This post started out as a reply to this post by Mark over at Medic999. Once I realized that my comment was about twice as long as the original post, I decided to turn it into a post.

For context, I recommend that you read his post first so that you you might better understand my comments.

Assessment is, and at least in my system, always has been the most important “skill” we have. Without strong assessment skills, we have no way of knowing if we are treating a patient correctly. Which I guess exposes another great EMS myth; that paramedics don’t diagnose. We might not call it that, although my last medical director was very honest in saying that we did and shouldn’t be shy about stating that. Paramedics know a lot about a fairly narrow range of medical problems, which makes sense given that our EMS system (in the US at least) is based on treating life threatening or at the least serious emergencies. I could, and have, go on and on about tiered systems with a smaller number of highly trained paramedics who don’t go to every call. What studies have been done strongly point to all ALS systems, especially medic/basic systems having more rust out than tiered systems. There is that whole debate about medics treating non life threatening, but painful conditions with pain medications. I won’t directly reply to that, but you can infer where I (and my system) stand on that issue.

Another thing that studies have shown, and a good friend of mine who is a paramedic and RN has read them all, is that at least in the US paramedics are bad at determining who should go to the hospital and who can stay home. Which emphatically is NOT the same thing as deciding who needs ALS and who can be safely transported by BLS. The UK system takes a different approach to that, but that’s a system design issue. Your system is designed with the necessary support structures in place to make that work, ours clearly is not. There are many causes of the current “health care crisis” in the US, which is more of a funding and resource allocation crisis than a lack of good health care.

One of the weaknesses of our system is the shortage of primary care physicians. That shortage is getting worse in a large part because specialists make far more money than PCPs.

I think that if the US medical system were to increase support for primary care, then the pressure on EMS systems would decrease quite a bit. After all, much of what we do is what GPs used to do when I was a kid. The big difference is that we don’t have the broader medical knowledge required to advise people to stay home or to seek non emergency care. Then again, GPs probably can’t do that anymore since medicine is so technology driven now that they could never contain all the required equipment in their little “black bags”.

Maybe the answer is some sort of hybrid system with non transporting units staffed by PAs or NPs supplementing paramedics and EMTs. I’ll leave it to greater minds than mine to figure that one out.

My comments about trauma care are mostly covered in Pearls of Wisdom, which I posted last week.

This part of Mark’s post,

I am already aware of the recent move to disprove the concept of the Golden Hour, and when I have been talking to colleagues at work about it, I have basically said that all it proves is that if your injuries are going to kill you, then it doesn’t matter if you are on scene for 10 minutes or 30 minutes (or so the current thinking is telling us), and likewise if you are going to survive, then you will unless you are kept out of the hospital for a significantly prolonged period of time.

leaves out something which I think is very important. While it is true that some patients have sustained mortal injuries and nothing we or anyone can do will save them, while some patients have injuries from which they would recover even if we did nothing, there remains a fairly large proportion of patients who will sustain serious, life threatening injuries. These injuries are survivable if they receive prompt care. Paramedics can not provide that care, at best we can temporize until until we can get the patient to definitive care. Which in the case of life threatening trauma is surgical intervention.

As I noted in Pearls Of Wisdom one of the dividends of war is that medicine, especially trauma care, advances very quickly. Since studies have shown that mortality increases with ALS interventions in the field (especially intubation) the ABCs, including external hemorrhage control and rapid transport to a trauma center are the modalities on which we need to concentrate.

While the arbitrary 60 minutes of the “Golden Hour” is not valid, the concept of rapid surgical intervention is entirely valid. Dilly dallying on scene is flat out bad for those patients who are “on the bubble”. While IV access is helpful to the surgeons (and thus the patients), delaying on scene to start an IV is not.

Maybe one of the things that EMS 2.0 should look at is whether we should decrease the emphasis on ALS for trauma and concentrate on bringing BLS skills up to par. I’d not recommend that we (or the UK) adopt the French model of bringing doctors to the scene. That didn’t seem to work out too well for Princess Diana.

On this matter, I’ll go with the experience of the surgeons saving our troops in Iraq and Afghanistan. I wonder what the UK surgeons serving over there have to say on the subject?

Other than that, I really don’t have any thoughts on the subject.