Question: Why are all the directives based upon an urban setting assumption given that there are very rural areas in which paramedics work in besides big cities? Further to this, one could suggest that certain advanced skills are more appropriate if not life saving the further from a hospital. Has there ever been any consideration to consider such advanced care skills such as midazolam for seizures, needle thoracostomy, peds IO and even cricothyrotomy to name a few. Why are these not even considered in areas with transport times exceeding well over 1-2hrs. These are skills that overall can make a significant difference in patient outcomes especially when no other care is available. To add, these are not skills that can be deemed to be well learned for even experienced ACP's as actual prevalence even in an urban setting is very low. Thus, the number needed learn position can be put forth ACP's anymore than PCP's but the difference in distance to more advanced care certainly can.
The answer to your question is complicated. Paramedic scope of practice expanded on the assumption that Emergency Department practices could be moved into the pre-hospital setting for the emergent care of critically ill or injured people. This was based on analogies to the successful reduction of mortality from blood transfusions and forward operating medical capability on the battlefield. It was also clear that survival from conditions such as cardiac arrest from ventricular fibrillation is improved by pre-hospital defibrillation. It made sense that early treatment of other conditions would be beneficial. Paramedic scope of practice in Ontario expanded initially in urban areas because it was believed the volume of patients who might potentially benefit from these skills was high and because the response time was relatively low. Initially it was felt that the low volume of cases in rural areas that required specific ALS skills was too small to make the training and maintenance of competence practical. The argument, similar to the one you made in your question, was also made by the provincial MACs Rural and Remote Working Group in 2002. The recommendations from that group led to the expansion of PCP skills beyond the 5 original symptom relief drugs and defibrillation capability. Now PCPs start IVs, administer multiple medications, including analgesics in both urban and rural areas. This was all based on the same argument that you made that these paramedic capabilities are even more needed in rural areas.
Unfortunately, the research based evidence for a benefit of any of these added skills is small or non-existent. What evidence we do have, from studies such as OPALS, does not support the stay and play approach to trauma. There is evidence that these practices might even be harmful. None of the commonly used medications given in to patients in cardiac arrest have an evidence base for their effectiveness. In rural areas the advanced skills are seldom used. There has been consideration to introduce procedures, such as needle thoracostomy, drugs for seizures, and criothyroidotomy, that you mention. There is evidence that these skills are infrequently used by ACPs, even in urban areas. Despite your claim that these skills make a significant difference in patient outcomes there is no evidence other than the occasional anecdotal, case of 1 type evidence, to support that claim. Although we all believe it should make a difference, it is difficult to justify the addition of rarely used skills. There is a substantial use of resources to train and maintain the competence to use these skills that might be better used elsewhere. Prehospital research to determine whether many of the ALS procedures are effective or not is extremely difficult and costly to do. The system continues to advance but it will likely advance in small increments for the foreseeable future.