The paper that started this thread found worse outcomes for some patients with ALS vs BLS. You suggested this was due to incompetent medics. I was pointing out that this is not a logical explanation, since your hypothesis would require the ALS providers to be less competent than the BLS ones.
It does not require the medics to be less competent than the basic EMTs. There really is not much ALS that is likely to help in trauma. People have mentioned that some medics will sit on scene in the ambulance to make sure they get their 2 large bore IVs to satisfy the protocol. The protocol does not require that they do this on scene, but their skills are poor enough that they are unlikely to successfully obtain access that meets protocol "requirements" en route.
IVs do not save lives and any organization that places emphasis on having IVs in trauma, rather than on the appropriate treatment of the patient, is going to skew the results of the research. How much does it take to come up with a worse outcome from ALS? We don't know, but to assume that all ALS has to be bad for the BLS care (which is no worse than ALS care in trauma) to provide better outcomes is ridiculous.
There is no reason to believe that ALS provides benefit in trauma, except in a few specific situations. So, the more ALS you provide, the worse the outcome is likely to be. All the ALS is accomplishing is delaying interventions that have been shown to make a difference.
I would classify pain management differently, since it is symptom relief that is not likely to lead to any life/limb benefit. It is still important and underused.
1. It's striking to me that you have such an obsession with holding medical directors responsible for all failings in EMS. What about the responsibility of individual medics and EMTs to maintain their skills and education? What about the administrators who oversee day-to-day operations (almost never the MD)? What about the head of the system, such as the fire chief or even the mayor?
The medical director is the highest level medical provider in the organization and should be the most qualified to make decisions about provider competence.
I do not exclude medics from responsibility to better themselves, but an organization with a bunch of bottom feeders is not likely to happen with a medical director who demands competence.
A fire chief is someone trained in fire suppression and prevention. What does that have to do with medical care? The administrators of non-fire department EMS have similar limitations on medical background. They may be very good at EMS, but it is not necessary to run the organization. They should be focusing on the best care, but they work within budgets and deal with politics that often lead to taking shortcuts. That is where the one person who exists to authorize provision of medical care, or to deny the provision of medical care, needs to say "I do not authorize this." Whether it is one dangerous medic, one dangerous practice, or a bunch of dangerous things, the medical director is the one who has the responsibility to say Yes or No.
All of these other people, mayor, administrator, fire chief, . . . , can say "I am not a doctor. We hired a doctor to oversee medical care. The doctor did not do this adequately."
2. "Too many medics." I understand the argument of dilution of skills, but there is a powerful flip side to this: having more educated providers. In most areas of healthcare this is seen as a very positive thing. Paramedics may not put out fires any better, but the call volume of most fire departments is >90% EMS.
You are assuming that they are competent, maintain competence, and care about what they are doing. The person who wants to be a fire fighter, but is told "You have to become a paramedic to be hired," does not become motivated to care for patients, just because of medic training. We have a problem of a lot of incompetent medics, who have been trained to pass the National Registry memorization test. They have been trained to just follow protocol to not get in trouble. Look at the number of pneumonia patients treated with Lasix. These are not medics who have a clue, but there is no follow up, no remediation, no elimination of those who just don't get it.
Having a call volume of mostly EMS, but 5 medics showing up on a call means that it isn't a sensible use of personnel. How does having more medics help, if they routinely travel in groups?
Give me a medic with a basic EMT partner and leave the other apparatus out of it (except where specifically needed). Or a dual medic system with a lot more BLS ambulances, so that the medics are only used on serious calls and become very good at what they do. Get rid of all of the lowest common denominator medics.
3. In systems that have trouble getting even part-time medical direction, would you prefer to increase the burden on the MDs and then end up destroying the system? Is it better to have an imperfect system, or make people drive themselves to the hospital?
If a system has trouble getting medical direction and has to settle for bad medical direction, there is no difficult choice. Don't settle. You cannot afford ALS. Protect your patients and keep the "good enough" people from killing them with good intentions.
One of the reasons we cannot consistently show the benefit of ALS is that there are so many bad medics out there. The only reason they are allowed to be there is a medical director allows it.
It is paramedic or nothing? I guess that is the way the country is going. We dislike the idea of anyone being considered special, or having special training. In Canada they have made it so that all EMS providers are called paramedic, so that everyone gets a paramedic.
The idea that it is a choice between having paramedics and driving your self to the hospital is not as bad as you make it seem. There are places where you would be better off not letting EMS touch you and driving yourself (preferably having someone else drive you) to the appropriate hospital.
