# A Question for Those Down Under



## thegreypilgrim (Jan 20, 2011)

OK, I know you guys don't exactly function under "protocols" in the same sense that we do here in the US but instead have "clinical practice guidelines" (one of the many highlights of your system). So, anyway, my question is despite the progressive nature of the AU/NZ EMS systems, is the "emphasis" (for lack of a better term) still on transportation? Here in the States, even in our most progressive systems, it seems the emphasis is still on transport of the patient, and nothing is really supposed to cause delays in this regard.

Indeed, statements such as "Assessment and treatment should rarely delay patient transport" are common in US protocol manuals. This near 40 year old feature of EMS is still the number one expectation around here - or so it would seem.

Having said that, is this sort of thing still expected of you guys? Or has the emphasis shifted to providing medical care?


----------



## jjesusfreak01 (Jan 20, 2011)

American here working in Wake County NC...I think many of the limitations on what we can do are because of both limited education as well as access to resources, which is going to be a problem in any system, regardless of location. You can only have so much gear and so many medications on an ambulance, while you can have pretty much everything you want in a hospital. If you want to be able to treat more conditions in the field, you will have to increase the number of medications carried on the trucks, as well as the equipment and training. Remember that ER docs also rely on further diagnostic tools to confirm many diagnoses and treatments. Even pneumothoraces are often confirmed by x-ray before decompression in ERs.


----------



## AUSEMT (Feb 20, 2011)

thegreypilgrim said:


> OK, I know you guys don't exactly function under "protocols" in the same sense that we do here in the US but instead have "clinical practice guidelines" (one of the many highlights of your system). So, anyway, my question is despite the progressive nature of the AU/NZ EMS systems, is the "emphasis" (for lack of a better term) still on transportation? Here in the States, even in our most progressive systems, it seems the emphasis is still on transport of the patient, and nothing is really supposed to cause delays in this regard.
> 
> Indeed, statements such as "Assessment and treatment should rarely delay patient transport" are common in US protocol manuals. This near 40 year old feature of EMS is still the number one expectation around here - or so it would seem.
> 
> Having said that, is this sort of thing still expected of you guys? Or has the emphasis shifted to providing medical care?



In Australia (cant speak for NZ) there are paramedics, Intensive care paramedics and extended care paramedics. To become a paramedic nowadays you must hold a bachelor of Health Science (paramedicine) or equivalent degree. then extra certifications afterwards.

aus is very much an combination of the euro-germanic model of 'physicians on scene' and the american 'transport to the hospital' ideology. we rarely if ever have "medical direction", rather there is scope of practice and professional knowledge. we are also fully operated by the state, one ambulance service per state, so the system in New South wales for example is totally uniform.

where we differ is that we are starting to increase emphasis of treatment at location and reducing unnecessary transports. our trial program of Extended care paramedics gives very experienced intensivists with additional training the ability to perform clinical skills for non-emergency patients out of a fly-car. they can suture wounds, replace catheters, assist immobile persons, prescribe some drugs, and do basic non-emergency physician (i use the term lightly) at people's homes/ on site so as to free up stretcher ambo's for emergency transports and to free up ERs.  

if you search extended care paramedics on 'youtube' you'll find the video 
hope that helps?


----------



## MrBrown (Feb 20, 2011)

New Zealand is shifting toward non-transport wherever possible, the UK is also trying to move towards a "respond and not convey" model but Brown hears its a bit problematic.

It is not reasonable and simply impractical to transport everybody and cannot understand on earth the US does it without hospitals breaking down due to massive systemic overload of emergency departments.  

Should you dial up 111 on the telephone machine and a Jeff Clawson approved humanoid determine so, you might not even be sent an ambulance.  This is the exception rather than the rule but it does happen each day.

Now if Brown and Black turn up in thier big white van with flashing lights and medical gizmos and poke, prod and oggle at you sufficently they can recommend you do not go to hospital.  

Basically we ask ourselves "is this patient going to be best served by going to the emergency department right now?" and if the answer is no, then they are probably not going to go.


----------



## ukcanuck (Feb 20, 2011)

I have only been out of the UK system for a year now and worked a Canadian 911 system for a few months but the biggest difference is that the system in the UK is geared towards "admission avoidance".

In the UK the emphasis is to provide the point of contact care where and when appropriate and possible. That may be referring them, leaving them or actually taking them to a hospital.

Starts at the 999 call where the dispatcher can transfer the caller to NHS DIRECT(aka redirect) who can offer medical advice over the phone rather than sending an ambo. A nurse advisor who can do follow up calls to IDDM pts that we have woken up with D10W and left at scene with a resposible adult.
Whether it is a diabetic nurse who will see my pt for changes in their insulin and further advice to the asthma nurse who will see my pt who responded well to a neb. Night time care teams made up of multi disciplanary care levels who will come out and see pts on referral by the ambo crews.
There are Emergency Care Paramedics who can pop out and see my pt and close their wound/give antibiotics/dip urine and other bedside tests/etc
There are fall teams that take referrals from the paramedics to come out and assess patients to avoid another call and possible admission just by offering fall prevention and these teams help keep track of the chronic conditions meds comliance etc and report back to the pts doc. the paramedics acn even leave them at home with no further follow up and just advice on taking OTC meds etc Have to admit I always added that they could call again for  any reason if they have concerns or situation changes blah blah blah as a bit of an *** covering exercise.
There are other programs in place all aimed at keeping the pt out of hospital.

Are there problems - definitely, paramedics get it wrong from time to time just as any care provider does, you see x number of pts and eventually you will miss something - are all the teams seamless, cooperative, and dovetailing with all the other teams - nope not all the time. 

Education for the paramedics is crucial and from what I have seen most of the medics in Canada would be able to safely help a patient decide as to the most appropriate care to access. I haven't had much to do with the US systems so won't insult anyone by pretending and passing comment.

Lets face it - the typical paramedic will not give the option of not going to the ER if there was any doubt in their mind as to what was wrong or what the pt needed for care.

Some will say that the UK system is too far to one side on avoiding admission by not having enough transport trucks and too many single man response vehicles and some will say that the system causes some pts who need to be admitted to be treated at home until they are really sick......
don't know but I miss having the options when the sysmtem was working the way it was supposed to.

PS don't know how much the economic crunch has effected these teams as I know several where under scutiny for economic effectiveness so some may not even exist now


----------



## enjoynz (Feb 20, 2011)

Just thought I'd add a couple of things in here...re how NZ EMS works, or at least use to work a couple of years ago, when I was still with the service.
We were given the round number of 20 minutes...if you were still on scene after this time and your patient wasn't trapped or in cardiac arrest.
Dispatch, then Management, would be on your tail as to what was taking you so long to transport.

Sometimes in the case of rural areas, we would not transport the patients directly to hospital, if the local Medical Centre was open (only during the week days in our area),
 the EMT-I in charge, would stop by with the patient to get the local GP (Doctor) to check over the patient to detemine if they thought a trip to the hospital was necessary.

Then of course there is the case where your patient refuses to go to hospital...in which case they have to sign a refuse-treatment/transport form.
Things might be different in the city were Mr Brown is
.... the EMS workers in our area do prefer to take the percentage of their patients to hospital, as in many cases,
there is an hour's drive or more, in transport times, which has to be concidered. Most use their common sense though, in this regard. 

In some cases, they also let their patients know if they do get transported for something minor and the patient really wants to be transported,
 there is the very, very long wait to be treated in the ED.
 In some cases they could be sitting in the ED waiting room for 6 hours or more, after the triage nurse has seen them!!!

I can see that with their training, an EMT-P (Advanced Paramedic) maybe better qualified, to detemine if pt's need to make the trip to ED, after being  assessed and treated on scene.
As our ambulances do not carry Xray,MRI's or Lab equipment,etc,etc, nor for matter, does our local Medical Centre.
I's say for that reason, most patients are going to end up being transported regardless.

Enjoynz


----------



## Outbac1 (Feb 20, 2011)

We have recently started an Extended Care Paramedic role. These Paramedics,(all ACPs), received some extra training and refreshers on some procedures. Their function will be to attend low priority calls at nursing homes and provide on scene care and no transport. This has only just started in our capital city so needs to run for a few months yet before we pass judgement. Hopefully this works out OK and the program will expand to the rest of the province.  It will be nice to leave more people at home.


----------

