For those in NJ

[KyleWickman]

How many do you think they will do?





Report: Overhaul EMS system
Review makes 55 suggestions for improving emergency care

BY MICHAEL SYMONS
GANNETT STATE BUREAU
Saturday, September 22, 2007

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TRENTON -- Financial problems, a decline in volunteers, shortcomings in state law and a weakened advanced-life support system have pushed emergency medical services in New Jersey to "a state of near crisis," says a state-commissioned study issued Friday.

"New Jersey must develop and enact comprehensive legislation that overhauls the entire EMS system. The current legislation emphasizes restrictions and political pacification over an effective systems approach for quality EMS care," the report says.

The review -- mandated by the Legislature in January 2006 and months overdue -- recommends 55 changes for state officials to consider. The state Department of Health and Senior Services is reviewing the study to decide what it will advise doing next.

The report recommends sweeping changes in state law and procedures, such as:

• Requiring local municipalities to provide EMS, or cause it to be provided.

• Ending restrictions on paramedics and EMTs providing care in hospitals and other health-care settings.

• Requiring all EMS agencies to be licensed by the state, including volunteer ones.

• Encouraging mergers of small volunteer squads, through financial incentives.

• Allowing advanced life support services to be provided by nonhospital agencies.

• Transporting some patients to facilities other than emergency rooms for care.

• Changing rules to facilitate EMS research, which now requires multiple approvals for retrospective studies and is practically impossible for prospective research.

• Directing some money from a car registration surcharge now earmarked for State Police helicopters to a revamped state EMS office.

• Letting advanced life support ambulances be staffed by one emergency medical technician and one paramedic, rather than the two paramedics now required.

• Including paramedics and EMTs in the state's pension system for firefighters and police officers, or in a special section of the general public employee pension fund.

• Putting a state EMS medical director and three regional directors in charge of overseeing what is now a fragmented system that includes little coordination.

• Using county government to obtain and distribute Medicare payments to local EMS providers.

Sen. Joseph Vitale, D-Middlesex, the Senate health committee chairman, said he expects some, but not all, of the recommendations would get legislative approval. He also predicted some turf battles in the EMS field as lawmakers act to revamp the system.

"We have to be very careful because men and women, both young and old, have dedicated their lives to this kind of work, and we have to be really thoughtful of how they're treated and how they're respected," Vitale said.

Sen. Ronald Rice, D-Essex, was concerned about service until the system is fixed.

"The question is: If we're in such a mess, what are we going to do about it to make sure while we're cleaning up, people are getting the service that they're due and that they need?" Rice said.

The report was conducted by emergency services consulting firm TriData, a division of System Planning Corp. of Arlington, Va.

Regarding medical evacuation helicopters, the report found the two State Police medevac units, based in Bedminster and Voorhees, appear able to handle the calls and that commercial units should "re-examine the viability" of providing services.

That disappointed the three commercial operators in the state, who hoped it would declare the closest unit should respond to accident scenes. The report instead says they should be allowed to provide backup.

"That's wrong," said Jeff Behm, vice president of operations for MONOC, the Monmouth-Ocean Hospital Service Corp. "Why would you not want to send the closest helicopter to someone's injury?"

New Jersey uses a two-tiered system to provide basic and advanced life support services, including more than 25,000 volunteer and career providers, including first responders, 22,000 emergency medical technicians, 1,500 paramedics, nurses and doctors answering more than 800,000 requests for service each year.

[MG3610]

The funny part is that the state had to pay someone to tell them all that, imagine that!!

[DrParasite]

dammit kyle you beat me to it!!!
• Requiring local municipalities to provide EMS, or cause it to be provided.Absolutely. right now, only newark and camden are required to provide EMS by city charter (I could be wrong, but these are the only two I know for sure). the rest of the state don't have similar requirements, hence why many towns underpay their EMS systems and don't contribute with taxes. hopefully the state will pass legislation requiring this.
• Ending restrictions on paramedics and EMTs providing care in hospitals and other health-care settings.not exactly sure what this means.
• Requiring all EMS agencies to be licensed by the state, including volunteer ones.this should happen, but the first aid council will probably lobby against it. hopefully the legislature will tell them to shove it and pass the laws anyway. but I can see the NJFAC seeing this as a threat to their power.
• Encouraging mergers of small volunteer squads, through financial incentives.absolutely. get rid of home rule, not every town needs its own squad. more regionalization. it will never happen in NJ, because that means each town will lose power, and no one will ever allow that to happen. but it's a really good idea.
• Allowing advanced life support services to be provided by nonhospital agencies.ehhhhh, not really a good idea. you start to do this, and you create potential quality control issues. not only that, but you will end up over saturating ALS units (same problem LAFD has), which leads to more poorly trained medics.
• Transporting some patients to facilities other than emergency rooms for care.bad idea. NJ's EDs are over packed because of misuse of the ED's. maybe NJ EMTs can refer the patient (with a free taxi ride) to a clinic instead?
• Letting advanced life support ambulances be staffed by one emergency medical technician and one paramedic, rather than the two paramedics now required.yeah right. never going to happen. The ALS providers in the state will lobby against it. That ranks right up there with ALS transports; a good idea, but will never happen in NJ.
• Including paramedics and EMTs in the state's pension system for firefighters and police officers, or in a special section of the general public employee pension fund.hahaha. yeah, that's a good one. I would love this, but I don't see it ever happening. Too many potential problems with who can get in and who can not. along with fire and PD not wanting to let anyone else in.
• Using county government to obtain and distribute Medicare payments to local EMS providers.believe it when i see it.

[mitllesmertz1]

Quote:
• Ending restrictions on paramedics and EMTs providing care in hospitals and other health-care settings.
not exactly sure what this means.

Many RN unions battle against allowing medics to work in clinical settings, potentially letting ED's use lower paid staff to perform RN duties.


Quote:
• Allowing advanced life support services to be provided by nonhospital agencies.
ehhhhh, not really a good idea. you start to do this, and you create potential quality control issues. not only that, but you will end up over saturating ALS units (same problem LAFD has), which leads to more poorly trained medics.

So the only ALs providers are hospital based? Not sure if that's good or bad, but it is peculiar. Do they all get trained at the same place, or is it many different institutions doing the training?


Quote:
• Transporting some patients to facilities other than emergency rooms for care.
bad idea. NJ's EDs are over packed because of misuse of the ED's. maybe NJ EMTs can refer the patient (with a free taxi ride) to a clinic instead?

Did I miss something here? Wouldn't allowing your EMS to take patients to places OTHER than the ED help with ED overcrowding? Taking a non-urgent back pain to a clinic sounds like a good idea to me.


Overall sounds like they're taking some excellent steps!

[ShuckingGome]

Quote:
Quote:
• Transporting some patients to facilities other than emergency rooms for care.
bad idea. NJ's EDs are over packed because of misuse of the ED's. maybe NJ EMTs can refer the patient (with a free taxi ride) to a clinic instead?

Did I miss something here? Wouldn't allowing your EMS to take patients to places OTHER than the ED help with ED overcrowding? Taking a non-urgent back pain to a clinic sounds like a good idea to me.


Overall sounds like they're taking some excellent steps!




I really like the idea of being able to refer a patient to a clinic and giving them a voucher or something so they can take a taxi. Is there any place in the United States that has this type of system? I know other countries do things like this.

[DrParasite]

Quote:
• Allowing advanced life support services to be provided by nonhospital agencies.
ehhhhh, not really a good idea. you start to do this, and you create potential quality control issues. not only that, but you will end up over saturating ALS units (same problem LAFD has), which leads to more poorly trained medics.

So the only ALs providers are hospital based? Not sure if that's good or bad, but it is peculiar. Do they all get trained at the same place, or is it many different institutions doing the training?
Yes. in the State of NJ, all ALS providers that respond to 911 emergencies are hospital based (with the possible exception of MONOC, which is a different entity from what I have been told). They all work for a hospital, with medical control usually being their home ED physicians.

Training is kind of an interesting process. The process that one becomes a medic in NJ is as follows: a student applies to an ALS system for sponsorship to a medic program. The program accepts them in, and then sends them to a community college for their didactic portion of class. Once the student passes medic school (the didactic portion), they are sent back to the ALS agency for their hospital clinical. Once their hospital clinicals are completed, they go back to their ALS agency for field clinicals, where they learn local protocols and and evaluated based on their ALS agencies local protocols. Once they finish all all that, they may or may not be offered a job with their home agency, or they can apply for a position with one of the other ALS agencies.

So to answer your question, every ALS system can run their own ALS training system. Some schools send their students to the same location for their didactic portion (which is usually held at a community college, but not always) but each system does their own clinicals.

hope that made sense.

Quote:
• Transporting some patients to facilities other than emergency rooms for care.
bad idea. NJ's EDs are over packed because of misuse of the ED's. maybe NJ EMTs can refer the patient (with a free taxi ride) to a clinic instead?

Did I miss something here? Wouldn't allowing your EMS to take patients to places OTHER than the ED help with ED overcrowding? Taking a non-urgent back pain to a clinic sounds like a good idea to me.
I don't know how it is in other states, but we have several urban cites that have only have one ambulance providing primary coverage. We have others with two and three ambulances (running more than 12 calls in a 12 hour shift). Hell, I believe newark has 4 24/7 BLS ambulances, and they run between 12 and 20 EMS runs on a regular basis in a 12 hour shift.

now, right now we all transport to an ED, where we turn patients over to emergency nurses. can you really picture if we have to transport to clinics? who aren't used to rushing? or to a doctors office? or to a clinic, where you can't find a nurse to give a proper report and transfer patient care? or even worse, doctors offices and clinics outside of the primary area? and can you just see the EMS crew standing in the clinic waiting for a nurse for a report, while a cardiac arrest patient is holding waiting for the crew to be available, and the clinic nurse is too busy taking vitals on a 4 year old with a runny nose to be bother to accept the patient?

Don't get me wrong, it would serve to alleviate some of the backup in ERs. However I can see it causing a massive increase to the workload of some of the overworked BLS providers in NJ's municipalities (and yes, i mean that for both the paid and volunteer side.)

but if we could give out medicaid and medicare vouchers for taxis, now that would be a great idea. not that it would ever happen or anything, but a guy can dream can't he?

[DrParasite]

in case anyone cares, here is a PDF of the entire report

http://www.nj.gov/health/ems/documents/ems_study_report.pdf

[KyleWickman]

Thanks I was looking for that.

I am surprised you said that about LAFD. I am well versed in LA and have many friends that work for the LAFD. I have never heard them say that before.

[Bones42]

MONOC is hospital based. "They" are very much in favor of these recommendations with the exception of the non-hospital based ALS providers. (imagine that). They don't want any competition. It's not about level of care, it's about anyone having the ability to offer ALS at a reasonable rate, as opposed to the amounts MONOC charges.

As for the NJFAC, what power? They have power over themselves. Membership in the FAC is strictly voluntary. Don't want to have to follow FAC rules, don't join. No big deal.

Some of these proposals are surprising to me.

For instance, the requiring a town to offer EMS services. That's been around for my area for many years and I thought that was over.

Transporting to non-ED's. We routinely transport to an urgent care center...I guess that (under the state rules) qualifies as a ED?

Regionalization. We've been working on that for the last year as well. Not sure it's really helping anything though. Same number of calls for the area, same amount of people available to answer the calls, just doing it under 1 name now instead of 2. It's not getting calls answered any better/faster.



My gut feelings....in 1 year, nothing will be different.

[flipper123]

I really like the idea of being able to refer a patient to a clinic and giving them a voucher or something so they can take a taxi. Is there any place in the United States that has this type of system? I know other countries do things like this.

We have been issuing taxi vouchers for a couple years now.
Allows them to be taken to places like an urgent care for a minor boo-boo or cold symptoms.
Gets rid of alot of BLS transports for our local ambulance crews.

[DrParasite]

MONOC is hospital based. "They" are very much in favor of these recommendations with the exception of the non-hospital based ALS providers. (imagine that).No, MONOC isn't hospital based. and that was a direct quote from the supervisor of MONOC north. They are a separate company with all their ruling hospitals on their board of directors, however they receive no money from said hospitals. at least that was was the MONOC supervisor told me.
As for the NJFAC, what power? They have power over themselves. Membership in the FAC is strictly voluntary. Don't want to have to follow FAC rules, don't join. No big deal.ever look at your state laws? the NJFAC and MICU advisory council are supposed to be consulted on any new rules from the DOH. that's in the legislation. They have a tremendous amount of lobbying power in trenton, mainly because politicians don't want to loose the support of volunteers in their districts. and yes, this lobbying power is one of the things that is holding back EMS in NJ.
For instance, the requiring a town to offer EMS services. That's been around for my area for many years and I thought that was over. look at your urban ems areas, examine how many are under funded or how many cities don't want to give enough money to run a proper EMS system. and no, donations don't make enough to cover expenses when you are running close to 7000 calls a year.

Transporting to non-ED's. We routinely transport to an urgent care center...I guess that (under the state rules) qualifies as a ED? nope, you are actually violating state regulations. only a hospitals ED qualifies as an ED. and you know the old adage, just because you have been doing something for 10 years doesn't mean it is the right thing to do
My gut feelings....in 1 year, nothing will be different.agreed

[Bones42]

"MONOC, The Monmouth Ocean Hospital Service Corporation, is a non-profit company comprised of nineteen acute care hospitals " - Vince Robbins own description. He's the CEO.

"In MONOC’s case, we do not understand the consultant’s recommendation to reconfigure the paramedic system in the state to allow for non-hospital MICUs. After espousing the virtues of New Jersey’s regionalized, hospital based ALS system, they recommend against it? TriData correctly identifies that our current hospital based paramedic programs cover the entire state, provide for the highest possible quality of patient care, assure a fiscally necessary economy of scale, strike a needed balance of provider to volume thereby insuring skill retention, and guarantee an unparalleled continuum of care. Yet, with insufficient explanation, they recommend fragmenting the system by permitting non-hospital based MICUs. The difficulties faced by our current ALS tier of prehospital care is funding not structure." - again, their own words.

nope, you are actually violating state regulationsInteresting, as both the DOH and FAC approved of the decision. It was one of the requirements when the actual hospital closed a few years ago.


"In addition, administrative and financial resources are provided through committees with representation from each hospital." - that does not sound like they get $0 from their member hospitals to me.



as I said before....we'll see what actually happens. Most of their recommendations will have 0 impact on what's going on in my area.

[BoxAlarm187]

I know nothing more about NJ EMS other than the fact that I'm sitting in Tom's Brook typing this (doing ambulance inspections up the roads at PL Custom). However, there were a couple of a comments in the study that I thought were commenting about.

Here in Virginia, there is very, very, very little hospital-based ALS (or EMS for that matter). EMS is provided by the local volunteer rescue squads (first aid squads for you northerners), and or career/volunteer fire departments. This includes ALS care. There are hundreds of practicing volunteer paramedics in the state, along with firefighter/paramedics and the like. The local OMD (operational medical director) ensures that the precepting program allows for the proper delivery of ALS care.

ALS doesn't have to be hospital-based to be effective, quality care.

The other comment was allowing ALS rigs to be staffed by a medic and EMT. I know that there are medics which feel strongly about this (both ways), but coming from an agency that staffs all of it's ALS transport rigs this way, it's not dangerous nor impractical to do. Good BLS providers can make an ALS provider's day a lot better!

Always enjoy seeing proposed changes, and what the reactions to them are (both good and bad). Keep up the conversation...

[DrParasite]

Interesting, as both the DOH and FAC approved of the decision. It was one of the requirements when the actual hospital closed a few years ago.You have that in writing? can you e-mail it to me (or e-mail me the person (from both the DOH and FAC if possible) who sent you the written confirmation), as this is the first I have heard about it. I will forward it to my higher ups as a potential solution to ED overcrowding.

Thanks

[emt161]

There are hundreds of practicing volunteer paramedics in the state, along with firefighter/paramedics and the like.

This over-saturation of ALS is exactly what makes the NJ hospital-based system a pretty damn good idea in a lot of ways.


ALS doesn't have to be hospital-based to be effective, quality care.

Not at all. It's a question of numbers, not where the providers come from.

Still, I'm pretty sure the QA is going to be a lot better at a hospital than the local vollie squad. If it offends you, good. Do something about it.

[BoxAlarm187]

This over-saturation of ALS is exactly what makes the NJ hospital-based system a pretty damn good idea in a lot of ways.
Never have I heard the arguement made that there's too much ALS available. The idea that our field-based medics don't have as sharp as skills because there's another medic nearby and available for assistance is ridiculous.

Do some medics have better skills than others? Sure, but you're going to encounter that in NJ also. It doesn't have to do with over-saturation, it has to do with congnitive abilities.

Again, I'm just stumped that you can rationalize that the NJ medics are better because there are fewer to go around.

Still, I'm pretty sure the QA is going to be a lot better at a hospital than the local vollie squad. If it offends you, good. Do something about it.
Offend me? Not at all. I work for an ALS fire-based EMS agency. However, we work with volunteer ALS providers every day, and I see that they're as capable at this as the ALS folks in my agency.

Why would I want to "do something about it?" Our system works well for us, gives us ALS even in the remotest parts of our jurisdiction in just a couple of minutes. No need to wait for ALS from the hospital, or worry with making intercepts enroute to the ED.

[Bones42]

DrP, you'd have to contact Meridian Health Systems for that. It's their hospital and their urgent care center. They made the deal.

over-saturation of ALS Over-saturation of ALS? Yup, that explains why I don't have ALS available on about 5% of our calls.


Another thing that has me interested is the statewide level of care/training. I had thought all BLS members were trained to the State EMT-B level. You then have to acquire 48 CEU's every 3 years to maintain that certification. ALS was trained to EMT-P level and have their own CEU requirements. Isn't that already a statewide level of training?

What the sad part is, I'd bet that the majority of EMT's look for the simplest, least effort, quickest, cheapest way to get their CEU's. NJDOH even publishes a list of websites where you can do all your elective CEU's (24) online without ever doing much more than read a chapter and taking an online test. And you can use the "back" and "forward" buttons in IE to not even read the chapter.

[Scotttt]

Sadly, there has been little research on paramedic experience and how it relates to patient outcomes or skill retention/proficiency. However, there has been a decent amount of research into the experience of physicians and its relationship to patient outcomes. A physician who performs the same procedure more often will see fewer complications, be able to perform more quickly, and the patient will see shorter length of stays at the hospital. Level 1 trauma centers are required to prove that they treat at least 600 vic tims of trauma. This is to ensure that the surgical staff recieve adequate experience with trauma. Why is it that there are medical specialties?

It is very likely that an area with an oversaturation of paramedics will have medics who are less experienced with sick patients and thus be less proficient with advanced skills (i.e. intubation). Cognitive ability is likely the same between medics in oversaturated area and lowsaturated area, but it would be experience that determines who is more proficient.

Never have I heard the arguement made that there's too much ALS available. The idea that our field-based medics don't have as sharp as skills because there's another medic nearby and available for assistance is ridiculous.

Do some medics have better skills than others? Sure, but you're going to encounter that in NJ also. It doesn't have to do with over-saturation, it has to do with congnitive abilities.

Again, I'm just stumped that you can rationalize that the NJ medics are better because there are fewer to go around.


Offend me? Not at all. I work for an ALS fire-based EMS agency. However, we work with volunteer ALS providers every day, and I see that they're as capable at this as the ALS folks in my agency.

Why would I want to "do something about it?" Our system works well for us, gives us ALS even in the remotest parts of our jurisdiction in just a couple of minutes. No need to wait for ALS from the hospital, or worry with making intercepts enroute to the ED.

[DrParasite]

Another thing that has me interested is the statewide level of care/training. I had thought all BLS members were trained to the State EMT-B level. ehhh, not from what I hear. there are some volunteer squads, either those affiliated with the NJFAC or just unaffiliated, that don't have any EMTs on every ambulance. in fact, the NJFAC only requires 1 EMT on an ambulance. the DOH requires 2 EMTs on every BLS ambulance. Personally, I agree with the different amount of EMTs depending on paid or volunteer status, as long as every BLS truck has at least ONE EMT. those unaffiliated agencies might run with two people with first aid certs, even though they are responding to ambulance emergencies in a BLS ambulance.
What the sad part is, I'd bet that the majority of EMT's look for the simplest, least effort, quickest, cheapest way to get their CEU's. NJDOH even publishes a list of websites where you can do all your elective CEU's (24) online without ever doing much more than read a chapter and taking an online test. And you can use the "back" and "forward" buttons in IE to not even read the chapter.I don't think it is the majority, but I do believe a decent amount of people do this. and from both the paid and volunteer side. kinda scary isn't it?

[emt161]

Never have I heard the arguement made that there's too much ALS available

Then you haven't been paying attention. Sorry. Read some studies.

The idea that our field-based medics don't have as sharp as skills because there's another medic nearby and available for assistance is ridiculous.

Yeah, people really don't like thinking outside the box around here.

It doesn't have to do with over-saturation, it has to do with congnitive abilities.

So you're going to tell me that 6 medics in an engine/ambulance house are ALL going to have the same skills as 2 medics on a unit in a tiered system? The fact that those 6 guys are tripping over each other trying to use their skills on a call is GOOD for patient care?


Again, I'm just stumped that you can rationalize that the NJ medics are better because there are fewer to go around.

Again. Do some research. Read some studies. Explain why Seattle has a 45% SCA save rate, while LA, where every firefighter, streetsweeper, and garbage man is a medic, can't make double digits.

Our system works well for us, gives us ALS even in the remotest parts of our jurisdiction in just a couple of minutes.

Of course it works well for you. You're not the one on the stretcher.

Over-saturation of ALS? Yup, that explains why I don't have ALS available on about 5% of our calls.

If you've got ALS on 95% of your calls, THAT'S a problem. Is that 5% making a negative impact on patient outcomes? Is the 95% making a POSITIVE impact? You're telling me that that 5% of patients is dying because they aren't getting ALS? I can't wait to see the proof.



It is very likely that an area with an oversaturation of paramedics will have medics who are less experienced with sick patients and thus be less proficient with advanced skills (i.e. intubation). Cognitive ability is likely the same between medics in oversaturated area and lowsaturated area, but it would be experience that determines who is more proficient.

And there is peer-reviewed studies documenting this. The "All-ALS All the Time" crowd has squat.

[DrParasite]

If you've got ALS on 95% of your calls, THAT'S a problem. Is that 5% making a negative impact on patient outcomes? Is the 95% making a POSITIVE impact? You're telling me that that 5% of patients is dying because they aren't getting ALS? I can't wait to see the proof.no. I believe you are misunderstanding. out of all the total calls Bones's squad gets, 5% of the time when ALS criteria is met, the ALS unit is unavailable. I am assuming that the other times when ALS criteria is met, an ALS unit is dispatched. when ALS criteria is not met, (probably between 50 and 75% of the time), an ALS unit is not sent, and only a BLS (ambulance) unit is sent.

Bones, if I am incorrect here, feel free to correct me.

[Scotttt]

Over-saturation of ALS? Yup, that explains why I don't have ALS available on about 5% of our calls.


Funny, as a medic, the percentage of calls for which I am dispatched and am actually not needed is far above 5%. There are many reasons that ALS may not be available. One may be that there aren't enough ALS units. Other reasons may be that ALS is being inappropriately dispatched (covered in the EMS study) or not being recalled appropriately (also covered in the study).

[Bones42]

If you've got ALS on 95% of your calls, THAT'S a problem. Is that 5% making a negative impact on patient outcomes? Is the 95% making a POSITIVE impact? You're telling me that that 5% of patients is dying because they aren't getting ALS? I can't wait to see the proof. I see your confusion. DrP is correct, 5% of the calls where ALS would be needed they are not available.

the percentage of calls for which I am dispatched and am actually not needed is far above 5% On that, I will wholeheartedly agree. And you would think the medics would be "more willing" to release to BLS and make themselves available....yet I don't see that happening around here.

ehhh, not from what I hearYou got me. I don't know of any Squad that runs without 1 EMT on board. Hey, learn something new every day.

[BoxAlarm187]

Then you haven't been paying attention. Sorry. Read some studies.
You seem to be well versed in the studies, please point in the right direction so I can get a better idea of what I've been missing.

So you're going to tell me that 6 medics in an engine/ambulance house are ALL going to have the same skills as 2 medics on a unit in a tiered system? The fact that those 6 guys are tripping over each other trying to use their skills on a call is GOOD for patient care?
At my station, we have 10 FF's on the shift. 3 ALS providers, 7 BLS. One of the ALS people is always on the ambulance, the 2nd is generally on the engine (could be truck), and if the 3rd medic working that day, they'll be on whichever supression unit doesn't have ALS.

"Tripping all over themsevles?" Please, I have some of the most well-disciplined providers (ALS and BLS) that you'll ever see. No one tripping over themselves or making the team look stupid in front of the patient just because they want to get the stick or get that 12-lead started.

Our medic averages 10 calls a day, and with the ALS providers on it every third day, they keep their skills pretty well in practice.

Again. Do some research. Read some studies. Explain why Seattle has a 45% SCA save rate, while LA, where every firefighter, streetsweeper, and garbage man is a medic, can't make double digits.
I think that Medic 1's ROSC rate is higher for a number of reasons, not just the fact that they don't have the same number of medics as LAFD. Not saying it's not a contributing factor, but the reason doesn't lie soley within the number of providers.

Of course it works well for you. You're not the one on the stretcher.
I'll be sure to let all of the 170 ALS providers in my agency know how inept you think they are because they're not getting as many patient contacts as you think they should. Again, you're using a wide assumption about field-based ALS providers.

If you want to be close minded to the fact that field-based ALS doesn't work, that's your business. If you want me to listen to your side of things, show me where I can get some your studies. If you need me, I'll be making signs for our ambulances warning our patients they're in harms way because our ALS is coming from a hospital-based medic. :rolleyes: