Thank you very much for your thoughts.  Here are responses to some of the issues you raise…

1. Where have all the skills and competencies gone?

They have been diluted to the point of ineffectiveness.  Agencies have been very quick to add paramedics to the ranks without careful consideration to patient:paramedic encounter ratios.  When you have 2, 3 or in some cases, 4 paramedics PER TRUCK, multiplied by multiple trucks on a call, the skills opportunities are greatly diminished.  If you do not use the skill regularly, you lose it.  Reference the recent USA Today article summarizing the research on the highest cardiac arrest save rates occurring in EMS systems with fewer, more experienced paramedics. 

2. Identification of QA issues internally.

Many agencies do not track skills proficiency appropriately.  In several systems I am aware of, the type of detailed review being conducted by the recently published studies have never been done, perhaps because they either lacked to desire, or were afraid of the findings.  Further, some agencies are unable, or unwilling to invest the necessary resources to maintain adequate skill proficiency.  As a recent example of this, an agency invested huge sum of money to have a mobile human patient simulator brought to their station for 3 days.  They offered all local EMS agencies to send their paramedics through the simulator for FREE since it was going to be there anyway.  No one accepted the invitation.  Interesting…

3. Suctioning.

When I took my initial paramedic training (during the time that Truman was President I think), and all through my ACLS Instructor days, it was the standard of care to have suction ready PRIOR to inserting the laryngoscope to visualize the cords.  This was to facilitate the needed for quick suctioning while attempting to visualize the cords.  That has not changed to my knowledge.

4. Local Medical Oversight vs. AHA Recommendations.

The AHA has much more resources to investigate and research clinical issues than most EMS agencies.  As such, most, if not all, local medical directors rely on the AHA to develop recommendations regarding clinical care, especially for cardiac issues.  Look at virtually any EMS protocol and I’d be willing to bet the protocol follows the AHA Guidelines practically verbatim.  I agree this is a local decision, but a decision based on sound clinical research and a team of no less than 75 international experts is probably helpful.

5. Hospital Rotation/CME.

Most paramedic training program coordinators I talk to express significant difficulty getting clinical time for students, especially in OR’s.  Critical Care clinical areas are used not only by paramedic students, but nursing, anesthesia, physician assistant, radiology, respiratory therapy, etc.  To add the need for existing paramedics to routinely use these clinical areas to maintain their skills begs the question, why are we training them in the first place.

Your final statement troubles me greatly.  “Cardiac arrests are our most frequently intubated group…  Where is our skill level going to go with the loss of anywhere from 35 – 65% of our intubations.”  Are you suggesting that cardiac arrest patients are “practice” cases??  Used to maintain skill levels for the other cases?? 

If you have the option of using a treatment on a patient that works 50% of the time, or a treatment that works 100% of the time, and either produce the same outcome according to international research, which would you choose?