Kiwiology

We have two.

10-9 is require urgent police assistance for patient being combative

10-10 is emergency, ambulance staff being assaulted

The Dispatcher has to hear it, pick up the phone, dial the Police, wait for them to pick up, explain the situation to a call taker, the call taker has to transfer it to the dispatcher, the dispatcher has to dispatch the Police, the Police have to travel to the scene and assist.

If it's busy the Police phone system will wait for I think 30 seconds then divert you to another call center and continue until somebody answers. This really annoys me because all three services (Fire, Police and EMS) here use the Intergraph system which can be linked. Fire and Police have done it but we can't seem to grasp the concept.

We also don't have any stab resistant clothing or personal protection beyond our Maglite which can be seen as assault with a deadly weapon if the cops want to be pissy about it.

Well, the difference is both obvious and significant. Maturity necessary to facilitate intelligent clinical judgment is the difference.

But otherwise, your observation is spot-on. Both suck. BLS units provide a false sense of security, the illusion of EMS coverage where none really exists, because to the general public, and ambulance is an ambulance. And, so long as one of them keeps showing up, they all figure they've got what they need. Consequently, growth is extremely slow in coming because no problem is perceived. Now, give them that false sense of security for FREE (i.e. no salaries paid to keep that box rolling down the street), and you erect an even stronger barrier to professional growth of EMS in your community. MUCH stronger. And that is why those kids is worse than a BLS FDNY unit, although you are correct. Both suck.

I couldn't agree more. Sorry I'll clarify what I said a few pages back - I am not in favor of 16 year olf EMTs to provide first running cover for exactly those reasons you said there Dust. They don't have the maturity and clinical experience.

I also couldn't agree more that BLS sucks!. We have the same problem here in our smaller areas that rely on BLS by way of total volunteer crews and maybe a paid Paramedic during the day who is also on call at night.

Our union takes the same approach - to Joe Layman an ambulance is an ambulance, it doesn't matter what the guys in it have the ability to do. They expect every ambulance to be able to provide what they see on TV which is ALS invariably.

I am of the personal belief that BLS is an effective stopgap between ALS for true medical or trauma emergencies as I said before. They can try to keep me alive until the Paramedics arrive, I'd rather have them doing that than waiting for ALS to turn up.

For example here in good ole Kiwi Land only 19% of our stations can provide ALS 24x7 while 30% capable of providing ILS 24x7 and the rest, its BLS. We are working to get an EMT-I (ILS) on every ambulance which does not have ILS or ALS already.

I'd love to see a Paramedic on every ambulance, but, in the meantime if I am dying, I'd rather a BLS truck turn up first than a longer wait for ALS.

See, echo, I see it a different way. What if it is a heart attack? Hang on, I gotta get out of stupid lay public land, ahem, what if it is a true myocardial infarction? What exactly are these wunderkids going to do? Take a blood pressure? Apply oxygen? They're basics, they can't even do an EKG on the person. Except for the ride to the hospital, and maybe saving the triage nurse two to three seconds by having name, DOB, med list, and allergies, rushing out of class to go to this call neither benefits the patient, the provider, nor the community, in fact, it does a disservice by convincing the community they are getting proper care for emergencies.

And if its an arrest, by the time they're done changing the window for AED use will have gone the way of Britney Spear's hair.

Interesting, and I agree with your point there Asys but let me look at this another way. I'm at the 14 St subway station at rush hour, my Metcard won't work and my train is leaving. I have a heart attack, er, myocardial infarction. The good people at the FDNY will dispatch an ambulance to me.

The closest BLS unit is 06 Adam (CSL: 14th & 2nd Ave) so they kick off the bums who are hassling them for medical care having been annexed from the firehouse and light up the LED and speed to my locale.

Wait a minute... Adam is a BLS unit, same as the 16 year old Superkids in CT. They can only pull out the AED and await an ALS unit. Closest FDNY ALS is 6 Xray at E 23rd & 2nd Ave by the FDR. Too bad 6X only works from 6am until 2pm. If I code at 3pm well ALS looks like it'll be 7 Robert from W 34th and Avenue of the Ameircas which is even further uptown.

I don't see how the 16 year olds being BLS and relying on Paramedics from county mutual aid is any different than your FDNY BLS unit being BLS are relying on FDNY EMS or perhaps somebody from Bellevue or one of the other providers I've seen around the city.

Nine times out of ten, their patients would be better off with nothing but a ride to the hospital, with absolutely no medically trained personnel, and a driver with professional training and experience way beyond that of an EMT (of any age).

These kids are kidding themselves if they think they are really making any difference in their community beyond saving tax dollars to be used on mowing the grass at parks and emptying the trash at city hall. They're not. They're screwing themselves and their community, and are too stupid to even realise it.

I understand that and I can see where you are coming from. Something is wrong at City Hall if they think providing first running EMS to medical emergencies with teenagers is acceptable. Is it better than nothing? Yes, is it as good as a professionally run, career orentaited EMS service? No.

But, what differentiates them from the many other volunteer EMS (be they BLS or ALS) agencies around the world apart from thier age? Now I may be wrong, but, given that many small communities rely on the good nature of volunteer firefighters and EMTs to provide a "first running" response to fire and medical emergencies I just don't see the problem.

In leiu of a professionally run and funded EMS system which may not be financially viable or practical given a low workload what else can we offer? Nothing. That sounds good! Whoops too bad if you're dying, I mean really dying, from lets say massive hypovalemic shock while blood gushes from a severed artery.

Well you can wait for county ALS or a fly car to turn up but hmm that might take a while, in the meantime we could have had some volunteer EMTs turn up and apply bleeding control, O2 and those blow up MAST pants I have noticed we don't carry anymore.

I know which I would rather have.

Not sure if all of you have seen this but it is was originally a book and DVD released by the late, great James O. Page (founder of JEMS and former Captain of the first LAFD Paramedic unit).

I came across the video on YouTube (watch it here) but have also got the expanded DVD edition which can be ordered from Amazon.com here

'Tis an absolute must watch and is really interesting to see where we have come from.

Hope it's of use.

I used to be in the Army and I know a bit about combat medicine. One of my personal interests is the history of civillian EMS which has its beginnings with the French during the Napoleonic War if I remember correctly.

The Royal New Zealand Army Medical Corps (RNZAMC) teaches our medics along the same track as our civillian Paramedics, emphasising a clinical knowledgebase and competency in emergency and trauma care. I think it's necessary to know both sides of the equation - i.e. general medicine (treating a sore tummy or foot full of blisters from too much PT) and also traumatic combat injuries.

Note I said combat medicine because that is different than military medicine. I differentiate the two because on base in the military you don't get a lot of people with major trauma, gunshot wounds, ordaniance embedded in various bodily cavities etc. You can go along to the doctor and he'll take an exam, maybe take some bloods and give an Rx (and if you're lucky a day or two off PT). Out on the line there are people who have had limbs blown off, thier chest ripped open and insides shredded, who are bleeding profusely etc etc.

In that situation it's (arguably) not necessary to know how to treat a medical problem such as a sore tummy because this guy who has lost 1/2 of his blood volume probably and is seriously hypovalemic probably doesn't care. All he wants is some blood, those funny looking blow up MAST pants which seem to be used less and less these days, and a spot on the chopper to a MASH.

Now in saying that not every waking second of combat is er, combat. So if you've got said sore tummy in your foxhole at 2am then yes, I would want my co medic to be able to tell if I had a bleeding ulcer, appenditicis or a perforated colon due to the mystery meat we ate at chow.

There is a place for both but figuring out why my tummy is sore and how to treat me when I am shot up and bleeding.

Ya know, the fact that a 21 year old kid in a third-world country, ten-thousand miles from U.S. shores, has to school American EMS personnel on the most basic aspects of their own history speaks volumes to how badly American EMS sucks. :?

Sorry I missed that until now, I was out with the local malitia fighting the CIA installed General who has overthrown our poor third world country's Government in a coup and on the way back I had to check how the well digging was going because I am sick of walking 10 miles for water. Boy it sure does suck to live in a country that's considered in the First World huh?.

*removes tounge from cheek*

Our EMT-Bs (which is a mix of EMT-I/85 and EMT- can do the following:

Independant

- O2 and OPA

- LMA and NPA

- Entonox and methoxyflurane

- AED

- Asprin & tylenol

- Nebulized allbuterol

- Nitro

- IM Glucagon

Authorized by medical control or a Paramedic

- IM adrenaline

- Nebulized adrenaline

These are the advanced skills EMT-Bs need:

Establish IV (NS, LR, D5)

Nitro

ASA

Narcan

Albuterol

Glucose Monitering

Acquire 12 Leads

IVs: Maybe way out in the boon docks. IVs and other invasive interventions carry risks, benefits and consequences. I am studying for my EMT-I qualification here which is a combination of I/85 and EMT-IV so part of it is IV cannulation and fluids. I don't find the procedure that hard to learn and understand but you must consider the implications of a failed IV. What do you teach them to do? IM, IN etc? I am generally against EMT-Bs being given the ability to start an IV.

GTN, ASA, BGL, 12 lead, allbuterol: We can do them here except 12 lead acquisition but that's not hard to teach so I don't see the problem.

Naloxone: Abrupt reversal of narcotic depression may result in nausea, vomiting, sweating, tachycardia, increased blood pressure, tremulousness, seizures and cardiac arrest. EMT-Bs don't really have the skills to treat those (such as nausea and vomiting - they can't give metaclopramide (maloxon) or IV fluids) so I'm generally not going to support it. Maybe under the the supervision of a Paramedic they could do it. I can see the logic in including it but I'd need to do some further digging.

Yup its true. Los Angeles was one of the original Paramedic cities - along with Jax and Miami. Remember John Gage from Emergency? - John Gage comes from Jim Page who was the Captain at LAFD Station 7 at the time NBC came to do research on thier Paramedics.

See this is what happens when you like EMS too much, end up full of usless information

Us Kiwi's have 5 which will soon be 4 because EMT-IV and EMT-I are being merged.

FR + AED (O2, AED, Entonox)

EMT-B (mix of EMT-B and EMT-I/85 (LMA, GTN, allbuterol) )

EMT-IV (0.9% NaCI, manual defib, IV cannula)

EMT-I (Epi, Naloxone, D5W, Metoclopramide (maloxon) and morphine)

EMT-P (NREMT-P)

Any one of these can work on the ambulance.

Since 1973 the LAFD has run EMS in LA City and unlike the FDNY I believe all Paramedics are also firefighters.

No breath sounds, ok, so this guy is obviously not breathing. That's my main issue.

If he has COAD or asthma or some other resp disorder / allergy he's going to have to meds or a medic alert bracelet or something of that nature.

I would start on O2 at 8 lpm and check out ETCO2/chest rise & fall and re-evaluate breath sounds with a view toward BVM if he's not improving and requires manual ventilation.

I am thinking this is one of the following:

1. airway obstruction: laryngascopy and remove with McGills forceps or push the endotracheal tube right down to dislodge the object.

2. asthma or COAD: 0.5mg IM adrenaline and get an IV line, if not improving intubate and start infusion of 1mg epi/hr in a litre of NS with epi boluses of 0.01mg IV as required q1-2.

3. allergic rection / anaphalyxis: 0.5mg IM adrenaline, if not improving intubate and start infusion of 1mg epi/hr in a litre of NS with epi boluses of 0.01mg IV as required q1-2.

I would be interested to see how this turns out: I don't think its poisioning or a sting or some kind because I'd suspect he would have mentioned it to the EMD.

What about environmental: gas leak or something?

New Zealand's fleet is making the transition to Merceedes Sprinters from Fords and Chevvy Silverados. I dont like them, they are not purpose built ambulances and are really, really crappy.

They are bought mainly to proivde the highest possible degree of resale value simply because our funding is not sufficent to buy proper Type III ambulances.

A picture of the interior of what I believe to be an ILS or ALS capable ambulance is below.

You will note two stretchers (which is a historic inclusion and never went away), no cabinets and the fact the patient stretcher is right up against the wall.

The Lifepak 12 up on the left hand side either stays there or on the spare stretcher (on the left) so its prone to sliding around. The orange trauma kit down at the bottom left is the same, it will slide around.

We have long spine boards and the like in an exterior locker by the passengers side door. Note what I believe to be the ALS jump kit on the left hand front beside the passenger seat. All the drugs and stuff are in there. Even that is problematic as you have to dump all your gear on the spare steretcher to use it.

The Paramedic's seat is really only useful for intubating or procedures on the top half of the pt. and therefore rarely used, they'll just sit on the spare stretcher.

Can somebody PLEASE get us a good Ford E450 with some wall side cabinets and a proper interior with only one stretcher?

Most of the ER/surgical docs I know think highly of medics. If they get on your case, offer them a seat in the truck on a Friday night, I bet you they decline real fast. I know some who wouldn't touch the street unless it came through the ER doors - oh they say its too dangerous.

Our medical students do ONE 12hr shift with EMS for the entire 4 years they are in medical school! Our Paramedic degree guys do placements for the entire 3 years of thier degree.

Not sure where this high and mighty mentality comes from, after all, doctors like Eugene Nagel and William Grace, not to mention all those pre-1980 ACEP members invented EMS.

If they get too uppity remind em that it was physicians who came up with the idea of prehospital ALS, so they are jumping up and down about a program THEY invented, that should shut up em up

Oh, and if it makes any difference, our protocol says:

SEIZURES

1.5mg midaz IV q 3-5 max 15mg

5-10mg midaz IM max x2 q20

15mg midaz IN q20 max x 2

Sounds like some of the guys I know, they can't comprehemd being told what to do or follow instructions.

Well now we cant have you looking like a firefighter now can we, thats a "promotion" - *tounge in cheek* - what a crock, I feel sorry for you guys who aren't even allowed in the house and get dumped at some CSL where the crazies can badge you.

Far as uniform, I like the dark blue or green jumpsuit (like the Londoners wear) with the SoL all over it or something like ours, just a shirt and pants.

I know one or two places that use total white - I wonder if they have a Superior ambulance with the yellow lights and glass IVs too!

We don't even have the Star of Life on ours - we used to but not any more, and our protective clothing is a hard hat and a reflective vest. I sure could go for the thick bunker coat those FDNY guys stuck at ther CSL's have.

I think for safety medics need to be "nuteral" ie not look like a cop so that the nutters don't confuse the two.

Bring on the jumpsuit!

We just have a standard cop style shirt with your qualification level written on it (e.g. "PARAMEDIC" ), black pants and shoes. We also have a dark green V neck jersey if you want - but that just has "St John" written on it.

I know most guys in the UK and Oz wear a green or blue jumpsuit with the Star of Life on the back and "PARAMEDIC" in big letters.

Didn't NYC*EMS do something like that ...I seem to remember them using a white shirt and dark green or blue jacket?

Well not to sound like a smart arse, what are we supposed to use?

I dug out the GSA KKK Specs and the ACS minimum equipment lists but that differs from our national prescription on equipment and also ourr drug suppliers supply our drugs in NZD based on the prices we have haggled to the death to get (damn cardiac arrests are expensive and we're broke!) ... so am I supposed to convert all those to USD etc?

And take my new pimped out Ford E450 Ultramedic, best place to find a price on one of those is online, not sure our local Ford dealer stocks them

Now, does it matter what we place INTO the ambulance, clinically wise? i.e. if I want to choose EZ-IO over Cooks or amiodarone over lido does it matter?

This is fun, its got me dreaming of a rig our current funding cant possibly provide!

Did I mention our entire budget is around $8 million to run 194 stations and serve around 2.9 million people?

$187,000 for an ambulance and all the toys in it ... wowee! I'm in heaven!

Can we use the cash to employ an additional three Advanced Paramedics coz I'm sick of single crewing?

ROFLAMO I love it!

Howdy;

I am interested in finding out about your scopes of practice by jurisdiction (be it national or at state level). Its unfortunate but New Zealand's EMS system is currently in bad need of an overhaul in terms of qualifications and funding. Our qualifications are standardized by the Government but the SoP is not, and as such, we're looking to develop a national standard with three levels (BLS, ILS & ALS). We currently have five (CFR+D, BLS, 2 x ILS & ALS) any one of which can crew a rig.

Ours are below, any international comparison would be appreciated.

1. CFR+D (Pre Hospital Emergency Care or "Please Help, Educaton must Continue")

- Advanced first aiid & splinting

- AED

- O2 & OPA

- Entonox/methoxyflurane

2. BLS (Ambulance Officer or "Blast! limited skills, so only able to offer some care")

- IM Glucagon

- LMA

- NPA

- Allbuterol (salbutamol)

- GTN

3. Paramedic

- Manual defib

- IV NaCI & D50W

- 12 lead EKG

4. ILS Paramedic (or "I am likely to save people")

- Morphine

- Metaclopramide (maloxon)

- Epi

- Naloxine (naloxone)

5. Advanced Paramedic (or ALS Paramedic -- "auctually likely to save people")

- ETT (incl RSI)

- Thoracostomy

- Cricothyriodotomy

- IO

- Pacing

- Frusemide (frusomide)

- Ketamine

- Atropine

- Amiodarone

- Midazolam

Thanks for reading!

Great topic. We Kiwis are in a simmilar situation, most rural services are run by volly medics, if they are at work, well, sorry no cover. Mutual aid, well, sorry, we've only got one or two paid medics in the next town over because they have a low call volume so your mutual aid is probably going to be a single crew transport, if you're lucky, the fire service (also vollys) will get turned out to provide some O2 or first aid.

If you need ALS you're probably going to have to wait for a fly car or the whirly bird. We put resources into areas depending on the need - by which I mean, "how much do we REALLY NEED to spend this money?"

Our BLS service here is a mix of BLS and CFR+D so if you live in a low workload area, your local ambulance may turn up with one EMT-B and a CFR+D or two CFR+D or worse yet, a single EMT-B or CFR+D because nobody else is able to be rostered on (paid staff to vollys is about 1:3 here)

Lets say that your local BLS rig turns up with one EMT-B and a CFR+D to a high speed car crash or some guy crushed by his John Deere (hey, they're out in the boon docks remember?). Or perhaps its some old guy on his farm who codes ... the call goes out for an Advanced Paramedic. Well, Dispatch is either going to send the nearest ILS or ALS ambulance or the chopper (ALS). Long wait, long transport time etc etc etc ... same problem world wide

I guess it just does not make financial sense to have Paramedics sitting round in the boon docks playin the banjo and whittlin'. Sad.

Here's the lowdown on how it works here. Remember: In our system you can't sue an EMS provider for anything, you may be able to bring a private claim against the individual Paramedic for neglegance but I have never herad of it happening. I dont totally agree with that system but anyway;

1.6 NON TRANSPORT

- is medical treatment required?

- Is transport to a medical facility required?

- If transport is required, what form of transport is most appropriate?

Transport must be recommended if any of the following are present.

- Personnel are unable to condifently exclude serious illness or injury or

- Interventions (including IV fluid and/oror pharmacologics) have been given, excluding consumer oral anelgesia (eg Tylenol)

- There is an exception to (2) in that medical control may state transport is not required

When a competent patient declines

- Explain the consequences

- Involve family, friends and family doctor as appropriate

- Provide advice on what to do if they get worse

- Read, have them sign and provide thier copy of the AMA statement on the run sheet

Basically if you need medical treatment you will be transported. I don't like that, EMS isint a darn taxi service or a replacement for going to your doctor so while transporting you and your stomach flu which you thought was appendicitis somebody else has a heart attack which we can't get to.

As far as refusing treatment (i.e. will not treat you) we have nothing in writing but its common sense, if you are agressive or off the planet or nutting out or something like that.

ILS SoP

- Manual defib

- LMA, NPA, OPA

- Morphine, epi, naloxone, metaclopramide (malaxon)

- IV NaCI, glucose, D5 and D50W

ALS SoP

- ETT

- Surgical or needle airway (cricothyriod puncture)

- Needle thorocostomy

- IO

- Atropine (brady only)

- Frusemide (frusomide)

- Amiodarone or lido

- Midazolam (benzo)

- Ketamine (St John)

- TCP & cardioversion

- Thrombo (WFA)

- CPAP (WFA)

Our standing order for codes is 1mg epi q4 and 300mg amiodarone x1 no atropine or bicarb so thats why its not in the ILS skills - I know .... I dont like it either.

If you want to come down here, I hate to say it, but, go to WFA. They run only ILS and ALS ambulances - no BLS. Our BLS req here gives basic a new term, its a 5 day course basically equiv to CFR+D (first responder) in the US.

As far as vacancies go .... there are always vacancies, we have a national shortage of something like 400 medics.

Food for thought anyway.

Not bad, if you're an EMT-P ("Advanced Paramedic" in our lingo) the pay is around $800p/w (US) or $1k NZ but it varies depending where you work. Cost of living is comparable, maybe a little more because of the transport requirements (not unlike Hawaii).

Our two big providers are St John and Wellington Free - personally I perfer the latter, they are better funded and run only an ILS/ALS mix.

Have a look round and feel free to ask any other Q's.

<SHAMELESS SELF PROMOTION>

Come to New Zealand, we need Advanced Paramedics (EMT-Ps) something terrible and its not that far from Oz!

Most likely, you'll even get a neat looking fly car (link for pic) and be able to ride the chopper depending on where you are based.

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