The Same Problem from Opposite Ends
How American and Italian prehospital systems are asking the same questions
One system sends physicians to the scene. The other sends paramedics. One is centralized, state-funded, coordinated from a single dispatch. The other is a patchwork of more than 14,000 agencies operating under different protocols, different funding models, different cultures.
And yet, when you sit down with Nick Nudell — paramedic, governance researcher, director of medical operations for ultra-endurance events across the Rocky Mountains — the differences start to look like variations on a single theme.
In this second conversation, we pushed further: into the structural tensions that shape prehospital care, the lessons that flow between a 100-mile mountain race and a rural ambulance shift, and the question of whether two systems built from opposite starting points might actually be solving the same problem.
In Valle d'Aosta — an Alpine region of 125,000 people — we have a single, centralized EMS system covering the entire territory. In rural Colorado, you might have a volunteer squad, a fire-based service, and a private ambulance company operating in neighboring counties with completely different protocols. How does this fragmentation affect patient outcomes?
“Colorado has more than 240 EMS agencies serving approximately six million residents. Across the United States, roughly 14,000 ambulance services are operating under various models: municipal, fire-based, hospital-based, private, nonprofit, ground, and air.
Fragmentation creates variability in funding, protocol adoption, training pathways, and operational culture. That variability can influence consistency and equity. — says Nudell — At the same time, centralized systems have tradeoffs. Large unified systems may achieve standardization but can also develop bureaucratic rigidity. Smaller systems may innovate more rapidly but face sustainability challenges.
Structure alone does not determine performance. Governance quality, accountability mechanisms, funding alignment, workforce stability, and community integration are more predictive of outcomes than whether a system is centralized or fragmented.”
Your doctoral research focuses on governance frameworks for public safety networks. If you had to redesign rural EMS governance from scratch, what would you keep from the American model and what would you borrow from European systems?
“I appreciate this question because it resists easy answers. — says Nudell — What I would keep from the American model is its adaptability and community-level engagement. Many rural EMS systems in the United States are locally governed by municipalities, counties, fire districts, or nonprofit boards. That structure allows communities to shape services around geography and risk profile. In theory, it fosters responsiveness. In practice, it can also create inequity. But the principle of decisions being made closest to the affected population has value.
Another strength worth preserving is the maturation toward comprehensive clinical governance. Many systems are moving beyond traditional physician "medical direction" models toward broader structures that include protocol development, quality assurance, audit, performance metrics, continuing education, and interdisciplinary accountability. That shift strengthens professional credibility while maintaining collaboration.
From European systems, I am drawn to structural coherence. — he continues — Clear integration with national health services, standardized educational pathways, and regional coordination may reduce variability and promote equity across territories.
If I were redesigning governance, I would aim for regional coordination that ensures equity and data transparency while preserving local operational flexibility. Above all, reform should be outcome-driven rather than identity-driven.”
In Italy, the 118 dispatch center is staffed by physicians and nurses who provide real-time clinical guidance. In the US, dispatchers follow algorithm-based protocols. You've researched machine learning for dispatch optimization — do you see AI as the bridge between these two approaches?
“Dispatch is fundamentally a decision science problem. — says Nudell — A distressed caller provides fragmented information. The dispatcher must interpret that information, assign acuity, allocate resources, and provide instructions. Clinician-staffed dispatch may allow nuanced interpretation, but it is resource-intensive. Protocol-based dispatch promotes consistency and scalability.
Artificial intelligence offers the possibility of augmentation. AI systems could analyze historical outcomes, geographic data, language patterns, and environmental variables to assist human decision-makers. The goal is not replacement but cognitive support. With appropriate governance and transparency, AI could strengthen both clinician-led and protocol-based dispatch models.”
You've directed medical operations for over 50 ultra-endurance events. When you set up a medical system for a 100-mile race through the Rocky Mountains, how much of that planning transfers from your rural EMS experience — and where does it break down completely?
“It is difficult for me to separate my ultra-endurance event work from my rural EMS experience because the latter shapes how I think operationally. — says Nudell —
Most 100-mile races occur in terrain that is geographically constrained in exactly the way rural EMS is constrained: distance, limited access, environmental unpredictability, and imperfect information. An athlete may be several kilometers from the nearest aid station. Communication can be unreliable. The weather can change rapidly. Extraction routes may require hiking, off-road vehicles, or technical rescue. When a call comes in from the course, the information is often incomplete. That mirrors rural response.
Planning, therefore, becomes layered contingency thinking. What is most likely? What is the worst case? What if evacuation is delayed? What if aviation is unavailable? Those are rural EMS questions.
The difference lies in epidemiology and psychology. — he continues — Athletes are generally healthier, but they may minimize symptoms or push through physiologic warning signs. That requires a different kind of clinical conversation.
Another nuance is the non-athlete patient — volunteers, spectators, family members. These individuals may present with unrelated conditions and may carry a higher baseline risk.
What transfers most directly from rural EMS is mindset: comfort with uncertainty, readiness for prolonged care, and operational discipline when transport is not immediately available.”
The American College of Paramedics proposes a tiered clinician framework that would professionalize paramedicine closer to the UK or Australian model. From an Italian perspective, we already have physicians in the field, but struggle with standardization across regions. Are we solving the same problem from opposite ends?
“I think we may be. — says Nudell —
In North America, paramedicine developed rapidly and unevenly. Educational standards vary by state and province. Scope of practice is regulated at the jurisdictional level. Workforce composition differs across regions. That variability has created inconsistencies in identity and expectations. The movement toward tiered clinician frameworks is, in many ways, an effort to bring coherence — to clarify educational pathways, clinical competencies, and governance accountability.
If Italy experiences variability despite deploying physicians in the field, that suggests the underlying issue may not be whether a physician or paramedic is present. It may instead be how governance structures coordinate standards, oversight, data collection, and regional integration.
Across systems, we sometimes focus on professional designation as the primary determinant of quality. — he continues — In reality, governance architecture may be more influential. How are protocols standardized? Who audits performance? How are adverse events reviewed? How is continuing education structured? How is funding aligned with operational needs? Those structural questions shape consistency more than a professional title alone.
North America may be attempting to standardize upward from a decentralized paramedic foundation, while parts of Europe are attempting to harmonize regional practice within physician-led frameworks. Both efforts may reflect the same pressures: workforce sustainability, financial constraint, increasing clinical complexity, and public expectations of accountability.
If that is true, then the dialogue between systems becomes collaborative rather than comparative. We may be addressing similar structural tensions from different historical starting points.”
