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I do believe that "medical control" as we know it here in the US is an outmoded concept. That being said, I STRONGLY agree that some sort of online "medical consultation" SHOULD be available, whether it be with an agency medical director, an attending physician at the receiving hospital, or even, depending on the system, a more experienced/educated Paramedic with your agency such as a supervisor. I would suggest that as long as the education of Paramedics, especially in the US, is as it is, this is absolutely necessary. That being said, I also agree with all of you that greatly increased educational standards are necessary - I forsee three levels. I am speaking with reference to US educational credentials as I have experienced them, as this is what I know best. 1. An EMT/EMR/CFR (whatever you want to call it) - these personnel would have a greatly expanded coursework (minimum 3 times the number of didactic hours with about 5 times clinical hours - if you're going to measure that way), and would be permitted to work either in a first response capacity, such as with a fire department, or with an IFT agency. I don't believe that many of our BLS IFT transfers require more highly educated Paramedics, or do I believe that 911 ambulances should be performing these transports. While "grandma" absolutely deserves to be transported home from the hospital with dignity, her non-ambulatory status and being oxygen dependent do not, in my opinion, justify taking an ambulance out of service. This practice both decreases the number of ambulances available for emergencies, and decreases the number of emergency patients Paramedics are in contact with, because they are too busy performing these transports, especially in so-called "high-performance" systems. 2. A Paramedic/Primary Care Paramedic - these personnel would have, at minimum, an Associate's degree. Every 911 ambulance would have a minimum of two Paramedics. I believe that a more traditional educational setting, and requiring degreed Paramedics, would lead to better practitioners. I don't believe that the standard Paramedic course, of whatever length, is adequate education. I don't think you can have a single instructor teaching every subject, with class 2-3 nights a week for 10 weeks - 18 months+, depending on the program, and produce providers of the level that we really need to have in prehospital medicine, unless these providers are willing to educate themselves further, on their own initiative, to achieve excellence. We need to provide Paramedics with the tools to succeed while they are still in the educational loop. Paramedics, in my opinion, may have less of a "skill set" than what we typically think of as a Paramedic in the US, but would still be able to handle 75% + of our typical "ALS criteria" calls - i.e. chest pain, shortness of breath, seizures, diabetic emergencies, etc. 3. An Advanced Care Paramedic/Intensive Care Paramedic - these personnel would have, at minimum, a Baccalaureate degree, and would have more advanced pharmocological interventions and advanced airway management. Some of the more rare conditions that we respond to would be the realm of the more "advanced" provider. I feel that by limiting the not necessarily more difficult, but are easier to "screw up," leading to poor patient outcomes, to a much fewer number of providers, we will greatly reduce the chance for error. Using the 80/20 rule that several people in my system, whom I believe to be reliable, have said does apply - 80% of our major medical errors, system-wide, come from 20% of the interventions performed - often the medications we use more infrequently. I know I have deviated from the topic at hand slightly, but I had a reason for doing so (in my mind). By increasing the standards, whether it be as defined above or otherwise, we will reduce the need for online contact. In the current system in the US, from what I have read and heard from other people, most systems that require two Paramedics on an ambulance do so not because they feel it is in the best interests of the patient, but because they feel that their Paramedics aren't good enough to practice on their own. This is not to say that Paramedics necessarily should be working on their own with an under-educated "technician" as their partner, but it is a sad state of affairs. This is typically in the systems with 10 week Paramedic courses. These providers absolutely NEED somebody else, with a higher level of education, to contact, even if they do have a second Paramedic standing next to them. For the systems who run ALS/BLS ambulances, their partner is somebody who has a 120-hour "education" behind them, and in many instances the ink is still damp on their certification/license. This is not somebody who will usually be terribly helpful when attempting to discuss a differential diagnosis on a difficult patient. By increasing educational standards, and making it so that only more highly educated Paramedics are responding to "emergencies," however you define those, you ensure that two highly educated personnel are available, and they have each other as resources. Online medical CONSULTATION may still be useful in very limited circumstances, but it is much less of an absolute NEED that I see, in my honest opinion, medical control being in many areas of the US today. For those not familiar with the educational credentials I refer to, an Associate's degree is usually about 2 years in length with 60-70 credit hours required (a credit hour being defined, typically, as a unit measurement of a course, in which you would be expected to spend one hour per week, for a 15-week semester, in lecture, and one hour per week on homework/studying - a typical course, such as Anatomy & Physiology I, would award 3-4 credit hours). A Baccalaureate/Bachelor's degree would typically take 4 years to complete, with 120-130 credit hours required for completion. Sorry for my long-winded post - thanks for listening.

Boeing, rather than posting a purely emotional response, which was irrelevant to the original post and article, perhaps you could try to justify the actions of the firefighters in the article that Dust posted. Explain to me WHY the FD in this article want to “be exempt from any medical or emergency oversight when they're at a scene.” How does this improve care? How does this further EMS? Explain to me the justification of the following quote from the article: “the intent of the legislation is that we don't need the EMS board in on our discipline. A lot of the firefighters think they treat us like criminals, like we’re always wrong." IMHO, this quote shows the true reason for this legislation – pride, not quality of service, is the priority. So, if you can justify how this legislation in this article improves patient care and improves EMS as a profession, I will discuss this with you. If you want to post an emotional outburst of how “EMS is always hacking fire,” and how amalgamated services are working so well, I am certain that many on this site will be happy to argue that point, and provide statistics and recent articles on areas where it is not working at all. The gross generalization of “come down to the states where the service is combined” is incorrect, as there are many services that are EMS only in the USA. I may be mis-reading that, in that you may have meant “come down to individual states;” however, again, I am sure there are examples even in those states where combines services is not working well. “Those of us who care about our roles in this dual profession dont sit here and whine and complain and think of what negative thing to say to or about all of you who still work in single role depts, whose days are limited….” Wow. That is a completely arrogant and uneducated comment. Combining services does not improve EMS care, it does not improve EMS as a profession. It is a good way for fire departments to increase their call volume figures to justify budgets, as has been shown on numerous threads here. It is exactly comments like that which will draw fire, (no pun intended) because the reasoning for combining services has nothing to do with improving care. Ok, now that I have hijacked my own post, back to my original thoughts: boeing, stick to the thread. If you want to start a thread about how EMS are big meanies and like to hack fire departments, you are welcome to do that. In this thread, we are discussing a specific article, and the negative outcome of this legislation. So, refer to the OP, and post an argument in favor of the legislation if you agree that the FD in this situation is in the right. I will await your reply.

Shame on us for knowing that at the rate our current President and his cronies are going through the government coffers and giving it away to people that haven't contributed a dime, that we can't afford to go futher into debt than we've already been thrown? Shame on us working class who have been left to pay not only the tab for those who REFUSE to work, but would rather sit back and suck up on the government handouts; as well as pick up the tab for the actions of those that think we're beneath them? So far, the 'working class stiffs' have had around three TRILLION dollars more debt thrown onto us by the 'governing body'. And you 'shame on us' for crying 'uncle'? Tell me, why should we be 'comfortable' knowing that if we don't purchase health insurance by 2014 (not even discussing if we can AFFORD to purchase it), we'll be fined for noncompliance. How is that 'helping'? We, the working class stiffs, can barely afford to keep our houses, and they want to take more of the 'disposable income' that we DON'T have and FORCE us to spend more for things that we can't afford in the first place! So far, the ONLY ones to benefit from this 'reform bill' is the insurance companies who still rake in BILLIONS of dollars a year in PROFIT, and find every reason under the sun to deny having to pay any of the bills! It seems that the only people that are getting 'socially stimulated' are those in power, while those of us 'in the ditches' can pretty well do with out.

Quite interesting that MOT regulations state that due to safety Pilots and Flight Attendants subjected to the stressors of flight and are limited to a 14 hour duty day ... all I will say on this topic its about DAMN time Flight Medics health and the safety of those that fall under their care are in placed in jeopardy. GO get em HSAA its way and in passing both the regulatory body and Employment standards Alberta and Federally are aware of this situation since 2004 (practice beyond safety for rest periods) ... Where was the regulatory body in this protecting the public safety with this very serious situation once again ? Alberta Labour get your head out of your sphincter do whats SAFE for Albertans that are sick or injured.

You're missing the point here. The point is they defied the will of the people; the overwhelmingly against this bill people. But yes, this bill is terrible for this bill. No one disagrees reform is necessary, but not this bill. Not this bill, in this economy.

No offense, but if our system, society, and health care is so lousy, why are people fighting to COME vs going elsewhere? Why do people come here from all over the world to get state of the art medical care? You can have "Decent" health care- I'd prefer to have the "best"- with all it's flaws. Instead of fixing the problems, we are blowing up the entire system. FAIL.

Well, since the vox populi here so far seems to pretty negative about the pending Healthcare reforms then let me re-adress the balance: I think that it's a travesty that one of the world's richest and powerful countries has waited so long to adopt decent healthcare for all, regardless od socio-economic status. Shame on you all for opposing this bill. And yes, I'm an outsider. An outsider that pays 52% income-tax to benefit from one of the world's most developed social security systems. No, we are not going to hell in a handcart from all the those free-loading parasites costing us a fortune. I live in a prosperous, caring country. No-one in the developed world such need to worry about a basic right such as decent healthcare. You want a strong opinion, you got it! WM

I suggest the following to prepare for the potential consequences: Take care, chbare.

I believe independant practice as I defined it earlier in the thread does make allowances for the type of situations you are concerned about. A well educated paramedic should be able to function completely independantly within their SOP. IE. working under your own licence as opposed to under a medical directors for everything that falls within your licenced SOP. Though able to function independantly medical consultation should be available to providers for unusual or complex cases. No different than a GP spying something something that seems "out of place" on an x-ray and choosing to consult a radiologist. I think the whole point many of us are trying to make is that medical control should be removed from regular practice and reserved only for situations that fall outside the set standard of practice. Things like on ambulance drug or procedure trials such as pre-hospital thrombolytics for example.

With all the government 'give aways' like social security to illegal immigrants, welfare abuse and now this.... It seems that Obama's main goal in his tenure as President is to bankrupt this country! The only 'beneficiaries' of his 'social programs' have been the government, and those that have caused this mess. Look at his cabinet....there's at least one of the CEO's from the mortgage industry serving there (in addition to their 'golden parachute' severance package). The whole concept of 'a few hundred billion here,...a few hundred billion there...here a trillion, there a trillion, eee eye eee eye oh' needs to be stopped! The working class poor can't afford any more of these 'give away programs' that benefit everyone EXCEPT them! We spend billions and trillions of dollars taking care of everyone but those that have to pay for it all. What kind of 'relief' is it to fine someone who cant afford healthcare in the first place? If health insurance is beyond someone's means, taking more money from them ISNT 'helping them'! Social Security is in shambles because you only have to 'work' for 4 years as a Senator or Representative, and you qualify for benefits that the working class will NEVER see... These programs were instituted to take care of the AMERICAN worker after they've 'done their part' for 30 years, not to just hand out to any illegal that can get one 'wet foot on dry land'!

No, now you just have to live in fear of the federal government and the rationing that will certainly follow. Now you have to worry about the huge tax and fee increases that are absolutely going to have to take place for this to have any chance of being funded. Then you have to worry about whether or not there will be a doctor to see you, since now there will be huge shortages. This bill, did nothing for American's except complicate everything and make health care worse! <BR><BR>Sorry, I'm new to this place, but I have strong opinions. The vote last night was the worst day in American History. It's the beginning of the end of America as we know it, unless we all do something to stop it!

.....*gets out the popcorn and pulls out a chair for this one*.....

Yeah, made an acct, tried to post..... "I, as well, don't see the problem here. Well over half of the calls that the firefighters are running are medical. They don't want to be held to professional standards and oversight like the rest of the medical community, so it's simple really. Lay off half of the firemen, replace them with ambulances carrying medical professionals. Then an ambulance will be the first vehicle to arrive when a person needs medical attention and it will be staffed with personnel that have chosen to be on a medical scene instead of someone that finds medical care and the educational and accountability burdens that that entails distasteful. Why make this more difficult than it has to be? Some people want to educate themselves and be held accountable. Those people should survive and flourish, others don't, and they should be eliminated. Of course, there is not a snow balls chance in heck that this bill will pass, so the majority of this will end up to be mental Mast....., you know, at best. But that's not always a bad thing. I'm confident however that there are many fire professionals that study, stay sharp, and have no fear at all of medical oversight. For them I'm sorry, as they'll be painted with the same brush meant for the ignorant yahoos." Got this... "You comment contains a word or words which are considered inappropriate. Please edit your comment and resubmit." Pricks!....(I added the pricks part.) So I changed "Chance in hell" to "chance in heck." Changed "Mental masturbation" to "mental Mast....., you know" changed mental Mast....., you know" to "moot" and I refuse to change ignorant Yahoos to anything else as it just has a nice flavor when speaking about these dipshits. Finally I just gave up. I'm thinking that if "heck" the offending word then I probably don't have the communication style necessary to make my point in that theater. I've discovered I'm really not very good at expressing my opinion when strict censorship is invloved.. :-) but I have no idea what the hell is wrong with the above... Dwayne

Maybe. If you are on your 3rd dose of epi and the patient is 55 years old (which makes epinephrine a dangerous proposition!), perhaps there is something else that ought to be considered. A lot of epinephrine in an elderly patient is something that isn't to be taken lightly. I agree that neither is respiratory distress, but we too abide by a "do no harm" principle. I personally feel like these kinds of "oh crap" situations deserve fresh eyes, and I don't consider it a personal insult to ask for help or a second opinion. Agreed. Although epinephrine infusions for this particular scenario haven't quite made it to the pages of our local guideline books (they actually do say "paramedic guidelines" on the front). An epinephrine infusion would definitely be the subject of my consultation with OLMC in this case. I understand that a paramedic could likely do this on standing order, but epi infusions are not yet commonplace here and it would definitely be prudent to have a talk about it with the doc before we start making things up based on what we may have read about or heard someplace. Hopefully if anyone can, its me! haha. How about: 1. Extended treatment options for field treatment of severe hyper-k without lab results. This is a dangerous condition that we can do something about in the field, but often do not for lack of definitive lab values (and reasonably so!). A conversation with a doc where the paramedic relays the pertinent clinical findings could lead to a field treatment that otherwise may not have been prudent, which could be life saving. This one is from my own experience. 2. Tox syndromes. Toxicology is a whole medical sub-specialty, and there is a lot more out there than the usual narcotic/beta blocker/TCA/organophosphate stuff we are more familiar with. A conversation with a physician in an unusual OD scenario can be extremely valuable. 3. Deep ACLS. Management of refractive brady or tachyarrhythmias (wide complex especially) can definitely benefit from a fresh set of eyes. I have absolutely no problem forwarding an ECG to medical control for a 2nd opinion if I am concerned about WPW in a patient that might otherwise get Cardizem, or a potential VT in a patient who is refractive to Amiodorone. These are tricky scenarios that even cardiologists sweat over. Why make this decision on your own if you don't have to? How about those? We talk to the ED attending that picks up the phone. Our local guidelines contain an agreement between hospitals that the receiving attending ED physician is the acting medical control doctor for that particular patient.

I think there are big differences here in what "on line medical control" means to each of us. I see some people commenting that they have to call a physician and ask about first round analgesia dosing, and I also see people referring to their protocol as "guidelines." These are two opposite ends of the spectrum, and both are represented here. Personally, I don't think we should ever be without on-line medical control for some things. Where I work, we call a physician on the radio when we truly need another opinion on a difficult topic (Should I give a third SQ epinephrine to this 55 year old woman with severe asthma? Do you agree with my assessment of this STEMI patient so that we can bypass the ED for the cath lab? I've got a difficult syndrome here in a critically ill patient and I'm not sure which path to take...). It is my feeling that these calls are open and honest consultations with colleagues, and a recognition that there is a whole lot out there that we Paramedics, or any individual for that matter, doesn't know. Even doctors call other doctors to discuss things if they get in a bind. Who's to say that we are too good for that?

Seriously, this is the most blatantly brazen anti-EMS move that I've seen the firemonkeys ever make. I have to say that I am genuinely flabbergasted. They have truly soared to a new low.

nuclear explosion?

sounds like a power plant explosion knocked out all electronically controlled devices. Hope your shoes are comfy.

What is a RCMP officer? Was that someone he was working with? How sad, just sad. Last February I had a tonsilectomy that put me in the ER about a week later with massive hemorrhaging. The blood was puring out my nose, and my mouth, but I still did the best I could to thank the medics who rushed me to the ER...

Finally getting the proof that my voice does not matter to my Government hit hard last night. Watching that witch Nancy Pelosi strut in front of protesters with the gavel made me sick. Every single time I heard "this is for Americans" it made my blood boil. I am actually scared, scared for my family, and for my children. I have NO faith or hope, esp. with Obama and Nancy needing the power as much as they do! IRS agents *edited to add link about new IRS forms, and agents for new health care

Anyoe here use/used the R-aid medical pack by Tactical Medical Solutions? My unit is ordering some for the medics. Somedic

This was a little more than tonsilectomy ... What kind of cop WOULDN'T have a vest on? Unfortunately they don't make them for tracheas ... This was an extreme situation that doesn't happen every day. DUH, I think we all know these medics SHOULDN'T have done what they did. Great thing to point out there rock ... I only hope I have the same courage to do what they all did, should I ever be faced with that situation because I know I couldn't live with myself if I ran away. Yup.

The story reported on in the link I posted was a fatality of "one of our own". I made a simple comment that the situation was a little more serious than tonsils, which I *hope* most would agree with. Nowhere in that post did I make mention of sincerity. So, what I am saying is that I will not apologize for your misinterpretation of my comment. It certainly is unfortunate with several lives being turned upside down. I hope none of us ever have to find out what it's like to be in that situation. Yeah, a lot of unrelated stuff ... seems to be the norm for these forums though.

http://www.canada.com/news/national/Dying+officer+thanked+paramedic+rescuers/2426743/story.html

Hehehe ... breakfast at Denny's at 330am, several cups of coffee and a strawberry milkshake ...

The wide awake drunk as someone already said. Anyone ever had a Jagerbomb? Or several? Terrible feeling the next morning ...

Fiz, I think you will find it was I that used pain relief as an example, thats all it was. It wasn't just about first round doseing, it was about the administration of analgesia. Just so were clear, here is what I said Changes the relevance of your comment. A protocol is nothing more than a guideline. Again, using analgesia as an example, I can give up to 5mg bolus with repeat doses of 2.5 to 5mg every 2 mins to a max of 5.mg/kg. NO further questions asked. Why does it have to be a doctor? We have clinical assistance lines that perform the same function. If you have to ask this question, then you really need to have your accreditation reviewed. Lets see. The person is having severe respiritory distress issues. There is minimal air movement. I give dose 1. Slight implrovment. I give dose 2. Slight improvment. What the hell am i calling for advice or, either the patient needs their airway open to breath, or they die. If they have a cardiac event post epi, was it caused by the epi, or was it caused because the myocardium had been working too hard when they couldnt breathe? This one is a no brainer. STEMI, I agree, ECG is open to interpretation & you are better to be sure. Huh? This is prehospital care. You have a symptom, treat it. I had this discussion in the chat recently. EMS treats symptomatically. It is not up to us to determine most root causes & the person you are discribing needs the benefit of a HOSPITAL with doctors, nurses, & those wonderful things called pathology labs. Treat what you see/find, & get em to hospital, you dont need a doctor to tell you that. I agree there is much we dont know, however, they are not a consult. they are a CYA tool for lazy medics who fail to use their brain. They are a failsafe method for people to say I only did what I was told, a Neuremberg defence when it all goes to shit. Now your stuff. Treat what you see/find, get rid of medical control. Yes doctors consult, but they are usually having a consult over a patient who has more care than they can poke a stick at. They have usually got the patient through the critical period & are looking at the case retrospectivley to determine future treatments & how they may have improved past treatments.

It always amuses me how many of you "paramedics" blast the fire service, i'd like to see all of you " Top Notch " medics come down to the states where the service is combined. Unless im mistaken Miami/Dade, St Johns County and several other Florida cities/counties are doing more than most of the country, most of the firefighter/paramedics are the people on the helicopters as well as the local pvt ambulance ( which is a glorified geriatric transport truck ). But yet were firemonkeys, seems to me I work on a rescue in the fire dept, or a "ambulance" for those who are not familiar with our terminology. Those of us who care about our roles in this dual profession dont sit here and whine and complain and think of what negative thing to say to or about all of you who still work in single role depts, whose days are limited, fire/rescue is spreading like a wildfire. It does not matter why, it is happening everyday though. I saw someone post to fire half the firefighters, how about adding rescues and sending them through paramedic school, or doing like many here are doing, making you sign a contract stating you will go with in your first 3 years of service, which has been working to weed out the people who are single minded and think this is still the 80's where we had lots of fire, and medical was separate. Long story short, some of us work dual role, some of us care, just as it is racist to lump a whole race into one foul word, it is the same to lump us together.