The perfect system.

[AZCEP]

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Bottom line is there is NO EASY WAY TO PROVIDE CONSISTENTLY SYSTEM WIDE ALS CARE TO RURAL COMMUNITIES. I say again, many rural residents would receive better care by well trained ILS service than a poorly trained under utilized ALS service. Any system design for rural communities needs to take the challenges of providing ALS care to a sparse population with lower call volumes in effect.

Wow...this is a first for me. I actually agree and disagree with with you in the span of two sentences.

There is absolutely no EASY way to do this, but then nothing worth doing ever is. The communities, or regions, that most need the full spectrum of ALS are those furthest from receiving facilities. A BLS/ILS first response may work well, but once they are on their way, these patients need to have the highest level of care possible.

Can it be don? probably...but in most cases is too much work for the stake holders.

I think the biggest stake holder would be the public that is being served.

[croaker260]

Wow...this is a first for me. I actually agree and disagree with with you in the span of two sentences.

Remember AZCEP, what the full EMT-I curricula entails. Intubation of dead floppy patients, breathing treatments, basic cardiac rhythm recognition, your basic first line ACLS drugs, dextrose, and a hand ful of other stuff. I think they may even get nasal tubes, I dont remember though. Basically what many rural ALS services (not all, but many) are doing anyway. The new curricula also includes basic pain management.

My argument is a well trained EMT-I with medical control contact can do better than a poorly trained medic working on his own.

You want to put well trained/educated medics in rural settings, fine. I agree that they are needed. But show me how this can be SUPPORTED clinically, so that the system quality is self sustaining, so that in 5-10 years, the system is as solid, and the care as good, and the provider is as good (no skill degradation) as when the program started.

Sure people say..."well, we will train harder". It just doesn't happen due to limited resources, etc. (who has the 30K $$ for the sim man with difficult airway modules?)

Sure people say "we will get them in the OR" well, even a recent article in "Prehospital Emergency Care" discussed that this is extremely (and increasingly) difficult. so again, this doesn't happen like it should.

Just because there may be the resources or will to keep the medics certified, does not mean there are the resources or will to keep them competent When that happens there are a few outstanding medics that the extra mile and a lot who pass time. This is as true in urban settings as it is in rural settings. The big difference is in an urban setting, most ALS patients (excluding those with airway issues, and sometimes even then) will survive incompetence long enough to get tot the hospital.

All this goes back to my point is that I believe that there must not only be a "certificate of need"(CON), but a certificate of ability to support (COAS??). Especially if this had to be renewed. If this was the case , then areas, including the public, would put pressure on agencies to raise the bar. They would ask hospitals why they were not letting medics in their OR's. They would be as concerned about intubation success rates as they were about response times.

Otherwise, stay at and function at the ILS level. You will kill less patients that way as a system, and do about the same amount of good.

A BLS/ILS first response may work well, but once they are on their way, these patients need to have the highest level of care possible.

I guess I believe that good ILS is better care and a higher level of care than poor ALS. Would rather see someone (ILS) ventilate some patient on in , than have someone (ALS) RSI a patient and have a gut tube because they were too stupid to know the difference..which appears to be a major issue in many ALS systems today. Wnat some more examples, simply look at that "other web site" where there is a discussion on PSVT, and some medic who SCV a DKA patient. I believe your response was "God help that community"? If a system cant correct obvious problems like that, then perhaps they dont need to be ALS, and would be better off ILS?

Keep in mind that if the New scope of practice had kept the "Paramedic" and the "Advanced Practice Paramedic" we wouldn't even be having this disucssions...as most rural communities could have the "paramedic level" which is pretty much what they can support, and progressive places can function at the advanced practice paramedic..but alas, the advance practice paramedic..and the degree requirement..was dropped at the request of...guess who?

In summery, I am in favor or ANY community, urban or rural, that can prove the ability, and prove that they do, actually support their ALS program, getting medics (only in numbers they can support)....but I am not in favor of the idea of letting areas have medics (regardless of size or location) have medics because "well , they are doing the best they can..they are small...what do you expect?".

I expect competence from a system. Which brings me to re-emphasize my closing sentence....

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Any system design for rural communities needs to take the challenges of providing ALS care to a sparse population with lower call volumes in effect.

Dont know if that ramble made sense, but I hope you can see where I am coming from.