In terms of cardiac arrest, an ER simply is not “way beyond ACLS.” What truly has been shown to work is quality CPR and early defibrillation.
I think you’re underestimating the current prehospital EMS scope of practice. Paramedics can have RSI, video laryngoscopy, ultrasound, LMA and other supraglottic airways, cricothyrotomy, needle decompression, defibrillation, pacing, cardioversion, etc. Thoracostomy and cardiac massage are unlikely to be indicated in the situations we’re discussing here. There’s not a cath lab in the ED either.
Well duh. No kidding. But in medium to larger hospitals the Cath lab is a heck of a lot closer than it is to the field.
I have a reading suggestion for you.
https://www.goodreads.com/book/show/15819230-erasing-death
The first chapter alone should help you understand the difference between the field and the ED.
Also not every county has a paramedic available.
And some have none.