American Paramedic interested in Australia or NZ

[thegreypilgrim]

Hey everyone.

I'm currently a paramedic from Southern California in the US. I'm interested to know what the process would be if one were looking to relocate to either one of the wonderful nations of Australia (i.e. prison colony) or New Zealand (i.e. sheep colony).

What, exactly, would I have to do? Is there any sort of mechanism for reciprocity? Would I have to complete an Aussie or NZ approved paramedic course (as I understand it, these are usually bachelor-degree appropriate). What if I have a degree in EMS? How is the job market for paramedics in your respective countries?

Thank you guys so much for any input.

 

[MrBrown]

If you were bad in England you got sent to Oz if you were bad in Oz they sent you here .... what does that say about us?

Everything is changing here; but basically works like this: EMS here is provided under contract to the Ministry of Health by two hospital based services (Wairarapa and Taranaki District Health Boards -- don't worry about the pronounciation even I can't quite get it down) and two private not for profits, Wellington Free (again, a minority provder) and St John (that covers 90% of the country).

Reciprocity is at the behest of the service, there is no nationally consistent structure and the system is so fragmented it's a bit of a nightmare as qualifications, titles, scopes of practice, remuneration and who gets what in terms of authority to practice and reumeration is totally controlled by the individual services.

I can only speak for St John and less specifically, Wellington Free as I have no experience in the DHB services.

St John ("the service") is a not for profit charity that provides EMS to around 90% of the country (it also does a million bloody other things that really amount to touchy feely and warm fuzzy jerking off which has no realation to EMS whatsoever and detract from the professional progression of the Paramedic profession in this country). You will be hard pressed to find a paid member of staff who does not have some problem with how St John operates.

There are five clinical practice levels within St John.

• Primary Care: OPA & O2, entonox, splints and AED
• Ambulance Officer: NPA, LMA, NTG, glucagon IM, ventolin, asa
• Paramedic: 3 lead ECGs, Manual defib, IV NS & 10% dextrose
• Upskilled Paramedic: adrenaline, morphine, zofran and naloxone
• Advanced Paramedic: ALS

The service selects who gets what training and what they can practice as. Even tho you might have completed say the AO course, there is no guarentee you will be given the authority to practice at that level or remunerated as such.

We are trying to transition towards a nationally consistent model for education and scope of practice as well as registration as a health professional under NZ law (these will come by around 2014 from all accounts)

You can find our clinical procedures herehttp://stjohn.org.nz/files/201054_2007827116.PDF. It explains our practice levels and prodedures. We are getting new procedures this month and I will post a link when I have one.

Coming in from overseas is not .... difficult but it's a challenge as the industry here is self-regulating and therefore, you are at the mercy of the service, so to speak.

NZ does offer some great places to work in terms of scenery and some very nice people; we also offer "freedom" from having to call up for orders and have an MD breathing down your neck but there are some unique aspects of the service you need to be aware of.

If you need any help let me know!

 

[ah2388]

There are five clinical practice levels within St John.

• Primary Care: OPA & O2, entonox, splints and AED
• Ambulance Officer: NPA, LMA, NTG, glucagon IM, ventolin, asa
• Paramedic: 3 lead ECGs, Manual defib, IV NS & 10% dextrose
• Upskilled Paramedic: adrenaline, morphine, zofran and naloxone
• Advanced Paramedic: ALS

sounds ultra confusing, i was interested in opportunities like this as well.

Id be interested to learn more about what say an NREMT-P license in the states translates to overseas, although i guess in this isntance its as you said "at the mercy of the service"

 

[medic417]

I believe they require more education than the USA Paramedic but not sure. If I'm right you would probably have to go back to college.

 

[MrBrown]

sounds ultra confusing, i was interested in opportunities like this as well.

Yes it is ... the ambulance services here are totally self regulating (with the exception of the KPIs required by the Ministry of Health; which is basically response times, response times, response times) so you really have to go with whatever they come up with ... which sometimes don't make sense!

When it comes to your coming in from overseas you go to a body called Ambulance New Zealand; which is the national lobby group ("big ambulance" lol). They are not a Government body, have no regulatory powers or anything like that and basically personally they don't seem to do much. But for you they take a look at your qualifications and say well you fit here.

This is also complicated by the fact although we have nationally consistent qualifications from the standpoint of the qualifications regulatory body (called NZQA - NZ Qualifications Authority) the services (largely out of need) has fragmented them to serve thier own individual needs.

You are also correct we offer Bachelors degrees in EMS (Bachelor of Health Science (Paramedic)). However these were not the idea of the service (well St John at least) and the acceptance of degree graduates has been a bit of a contensious issue. As to whether they would make you go back to school or not I can't say; I doubt it but I can't say.

From what I have seen most overseas people are employed at either Ambulance Officer or Paramedic level (see above, this is not the same as a US Paramedic!) and then they work up to Upskill Paramedic and hopefully, Advanced Paramedic but well as to how long this takes is sort of like following Alice down the rabbit hole .....

The whole issue is complicated by regional variation in what should be a nationally consistent model of service delivery. We have a national structure and set of procedures for operating but this is complicated by the fact the national management of St John maintains contracts if you will with regional management boards which then deliver the ambulance service. While there is less regional variation than there used to be (the Clinical Management Group and our Medical Director are really making a push towards a nationally consistent model because they know this regionalisation has caused more than a few problems). It is therefore left up to the regions to decide how they want to progress thier staff through the qualification levels, who gets picked, how they get picked, favouritisim etc

The good news is that we have a new system called "Road to Clinical Excellence" which recognises all little issues like regionalisation, five practice levels, different levels of clinical support, different medical advisors for each region etc and that is putting in place a new framework that will hopefully solve them.

This new process has three practice levels

• 
  * Ambulance Technician: current Ambulance Officer (Diploma)
  * Paramedic: current Upskilled Paramedic (Bachelors Degree)
  * Intensive Care Paramedic: current Advanced Paramedic (Post Graduate Certificate)

This new process will hopefully make reciprocity easier for all because it is based upon proper university education so you should get reciprocity in terms of a qualification but may have to do one or two classes here to get the qualification. It is the ultimate goal that these qualifications will be the benchmarks for registration with an indepandant licensing body for Paramedics who will give you a license to practice at a certian level.

These changes are at least two and up to five (or more) years away as it stands at the moment.

In the meantime .... I suggest you email recruitmentservices@stjohn.org.nz or work@wfa.org.nz. I hear WFA are more friendly with overseas applicants as they have been transitioning to the new 3 level education system for some time.

I hope this helps, if you need any more information I'll do the best I can.

 

[thegreypilgrim]

Thank you very much MrBrown for all the information!

 

[Melclin]

Id be interested to learn more about what say an NREMT-P license in the states translates to overseas, although i guess in this isntance its as you said "at the mercy of the service"

+ thegreypilgrim.

Without trying to sound mean, here in Victoria at least, I would imagine American qualifications would mean sweet FA. However, I honestly can't say for sure and I think it would differ depending on what your qualifications actually were.

We have two levels of 000 (911) ground response:

Ambulance Paramedic(3yr Bachelors degree): 3 lead, LMA, IV NS, IV/IM Adrenaline, IV/IM Morphine, IN Fentanyl, IV Metaclopramide, IM Prochlorperazine, IM Midazolam, Methoxyflurane, ASA, GTN, Glucagon, D10, Ceftriaxone, Lidocaine, Salbutamol, Atrovent, IM Naloxone. More importantly, enough scope to step outside the guidelines as long as you can justify it medically (education education education).

Mobile Intensive Care Ambulance (MICA) Paramedic(in addition to the bachelors degree, and 3yrs experience, 1yr Grad-cert/dip.): This is our equivalent to ALS backup. Every case gets two ambulance paramedics and some cases also get a MICA response (or you can request it as an AP, if you get on scene and the s**t hits the fan): Their scope includes most of the ALS you would have in a typical progressive agency. 12-lead, RSI, pneumocath, cric, Prehospital thrombolysis, sedation for sync cardio version, pre-hospital triage (direct-to-cath-lab type deals).

We have a completely different approach to ambulance here which might end up being somewhat difficult to take in. Autonomous clinical decision making and our ability to treat pts outside of the guidelines (within reason) seem to be significantly above that of our American counterparts and we also seem to have different foci (eg analgesia is very important here, while C-spine precautions aren't; we also have a lesser emphasis on pharmacology). We don't call for orders and we don't have medical control. If we want advice or we want to do something novelle, it is expected that Ambulance paramedics should call "the clinician" (eg our ceftriaxone is for meningococcal but if we came across a severely septic pt we should call the clinician) who is also a paramedic, albeit a highly educated and experienced one, and consultation with trauma services regarding specifically complex cases is common, but it is a consult, its not asking for permission.

I can't help but sound like a bit of a wanker saying all this, but I'm honestly not trying to say, "look how special we are, you'll never be this good". I'm just explaining why it is that your qualifications will need to be significantly upgraded. The American paramedic education system and EMS in general is a pretty big joke over here (again not trying to be a d**k, its just how it is I'm afraid) so I can't see an American qualification counting for very much.

What I think you'll have to do, at least here in Vic (requirements may be a bit more stringent here given our extra scope to make our own decisions), if you have one of those American "associate degrees" (we don't have them here, some I'm not quite sure how they would stack up) you might be able to enter a a degree on advanced entry. Its for people who already have degrees in other health care fields. Nurses, example, can get advanced entry, which means the degree only takes two years instead of three. Any which way you look at it though, you won't be practicing at what you'd consider ALS level (it typically takes at least 7-8 yrs to get there, 4 of them at university, so 2 years or less at unrecognized institutions is not going to fly regardless of experience).

While its different in all states, educations requirements are pretty uniformly becoming the bachelors degree for basic practice. If you or anyone else are serious I can easily ask at uni what you'll have to do so you can find out for sure.

A word to the wise, look in the state of South Australia, they are paying almost $20,000 more a year than some other states (you can easily earn well over $100,000 a year there). And don't even think about Western Australia. The system there is run by St. John and as Brown said, they have some pretty big problems and they pay bugger all. Pretty much everywhere is desperate for MICA/Intensive care medics and certainly Ambulance Victoria are taking more and more Ambulance paramedics every year. With your experience and an upgrade on your degree, you'd be guaranteed a job. And we have tim-tams...lots and lots of tim-tams

 

[MrBrown]

Basically what Mel says stacks up here but we just don't really have the good clinical infastructure to support it 100% yet; the ambulance service here is very different.

We are goverened by a "medical director" who chairs our Clinical Advisory Group (a panel of 5 emergency/IC physicans and 5 IC Paramedics) and they set our procedures, run the medical audit etc but they do not get involved in the day-to-day clinical decision making of our officers.

If road-staff encounter a very sick patient or somebody they have no idea how to treat (which is very, very rare) they can consult with a medical advisor (one of the 5 physicans on the CAG) or the senior registrar/consultant (attending physician or higher) at thier destination ED via cellphone). Nationally this happens about once a day maybe for about 4.6 million people. Note I said consult you are not asking for permission to do anything because on-road you are expected to have enough clout and nouce to figure it out on your own.

That is not to say we simply cut you loose off into the wild blue yonder and set you free to battle all by your lonesome but you are expected to be a professional capable of unsupervised, self directed practice. This all goes back to the seventies but you have never had to "call for orders" because the origins of our two systems (NZ vs US) is very different; yours is very much physican led from the beginning - it was Nagel and Hirschman and oh blast what the devil was his name, dude in Seattle, Cobb and Cohen and whatnot who developed the idea. Here, the system sort of grew up independant of the auspicies of medicine and has used them when necessary; for example to allow us to carry controlled drugs legally. We do have a good relationship with our physican leadership and there is now greater emphasis upon clinical support and leadership than there was say ten or even five years ago but the two are still very much onpar here; we are not "remote control medicine" by any means of the term and we will vehemently resist any form of attempt to make us so.

Not to sound like a total wanker here mate; but California (partic SoCal) has some of the worst paramedics I have ever met; they are nothing more than a [fire department] patch factory graudate who has passed a test that reads at the eleventh grade, does not test any form of understanding of anatomy and physiology, patho or pharmokenetics and that I could probably pass tommorow if I studied drug doses from Bledsoe, Porter etal and went to a PearsonVue Center.

There was a guy I knew from Texas who came down here with his EMT-Paramedic certificate from the local community college who was practicing at ALS level there and who was very suprised when St John would not recognize anything above his basic EMT card because his manager and regional medical advisor were not confident in allowing him to practice indepndantly on what really amounted to sweet FA education.

The Paramedic of tommorow in this part of the world will be a Bachelors Degree educated, registered and licensed health professional with autonomy and the knowlege/exp to make autonmous decisions but with recall to appropriate medical consulation medium should they require it.

I have to agree with Mel; your system is something of a joke around the coffee table here and it's really sad to say that because you guys are trying so very hard to advance.

We're not saying this to be nasty or mean mate because I (personally) think the US is a great country I really like the people, have worked (non EMS) and travelled there extensively but it's just a very different game.

If I were you I would look into going to Australia; we are a great system here but we don't have the clincal infastructure or appropriate funding to really come up and out of a "holding" position operating "to our best endeavours" because of a lack of funding.

As a side note Mel my Australian mate; what sort of clinical oversight or medical direction does ASV/MAS have - surely you have a physician (or his signature) lurking around there somewhere to allow you to perform controlled acts or deliver rx/controlled medication to patients as you are not yet rego'd?

 

[MrBrown]

As a follow up:

Our procuedures (you can read ours online herehttp://stjohn.org.nz/files/201054_2007827116.PDF) are very different and have (as Mel says) a different focus than the US. Your procedures seem to be very "here is what you can do, ask for permission for everything else". I've read the Los Angeles County EMSA procedures and they still require "base contact" with a "base hospital" for everything; you are given a little window of autonomy to treat life threatning things w/o wasting time calling OLMC but you must call a physician after you do. I don't know if this is a litigious manifestation to prevent people from suing you for malpractice or lack of practice or lack of consult with a "real" doctor or if the base physicians do not trust you given your variable delivery of what is an already inconsistent and inadquate education (that's mostly a personal observation but nothing personal on you mate) but it's just not how we work here.

For example: if I get a patient who I think requires cervical spine immobilisation I can follow the guidance given in our protocol on pages 14-16 of our procedures and apply clinical judgement whereas you are bound by a very tight set of criteria that make only minimal sense. For reference the LA County protocol. We do not even carry longboards any more and I saw a pair of head blocks gathering dust out in the vehicle bay last time I was on station.

We are very agressive about pain management (see the blue section at the back of our procedures) and carry six different analgesics (entonox, methoxyflurane, paracetamol, fentanyl, midazolam and ketamine) whereas the LA protocol is something out of about 1992 here and seems to only allow large doses of morphine.

If you do come down here to work be prepared for a very different way of operating.

If we can be of any more help then please let us know; might I also suggest you check out the Ambulance Service of NSW as they have a whole section on Internationals.

 

[Melclin]

As a side note Mel my Australian mate; what sort of clinical oversight or medical direction does ASV/MAS have - surely you have a physician (or his signature) lurking around there somewhere to allow you to perform controlled acts or deliver rx/controlled medication to patients as you are not yet rego'd?

I couldn't say for sure. Being a student, I don't actually work for them yet and its constantly changing, esp lately with the unification of rural and metro. My understanding though is that it works a little something like this:

There is a doctor who is effectively a medical director who has the power to change guidelines to a degree. If it requires logistical or financial changes it must be okayed by the relevant committees/board/whatever. There is also a comitee of doctors (a few of each: ED, cardio, pulmonary, ICU, paed...if memory serves). Who the director consults, and who review the guidelines regularly and who must agree on certain changes to guidelines.

This is old news, but it probably still works similarly. Now days I know that there are some super dooper MICA medics invovled in the process to a significgant degree, but how that works exactly I don't know. The point is though, just as with your system Brown, that the docs have nothing to do with individual case management.

We are very agressive about pain management (see the blue section at the back of our procedures) and carry six different analgesics (entonox, methoxyflurane, paracetamol, fentanyl, midazolam and ketamine) whereas the LA protocol is something out of about 1992 here and seems to only allow large doses of morphine.

I wish we had IV paracetamol. Its bloody brilliant stuff. Is yours IV or PO? Doesn't seem much point in having PO paracetamol, unless you're more involved in the paramedic practitioner side of things.

I've heard that given the general awesomeness of IN fentanyl, that Methoxyflurane might go the way of the dodo.

Ketamine is being investigated for use here. I don't agree with it entirely. I think doctors underestimate the psychological effects of dissociatives/hallucinogens. There is alot of anecdotal evidence kicking around the recreational scene about the effects of "bad trips" etc. I also know a man who received ketamine in ICU. His brain just doesn't work the same. Reminds me of talking too old hippies who've had a few to many drops of LCD. I don't know..its alright for short term use I suppose, I'd just like for doctors to expand their understanding of drugs beyond what they read in their textbooks.

 

[downunderwunda]

I couldn't say for sure. Being a student, I don't actually work for them yet and its constantly changing, esp lately with the unification of rural and metro. My understanding though is that it works a little something like this:

There is a doctor who is effectively a medical director who has the power to change guidelines to a degree. If it requires logistical or financial changes it must be okayed by the relevant committees/board/whatever. There is also a comitee of doctors (a few of each: ED, cardio, pulmonary, ICU, paed...if memory serves). Who the director consults, and who review the guidelines regularly and who must agree on certain changes to guidelines.

This is old news, but it probably still works similarly. Now days I know that there are some super dooper MICA medics invovled in the process to a significgant degree, but how that works exactly I don't know. The point is though, just as with your system Brown, that the docs have nothing to do with individual case management.




I wish we had IV paracetamol. Its bloody brilliant stuff. Is yours IV or PO? Doesn't seem much point in having PO paracetamol, unless you're more involved in the paramedic practitioner side of things.

I've heard that given the general awesomeness of IN fentanyl, that Methoxyflurane might go the way of the dodo.

Ketamine is being investigated for use here. I don't agree with it entirely. I think doctors underestimate the psychological effects of dissociatives/hallucinogens. There is alot of anecdotal evidence kicking around the recreational scene about the effects of "bad trips" etc. I also know a man who received ketamine in ICU. His brain just doesn't work the same. Reminds me of talking too old hippies who've had a few to many drops of LCD. I don't know..its alright for short term use I suppose, I'd just like for doctors to expand their understanding of drugs beyond what they read in their textbooks.

All Aussie sevices work under a Medical Director who in essence reviews current practice & authorises changes to protocol, pharmacology & proceedure in line with worldwide evidence based practice.

This being said, there is no need for us as pre hospital care practitioners to contact a Doctor.

People tend to think EMS is more than what it is. Treat the symptoms in front of you. Who needs a Dr who cant see the patient telling you what to do? But this is from a country that treats EMS as second class citizens to their tossers, i mean FD.

 

[MrBrown]

All Aussie sevices work under a Medical Director who in essence reviews current practice & authorises changes to protocol, pharmacology & proceedure in line with worldwide evidence based practice.

That is essentially how it works here; we have a ten person panel made up of five physicians (all of whom work in emerg or IC) and five IC Paramedics who review various things (evidence, journals, cases that go pear shaped), set our procedures and consume a lot of coffee

They do not get involved in the day-to-day clinical decision making of the roads crews except ...

This being said, there is no need for us as pre hospital care practitioners to contact a Doctor.

... well I do agree with what you mean here mate; no we shouldn't have to scurry off and crank up the Johnn and Roy biophone to ask "doctor may I?" but we have avenues of consult a physician and there are certian situations as Mel said which they can be of some use.

Example:

- Severely septic patient, can you send somebody out to meet me enroute for IV antibiotics?
- Consult for most appropriate destination facility for ? CVA, severe burns, STEMI, orthopeadic cases etc. This is not really applicable to most of the country but some places it is; like here you have two hospitals that some crews are time-wise not much closer to one than the other however one is more appropriate for major trauma etc
- Really whacky things you just do not know how to treat

There are also the little towns which only have one or two GPs (PCP) and these practitioners often well known to the local ambulance crew (usually a paid officer + vollies or totally volly) and they are really invaluable for things that the crews don't know how to treat or need advice on; now you'll notice I'm saying "advice" and "consult"; we are not asking for permission to do anything!

It's not generally something that our crew make habit of talking with a physician about what to do because if something is outside of your scope or experience, call for an IC Paramedic (often easier said than done in some parts of the country) or your Watch Manager (who are all IC Paramedics and often very experienced). But in podunk towns at one am when you are working on your own and presented with something troubling hey it's going to take an hour for an IC Paramedic to get here so it's just easier to pull the trusty 21st century Biophone out and have a word with the local GP.

There is also some use of GPs here rurally for things like morphine or pre-hospital antibiotics but this is really a symptom of the wider disease that rural crews aren't that well qualified and can't give IV analgesia. It's often again, easier to whip round to the local GP clinic and have the doctor give some morphine then take the patient into ED than meeting backup on the way because in some cases there is no backup.

God we're starting to sound like WA here; yikes if we get that bad I'm worried!

I wish we had IV paracetamol. Its bloody brilliant stuff. Is yours IV or PO? Doesn't seem much point in having PO paracetamol, unless you're more involved in the paramedic practitioner side of things.

No our is PO; it's given to all our clinical levels to dish out for minor headaches, muscle pain etc but its use is on-road at least not very common; it's mainly for the events guys (this is the Johnnos remember?)

I've heard that given the general awesomeness of IN fentanyl, that Methoxyflurane might go the way of the dodo.

Fentanly is only very new here; like last week new so I have not seen how we plan to administer it but we do have IN naloxone and midazolam so I'd have a guess that it might be in there.

Methoxyflurane will never go away here; again because there are too many people that do events work for St John who will never, ever, ever be qualified enough to dish out narcotic analgesia.

With the new system we are getting (which is pretty much going to be national I hope) there is a "play" level for the events and touchy feely people who don't do emergency work and who take nana to the clinic and cover the rugger; so methoxy is cheap and effective for them.

As far as emergency work is concerned we will also keep methoxy for the volunteer ambo's but that's it; for the paid ambos there is now a total shift towards a quasi Australian/UK model which goes from four levels to two:

Paramedic: ASA, paracetamol, methoxy, GTN, salbutamol neb, IM Glucagon, 3 lead, LMA, manual defib, IV NS, IV 10% glucose, IV/IM/neb adrenaline, IV/IM/PO zofran, fentanyl, IV/IM/IN naloxone, tourniquet

Intensive Care Paramedic: Standard ALS: 12 leads, intubation, ketamine, midaz, atropine, cardioversion, pacing, amiodarone, frusemide, intraosseous, RSI (select) ... and in the future prehospital thrombolysis

Ketamine is being investigated for use here. I don't agree with it entirely. I think doctors underestimate the psychological effects of dissociatives/hallucinogens. There is alot of anecdotal evidence kicking around the recreational scene about the effects of "bad trips" etc. I also know a man who received ketamine in ICU. His brain just doesn't work the same. Reminds me of talking too old hippies who've had a few to many drops of LCD. I don't know..its alright for short term use I suppose, I'd just like for doctors to expand their understanding of drugs beyond what they read in their textbooks.

I've seen great results with ketamine; yes there are some people (esp peads) who have bad emergence syndrome but overall I think its realy great; unless we want to start carrying etomidate or something like that I'm not sure what else we could use

 

[downunderwunda]

Are you for real. Let me address your examples individually.

... well I do agree with what you mean here mate; no we shouldn't have to scurry off and crank up the Johnn and Roy biophone to ask "doctor may I?" but we have avenues of consult a physician and there are certian situations as Mel said which they can be of some use.

Example:

- Severely septic patient, can you send somebody out to meet me enroute for IV antibiotics?
- Consult for most appropriate destination facility for ? CVA, severe burns, STEMI, orthopeadic cases etc. This is not really applicable to most of the country but some places it is; like here you have two hospitals that some crews are time-wise not much closer to one than the other however one is more appropriate for major trauma etc
- Really whacky things you just do not know how to treat

Severly Septic Patient.

Where do I start. This patient is now in your care & en route to hospital with a transport time of up to 90 minutes - is there really going to be a difference in administering antibiotics en route. NO. Wait, let them administer in a hospital environment. The only exception is for meningococcal septecaemia where we carry IV antibiotics oin the kit.

Consult for most appropriate destination facility for ? CVA, severe burns, STEMI, orthopeadic cases etc. This is not really applicable to most of the country but some places it is; like here you have two hospitals that some crews are time-wise not much closer to one than the other however one is more appropriate for major trauma etc

WTF????? You are unable to make this decision yourself knowing what the condition of your patient is? Surley anyone with HALF a brain should know this. I am assuming you have half a brain here. You should know through your dispatch if one hospital is busier than another, & make a transport decision from there. Hell we have crews that sit in the ER on bed block for hours. Esp with ortho cases because, in general they are not life threatening.

Really whacky things you just do not know how to treat

I am assuming that you use the term Really Whacky as a medical term. Did you read what I wrote last time. The patient will have some SYMPTOMS. TREAT THEM. You dont need a doctor for any of what you have described. Now to prove you are not a complete moron. Would you like to try again?

Methoxyflurane will never go away here; again because there are too many people that do events work for St John who will never, ever, ever be qualified enough to dish out narcotic analgesia.

Methoxy will go away due to the nephrotoxicity. St Johns will be one of the last to get rid of it because they want to do everything on the cheap, if their people are not intelligent enough to use narcotic analgeasia, then they need new people.

 

[MrBrown]

Are you for real. Let me address your examples individually.

Where do I start. This patient is now in your care & en route to hospital with a transport time of up to 90 minutes - is there really going to be a difference in administering antibiotics en route. NO. Wait, let them administer in a hospital environment. The only exception is for meningococcal septecaemia where we carry IV antibiotics oin the kit.

That's my thought too because it has been documented that once we deliver antibiotics ... ie kill the bacteria they will release endotoxin which can cause even more problems.

The services that have introduced IV antibiotics for meningcoccal disease or sepsis have found thier use to be very, very rare.

Maybe not the best example but in very remote areas of Northland with significant transport times our standard procedure is to seek pre-hospital administration of penicillin from a local GP.

WTF????? You are unable to make this decision yourself knowing what the condition of your patient is? Surley anyone with HALF a brain should know this. I am assuming you have half a brain here. You should know through your dispatch if one hospital is busier than another, & make a transport decision from there. Hell we have crews that sit in the ER on bed block for hours. Esp with ortho cases because, in general they are not life threatening.

We don't know how busy the hospitals are it is not inherent capability we have, can't mind-read how busy the ED or cath lab is or if they have an orthopeadic surgeon at the hospital or not or whatever.

Early consultation and notification allows them, for instance, to arrange for the on call thoracic or cardiovascular surgeon (there is are always surgeons at the hospital but at night or the weekend the specialties are not there) or whoever to come back rather than waiting for us to radio up we are five minutes away with a patient who needs somebody that will take half an hour to get to the hospital, scrubbed and ready to operate when we could have called and asked "hey, do you want us to take this guy to hospital A or bring him to you?" and they would have said "oh sure bring him here we will get the ortho surgeon out of bed for you guys when you get here in 20 minutes".

I am assuming that you use the term Really Whacky as a medical term. Did you read what I wrote last time. The patient will have some SYMPTOMS. TREAT THEM. You dont need a doctor for any of what you have described. Now to prove you are not a complete moron. Would you like to try again?

Our first line of recourse it not to a physician; it is to an IC Paramedic or our Watch Manager. I am in an urban area with IC Paramedics and a trauma facility ten minutes down the road and have never spoken to a physician in my on-road life to ask them what to do or to do something for me as I can think for myself.

Some people here in the boonies are not that lucky. They have no IC Paramedics or backup and they are volunteers who know how to package a patient and dish out five drugs they cannot screw up that bad (GTN, ASA, IM glucagon, paracetamol and methoxy). In small towns with single crewed officers (even tho this is not always the case) it is much easier to get the local GP to give morphine rather than wait around for backup which in some cases will be an hour, or more, away.

You dont need a doctor for any of what you have described

You presumably work in one of the states where the ambulance service is a well funded, well resourced, well educated and well trained third-service run by the state as a core health activity. Most states I have seen in Australia use only two levels. We are not that lucky mate, St John is atrotiously under-funded and we have four different levels; many ambulance crews here are not qualifed to give IV analgesia and many more are volunteer officers who have never been exposed to the same volume of peer review, peer critique and generally, patient encounters that our urban staff have.

We aim to shift to a new two-level model of care by 2011 where all staff who are not volunteers will be qualified in things like IV analgesia and have a much better education because we are putting them through the Bachelors Degree which will become mandatory for practice for paid staff because of exactly this reason.

Until then, if we need to talk to a doctor (which is extremely rare) then we will do so.

Understand that some systems work differently than yours because it is the practical reality of the situation we are faced with rather than being a wanker and saying we should not require it.

Methoxy will go away due to the nephrotoxicity. St Johns will be one of the last to get rid of it because they want to do everything on the cheap, if their people are not intelligent enough to use narcotic analgeasia, then they need new people.

Yes they do. You have to remember the Johnnos here have over 5,000 "clinical people" the majority of which are old farts who do nothing more than sit on the sidelines at the rugby. They will never, especially in our new system, never ever get anywhere near narcotic analgesia in a million years.

Even our volunteer ambulance officers are not that well educated; they are taught the fundamentals of managing acute symptoms using a small number of drugs and to package and transport a patient.

If you want to talk about not reading; then read what I wrote before

It's not generally something that our crew make habit of talking with a physician about what to do ...

It happens about once a day nationally for over four million people. Road crews are able to talk to an emergency department physician or St John medical advisor for advice for the best way to manage thier patient -- 99% of cases this is "which ED do I take him to?" (i.e. which is MOST appropriate); we do not carry some sort of telepathy device which lets us know if there is a cardiovascular surgeon at the hospital to the left or to the right; there might be one there but hey he might be busy with cases all day so I cannot call him out of surgery for an emergency and leave his patient half operated on!

There is also some use of GPs here rurally for things like morphine ... but this is really a symptom of the wider disease that rural crews aren't that well qualified and can't give IV analgesia. It's often again, easier to whip round to the local GP clinic and have the doctor give some morphine then take the patient into ED than meeting backup on the way because in some cases there is no backup.

I would rather nick round to the GP clinic and say "hey doc I'm gonna transport this guy into ED and it'll take an hour, can you top him up with some morphine?" rather than having to pee around trying to arrange for somebody who can give IV analgesia to come meet me enroute; which could be in the other direction or it could be that backup is busy with something else.

I don't see the problem in making use of a physician if I need one, I'm not a wanky egotist who thinks "hey I don't need a doctor". No, in 99.9% of cases I do not require a physician to tell me what to do or to do something for me.

But if I am working in a rural location and need to use the GP to administer some pain relief because I am a volunteer officer who is not qualified to give it then I do not see the problem.

 

[downunderwunda]

We are not that lucky mate, St John is atrotiously under-funded and we have four different levels; many ambulance crews here are not qualifed to give IV analgesia and many more are volunteer officers who have never been exposed to the same volume of peer review, peer critique and generally, patient encounters that our urban staff have.

The New Zealand needs to move into the 21st century & get away from a failing system. Ter reliance on vollies is reprehensable. EMS is a profession. It should be funded & treated as such. St Johns are & always will be a volly organisation who, in Aussie have gotten themselves into a lot of trouble trying to run a professional service as a volly organisation. If you dont know the case, [URL="http://www.abc.net.au/4corners/content/2009/s2615353.htm"]http://www.abc.net.au/4corners/content/2009/s2615353.htm[/URL]. They should be stopped from killing people.

This is the Kiwi attempt at americanising EMS & the only positive is they have not included the FD as an integral part.

 

[Smash]

Wow, those posts make me want to move downunder too! It's just like the absurd FF/EMS pissing matches, only on a nationwide scale!

So much lucid and well thought out argument, I'll just pick a few to comment on.

Ketamine is being investigated for use here. I don't agree with it entirely. I think doctors underestimate the psychological effects of dissociatives/hallucinogens. There is alot of anecdotal evidence kicking around the recreational scene about the effects of "bad trips" etc. I also know a man who received ketamine in ICU. His brain just doesn't work the same. Reminds me of talking too old hippies who've had a few to many drops of LCD. I don't know..its alright for short term use I suppose, I'd just like for doctors to expand their understanding of drugs beyond what they read in their textbooks.

What is it that makes you think that doctors don't appreciate the potential risks of dissociateiv analgesia? Do you have studies that show adverse effects or cavalier attitudes by Doctors causing harm in the use of ketamine for analgesia?

I agree with you though about the anecdotal evidence from the rave scene. After all, the experiences of a few substances abusers who misuse powerful anaesthetics for recreational purposes sure beats "what doctors read in a textbook" (actually, I'm curious, how do you propose that we teach doctors instead? Give them some special K to get high on? How is it that you are expanding your knowledge? Or as a paramedic student do you not need to?)

That's like saying that because some recreational drug users overdose on morphine we shouldn't have morphine for pain relief in ambulances.

Why was your acquaintance in ICU? Head injury? I'm picking it wasn't something good, as he was in ICU. It might pay to investigate the phenomenon of ICU psychosis before you go pinning it all on one drug (out of a regimen of dozens no doubt)

Ketamine is one of the most used substances for pain relief and anaesthesia in the world. It's unfortunate that it is used almost exclusively in Third and developing World countries due to it's low cost, high effectiveness and low side effect profile, otherwise we might be a bit more used to it here in the 'developed' world.

You're welcome to have an opinion on ketamine, but maybe one formed on evidence and experience might serve you better.

Where do I start. This patient is now in your care & en route to hospital with a transport time of up to 90 minutes - is there really going to be a difference in administering antibiotics en route. NO.

Sure! Why not? And while you are at it, why bother with that fluid, they can do it at hospital. And those inotropes, they have lots of them there too, let the hospital start them.

Early empirical antibiotic therapy in severe sepsis is related to significant reductions in mortality and morbidity. Not every septic patient needs in field antibiotics, but to rule out any for all and sundry (except the dread N. Meningitidis) is short sighted and foolish. If I had a septic patient with a 90 minute transport time who required intervention such as inotropes, they would also be getting cefataxine and low dose steroids too. But then, I like my patients to do well.

That's my thought too because it has been documented that once we deliver antibiotics ... ie kill the bacteria they will release endotoxin which can cause even more problems.

The services that have introduced IV antibiotics for meningcoccal disease or sepsis have found thier use to be very, very rare.

Documented where? Endotoxic shock, septic shower, septic storm, whatever you want to call it, is indeed a real risk when delivering antibiotics to gram negative infected patients. However, a single 1gm dose of ceftriaxone is bacteriostatic, not bacteriocidal, so it is unlikely that you are going to see endotoxic shock from meningococcal septicaemia in the field. If your indicator for giving antibiotics is purpura fulminans, then it is somewhat academic anyway I suspect.

The use of antiobiotics for meningococcal disease should be rare, as it is a relatively rare disease, with the exception of the sub-Saharan meningitis belt and parts of South Auckland and the far north of NZ. Even then, rates are nowhere near what they used to be.

St Johns are & always will be a volly organisation who, in Aussie have gotten themselves into a lot of trouble trying to run a professional service as a volly organisation. If you dont know the case, http://www.abc.net.au/4corners/conte...9/s2615353.htm. They should be stopped from killing people.

I don't know much about St Johns, but your logic of "bad things occur in one country, therefore all St Johns are death merchants" is... dubious, to say the least.

 

[Melclin]

What is it that makes you think that doctors don't appreciate the potential risks of dissociateiv analgesia? Do you have studies that show adverse effects or cavalier attitudes by Doctors causing harm in the use of ketamine for analgesia?

I agree with you though about the anecdotal evidence from the rave scene. After all, the experiences of a few substances abusers who misuse powerful anaesthetics for recreational purposes sure beats "what doctors read in a textbook" (actually, I'm curious, how do you propose that we teach doctors instead? Give them some special K to get high on? How is it that you are expanding your knowledge? Or as a paramedic student do you not need to?)

That's like saying that because some recreational drug users overdose on morphine we shouldn't have morphine for pain relief in ambulances.

Why was your acquaintance in ICU? Head injury? I'm picking it wasn't something good, as he was in ICU. It might pay to investigate the phenomenon of ICU psychosis before you go pinning it all on one drug (out of a regimen of dozens no doubt)

Ketamine is one of the most used substances for pain relief and anaesthesia in the world. It's unfortunate that it is used almost exclusively in Third and developing World countries due to it's low cost, high effectiveness and low side effect profile, otherwise we might be a bit more used to it here in the 'developed' world.

You're welcome to have an opinion on ketamine, but maybe one formed on evidence and experience might serve you better.



I don't know much about St Johns, but your logic of "bad things occur in one country, therefore all St Johns are death merchants" is... dubious, to say the least.

As usual you make many well thought out points. I perhaps should have qualified my position a little more. I absolutely do not have any real evidence damning ketamine. I think for the most part it would work very well. I certainly would like to see its use extended into the pre-hospital arena here and I would love to have it as an option. However, there is something that I find troubling about it. I can't properly quantify it nor provide any evidence for it, so I would never make any real or important decisions based on it.

I have noticed, however, a tendency that doctors have to overestimate the scope of their knowledge. Its a tendency that alot of well educated people have. They do not well appreciate the limits of their knowledge. They are often not open to the fact that they might be wrong, or, more commonly, that there might be some modifying factor to their knowledge. I have some extensive experience with psychiatrists who show their ignorance of their effects of the drugs they prescribe on a daily basis.

Doctors and many well educated, reasonable people belittle the experiences caused by and effects of hallucinogens, psychedelics and dissociatives. I'm by no means attributing them with some great mind expanding metaphysical powers. But it just makes plain good sense that powerful experiences can change people's personalities and I don't doubt that the aforementioned drugs can give you powerful experiences. I think the extent of the power of those experiences and the effect that they can have on your life is underestimated in people like doctors because they get written off as hippie pseudo spiritual nonsense. I'm not saying these effects can't be quantified and empirically observed (I wholeheartedly believe that can be), but the difficulty in doing so means that they may be neglected; and then absence of evidence is taken to be the evidence of absence by too many. I would just like to see doctors more open to the idea that there might be greater levels of complexity to some of the drugs they prescribe (esp when it comes to psychological effects) than is immediately apparent; some intellectual humility. This is an ongoing issue I have with many in the scientific and medical fraternity and I may be unfairly dragging ketamine into it based on some personal experiences.

He was in ICU for sepsis and undoubtedly he was on many other drugs and there would be many other possible reasons for his changes in personality and thought patterns, if not only that fact that he very nearly died. (I myself have experience psychosis in the ICU, which is an odd coincidence. I was quite certain that I was being held against my will in an evil green police station and had a few words to say about it to the nurses. ) I'm completely aware of the dubious level of evidence I have regarding my bad feeling about ketamine, which is why I call it nothing more than a bad feeling. As I said, if I was to use it clinically I'd do my best to ignore it. I just think its an issue worth some further investigation.

 

[downunderwunda]

I don't know much about St Johns, but your logic of "bad things occur in one country, therefore all St Johns are death merchants" is... dubious, to say the least.

It is obvious from this that you did not look at the link I posted that shows in graphic detail the failures of this organisation & how they attempt to hide behind their volly status.

Allery to penecillin is common & potentially lethal.

The first rule of EMS is - FIRST DO NO HARM. So you advocate the administration of Benzyl Penecillin risking in many cases, severe Anaphalaxis, in an uncontrolled environment when it is unnecesarry?

Why not wait for the person to arrive in hospital, that is a CONTROLLED environment to administer a drug that can potentially kill.

Like it or not, an ambulance in not a controlled environment. Administration of fluids is beneficial & will not harm the patient.

 

[Smash]

It is obvious from this that you did not look at the link I posted that shows in graphic detail the failures of this organisation & how they attempt to hide behind their volly status.

Allery to penecillin is common & potentially lethal.

The first rule of EMS is - FIRST DO NO HARM. So you advocate the administration of Benzyl Penecillin risking in many cases, severe Anaphalaxis, in an uncontrolled environment when it is unnecesarry?

Why not wait for the person to arrive in hospital, that is a CONTROLLED environment to administer a drug that can potentially kill.

Like it or not, an ambulance in not a controlled environment. Administration of fluids is beneficial & will not harm the patient.

I read an article that describes in 'graphic detail' the failings of the Western Australian Ambulance Services communcations systems.

"The reason is simple.

They claim that for some time now they have been telling senior managers the service must introduce a computerised system to prioritise emergency calls, and when things go wrong the cases must be fully investigated"


I saw nothing that stated that the same communication system is used in New Zealand, nor that the same people who run the West Australia service also run New Zealand, nor that the same failings are seen in NZ. Not once in that article was Volunteerism mentioned. I also know for a fact that the New Zealand ambulance service runs AMPDS.

Don't look now, but your prejudice is showing.

Allery to penecillin is common & potentially lethal.

The first rule of EMS is - FIRST DO NO HARM. So you advocate the administration of Benzyl Penecillin risking in many cases, severe Anaphalaxis, in an uncontrolled environment when it is unnecesarry?

Why not wait for the person to arrive in hospital, that is a CONTROLLED environment to administer a drug that can potentially kill.

Like it or not, an ambulance in not a controlled environment. Administration of fluids is beneficial & will not harm the patient

First, show me where I said that we should be administering benzylpenicillin... that's right, nowhere. I didn't in fact state which antibiotic I give, although I mentioned by name both cefotaxine and ceftriaxone. I realise that logic may not be a strong point, but at least don't make stuff up.

I am more than happy to administer these in the controlled environment of my ambulance. It's a risk/benefit thing. The risk is, I cause an anaphylactic reaction. Which I can treat. Or, I can leave the sepsis to fulminate, thus killing the patient. It's like cardioverting an unstable conscious VT. The risk is that they die. About as serious a risk as there is. Of course we still do it, because we know that the may die if we do but they will die if we don't. But of course, we should wait until hospital to administer a treatment that may kill! Risk/Benefit?

Administration of fluids indeed will be beneficial, but to make a blanket statement that they will not harm the patient shows a lack of understanding of the pathophysiology and potential pitfalls of treating sepsis. Fluids will be administered, as will inotropes and most likely steroids, intubation quite possibly be carried out (with RSI if need be) in most cases, but unless we are going to take a shot at the causative agent as well as the host response, all these things are largely pointless. Untreated sepsis kills. Simple as that.

You may find it unnecessary to treat your patients. I don't

 

[MrBrown]

The New Zealand needs to move into the 21st century & get away from a failing system ...they should be stopped from killing people.

I've seen Four Corners and it's egregious thier medical director and that wanker of a mouthpiece Ahern should be put taken out back and shot.

Now ... you dig in my backyard so I'll dig in yours. Lookee here I found a report on the Ambulance Service of NSW on the Four Corners site. I don't know where you work but it seems Australia is no better than the death merchant Johnnos!

...bullying and harassment ...within the Ambulance Service, which may have resulted in depression, anxiety, self-harm and even suicide amongst ambulance officers ... managers do not encourage officers to make use of ...support services ... inadequate staffing ...means that managers are placed under ...pressure to put distraught officers back on the road before they are ready... (pg. XIV)

Our culture flat sucks too I don't know any officers' who have capped themselves. Sounds like a fab place to work, having to have a breakdown in the truck on the way to a job.

...The management culture is one of nepotism, elitism and cronyism... (pg 12)

We have that problem too.

After completing their probationary period, [many] trainee... are then posted to rural areas.

The ‘revolving door’ effect at some rural stations ...'A lot of time spent at these stations is spent on applications trying to get out’ (pg 99)

That's not good. You get sparky who has done his degree or whatever in Sydney doing 10-12 jobs a day suddenly he's in the middle of bum-bum nowhere doing 1 job a day; there goes those skills.

...the abolition of training for ...ALS... paramedics in rural areas (pg 106)

... not having paramedics who can administer [morphine, adrenaline and midazolam] in rural areas is that the nearest backup is a long way off, and the availability of doctors is limited.
(pg 107)

Using doctors, my gosh, I thought such practice was not required in prehospital medicine.

That's exactly it, out in the sticks it's often easier to whip around to the local GP and get him or her to give some morph rather than waiting for very limited backup.

Death merchant St John are rolling out a new system by 2011; all paid officers (incuding the rurals) will be qualifed in adrenaline, fentanyl, zofran, naloxone (in addition to GTN, salbutamol, glucose IV, glucagon IM and aspirin)

Immagine that, the death merchants providing a higher level of care than may be avaliable in the state-run NSW service. Although I say that with hesitation because I believe NSW is very close to a totally two-level system like the one we are moving towards by 2011.

...single officer ambulance crews (pg 110)

Modern and progressive Australia still providing crews of only ONE officer? Wow, you're now on the level with some of the rural areas here, not even WA does that ... immagine that; death merchant WA providing better staffing

Recently a friend has had an awful time ... one of the DOs said to her, "I find the best counselling is drinking bourbon and watching porn. Do you want to do that?" (pg 121)

I do like to drink Jim Beam with ginga ale and watch porn but that's hardly an appropriate response when somebody asks for counselling now is it?

...announced that eight...ambulance rescue units would be taken over by the NSW Fire Brigades...

Looks like you are not immune either mate, while the Fire Service here has declined any attempts to get involved in Ambulance apart from rural first response in remote areas.

Hospital block is a major problem for paramedics, who often experience lengthy delays at hospitals before they are able to offload patients ... a lot of the time ‘bed block’ is created because the Hospital has triaged the patient and decided that he/she requires a bed and needs to be supervised (pg 136)

Call me cruel but we dump them on a hospital gurney and leave them in the hall if need be. It's not our job to supervise patients and I will tell ED staff in no uncertian terms we are not thier babysitters. Yes we also get the same problem.

...on-duty single officer crews that are being utilised in the Hunter region as a standard response ... [include] treating and transporting patients alone, some times requiring the help of bystanders to drive the ambulance while the patient was resuscitated in be back. Other incidences include delivering a baby alone, and resuscitating alone ... although NSW Health stated that single officer responses are routinely supported by a ‘simultaneous dispatch of the duty crew, on-call officer, Police, community first responders or an Ambulance helicopter' evidence heard by the Committee indicates that this back-up is often not available.

You are again lowering yourself to the standards of the "death merchants" ... immagine that!

This is the Kiwi attempt at americanising EMS & the only positive is they have not included the FD as an integral part.

You are not listening to what I am saying.

I contrast the two in the we have autonomous decision making capability concerning how and when we treat a patient; if we transport them etc.

The American system does not; it does not allow for non-transport (except for a refusal) and most systems (even Seattle) still rely upon voice contact with a physician for orders.

Our protocols are based upon evidence and more is not always better; eg spinal immobilisation is not "board, blocks, collar & tape for everybody" here whereas it is very much that way in the US.

We don't put everybody on NRBM at 15lpm either; most people get 2-4lpm NC, if they get oxygen at all.

If I got on the radio and asked to speak to a doctor at the hospital to get orders they would laugh me right off the channel and into submission and I'd become something of a joke within the service.

Let me say again yes, we can speak with an ED doc about which is the most appropriate destination if we have a choice or talk to the hospital via radio and advsie we are bringing in a patient who requires something which they need to arrange; e.g. getting the on-call vascular surgeon out of bed for us because the 20 minutes its going to take us to get there means he can be in his Ferarri and at the hospital, scrubbed and ready for us by the time we are unloading the truck at ED.

Consultation is key here, this is not seeking permission and if you somehow find something wrong, degrading or "un-necessary" about speaking with a physician about the best destination for the patient or alerting them early for some things so they can arrange appropriate resources in a timely fashion well then you mate are a wank*r who needs to pull your perception of yourself out your arse.

So to take your logic we shouldn't be talking to the doctors at all; wow, remind me never to do a patch to the hospital to let them know what we are bringing in and we'll just roll up to the ambulance bay and crash resus with no notification.

...the exception of the sub-Saharan meningitis belt and parts of South Auckland and the far north of NZ...

No that's true, your local knowledge is impressive.

...nor that the same failings are seen in NZ...I also know for a fact that the New Zealand ambulance service runs AMPDS.

We use AMPDS yes.

No we just have different failings. Our medical director and clinical advisory panel are not wank*rs and we work with them well.

Most of our problem comes from a lack of money. We are also have a small population with a large spread that combined with St John's "volunteer" ethos means that they actively promote volunteers are a reasonable method to crew ambulances which is not acceptable in my point of view.

St John "part charges" and then writes off a significant portion of nonpayment because it would not be in the "brand image"'s favour to go collecting bad debt and it would probably cost more than it would collect.

The Ministry of Health recognises that we can part-charge therefore caps our funding (or reduces it because we can "make up" the reduction by part-charging) there is also a contractual clause that prevents us from raising the part-charge if we are to get X level of funding.

Although I can speak-ill of our funding arrangements and management (to a degree) I must speak highly of what we are doing right;

1. We don't have to talk to a physician for "orders" to do anything
2. Our procedures are vastly more flexible that the Americans
3. Bachelors Degrees are mandatory from 2011 for paid staff
4. We will move from five clinical levels to three
5. Paid staff will work under a quasi Australian system with two levels
6. We have over 95% success with RSI since it was introduced in 2006
7. We are trialling-to-introduce prehospital cardiac thrombolysis
8. We are working with other providers to introduce electronic PCRs
9. Central Govt is engaging in a strategy review of Ambulance
10. We are moving towards becoming a registered/licensed health profession under NZ law that removes St John from the right-to-practice equation and gives it to an external council
11. With #10 will come national licensing and procedures indepndant of service provider

Check out www.naso.govt.nz