In the news…

First in the news this week, an EMT in New York City quits after posting to twitter. Oh, yes he is the son of the FDNY fire commissioner. no real big deal, other than a PR black eye on the service, right? Wrong. The commissioner’s son was only working EMS so he could get on the fire side. This is the type of person who works for a service just to get on the fire engine. Read the article, he is biding his time and doing time until he can transfer to the fire side. If you want quality people, you need to have a service that is not just a stepping stone to a fire engine.

Winnipeg EMS is going to start a Community Paramedic Program, to be in operation by spring.

Two articles about the University of Pittsburgh Medical Center starting a Community Paramedic program. One from Pittsburgh Businesstimes and one from the University of Pittsburgh, who says that this will be one of the largest community paramedic programs in the country. It’s nice to read how the community paramedic program is slowly being recognized in this country as an option.

EMS director for the County of Frontenac in Canada says that staffing a community paramedic in a clinic could help cut down on 911 calls.

Just a few bits of news you might have missed. Be safe.

NREMT Transition

While compiling my NREMT re-certification paperwork today, I found a few interesting items.

First, and most important, Kentucky Board of Emergency Medical Services (KBEMS)  has opened the transition web course applications for paramedics who will re-certify NREMT in March 2013. You can follow this link for the details. http://kbems.kctcs.edu/News%20and%20Events/newsItem?id=%7B9F459294-4503-4F46-A09C-8844FAF3F85D%7D

Also, from a blog post on the Courier-Journal website, Baptist Health had a press conference on March 1, 2013 where they stated that EMTs in Kentucky will be allowed to perform 12 lead ECGs in the field. I think this is a great idea, especially given that there are many BLS only services in the state. I wonder why KBEMS has not informed the EMTs or Paramedics about this change? The link to the blog post is below, I will continue to search for more details and try to keep you informed.

Team efforts will improve heart attack care in Kentucky

One parapgraph

My literature assignment this week was to write a paragraph in the style William Faulkner’s “Barn Burning”. Specifically to copy the style of the first paragraph, which you can read here. I offer you my one paragraph in this style. Thank you and enjoy.

The floor of the ambulance was caked with mud and snow. The man, laying on the aluminum wheeled bed, yellow and black in color, cold from the night air, and more: the floor littered with discarded  equipment previously sealed to keep implements sterile, a snake like hissing from the oxygen regulator full open, brushed steel instruments once clean now blood tinged lay about the counter space directly to the right, reminding them of the twice missed opportunity to secure an airway, failing to change the blue pallor back to pink, warm and dry- this, the laryngoscope with its light still on mocking them, turning their hope to grief, leaving one last solution, a vain attempt at respiration turning frustration to fear, fear that they will not be able to save this one. The medic could not see the fourth passenger, patiently sitting on the far end of the bench seat against the wall, but knew he was watching, the medic’s enemy  (our enemy, he thought with familiar melancholy: mine! My patient’s! He’s my patient!) , the Angel of Death sat waiting to gather what belonged now to him.

EMT required for paramedic?

Yesterday I was listening to the EMS Educast episode on Mike Ward’s article EMT not needed for paramedic certification on EMS1.com.

I use to have very strong opinions regarding prerequisites for a paramedic program. I thought that an EMT certification plus one year experience should be required.

Now I have to wonder why would we require paramedics to be EMTs prior to being paramedics? Do nursing programs require a LPN certification before becoming an RN (Yes, actually there are some nursing programs out there that make you sit for your LPN before moving on to the RN)? Are doctors or physician assistants required to be paramedics, nurses or medical assistants before enrolling in medical school or a PA program? Not that I know of, you can have no experience in medicine and still get in to med school, so why are EMS educational programs sticking with the antiquated EMT before paramedic path?

I believe that the right paramedic program can take someone with no medical experience and turn out paramedics. That is the catch, the right program. Most paramedic programs around me assume that the potential students are all EMTs and they take the knowledge that the EMTs are suppose to have for granted, although not every EMT has maintained their knowledge base to make it practical. The instructors spend time reviewing information that the EMT should know, so what was the purpose of requiring EMT certification for entry to the paramedic program?

Some EMTs want to become paramedics, but not all. We need to rethink how we educate the providers, paramedics are doing more and we need to be able to educate them to be able to provide out of hospital care in to the future.

Community Paramedicine News

Community Paramedicine is slowly creeping in to the national discussion about health care, and it’s about time.  Until now, most of the community paramedicine talk and focus has been around rural health care. There are few urban agencies that have turned towards CP to ease the stress on the health care systems in larger cities.

Los Angeles County EMS, one of the largest multijurisdictional EMS agencies in the country, is officially looking in to the possibility of Community Paramedicine. The article is from California Healthline, and well worth the read. This will be a very interesting process to follow, and I encourage everyone with a vested interest in EMS to keep track of this initiative. IF L.A. County EMS moves towards community paramedicine it could set the national model for urban community paramedicine, and it’s about time.

Congratulations, California, for again being the leader in EMS.

Time to walk

As EMS week continues, more bloggers are talking about the problems in EMS. The direction we are going (or not going), the educational standards, and the salary we are paid.   Rescuing Providence posted “EMS Week, ‘Take it, It’s There‘”, and the venerable Skip K., replied with his standard mantra of “you have to invest first before reaping the rewards”, and he is correct.

Too Old To Work (TOTWTYTR), replied in his blog post “The Other EMS Week Post“.

I agree with Skip. As long as EMS continually accepts the lowest standard, and caters to the lowest common denominator, we will never grow as a profession. My question to the EMS chiefs in the U.S. is, When will we stop the rhetoric and take action? 

We settle for the lowest educational standards, but we don’t have to settle. We cannot individually change the educational standards for your local licensing authority, and there NEEDS to be a place for entry level paramedics and EMTs. We CAN make promotional positions require more education. IF you have a paramilitary style organization (with ranks) you, as EMS chief, can say that the minimum requirement for becoming a sergeant is an Associate Degree. Captains and/or Lieutenant have to have a Bachelor degree. No ranking system in your agency? Do you have FTOs (you should), then make them a different pay scale and require them to have an Associate Degree. EMS Chiefs have the ability to enforce higher educational standards. Why aren’t they?

The time to blog endlessly about the woes of the EMS system, and how great it could be is over. The time to take action and make a change had started. Walk the Talk.

National EMS week 2012

It’s that time of year again, where everyone thanks EMS professionals for the service they provide. The one week a year you get when not every nurse greets you with a scowl. Not all is well in EMS though, some people believe that we need to actually make improvements in the system, improvements in reimbursment, and improvements in professionalism.

The Fossil Medic has two excellent posts about his thoughts, Is EMS Really a Calling? , and How EMS physicians Became Recognized and Rewarded. Go read them both, especially Skip Kirkwood’s comment on ‘Is EMS really a calling?’

Bob Sullivan over at The EMS Patient Perspective also had some thoughts in his post, EMS: Calling, Job, or Prison Sentence?

I’ll get my opinion out of the way, regrading these “National Week” type events. I understand that it is suppose to raise awareness and appreciation for the EMS professionals (wouldn’t it be easier if I could just say paramedics?). I don’t buy in to the hype. Emergency Service workers should always be appreciated, not just once a year. It is the same way with fire fighters, (yes I mentioned fire fighters in an EMS post). During the Sept. 11 memorials, they are revered. The next day they are just in the way, or harrassing the public with their inspections (I have been told that by business owners in the past). Appreciate the people who choose to risk their lives for yours every day, not just when you need them.

Professionalism. Skip Kirkwood continuously brings up this topic, and rightly so, about advancing EMS. Some people like to lay partial blame on EMS volunteers, saying that they are keeping our pay scales low. There are far more volunteer firefighters in the U.S. than paid firefighters. I don’t see firefighter salaries as low as EMS salaries. I seriously doubt the problem is with volunteers.

If you are looking to point the finger for all the woes of EMS, turn the finger around and point it at yourself.  What are you doing to advance the image of EMS? What actions are you taking? How’s you attitude lately? How is your partner’s attitude? Do you dress like a professional, or insist on wearing a tee shirt on duty? Do you attend as many EMS conferences as you can? Are you working towards a degree? Are you doing anything to improve your medical knowledge and patient care?

Stop trying to place the blame on everyone else. You want to celebrate EMS week this year, start by BEING the person who people will call a professional. Attitudes are infectious, having a positive one will raise the people around you.

Helicopters are better?

EMS1.com posted an article from the University of Maryland titled: Helicopter beats ambulance for trauma patients.

Please take a moment to read the article, then come back for a few questions I have.

First, this is a summary of a study published in the Journal of the American Medical Association. I do not have access to JAMA, so I have not been able to review the actual study.

A total of 223,475 adult patients met the criteria: ground transport accounted for 161,566, while 61,909 patients were flown in helicopters. Overall, 7,813 (12.6 percent) HEMS patients died compared to 17,775 (11 percent) transported by GEMS.

The raw data suggests that more HEMS patients do not survive. Appears obvious to me, since we should only be flying the most critically injured patients. If you only fly the most critically injured patients, then mortality should be higher. It’s the next line in the article that bothers me a little.

This raw data shows a significant difference, but Dr. Galvagno says the odds for helicopter transport improved when statistical models were applied to the numbers to factor in so-called “confounding” factors that could lead to a misinterpretation of the data.

So the raw data wasn’t enough, they applied their own statistical model to get their results. I raised an eyebrow, but not being a statistician, I will just have to accept that this is normal. The last sentence in the paragraph really made me wonder.

The researchers also developed statistical models to account for missing data in the NTDB, including travel time and distance to trauma centers, key bits of information that could impact survival.

Missing bits of data? I think the most important pieces of data are, time of incident, time of EMS activation, time of EMS arrival, time of transport to level I or II trauma center and time from incident to arrival at Level I or II trauma center.

First, I am not going to rail about the theoretical golden hour, which studies are now showing to be ineffective. The times I want to see included in this study are comparisons between ground and HEMS. Theoretically, this study says if I am 2 blocks from a hospital, transport by a helicopter would give me a better statistical chance for survival.

The article states, as above, that they used a statistical model for the travel time and distance. Is a 20 minute helicopter ride better than a 20 minute ambulance ride? I doubt it, but the study doesn’t allow us to see these numbers. Now, let’s be realistic, the 20 minute helicopter ride will travel further than the 20 minute ambulance ride. The case should be made, that if a patient is over X miles from a level I or II trauma center, they would benefit from a helicopter ride. That’s the study that I would like to read, and the study that needs to performed.

Bridging the Gap

Health care in the United States has been the subject of many debates. While most debates revolve around mandates and issues of personal beliefs, the real problem remains out of the spot light. There is a crisis in the health care system. The aging population is booming, and the general practice health care practitioners are dwindling. Rural areas, across the globe, are most profoundly impacted by the decline of general practice physicians. Chronic diseases are increasing; diabetes affects 25.8 million people in the United States, and is the seventh leading cause of death (Center for Disease Control and Prevention 2011). Chronic diseases are complex and require frequent visits to a physician’s office to monitor lab results and general health.

As early as 1968, a study showing a decrease of 18% in general practice physicians worried the medical community (Fahs and Peterson 1968). General practitioners are normally one of a few specialty programs including, family practice, internal medicine, and pediatric, that focus on being a generalist and can treat a wide variety of problems.   In the mid 1960s, the shortage of doctors forced health care professionals to find alternate modes of delivering care. Nursing has been around since the late 19th century and when faced with a shortage of physicians, they expanded their role in health care. The Nurse Practitioner level provider was created and provides care under a physician’s guidance. Most RNP (registered nurse practitioner) graduates have a master’s level education and, increasingly, a doctorate degree. The Physician Assistant model of provider was derived from doctors who created a “fast-track” program similar to medical school. The majority of Physician Assistants hold master degrees, and works under the supervision of a physician. Both Nurse Practitioners and Physician Assistants can specialize in areas of medicine other than general practice. Opportunity to make more money in specialties has taken both professions away from general practice. Retention for Nurse Practitioners in family medicine has decreased by 40% in 2004 (Bowman n.d.).

Financial rewards, higher standard of living, and professional prestige are all reasons cited by medical students for going into specialties other than family practice. As health care costs continue to increase, and the number of people who can no longer afford health insurance increases, the pressure on the Emergency Department and urgent care clinics rise. Many people are using their local emergency physician as a family practitioner. The system is broken, and needs to be repaired. One possible solution which is emerging is the Community Paramedic.

Where did EMS come from?

The National Academy of Sciences Committee on Trauma and Committee on Shock published a paper called Accidental Death and Disability: The Neglected Disease of Modern Society in 1966. This report is known as The White Paper, it outlined recommendations for training emergency care providers to reduce the mortality of motor vehicle accidents. Until this point, ambulances were hearses, operated by funeral companies, which drove patients to the hospital. The ambulance attendants were not trained to provide any medical care, they simply drove the ambulance. The White Paper recommended that trained responders perform life saving actions on the scene, and became the basis for the current Emergency Medical Service system we know today. The Highway Safety Act of 1966 included federal funding for the training of the emergency care providers as recommended by The White Paper.

In 1973, The Public Safety Act (UCS Title 42 Chapter 6A, Subchapter X, Part A) included regulations for the establishment of a national Emergency Medical Service system, and provided for federal funding of EMS systems. Many states established EMS systems and, with federal funds, provided for training the responders. The Omnibus Budget Reconciliation act of 1981 eliminated all federal funds for EMS and put the responsibility on the state governments to provide funds for their EMS system. Today, most of the budget for an EMS service comes from billing patients and insurance companies.

The National Highway Transportation and Safety Administration, the federal agency who oversees EMS, published a paper in 1996 called The EMS Agenda for the Future with the intent to layout a national direction for emergency medical services. The committee recommended some very specific goals for EMS:

• Integration of health services:  “EMS delivers treatment as part of, or in combination with, systemic approaches intended to attenuate morbidity and mortality for specific patient subpopulations”.
• EMS should also maintain liaison with other community resources such as, public health, social service agencies, and health care provider networks
• Be proactive in affecting long term health by relaying information regarding potentially unhealthy situations
• Referrals to agencies with vested interest in maintaining the health of their clients
• Continuously engage in injury and illness prevention programs
• Identify community injury and illness problems
• Eliminate patient transport as a criteria for compensating EMS systems
• Expand the role of EMS in public health
• Involve EMS in community health monitoring activities

• Higher lever EMS education associated with academic institutions, facilitating development as a professional discipline
• Institutions of higher learning recognize EMS education as an achievement worthy of academic credit

Although EMS is often seen solely as a public safety agency, the NHTSA Agenda for the Future states, “EMS is a community health resource, able to initiate important follow-up care for patients, whether or not they are transported to a health care facility”.

Until recently, many of these objectives have been overlooked or not integrated in to EMS systems across the country. One program, with international implications, is implementing these recommendations and evolving EMS from a transportation system, into a health care delivery system. This is the Community Paramedic.

Bringing the health care to the patient

Alaska has one of the earliest, and most successful, models of providing health care to an underserved population. The Alaska Community Health Aid Program (CHAP) was first developed in the 1950s in response to a tuberculosis epidemic in rural Alaska. The community health aides are trained to deliver vaccination, suture wounds, provide preventative screening and are expanding to provide dental care, behavioral and elder care to rural Alaska. The federal government began providing funds for the CHA program in 1968. Today there are five hundred and fifty CHA practitioners serving native and rural area.

The first example of an EMS system providing preventative and non-emergent care was in Taos County, New Mexico. The Red River Project ran from 1995-2000. Taos County is a popular place for tourists during peak times.  The community did not have a physician practicing in the area, and the closest hospital is one hour away by ground transportation. The leaders decided to utilize the paramedics for the needs of the community. Paramedics would provide wound care (suturing), long term diabetes care, chronic health surveillance and treat upper respiratory infections with antibiotics. By using the treat at home method of care, the ambulance service was able to reduce transport to the hospital from 78% down to 11% (Wingrove and S. n.d.). It’s hard to imagine why a successful project failed, but they cite a few reasons, a physician assistant and nurse practitioner both started practicing in the county, reducing the need for paramedics to provide the service. They study says that the attrition rate for the paramedics was very high, making it difficult to maintain the level of service requested by the county. The final reason for closing the program was a lack of community awareness of the services provided by the paramedics. The Red River Project may not have been successful, but it still provides valuable data for advancing community paramedicine. The project suffered from poor public awareness and alternate family practice options arriving in the county.

The Canadian Province of Nova Scotia developed a community paramedic program which serves as a template for many similar programs being developed in North America. Born out of necessity, the communities of Long and Brier Islands had only one doctor who retired in 2000. The closest hospital was fifty minutes away, and required two ferries to get to the hospital. There was no ambulance stationed on the islands prior to the doctor retiring. The first phase of the program implemented was to have a paramedic and an ambulance on the island for emergency response. During the second phase, the paramedics provided flu shots, blood pressure checks and health clinics for the residents. The third and final phase was adding a Nurse Practitioner to the staff, allowing paramedics to expand their role, provide wound care and become involved in preventative education, such as fall prevention. A community liaison committee made recommendations to increase the role of the paramedics by adding blood draws, congestive heart failure assessments, administration of antibiotics, urine analysis, diabetes assessment, and medication compliance. The island residents could access the community paramedics in three ways. First was the patient or the family of a patient could request a visit from the community paramedics, a family physician could request the service as a follow up, or the nurse practitioner could refer patients directly to the service. The community paramedic program reduced visits to the emergency department by 23% (Community Paramedic, Program, Programming and Rural Health Delivery: A Nova Scotia Success Story n.d.), saving the residents from two hour round trip rides for minor procedures. The community paramedic program on Long and Brier Islands is so successful Nova Scotia is implementing the program in other counties in the province.

Wake County EMS in North Carolina uses a similar program, called Advanced Practice Paramedic (APP) that started operation in January of 2009. Within any EMS system, certain portions of the population require the services of the paramedics more; those people are called super users. The APP program was a response to super users who did not need transportation to an emergency room, but could benefit from alternate treatment modalities. The Advanced Practice Paramedics focus is to minimize or reduce medical crisis for people with specific medical conditions. Currently they are focused on diabetes, hypertension (high blood pressure), congestive heart failure, fall risks, substance abuse and children with asthma. Advanced Practice Paramedics can schedule meetings with patients to help them with medication compliance, or assess their needs. The Wake County EMS system also uses the APP in an emergency role, providing a higher level of care and extra hands on scene. The APP can arrange for transportation to alternate facilities, and in some cases even arrange admission to those facilities for behavioral or substance abuse problems.

The National Health Service (NHS) in the United Kingdom is also developing a program for paramedics trained beyond emergency care. The NHS Specialist Paramedic has been in service in the North East Ambulance Trust since 2006. As of September 2009, there were 720 Specialist Paramedics in England. The Specialist Paramedics are very successful at finding appropriate care pathways other than the emergency department. They have reduced the number of patient transports to the emergency departments by 50% – 66% (Association of Ambulance Chief Executives (GB) 2011). The Association of Ambulance Chief Executives published a report in June 2011 recommending that the clinical training for Specialist Paramedics be designed around the needs of the community served. They also recommended that more ambulance clinicians take routine assessments of patients in their homes, in partnership with the primary care team.

Fort Worth, Texas’s Area Metropolitan Ambulance Authority (MedStar) has a very successful Advanced Paramedic Program in place. Started in 2009, the Advanced Practice Paramedics identify super users of the 911 system, as well as congestive heart failure patients. The program has reduced the average monthly call volume from 342.3 to 143.3 (Agency for Healthcare Research Quality 2012). They have also saved the patients over $900,000 by not transporting them to the emergency department. The burden on the emergency room has also been eased by freeing up more than 14,000 bed hours, to be used by true emergencies (Agency for Healthcare Research Quality 2012).

Several other states, countries, and provinces are starting programs designed to bring the care to the patient using paramedics. The state of Maine just passed a bill, which was signed by the governor, allowing up to 12 community paramedic pilot programs in the state.

Roadblocks

The major issue in every aspect of health care is reimbursement and community paramedic programs are no different. The traditional reimbursement model in EMS is bill for transport, if the patient was not transported to the emergency department, then the EMS agency cannot bill the insurance. Two important strides forward have been made in recent months. Minnesota House of Representatives passed an amendment to statute 2010 256B.0625. The bill, H2060, will allow community paramedic programs to bill insurance companies for services rendered. This is a large step forward for funding community paramedic programs and state level recognition that a community paramedic is a health care provider.

Western Eagles County EMS, in Colorado has formulated a different method. Their community paramedic program is registered with the state as a home health agency, allowing them to bill for services rendered, just like visiting nurses and other home health agencies.

Nursing organizations and physician assistants might feel like the community paramedic program overlaps with services they already provide. The goal of community paramedic is not to take  jobs away from these professionals, rather to supplement those services and work with general practitioners, especially in the public health sector to provide health care services to those in need.

Where do we go from here?

The EMS agenda for the future provides a framework for the direction in which EMS systems should be heading.  The community paramedic concept achieves many of the goals set forth by the EMS agenda for the future.

Educational standards for EMS professionals in the United States vary widely between states, counties and even the cities. A unification of the educational standards should also be implemented. The United Kingdom, Australia, and Canada all require paramedics programs to be through the university. Paramedics are one of the most respected professions in United Kingdom and Australia, and among the least respected in the United States.  I propose the United States take similar actions and have paramedic programs be an associate level degree, and the community paramedic level be a bachelor level degree.  Most certificate paramedic programs are 1,100 to 1,500 hours in length, about 35 to 44 credit hours. An associate degree is normally 62 to 66 credit hours (Hseih 2012), by finishing a paramedic program you are two thirds of the way through an associate degree. By raising the educational standards for paramedics and providing an additional four year degree option with a community paramedic program the career options for EMS personnel will not stagnate, as they are currently.

Workers in the EMS career field suffer high attrition rates. Burn-out is very common in EMS with the average paramedic remaining in this career for only five years. Licensed paramedics have very few career options in the current EMS system. With no clear career path, paramedic retention can be difficult causing workers wishing to forward their education going on to nursing programs, while others leave the medical field all together. Licensed paramedics have very few career options in the current EMS system. A community paramedic level of licensure will enhance the career options for senior paramedics and those who wish to advance their medical knowledge, without having to leave the EMS field.

Many people debate whether EMS is health care or just public safety, like fire departments and police departments. I believe that Emergency Medical Service systems are both public safety and public health, and should exist as an entity in both.  Preventative programs like Child Safety Seat inspections, blood pressure checks, blood glucose monitoring, fall prevention and community CPR classes can all be done immediately, with no need for increasing scope of practice. These programs can be implemented tomorrow by any service willing to shift their focus from transportation to health education. Many EMS agencies are already providing service similar to public health departments, but many are not operating in cooperation with their department of public health.

EMS chiefs and medical directors are hesitant to increase the scope of practice for the paramedic. The Community Paramedic program is not intended to make drastic increases in the scope of practice, but rather to increase the role of the paramedic within the community. With additional education, the community paramedic can evaluate existing conditions, advise patients on possible medication interaction issues and provide preventative screenings using skills that are already available to the paramedic. As you saw above, some programs have decided to increase the scope of practice to include wound treatment, suturing and antibiotic prescription. EMS agencies should survey their population and, in conjunction with the department of public health, identify areas where high risk patients could benefit from preventative interventions. .  By expanding the role of paramedics in to public health, they can affect positive outcomes on the populations they serve. Community Paramedicine should be the vision for tomorrow, not ten years from now, but tomorrow.

Paramedics are underutilized, highly skilled, health care professionals. Raising the educational standards to the university level, can help ensure that everyone gets the same education and provide a pathway to career advancement within EMS. The gap between the aging population, and decline in general practitioners will only increase. Community Paramedic will fill this void, by extending the physician services to the door step of those in need.

Bibliography

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Reply to the Kaiser

Life Under the Lights, a well known EMS blogger, has posted a quagmire. He is challenging his belief in the current model of EMS in the United States. I started writing a reply, but it turned in to a soap box moment. Go read his post, then if you want to can read my reply below.

Chris,

You have issues, but being a hypocrite is not one of them. Regardless of what we want to believe EMS is still there mainly to bring the patient to the care. All the interventions we do are for stabilization purposes. How many service out there will actually allow you to treat a patient and release them? There are a few, but the majority of the systems require transport to “definitive care” at a hospital.

The entire health care system in the US is predicated on the idea of *treating* symptoms. We do VERY little on the prevention end of the spectrum (yes that is a pandora’s box of issues). How many fires do you prevent by extinguishing one? NONE. The fire service is doing an excellent job at PREVENTION through a variety of means. How many crimes to you prevent by arresting people? NONE. The law enforcement are very active at prevention. Why does the entire medical system (from doctors, hospitals, insurance companies, Ambulance services) think we can improve public health by treating symptoms?

You want to bring the care to the patient? So do I, we need to bring the public health office to the patient. Community Paramedic programs are starting to gain acceptance, bringing health checks, medication compliance, education to the community. There will ALWAYS be a need for an EMERGENCY medical service, but few interventions actually affect patient outcome (STEMI programs are a shining example of EMS improving patient outcome).

We need to stop thinking in the confines of a system built in the late 1960s and 1970s, that has stagnated in the “Taxi cab with lights and sirens” stage of development.

Ambulance systems are not intended to be a one size fits all. Germany also employs a physician based ambulance service. An ambulance crew consists of a physician and a paramedic. London Ambulance employs physicians on their HEMS wing (pun intended). I cannot say that physicians have no role on the ambulance. The system we have has not been designed for physicians to respond on or with an ambulance.

We have allowed paramedics to have a scope that is very narrow, but highly technical, to reduce the need for physicians on scene. Study’s have shown that paramedics are just as good at ECG interpretation as emergency physicians. Paramedics are also proficient at intubation, IV administration, and diagnosing specific, emergent life threatening problems.

Each EMS system needs to be tailored to the community it serves. We need to dissuade the notion of “Emergency only” when we think of ambulances. How many communities asked paramedics to administer H1N1 vaccinations not that long ago? Is that an “emergency” service? Paramedics are part public health, part public safety. Lets stop thinking only in terms of bringing the treatment of symptoms to the patients, and lets bring prevention to the masses.

</Soap Box Rant>