The very word "paramedic" translates into so many variations of protocols and definitions, even across state lines let alone international ones, that it is hard to come up with one model that suits all resource bases or discussions on protocols.
I say "resource base" because that is what should be driving this argument. It stands to reason that having a trauma hospital ED on each traffic intersection would (in a resource unlimited world) be the ideal solution. From that ideal to having just one ED in a city of 20 million for a resource poor situation is simply a matter of the individual cost benefit analysis. And as armed with all the facts and figures as we like to think we are, we rarely get to decide on the resource allocations that settle arguments like this.
Resource base expansion enabled the ground ambulance in the first place. What a great idea to get initial medical help to the patient, then retrieve that patient back to the hospital. By doing that we don't have to build multiple r trauma centres - cost effective for the gummint and patient outcome positive.
Same argument for the advent of the helicopter air ambulance. Only now it is possible to cover a much larger area too. It has three sudden advantages:
1. The rapid transport - aka golden hour advantages as pointed out numerous times in this thread already.
2. The ability to concentrate higher medical resources quickly.
3. The ability to access (by speed or environment) patients that previously could not be accessed either at all, or in time to prevent a poor outcome.
Forgetting the rescue elements of the third point which are not really being debated here, it is this second one that could be included in our considerations. Do we spend millions of dollars on providing a rapid transport vehicle to bring more paramedics to a scene that already has paramedics, OR do we try and multiply the benefits of the expenditure by throwing on a higher level of medical capability?
I note that even where non-doctor models are the norm, it seems most operations would ascribe to this point because they already put the highest trained or "level" of ambulance officer on board - ie paramedic. And most of this thread calls for increased training and a higher level of protocol for the paramedics.
SO what is the difference between the doctor and the high level of paramedic? Dollars?
NOT ONLY. The typical paramedic has an enormous amount of scene experience and pre hospital medical experience that just cannot be learned from a hospital ED, and the doctor brings an enormous amount of medical experience that cannot be learned pre-hospital. Surely the most appropriate model is a combination?????
It seems this thread has not discussed the fact that a paramedic/doctor can operate as an effective team bringing all the attributes that each side of this argument has so forcefully put forward.
In NSW, that is how the Sydney basin runs. The helicopters are manned by the highest level of paramedic who runs scene management, rescue situations, and enables the doctor to be protected, safe, and able to perform the medical intervention. He is also able to maintain the situational awareness re curing on roadside V getting back to the ED. He can also effectively manage medical interventions on patients in multiple casualty situations, provide a higher level of care using the scene doctor's protocols and liaise effectively with ground ambulance assets (he understands the system) to produce the most effective outcome.
The doctor is a senior trauma or anesthetic registrar or consultant who can manage the medical intervention, and rapidly provide triage. Given enough equipment, he can bring the golden hour care to the patient in a majority of cases. AND they get trained to listen to the scene experience of the paramedic and to take that advice - something that is not always part of their hospital backgrounds.
Great model if you have the resources. But it only takes one or two casualties experiencing a poor outcome per year for this resource expenditure to become viable - let alone the human value aspects!