlooked and complacency sets in. I believe however that when you have two people who have different specialties working toward the same goal, less gets overlooked, and both sides get a chance to keep divergent skills fresh and in practice, or learn new skills that one didn't know at the outset. Having only basics in a system would be even more disastrous than having 2 medics... I recognize that. All I have been trying to point out is that a good system should have a balance of licensure and skills. Only working with people in your own level can cause serious gaps in knowledge and skills, and keep you further away from mastering your craft. And these gaps can and do lead to poor patient outcomes.

If this has been argued, or requires a new thread then that's ok too.

I don't understand your balance. I don't know your cert level, but I can't imagine that you're a medic. Not because I don't think you're smart, but because if you were and had worked with other medics I think you'd find very few medics that have similar strengths.

At my last job I worked regularly with a rotating crew of 6 medics. We all felt like strong medics, but none of us excelled at the same things. One had near xray vision where bone and muscle injuries were concerned, another loved derm issues, I tended to be strongest at following multi system physiological disease stuff, and on and on. We went to each other daily for 'second opinions' and learned from each other constantly.

Also, I would never allow them to 'best' me if I could help it, and they felt the same. I grew stronger there in a few months than I expect to do here in a few years.

So I guess my initial argument, without having spent a lot of time thinking on it so far, would be, how is combining ignorance and (hopefully) intelligence considered balance? I lift every pt, often making what I consider significant improvements over my Basics ideas for doing so. How is his lack of education an advantage to our team? And I'm not clear how a more advanced education is somehow a detriment to proper lifting? I'm just not seeing it so far. Perhaps you and I can do better with these issues...

And in reference to our previous conversation. I can't really get what you're saying, and I see the same from you. But I do believe that one of the things that are lacking here are examples of good arguments. Arguments and debate are valuable skills, and I believe EMS would be much stronger if people could do it without anger. I don't see out previous dialog as wasted time, would be my convoluted point.

I look forward to your thoughts.

Dwayne

[cosgrojo]

Yeah, I get some of that, and having reread your posts I guess I can see where you're coming from, don't completely agree, but I think I get it.

So, if no one objects, in the spirit of restarting the thread, how about if we start again here?:

If this has been argued, or requires a new thread then that's ok too.

I don't understand your balance. I don't know your cert level, but I can't imagine that you're a medic. Not because I don't think you're smart, but because if you were and had worked with other medics I think you'd find very few medics that have similar strengths.

At my last job I worked regularly with a rotating crew of 6 medics. We all felt like strong medics, but none of us excelled at the same things. One had near xray vision where bone and muscle injuries were concerned, another loved derm issues, I tended to be strongest at following multi system physiological disease stuff, and on and on. We went to each other daily for 'second opinions' and learned from each other constantly.

Also, I would never allow them to 'best' me if I could help it, and they felt the same. I grew stronger there in a few months than I expect to do here in a few years.

So I guess my initial argument, without having spent a lot of time thinking on it so far, would be, how is combining ignorance and (hopefully) intelligence considered balance? I lift every pt, often making what I consider significant improvements over my Basics ideas for doing so. How is his lack of education an advantage to our team? And I'm not clear how a more advanced education is somehow a detriment to proper lifting? I'm just not seeing it so far. Perhaps you and I can do better with these issues...

And in reference to our previous conversation. I can't really get what you're saying, and I see the same from you. But I do believe that one of the things that are lacking here are examples of good arguments. Arguments and debate are valuable skills, and I believe EMS would be much stronger if people could do it without anger. I don't see out previous dialog as wasted time, would be my convoluted point.

I look forward to your thoughts.

Dwayne

Excellent!!! I appreciate the turn of the page... water under the bridge and all that. I do not have time today to answer your questions you have posed (funny, as I've been formulating them for years). I am about 20 minutes away from leaving for my friends wedding, and will not be able to post again until tomorrow. I look forward to sharing with you my answers. I do not believe that I will sway you to my side... but that is kind of the fun of it.

Win, lose, or draw... I am happy to engage in the upcoming discussion.

Some of that got a bit heated... and as that is normally not my style, I fully and completely regret whatever back and forth we did that crossed over that sometimes blurry line. I hope that others too cautious to tread into the white-hot cauldron of debate we had before, will step into this new and improved conversation. BTW I'm going to NC in a couple of weeks... maybe Mateo can show me how fun he is at dinner parties...

I am off to see my friend into his last step of perpetual doom! Until tomorrow.

[DwayneEMTP]

Excellent!!! I appreciate the turn of the page... water under the bridge and all that. I do not have time today to answer your questions you have posed (funny, as I've been formulating them for years). I am about 20 minutes away from leaving for my friends wedding, and will not be able to post again until tomorrow. I look forward to sharing with you my answers. I do not believe that I will sway you to my side... but that is kind of the fun of it.

Win, lose, or draw... I am happy to engage in the upcoming discussion.

Some of that got a bit heated... and as that is normally not my style, I fully and completely regret whatever back and forth we did that crossed over that sometimes blurry line. I hope that others too cautious to tread into the white-hot cauldron of debate we had before, will step into this new and improved conversation. BTW I'm going to NC in a couple of weeks... maybe Mateo can show me how fun he is at dinner parties...

I am off to see my friend into his last step of perpetual doom! Until tomorrow.

Ditto man. I look forward to it. Hopefully we debate better than we argue.

Drive safe, and if you manage to track down Matty I believe you'll be pleasantly surprisedh by him.

Dwayne

Edited July 24, 2009 by DwayneEMTP

[Mateo_1387]

To start off, what you post is going to be interpreted many different ways. I can only base my responses by what you post. Where you may be a sly fox trying to project subtle humor, I am a more serious individual looking at the literal value of the sentence. Honestly, I have not taken much notice to your screen name. Also, I am not familiar with your forms of humor or seriousness. Although you claim I have misinterpreted what you say, I feel that I have correctly interpreted your form of posting.

You, in my opinion, have made some off the wall comments. Believe it or not, it was obvious you were looking for some confrontation. Being a bit bored, I decided to indulge your need to ‘piss some people off’. When I did, you really started laying in the BS, which is fine by me. I think anyone with half a brain could see that.

My responses are posted below. I know that in my absence, Dwayne has indulged your need to ‘piss some people off,’ and you both have come to a stopping point (for the most part). I feel as if I must follow up with what you started, being that I was the first to engage. Thanks Dwayne for posting in my absence. I did not expect him to post, but I thank one of the EMTCity Greats (in my opinion he is one) for backing my points.

Anyways, here are my responses… (with a spirit of development through debate, and not petty arguing)

I did come up with a lot, I was hoping that a bit of abject buffoonery would convince you that I am not taking any of this seriously, and you would be smart enough to recognize it. If you have ever been involved in any threads that I have posted in you would probably have understood that my tongue is usually planted firmly in cheek. It is no accident that I was not able to draw out Dust or any of the other City veterans... cuz they knew what I was doing. I think it is enough for them to chuckle at my ridiculousness. When you are finished putting on your boots... I will lend you my shovel... for that was the point.

Again, readers of your posts can only take what you type and interpret it the best they can. You claim that the City veterans did not indulge you because they knew your sly tactics. On the other hand, maybe they were tired of BS and just did not feel like entering debate like they have many times in the past. Maybe I am wrong, but to claim you know them that well is just a bit too arrogant IMO.

I am not getting why you are not taking this seriously. Maybe you changed your mind. My confusion comes because you later posted this…

Yes, I was trying to draw people out into debate and confrontation... isn't that the point? Post things that people may not agree with so that different views and ideas can be shared... isn't that a form of education?

So, are we debating this because we both want to grow as a collective, or is it because you want to ‘piss some people off’?

My bullshit argument was the ONLY argument being made that had ANYTHING in the way of evidence to back it up. The two articles that were the crux of the whole thread. Your party-pal Mateo didn't come to the ready with any facts, figures, or information to prove his statements (more of the same ALS vs. BLS malarkey that I even put a disclaimer on my original post to say I was bashing the SYSTEM, and not PARAMEDICS), and I don't here you calling him out.

Your argument did not have anything to back it up. Your original quote was “Further evidence that a 2 paramedic system leaves patients with sub-standard BLS care (i.e. lazy paramedics that are not accustomed to carrying people).” This quote is very general. It does not specify that you are talking about Mass., but rather any dual medic system.

Your disclaimer was an attempt to support your original quote, by using personal experience and a couple bad apples to support your generalization about dual medic systems. Anyone with half a brain saw it for what it was, I just decided to confront you about it.

Here is your disclaimer…

*DISCLAIMER* I am not saying all paramedics are lazy... but having worked in the Mass system of 2 medics for 911 trucks... and having worked in NH and Maine where a medic can be a medic regardless of their partner... I find that the 2 medic system breeds laziness that far too often leads to poor patient outcomes. So all the Medics on the city can now clamor about how you have never shirked your responsibility as a medic, and would never do as these medics have done... but it does not negate the fact that it is happening, and at a high frequency in this 2 medic system. *END OF DISCLAIMER*

Your disclaimer is also very general in nature. You state “I find that the 2 medic system breeds laziness that far too often leads to poor patient outcomes.” This my friend is general in nature. You then list Mass. as an example to support your claim. You do not specify Mass, but use it to support a broad generalization. Although the previous may not be your intended meaning, I feel that I have a vaild interpretation.

The way I interpret your disclaimer is: 2 medic systems breed laziness that leads to poor patient care. Mass. has a two medic system, and I know from personal experience it is happening with high frequency. Your disclaimer is not specific to Mass.

Again, point missed. Not about you... not about me... comments were about the two-medic system in Mass where the story posted took place. I am not trying to justify Basics.... you are the one making this an ALS vs. BLS argument, not me.

I hate it when you backtrack what you say previously. I interpreted a justification for BLS from this quote: “At least if two basics were there, they would not hesitate to carry the poor people down the stairs. This is why I prefer systems with BLS first response and ALS intercept trucks. ALS gets to do ALS, BLS gets to do BLS.” Why have BLS in the first place, why not teach the paramedics to provide better fundamental care? I read that BLS is needed to do a job that the paramedics are too lazy to do. Sounds like justification to me.

I am truly sorry if you and Mateo took these postings personally... it is regrettable, I only wish to have a little fun, and learn a few new perspectives at the same time.

Anyone that truly knows me, would know that I like to engage debate. I do not take what you say personally. I will not be losing any sleep over this. Being that you want to learn others’ perspectives, I shall engage you. Enjoy !

if you would like me to use simpler words and possibly write everything in lower case or maybe start writing a lot of grammatically incorrect run-on sentences that are devoid of punctuation so that you can feel better about yourself and don't have to be reminded that there are people that may know a few words more than you know so that i can now be judged solely on whether i know how to do cpr and i took 120 hr class and like to play with lights and sirens and man am i angry that those bastard medics dont talk to me... Nope can't do it.

That was kinda funny…

Mateo didn't need you to stand up for him Dwayne, he was doing fine on his own. Maybe we would have even come to some common ground eventually. The debate that was going on was derailed by the "hurt feelings" involved when people take things personally. Honestly, there are no personal hard feeling at all from me to you guys, if you feel any toward me than there isn't a whole heck of a lot I can do about it.

Thanks Cosgrojo for the complements. I am honored though to have a ‘vet’ stand with me on my stance. Thanks, my friend.

You assume we are taking things personally and are hurt by what you say. I just view our replies as calling you out. It is our opinion that you were using poor skills to make claims and back them up. Have we personally caused you hard feelings?

Disclaimer----- The last line of the above sentence was typed with no intentions of sexual meaning. J Farther, this disclaimer is put forth to claim that Dwayne and I have not been working together behind the scenes to confront you. His posts and my posts are separately original.-----End of Disclaimer

Unfortunately there are many here that will not demand that you make more than your silly 3rd grade level argument to back up your claims of superiority so you'll enjoy a few more pages of textual masturbation[/] before it's over.

My original reaction was.

Then I realized you said 'textual' and not sexual.

But I do believe that one of the things that are lacking here are examples of good arguments. Arguments and debate are valuable skills, and I believe EMS would be much stronger if people could do it without anger. I don't see out previous dialog as wasted time, would be my convoluted point.

This is why I decided to post my responses, even though they are a few days late. Sorry to anyone if I overstepped the line.

Cosgrojo “BTW I'm going to NC in a couple of weeks... maybe Mateo can show me how fun he is at dinner parties...“

DwayneEMTP “Drive safe, and if you manage to track down Matty I believe you'll be pleasantly surprisedh by him.”

DwayneEMTP “NOTE: Mateo is a kick in the ass at parties... Just sayin'...”

I’d be willing to meet up in NC, as long as you are not a sly axe-wielding murderer.

Just to clarify Dwayne’s last post, I do not believe he intended to mean I will kick your ass at the raging party, but just be warned to keep all windows up while on the ride. LOL.

[cosgrojo]

First off... Mateo. Thanks for replying. For obvious reasons we will allow that section to lay dormant until the end of time, but I appreciate the reasoning behind catching back up. Now on to the discussion...

Just for some initial background information, I am a Basic. I have worked in a variety of systems throughout Maine, New Hampshire, and Massachusetts over the last 11 years. Have worked closely and for long periods of time with providers of all the levels available in my area (Basics, Intermediates, Paramedics (regular and CCT)). The person most responsible for my stance on EMS and my passion for education and excellence is a Paramedic, and was my first full-time partner. My EMS mentor always believed that Basics are incredibly important to the success of any EMS system, and is still to this day making sure that the next generation of Basics are as well prepared as they can be (through the advent of his very own EMT school). He believes... and I believe that there is a lot more that can be done in that 120 hours that is traditionally not done to raise the bar for future EMS'ers (obviously we would like to have more than 120 hours, but the DOT will only let him do so much). The better Basic makes a better Intermediate, makes a better Medic. (And if said mentor happens to read this... I think that it might threaten his hat collection).

Dwayne, when you say "ignorance and (hopefully) intelligence," I will assume that you mean in regards of level of education and not the actual literal definitions of those terms. After arguing with you a bit so far, I really do not believe that you equate level of licensure with intelligence. So let me try and explain my stance by drawing upon some real world examples. And for the sake of this discussion about EMS systems, let's agree that all providers are proficient at their jobs, and that there are only quality Basics and Medics available to work for us (no lazy Medics, and no drooling basics).

In a hospital ER you have a myriad of different levels working together to try and provide the best care possible. From ED techs (LNA's, CNA's, sometimes EMT's), to RN, to PA, to MD and to on-call physician specialists. If your train of logic is correct and EMS should only comprise of the highest level of care (paramedics), then is your stance the same for ER's? Should they only have MD's staffing the ER? Of course not. Each level has their particular skill set that is used to ensure efficiency and positive patient outcomes. Obviously a MD has the skill and ability to stock shelves, change foley's, clean up rooms, and wipe granny's bottom after an accident... but it is not an appropriate thing for them to be doing. The same should hold true in EMS (in my opinion). There is an opportunity cost (I did learn something in Economics class... thank you Professor White) to everything that we do. On a seriously sick patient that will require multiple interventions in the field, I do not want my medic to waste even a second worrying about planning egress, moving patients, coordinating Fire/PD, moving bags and equipment, and securing loose items prior to transport. I don't want them to have to talk to the family/bystanders to get hx of present illness, when they should be attending to the patients needs and relying on their partner to gather the background information. I recognize that Medics are eminently capable of those skills, but it is rare to find those that can do ALL of those skills, while providing patient care to the best of their ability without at some point compromising some aspect of care.

So does an EMS system of Medic only have the ability to work, and often does...? absolutely. I believe however that it can work better with the proper support staff in place that can focus on their specialties all while working together moving toward definitive care.

In all the systems that I have worked in, I have seen the most success with Paramedic/Basic trucks. I believe that these two levels complement each other better than any other combination. When a competent Medic is paired with a competent Basic, things run more smoothly in my experience. The company I work for (AMR) creates reports on just about everything under the sun. A few years ago they started tracking response times... out of chute, on scene, turnaround times, etc... For a while they were posting the results on the common area cork boards. They showed pretty clearly that the 911 trucks in New Hampshire (P/I or P/B) had shorter on scene times than those of Mass (P/P) 911 trucks. By no means am I submitting this as rock solid statistical data, but since I have no access to any other data, I will at best recognize it as a trend in the Northeastern AMR devision. My evaluation of this data has always pointed to this efficiency variance as a product of the Dual Medic system in Mass. What I think is going on is that Medics can't help being Medics and want to do Medic skills and evaluations (can't blame them for that... if I spent that much money and time invested in school, I would want to utilize those skills as well). By the time they have conferred... compared their differential diagnoses... and done whatever interventions they are going to do... then they start planning egress and patient movement and so on. While it probably got done, it could be far more efficient if the proper support staff was in place.

Another under-discussed aspect of EMS is burnout and apathy. While I won't go too far into this because I don't want derail our debate, I believe there are aspects of it that are germane to the topic. I hear a lot of complaints by medics at my service about having to do all these "bull-caca" BLS calls. I have heard it in all States that I have worked in and from medics from many different services. A lot of these medics get so burnt out on these types of calls that they freely admit that it takes away from their joy of their job, and sometimes takes away from the way that they treat their patients. I believe that P/B staffed 911 trucks could also help reduce this burnout/apathy. BLS can handle all the calls that do not require a Medic's specialty, and keep the medics fresh and content with only having to tech the calls that demand their skills. This also gives BLS valuable experience and the opportunity to see how medics evaluate and triage patients according to their presentation and complaints.

That should be enough for now... I have more ideas and theories (completely devoid of facts, figures, or statistical corroboration), but I do not want this to turn into a completely unreadable manifesto...

Until next time...

[DwayneEMTP]

Hey man, I'm not ignoring you. I just got done breezing through your response and am surprised by your arguments, in a good way, though I think that they are mostly incorrect, I'm truly shocked by the parts I believed to be logical and intelligent. Not because I didn't think you could make such points, but because I didn't believe ANYONE could make such points on this topic.

No time to give an appropriate reply now, but will do so ASAP.

Thanks for your time and thoughts.

Dwayne

[CBEMT]

I believe that P/B staffed 911 trucks could also help reduce this burnout/apathy. BLS can handle all the calls that do not require a Medic's specialty, and keep the medics fresh and content with only having to tech the calls that demand their skills.

If you really did work (or worked) in the People's Republik, you'd know that your argument for a P/B truck is pointless, because in Massachusetts a Basic is not allowed to tech the call with a Paramedic (or even an Intermediate) onboard. This would in fact increase the risks of Paramedic burnout, because the Paramedic has no one to share the patient load with. They're all his/hers, unlike a P/P truck that can share the volume.

I would imagine that Mass isn't the only state with such a requirement.

Edited July 28, 2009 by CBEMT

[DwayneEMTP]

(obviously we would like to have more than 120 hours, but the DOT will only let him do so much).

How so? In my basic class we did, I think, about 160 hours. How is the DOT limitting his ability to make strong basics?

The better Basic makes a better Intermediate, makes a better Medic.

I have heard, and now found for myself, that often the more experienced basics have the least value. The vast majority are under educated, though because they had been behind the yellow tape, soon felt that their experience trumped the education of others, giving them value that they didn't truly have, and respect that they had never really earned. As Dust has asked many times, if experience before knowledge is a good thing, then why is EMS the only medical body that does it?

Now if what you are saying by "better basic" is that the cream of the crop of basics, those educated well beyond necessary minimums, professional, hard working, healthy, that if they were to become I's and then Medics that that would be a good thing, perhaps I can get on board with that. But they, in my experience, are terribly, terribly rare.

Dwayne, when you say "ignorance and (hopefully) intelligence," I will assume that you mean in regards of level of education and not the actual literal definitions of those terms. After arguing with you a bit so far, I really do not believe that you equate level of licensure with intelligence.

You are absolutely right. I meant ignorance and education. Certainly a lower certification doesn't denote inferior intelligence any more than the reverse would be true. It was a silly error, thank you for giving me the benefit of the doubt.

So let me try and explain my stance by drawing upon some real world examples. And for the sake of this discussion about EMS systems, let's agree that all providers are proficient at their jobs, and that there are only quality Basics and Medics available to work for us (no lazy Medics, and no drooling basics).

Ok for now, but I can't promise for ever.

In a hospital ER you have a myriad of different levels working together to try and provide the best care possible. From ED techs (LNA's, CNA's, sometimes EMT's), to RN, to PA, to MD and to on-call physician specialists. If your train of logic is correct and EMS should only comprise of the highest level of care (paramedics), then is your stance the same for ER's?

I see your point, but don't agree that it's valid from a cost benefit point of view. If you could create a Physician in as little as three months? Absolutely I would think that only Docs belonged in ERs. How does having a less educated nurse there improve pt care? I can only see one way, and that is because there are duties that some begin to feel are 'below' them, and others, if educated less, and paid less don't feel the same. Can a nurse clean a bottom, document, administer medications better than a doctor? Certainly not if we hold to your 'everyone is competent' rules.

It doesn't fit, where I can see, in the EMS that I have worked, again, simply because I haven't worked with medics that are 'too good' to do menial labor. When the basics I work with now tech a call I do all of the basic work. Clean and restock the rig, make the cot, chase down the necessary paperwork from the office...I have no issues with it nor have I seen any sign that the other medics do either.

My first 4 weeks at this service I worked with another medic full time. When I teched calls he asissted, as did I on his calls. The only side effect that I noticed is that he and I both wanted the rigs cleaner than any of the basics normally kept them, and that each pt had the benefit of two educations and streams of experience instead of one. (Meaning somewhat more advanced educations/experiences)Well, that and the fact that if I wanted narcs he had them avail and loaded before I needed to call for them.

Should they only have MD's staffing the ER? Of course not. Each level has their particular skill set that is used to ensure efficiency and positive patient outcomes.

What skill set does the nurse bring that the Dr. doesn't posses with the exception of a lower educational level and the willingness to work for less money? What else is she capable of that the doctor isn't?

(Have to continue in another post as there seems to be a new posting limit)

Hey Cos, I'm going to dump the rest in your email, if you want to PM an address.

I can't post the rest of this as I continue to get a [the following errors () were found] message. On the back of the [too many quoted texts] or some such crap errors, I'm giving up. (Actually, this was a separate post that somehow got attached to my last post...no idea what the hell is going on.)

I'll look for your response and send the rest privately if you like.

Have a good day.

Dwayne

Edited July 28, 2009 by DwayneEMTP

[chbare]

Unfortunately, I am not sure comparing EMS to the ER is a valid concept. EMS is a rather homogenous environment when considering the medical aspects of care. The ER is part of a much larger animal. Therefore, you have different providers bringing different skill sets to the patient. The hospital is more of a bigger picture scenario where you have multiple concepts that need to be completed. These tasks if you will cannot be completed by one provider, therefore we have nurses to coordinate and manage the overall nursing care, while allied health providers bring a specialty skill set and diagnostic advantage to the team, and finally, you have the physician looking at the overall picture and steering the boat toward the proper general direction if you will.

This is simply not the case in EMS where you have a very specific pathway to follow so to speak. Obviously, this is changing with the proliferation of critical care transport, remote medical care, and other methodologies.

Take care,

chbare.

[cosgrojo]

As I am at work and afraid of being cut short to have to perform my limited skill set (Note: Humour intended), I will not comprehensively reply at this time.

CBEMT - Most of my Utopian views are pointless... but I will never let that stop me. I am aware of the regional statutes of Medic/Medic response ambulances. And for people that don't know, if a P/B truck is asked to respond to a 911 call, the Medic can only act at the I level... Personally feel that to be highly insane... A medic can only be a medic if it has another medic to baby it them? I would like to believe that Medics have more competency than the State is allowing for.

Is every call you do of ALS in Nature? The majority of calls in my area (North Shore) end up as BLS transports (roughly estimating 3/1) requiring nothing more than a ride to the hospital... I would think that that would cause more Burnout... a medic having to spend two-thirds of there time doing calls that do not require their skills. Or do you work in a tiered system where BLS automatically do the primary response?

Dwayne - Thank you for the complements to my argument, am glad I at least brought something new to the table you may have not thought of before. I will respond in more detail later... BTW take my handle and add @comcast.net

CHbare - I'm not sure the argument is completely without merit. I obviously agree with your points and your assessment of the ER and hospital, but I think that maybe you underestimate the diversity of an EMS scene. In EMS we use a support team that is harder to manipulate due to their lack of medical knowledge. We need to know how to direct by-standers (admittedly rarely, but it does happen), fire fighters, and police officers... often of whom do not have much medical training or skills appropriate to our needs. While these are not skills that are necessarily learned in a traditional "class-room," they complicate scenes and sometimes delay patient care. In a hospital setting, things are more clinical in nature and you are relying only on people that have some form of education, training, and understanding of internal procedure. So I believe that your assessment of the "homogeneous" environment, is correct from a medical "scope" aspect, but not so homogeneous from an overall tasks aspect which is still things that EMS has to deal with, and Hospitals not AS much (meant to acknowledge that scenarios exist where procedure gets thrown out of wack, and hospital staff must respond appropriately).