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sihi

EM systems in different countries

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2. everything you could possibly need... propofol, sodium thiopental, etomidate, ketamine, fentanyl, morphine, succinylcholine, vecuronium...

http://en.wikipedia.org/wiki/Paramedics_in_germany a paramedic's scope of practice is defined nowhere. Some medical directors have started giving out guidelines, but that's about it.

Do ALS ambulance (paramedic) can use this drugs? Propofol, Etomidate ... for intubation? Or every state is different?

Our CRNAs require a 2 year master degree with an option of adding a 1-2 year doctorate after your 4 year BSN.

CRNA - nurse specialised into anesthesia?

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Some services utilise these medications, particularly flight crews and critical care transport crews. I'm not aware of widespread use of propofol for pre-hospital RSI but it is commonly used post intubation as a titrated infusion. Etimidate was particularly common when I started flying, but ketamine is becoming quite popular. States do much of the scope of practice regulation, so guidelines can change from place to place.

A CRNA is a nurse specialised in anaesthesia.

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In France, we have a 2-tier response:

I- First reponse

II - Medical response

NB: In France, "Medical" labels only real emergency physicians. For instance, what you call "EMTs" could never have "medical" in there french name. If it's "medical" only a doctor can do/operate it, or nurse instructed by a physician.

In France we have 4 great kinds of EMS strustures:

- The proper EMS, the SAMU (Service d'Aide Médicale Urgente = Emergency Medical Assistance Service)

- The Fire Brigade

- The Volunteer units

- The "private" responders

To help you see clearer, see table:

http://www.hostingpics.net/viewer.php?id=361189Capturedcran20130107155801.png'>361189Capturedcran20130107155801.png

I - First response:

The role of the first responders are:

- Assessing the patient's state with:

_clinical signs

_vital paramaters (blood sugar-level included)

_relevant questioning

- Apply the appropriate gestures (automated defib // immobilization etc..)

- Transmit the assessment to the EMS

- Apply the medical decision

The first responders do not perform any invasive gesture.

Who's in the ambulance? It depends on the responding structure:

http://www.hostingpics.net/viewer.php?id=964996Capturedcran20130107160812.png'>964996Capturedcran20130107160812.png

What drugs can be used? Do some of them need the authorization of a physician?

First responder do not deliver any drugs. Also, they do not possess what they're not allowed to used by themselves.

Yet, the volunteer units of the Protection Civil have a little protocol to deliver basic medicines like:

- Paracetamol

- Aspirin

- Salbutamol (Ventolin™)

And other little things like anti-nausea, anti-diarrhea...

This applies only to the Protection Civile. The Protection Civile is a "volunteer unit".

Also, oxygen is consider a medicine which is allowed for every first reponder. Glucose is available in several forms in every ambulance.

None of the above requires physician authorization.

II - Medical response.

The role of the medical team:

The medical teams are dispatched by the SAMU only. Most of the vehicles and crews belong to the SAMU itself, but in big city, the fire brigade has its own dispatcher and medical ambulances.

The medical team perform any procedure that can be done outside the hospital. They issue a diagnosis, start a comprehensive treatment and give instructions to the first responders.

They perform a fully medicalized CPR in cooperation with the first responders.

The ECMO unit can perform an... ECMO procedure anywhere, a surgeon and two trained nurses are on board.

Who's in the ambulance?

950789Capturedcran20130107163248.png

What drugs can be used? Do some of them need the authorization of a physician?

Of course I'm not qualified to tell you what's used by the medical crew except from the classic stuff i've seen being used many times (adrenaline etc...), but as a physician is there I guess the only limitation is to actually have the drugs in the ambulance ;)

I hope it's clear enough :D

post-44661-0-13469300-1357570729_thumb.p

post-44661-0-84436000-1357571310_thumb.p

Edited by Secouriste
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I want to work in France, only because SMUR translates to "Mobile Urgent Reanimation Service" and that sounds so cool! :D

Edited by Kiwiology

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Yup that was shot in the "Hotel-Dieu" Paris hospital ;)

Kiwiology: Yes SMUR refers to "Mobile Emergencies and Resuscitation Service". What's the difference between SAMU and SMUR then? They're two level of the same apparatus.

- SAMU is the dispatching center, but also the decision-making entity in the area of emergency response.

- SMUR is the service attached to an hospital, gathering the administrative services, the medical crews, the vehicles and equipments.

There is one SAMU, but ambulances are scattered among the different SMUR of the zone. For instance, Paris is the département (territorial subdivision) #75, if you take the ambulance attached to Necker Hospital is will say:

977940a1079b002a.jpg

You have both mentions ;)

The main audience knows only about SAMU. SMUR is for professionals to know where the ambulance comes from.

Edited by Secouriste

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This should give you some idea of what to expect in Canada.

http://en.wikipedia.org/wiki/Paramedics_in_Canada

This is the Wiki write up for BC, the province I currently work in as an ACP.

http://en.wikipedia.org/wiki/BCAS

I read through them both. They're relatively accurate overall. I'm also registered in Alberta as an EMT-P which actually includes the majority of the CCP SOP minus the additional education (Alberta doesn't currently have a defined CCP level so EMT-P's currently fill that hole with additional in house training from their respective employers).

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Fab is talking about Germany, but doesn't give the state. Actually, staffing is state dependent, allthough the basics should be the same everywhere:

  • Non-emergency transports: Usually one EMT ("Rettungssanitäter", 4 months education) on the patient's side and one driver (various qualifications due to state).
  • Emergency prehospital care & transports: Usually one paramedic ("Rettungsassistent", 2 years education) on the patient's side and one driver (various qualifications due to state).
This can be enhanced by emergency physicians, usually coming by seperate car (some big city systems use ambulances with additional physician on board, becomes rare). Dispatch or requesting of an emergency physician is regulated by a list of indications (critical conditions, possible severe symptoms and/or emergency descriptions).

Special units are interfacility intensive care transport, neonatal transport, tox units, those have special regulations. Usually the same as above (medic and physician, both specially trained). Nurses are rare, usually they have to be trained as paramedics as well, exceptions exist in sole interhospital transfer units.

Primary EMS helicopters usually are medically staffed with a physician and a medic. Interhospital transfer helis may be staffed by intensive care nurse and doctor, but this is rare in pure form, since most helicopters do primary prehospital care as well. Beeing a nurse doesn't qualifiy you for primary emergency care here, additional education as medic is needed then.

All other staffing and additional requirements, especially mass casualty training, are state dependent.

http://en.wikipedia.org/wiki/Paramedics_in_germany a paramedic's scope of practice is defined nowhere. Some medical directors have started giving out guidelines, but that's about it.

The wikipedia article is not quite correct either.

A "paramedic's scope of practice" isn't defined because we legally don't need a seperate one (I know, some colleagues may disagree here, because they want to be guided more by restrictions than by our present freedom...). We are bound to same national standards as all other medical professions. So there doesn't exist a list of things we may or may not do, there are no detailed flowcharts or SOPs. The basic rule just is, that we have to call a doctor in certain cases (emergency physician indication list) and pass the patient to a higher level of care - so we may not treat a patient ambulatory (allthough we are able to rule out non-emergencies, but that's not "treatment"). Until the doctor is present, we have to do all to save patients life or protect him from pain - after the doctor is present, we have to assist (hence, the part "assistant" in our job title). ~80% of all emergency calls are handled without emergency physician. So the real scope of practise is our own level of education/training and willingness to argue it (which includes a high skill in documentation!). :)

However, there are some employers which want to restrict employees. I wouldn't want to work there, it would put the responder in a potential legal trap. Some employers or regional medical directors (where implemented) are careful enough to give only guidelines as to set a certain level of quality, which is good. Some really try to keep their employees on a high continuing training standard, which is the best. Most others don't really care, which is reality, but you don't hear much of them in EMS news...

BTW, there is a new profession law in the processing, which will enhance the german medic's education to 3 years including beeing professionally paid during education time. This more or less exactly adresses the statement above: they want us to be better educated, the old job law ("2 years") is from 1989, update was needed.

Yes, I admit, it's a bit difficult to explain. From U.S. view see it as an enhancement to have a skilled emergency physician on scene, able to play out really all the fancy stuff they learn in med school which surely is above the scope of a street medic, including, sometimes, the arrogance against unwilling patients or family members...

With this in mind, the following statements of fab are absolutely right:

3. It would be unusual to call a doctor since you can have one physically present in a reasonable amount of time

4. paramedics: manual defibrillation, iv access, intubation, needle decompression, repositioning / physician: basically anything within sound clinical reasoning

Do ALS ambulance (paramedic) can use this drugs? Propofol, Etomidate ... for intubation? Or every state is different?

If the patient needs it, was instructed and is willing to get (or situation implies consent), the provider knows how to use and is able to handle side effects and no other less invasive procedure applies: then yes. Those points including documentation are always the basic things to have in mind when applying pre-hospital care in Germany, for any situation and any provider (especially medic, but physician as well).

The "knows how to use" rules out most lower EMT-levels from more invasive things, but generally applies to them as well. It adds a individual component to the level of care, but as a medic you at least have to fulfill a basic knowledge (defined by the job law) which you HAVE to know, including the things fab mentioned. Drug accompanied RSI isn't covered in this defined basic knowledge, but you indivdually may have had additional training on it. If you can justify it, you are legally able to do it (only exception would be restricted drugs as opioids, where applies an additional law).

In reality, it is rarely done. We're trained in a lot of things to hold a patient stable until an emergency physician gets there. Especially before RSI we usually have a lot of other things to do, all my RSI's up to now had time until physician (and thus more team members to handle the situation) were present: airway & bleeding control, i.v.-access, pain management, monitoring, extrication etc.

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I hear that from the next CPG update (middle of the year) Intensive Care Paramedics who have RSI will be getting transport ventilators to better combat bad dyscarboxaemic juj ju as well as all Intensive Care Paramedics getting thrombolysis.

I am sure we will be getting something else that is cool and new and flash; there is nothing else I can think of that is appropriate to be re-classified from ICP to Paramedic or from Paramedic to Technician so whatever updates to the scope of practice take places will be something new, I have absolutely no idea what it might be; last time it was oral loratadine (new medicine) and that was just totally unexpected; I believe New Zed be the only ambulance service in the world that has it.

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