Now that EMS is more than three decades old, a body of research has started to evolve that will define the future of the profession. More often than not, EMS practices that made perfect sense when the industry was in its infancy have been found to be ineffective or, in some cases, actually harmful. Thirty years ago, we gave large volumes of IV fluids for trauma. Today we only give judicious amounts. Endotracheal intubation was considered the “gold standard” for airway management. Today, many of the alternative airway devices are considered just as effective and even used in lieu of endotracheal intubation. Thirty years ago, we stressed the need for a rapid response and quick intervention. Today we know that in very few instances does speed and response time truly make a difference. Thirty years ago we pumped every possible drug into a cardiac arrest patient. Today, we only administer epinephrine — and that practice will probably soon cease. Thirty years ago, the purpose of EMS was primarily to resuscitate victims of cardiac arrest. Today, we’re starting to recognize that, for the most part, cardiac arrest resuscitation is futile. I know the saying is clich , but the paradigm is really shifting for us.

If you look at the big picture — what the sum total of research is telling us — it’s that the best use of EMS is to intervene earlier in the disease process. Instead of trying to raise the dead, we should be applying treatments that prevent cardiac arrest. You’ll save a lot more patients with a bottle of aspirin than you ever will with a defibrillator — I’ve been saying that for years. The treatment of trauma is changing from the old “load and go” to a more steady approach. While a small percentage of trauma patients need immediate surgery, most do not. Thus, the importance of prehospital procedures that help to minimize secondary injury is becoming increasingly important. The rapid and adequate treatment of pain improves outcomes. Proper hemorrhage control and splinting improves outcomes. Preventing hypoxia and hypercapnia improves outcomes. And, when there is little that we can do, we re starting to provide therapies that prevent secondary injury, such as inducing hypothermia. Truly, it’s a different ball game.

Intervening earlier in the disease process means that EMTs and paramedic must be better educated — not less. It’s more difficult to detect the signs and symptoms of illness and injury earlier in the illness/injury continuum. Thus, EMS personnel must have a better understanding of anatomy, physiology, pathophysiology and medicine in general. The paramedic of the future can’t rely upon rote memorization or utilize algorithm flow sheets to direct care. They must be able to recognize the patient s problem, determine the appropriate intervention, apply that intervention and monitor the patient for improvement or deterioration. EMS personnel must think and do so independently! They must recognize that each patient s different, and medications and treatments must be customized for the patient in question. It will no longer be satisfactory to justify administering a drug because page 134 of Wanker EMS’s protocols state that the drug should be given. Prehospital care has evolved to a point where EMS personnel aren t practicing as an extension of the system medical director. They’re practicing within a well-defined scope of practice. Protocols should become clinical guidelines. On-line medical direction should be limited and used for consultation with a physician for difficult or problematic cases. Furthermore, EMS personnel must take responsibility for their actions — not point at the protocol book, the dispatcher or a textbook as the reason for their decision.

Becoming better educated means spending more time in the classroom, It means spending more time reading, more time working in the clinical settings and more time in supervised field training. It means reading and following the scientific literature of the discipline. EMS programs now require the assets and capabilities only present in academic settings. These include such things as a reference library, access to cadavers and tissue samples, access to specialists in medicine and allied health, high-fidelity human simulators, computers, multi-media material and much more. The old days of buying a textbook, reviewing old tests and simply going through the motions during clinical rotations and field internships are a thing of the past. At the same time, academic centers must develop outreach and satellite programs whereby their faculty and resources are brought to an area that doesn’t have such resources. Distributive EMS education, primarily over the Internet, will become commonplace. To quote Bob Dylan, “Times they are a changin’.”

A lot still needs to be determined. Do we need as many paramedics as we have now? Should we no longer transport medical cardiac arrest patients who we’ve failed to resuscitate in the field? How involved should EMS personnel be in preventive medicine? Do we need paramedic practitioners to ease the load on hospital emergency departments and 9-1-1 services? Do I have all the answers? No. I’m not sure I have any of them. But, I have been in this business for more than 30 years and I follow the literature. Regardless, over the next few years, if nothing else, the journey will be interesting.