# Medical Oversight in Australia/NZ



## thegreypilgrim (Dec 3, 2010)

Hey guys.

I'm doing a research paper on direct/online-medical control and to my knowledge in neither Oz nor NZ is there anything comparable to a "base hospital" or online-medical control as it exists in the US. However, I need more information on the role of medical oversight in EMS in Australia/NZ.

How, exactly does it work? Can anyone link organizational policies (if any) or relevant statutes that spell out the standards for it?

Walk me through a typical "ALS" call as it unfolds in your system. Is there anyone that you do establish some sort of communications with in the course of your care and/or transport of the pt? Thanks to all who weigh in on this.


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## Scott33 (Dec 3, 2010)

Lots of down under types here who will help you out.

But you should really be looking at the US model as the exception, not the rule when it comes to EMS. Most other westernized systems, although having medical oversight and guidelines, do not have a doctor sitting at the end of a phone ready to tell the para what to do when they exhaust their SOPs. The para in the ambulance has the say in how they treat the patient, and is 100% accountable for their actions. 

Those practitioners in NZ, Oz, UK, Holland, Canada, etc have their own license to practice. They do not work under a physicians license so treat as they see fit. There are guidelines which they follow, and there are restrictions and contraindications in treatment modalities like everywhere else, but are less protocol driven than the US. Many will use their guidelines as we use protocols - per the letter, but others can step outside them if they can justify their actions. Evidence based practice drives the practice of the modern day non-US para, and it is very progressive.

Those (damn) socialist countries also benefit from being able to utilize alternative clinical pathways for their patients. Not everyone who dials 911 needs a taxi ride to a hospital, and many times the patient can either be treated and left at home, or (at the ECP level) have prescriptions written for them for clinical imaging or other basic tests - wherein they can go to a doc-in-the-box center to follow up. No need for _mother may I_ at any time. It doesn't exist. The idea is to leave the emergency department for (shockingly enough) emergencies.

Education is also a major difference, and NZ has been the most recent of "other" places to adopt the bachelors degree for practice as a para. Yes, we can do that here if we want too, but our degrees are usually a hotch-potch of liberal arts and fire suppression stuff, which have little bearing on focused patient care. Talking of which, those other countries have EMS as a stand-alone entity, and have as much in common with fire fighting, as they do with horticulture. Masters degrees in EMS common these days, again with a focus on advance clinical practice. The money is also way ahead of the US. Here is a recent posting for a UK position:

http://www.jobs.nhs.uk/cgi-bin/vacdetails.cgi?selection=912583826

Up to 80,000 Pounds per year - that's $126,000. I know some US paras can make that, but not for a 37 hour week. Before anyone chips in with taxation I have worked and paid tax in both countries for more than a decade in each - and under various governments. When all is said and done, there is little difference between the two. 

But I digress...

In summary, there is no medical control in the countries you mention. It is a US thing. 

I will link to the UK guidelines for you and will leave those funny-speaking types to do the same for their guidelines.

http://www2.warwick.ac.uk/fac/med/r...italcare/jrcalcstakeholderwebsite/guidelines/


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## MrBrown (Dec 3, 2010)

Brown resents being called a funning speaking type. now then lets give him a spray of GTN, if he passes out perhaps we could put in a cannulae and some increments of Hartmans? 

There is no medical control here, no online contact, no "base hospital", no orange box and no "orders" are required to do anything.  The Ambulance Officers on scene determine the treatment required and deliver it without recall to a Physician for authorisation.  While there are contraindications and praxis guidance in the procedures/guidelines it is up to the Officers to determine if the patient fits into them or how best to proceed with the larger clinical picture considered.  You are not put into the street until you have enough clout and sense to think for yourself and not follow a bloody cookbook that results in ringing up the Doctor for help when your twelve weeks of training is exhausted.

Ambulance Officers here are not rogue practitioners free to dispense whatever tretament as they see fit and left to thier unchecked devices but rather educated and experienced professionals who are given appropriate clinical autonomy and flexibility in determining what works best for thier patient at that particular time.

There is a fantastic relationship between the road crews, Clinical Standards Officers, Clinical Standards Managers, Regional Medical Advisors and the Medical Director.  Clinical support and education has come leaps and bounds in the last five years and is only getting stronger.  

As mentioned above, not everybody goes to the hospital and many of the patients Brown has been to get left at home for they do not need to be seen by the emergency department right now.  There is lots of work on extended pathways and deferring patients other than to the emergency department.  Patients do not have to refuse care (although they can) in order to be left at home, Ambulance Officers can recommend people stay at home.

Officers here do not have thier own license to practice (that is coming perhaps) but rather use a twist on the American model of delegated instrument of authority from a physician (regional medical advisor).  In order to obtain such authority to practice (at a particular level) you must pass the associated educational content, practical/viva/written assessments, demonstrate adequate experience (usually through a logbook/clinical diary) and satisfy both your Manager and the Medical Advisor that you are competent to practice at the appropriate level.  Each year you must complete 40 hours of continuing education and a revalidation of your skills and knowledge.

Whilst we have always been good down here in New Zealand (yay us?) we are getting better and sadly leaving the Americans (and maybe the Canadians and Brits to a degree) for dead.  

Brown remembers asking one of his Clinical Education Tutors (who happened to be an Intensive Care Paramedic) how much morphine he (the tutor) could give a patient.  The reply was "as much as I need to".  Enough said perhaps?


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## fortsmithman (Dec 3, 2010)

Since you mentioned Canada and I'm in northern Canada I thought I'd add something regarding EMS here in my neck of the woods. Here in the Northwest Territories we can't really do anything without medical control.  Two years ago our service's medical director resigned and moved to another province so we were without for a few months. We were pretty much restricted to first aid only.  Our only 3 EMT's/PCP's could not do anything they were trained for.  Then we got a new medical director then our EMTs/PCPs could do what they were trained to.  Currently if our EMTs/PCPs want to do an IV then we have to have approval from either the MD or RN in charge.   There are time in this town when we have no physicians in town just NPs, RNs and LPNs.   There are some communities here in the NWT that dont have any RNs just community health representatives which don't have that much medical training.  Most communities here in the NWT have no EMS in those cases it's the person with the available pick up truck or van or the local RCMP or volly FD.


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## MrBrown (Dec 3, 2010)

Yes but NWT are about as much a part of Canada as Quebec is! 

Brown is a bit suprised with Canada to be fair, given the education a Primary Care Paramedic recieves the scope of practice is pretty restrictive and it seems OLMC or base hospital contact is required for some things still.

Well, in Ontario anyway, Alberta seems to be more liberal.  Not sure about BC and Novia Scotia (EHS EMS) seems to be pretty onto it, nobody really knows WTF Quebec is doing.


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## Melclin (Dec 4, 2010)

*Typical ALS call*

Well its a little different than the American ALS/BLS paradigm. For starters, officially speaking, our two tiers are ALS/MICA (some bright spark had the idea that we could be good/better instead of bad/good). Its roughly equivalent to the American ILS/ALS but with much much more education behind both level. I'll use the American terminology to avoid confusiong that is:
-When I say ALS, I mean what we would call MICA.
-When I say ILS, I mean what we call ALS.

Every emerg ambulance is ILS (there are some rural exceptions) and can monitor, canulate, IV analgesia, LMA, fluids, antiemetics standard cardiac and athma meds, etc. Meaning that when ALS get called, its not because a persons heart rate is above 100 or their pulse is irregular. They much sicker than perhaps many American ALS call outs. This helps to reserve sick patients for a smaller group of ALS units. Someone mentioned some US ALS units have trouble getting a a few tubes a year, while I hear our metro ALS can average about a tube a week. 

A pretty normal ILS call out: Chest pain. Arrive, attendant moves to the pt and starts chatting, BP, GCS, etc. Partner will monitor/O2 if they look sick, but probably get meds and admin info from family. Assuming we decide its likely cardiac in origin: aspirin, GTN q5, cannulate, morphine + maxolon as required. More detailed family, medical, social history while transporting. NO MED CONTROL. If its a dead set MI, get ALS, 12-lead, cath lab activation + arrythmia/arrest/APO/cardiogenic shock management.

I'm a little less familiar with a _normal_ ALS call considering I'm no where near that yet. They do seem to spend a lot of time bouncing around the place and getting cancelled by the first on scene ILS truck. Here's job an ALS mentor of mine showed me a while back. Its reasonably common in the metro area, although not common enough if you talked to most MICA paramedics I suspect. Full arrest, 24y female, immediate good bystander CPR, ILS arrive, shock VF 4 times, reverts to Af, GCS 8, ALS arrive, RSI (sux, midaz, fent), rapid infusion cold saline, panc/midaz/morph for continuing paralysis, adrenaline infusion for cardiogenic shock. NO MEDICAL CONTROL.  

The closest to medical control:
Their is a medical standards committee that rules on guidelines, changes in clinical doctrine, etc. 

You can call "the clinician" (A very experience ALS paramedic) for clinical questions but I've never seen it happen. Mostly they look after appropriate hospitals, the clinical aspects of resourcing issues. If you want to go significantly beyond you guidelines, then you should consult with the clinician. If its reasonable and you sound like you know what you're talking about, you've got a decent chance of getting the go ahead. 

There are a few provisions in the guidelines for contacting doctors.
-Hypovolaemia refractory to 40mls/kg of NS. It says to contact the trauma centre you're going to for advice on the third round of 20mls/kg. Nothing says you have to obey them, but you would be pretty stupid if you didn't. It also says just do it if you can't get onto them.
-Ceftriaxone in sepsis. Docs get mad when you drop bucket of cef on a person before blood cultures unless they really need it, so they like you to try and talk to the receiving doc. 
-There is a neonatal hotline for all clinicians in the state of victoria that goes to a NETS team clinician for advice and NETS activation, not just for paramedics. 
-For complex paeds issues, a chat with the state childrens hospital is advised in varrying situations. 

I'll get back to you in more detail a bit later, I'm off to a BBQ.


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## MrBrown (Dec 5, 2010)

*Brown pictures some dark monolithic Darth Vader type in a blue jumpsuit with "CLINICIAN" written on the back .... 

Do RAV have a Clinician as well or is it just Metro?

Each watch here has a Team Manager who is an Intensive Care Paramedic, they are rung up for advice, alltho in Browns experience it is infrequent.


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## STXmedic (Dec 5, 2010)

All this talk is making me want to find a new place to practice in... Brown, you wouldn't be looking for a trainee, would you? Green jumpsuit with pre-doc perhaps?


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## fortsmithman (Dec 5, 2010)

MrBrown said:


> nobody really knows WTF Quebec is doing.



I don't think even Quebec knows what it's doing either.


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## Melclin (Dec 6, 2010)

MrBrown said:


> *Brown pictures some dark monolithic Darth Vader type in a blue jumpsuit with "CLINICIAN" written on the back ....
> 
> Do RAV have a Clinician as well or is it just Metro?
> 
> Each watch here has a Team Manager who is an Intensive Care Paramedic, they are rung up for advice, alltho in Browns experience it is infrequent.



I can see the imperial march playing over the HEMS chopper landing and a CSO getting out to meet a scared looking MICA paramedic standing in front of a troop of ALS medics at attention. 
"The construction of the new branch is behind schedule, Medic Veers". 
"We shall double our efforts my lord". 
"Gooooood, the minister of health is _not_ as forgiving as I am."

My understanding is that they have a clinician available statewide.


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## Outbac1 (Dec 6, 2010)

We have access to a medical control Dr. 24/7. At the moment we have no drugs that need prior approval to give. Our "protocols" are being changed to "guidelines" so we can use "our best clinical judgement". If we want medical advice, a second opinion when in doubt or just to cover our a$$ we can call our OLMC. In a couple of months we are getting TNK for field use. With it comes a mandatory OLMC contact before we give it.  Otherwise we are pretty much left to our own decisions.


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## Scott33 (Dec 7, 2010)

Have to apologise for my prior assumption. I didn't realise the diversity of training and standards of practice in Canada. Big-arsed Country though 

Any Ozzies care to give an overview of the system in Perth and if / how it differs from the systems in the likes of QLD and NSW?


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## MrBrown (Dec 7, 2010)

Scott33 said:


> Any Ozzies care to give an overview of the system in Perth and if / how it differs from the systems in the likes of QLD and NSW?



Ew mate, WA is scurge of the bloody earth with the freaking Johnno death merchants running round making ****s of themselves.

They make a 12 week trained barely homeostasasing Parathinkheis Houston Fire Department Medic look a touch more acceptable.


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## enjoynz (Dec 10, 2010)

Not sure if these links are of any help to you, but I'll post them anyway.

http://www.standards.co.nz/news/Media+archive/July+-+Sept+07/Ambulance+Services.htm

http://www.nzqa.govt.nz/nqfdocs/quals/pdf/0207.pdf

There are Medical Advisors within the different ambulance services in NZ that have to adhere to the rules of the Ambulance New Zealand guide lines (a NZ government department).
All staff under the Medical advisors, can only work within their scope of practice,
unless directed by a medical advisor and the patient report form (paperwork) has to be sent to the Medical advisor to be signed off, if you are advised to do a procedure out of your scope of practice.
(In other words.... if you don't get the big ok, from the big chief, you are in deep doo-doo's).
At least that was the case when I was working for the ambulance service here.

Cheers Enjoynz


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## MrBrown (Dec 11, 2010)

enjoynz said:


> Not sure if these links are of any help to you, but I'll post them anyway.
> 
> http://www.standards.co.nz/news/Media+archive/July+-+Sept+07/Ambulance+Services.htm
> 
> ...



Ambulance New Zealand has nothing to do with the Government.

While it is not so much operating over and above scope of practice it's more that we are not bound to a rigid protocol where patients must be sorted into various boxes before applying a standardised clinical methodology and taking them to the hospital or consulting with a physician in order to move beyond a certian point in the guideline.

Where in our little spiral bound book does it say you must consult with a Medical Advisor before applying treatment? It does not.  Within the framework of checks and balances an AO is totally autonomous to apply whatever treatment he or she thinks fit and appropriate at the time using thier professional knowledge and experience.  

Look at how broad our scopes of practice and clinical modalities are, we have RSI on road, thrombolysis is being trialed in Northland, ECPs in Central ....


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## enjoynz (Dec 11, 2010)

MrBrown said:


> Ambulance New Zealand has nothing to do with the Government.
> 
> I'm sorry, for some reason I thought it was....guess I've been out of the loop to longgggggggggggg.
> I thought Ambulance New Zealand was set up by the Government to oversee the medical emergency services....it must have been the following link I was thinking about.-_-
> ...


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## MrBrown (Dec 11, 2010)

NASO will hopefully become the foundation for a national, statutory ambulance service aligned with Fire and Police ....


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## thegreypilgrim (Dec 13, 2010)

Thanks so much to everyone who replied. I promise I'll return with a proper reply with further questions/clarifications, it's just I'm rather swamped at the moment! Again, thank you all so very much.


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