Kiwiology

Such legal protection could reasonably seen as infringing on a patients right to choice of treatment including lifesaving treatment. I understand your thinking there so let me explain how it works here, New Zealand is unique as the only country in the world to have a totally no-fault compensation system, but we have given up the right to sue to get it. It is almost nearly impossible to sue a health care professional here, we have the Accident Compensation Corporation that is responsible for providing compensation, rehabilitation, support etc as appropriate for treatment injuries or medical misadventure as a result of health treatment (not failure to comply with it). That is not to say we do not deal with practitioners who are negligent, we have the Health Practitioner Disciplinary Tribunal and Director of Proceedings (a spin-off of the High Court) as well as the appropriate health practitioner responsible authority for disciplining health practitioners up-to-and-including being banned from practising. A civil suit against a health practitioner can happen for damages over and above what ACC gives you or for emotional anguish or something but it is so difficult to make it work it's totally not worth it. You might be interested to know that Conrad Murray wouldn't have been able to get propofol here, because he would be registered in the vocational scope of "cardiology" and not "anaesthesia" or one of the vocational scopes approved to prescribe propofol. Michael Jackson would have had to hire a Consultant Anaesthetist or another vocational scope approved to prescribe propofol. Oh just to add, here a criminal charge can be bought against a Doctor or another health care professional but that is a matter for the Police and the Crown Prosecutor. Such a person here would make a complaint to the Health and Disability Commissioner and they would investigate and be told no fault. If they looked for medical lawyer to take the Doctor to Court they'd be told "that's $1,000 for my consultation now bugger off you have no case, can we get a forklift to help you down the stairs?" Not sure mate, when I was living up large in the Great Nation of Indiana I was south of you, hmm ....

Because it is the right of a patient or their parent in the case of a paediatric patient to refuse any treatment or care recommended, including lifesaving treatment? Because the Physician has a duty of ethics in care towards that patient and must respect the wishes, opinions and beliefs of the patient (or their parents for a paediatric patient)? Again, speaking of a physician who has that patient as an established consumer at their practice; not a "I'll only see you today because it is urgent and won't take you on as a permanent patient" situation which is different. Wow, I mean wow, this is totally got me deer-in-the-headlights'd especially considering the strongly worded ethical guidance from various international medical regulators including the GMC, the New Zealand Medical Council and the Medical Association of South Africa; all of which we could consider comparable nations to the US in terms of ethical issues and medical ethics. What is of interest is that the article Dwayne quoted is that even this practice has been the subject of guidance to the contrary by the American Academy of Paediatrics (sic)

I'm not trying to change your position, you are perfectly entitled to it and I respect that. I find your view that it is appropriate for a physician (GP) to terminate their care of a patient based on the patient choosing not to receive care somewhat perplexing but I'm not passing judgement on you for it.

You are welcome to your opinion and I respect that (unlike Dwayne, he doesn't respect me at all! I had to save him from being beat down by hookers in Las Vegas after he refused to pay citing poor service, jeez! lol) but I would be interested to explore your thoughts some more because this seems to have been carefully covered by various regulatory bodies internationally (as outlined above in my post) that the "issue" must be one of serious nature i.e. patient is violent or abusive or the doctor is no longer capable of providing care for the patient. It depends what the issue is and this is where we must carefully balance the right of the patient not to be discriminated against regardless of their opinion or beliefs and their right to choose which treatment they receive vs the right of the physician to freedom of choice of who they have as patients and their rights to end being a patients' physician. None of the guidance given by the various regulators I have sourced above "forces" a patient on a physician. Immunisation is a much more political and societally controversial topic than say something like diuretics for hypertension or salbutamol for asthma but none-the-less it is a treatment and the patient or their parent in the case of a paediatric patient has the right to choose whether or not they receive it. International guidance on ending patient-physician relationships varies from strongly saying it is inappropriate to end it for reasons other than criminal matters or issues of non-competence on part of the physician (UK, SA and NZ) to a bit more liberal view (AU and US); the Canadian Medical Association is in the middle putting in that ending a relationship must be for a "legitimate" reason. I've worked in a number of service industries often in management, I've offered thousands of customers what I think is best for them based on the evidence at hand, just like a physician does, some people have chosen to decline my recommendation and we still service them regardless. On par with the medical regulatory guidance we could refuse or stop servicing customers but only in extreme situations; drunk, theft, endangering staff etc A patient may choose not to receive a treatment on other grounds e.g. a moral objection or a religious one, which is the same as them deciding not to get Little Billy vaccinated, should they be treated the same?

I would recommend the Queensland Ambulance Service Have a read of their clinical practice manual http://www.ambulance.qld.gov.au/medical/pdf/CPM_Complete_31Jan12.pdf

I cannot agree with this; in fact I am aghast and feel quite ill at the notion that a Physician would (or is even allowed to) refuse to see a patient because of something like this. A competent patient (or their parent or guardian) has the right to refuse treatment (including vaccines and life saving treatment) until proven incompetent and subject to a Compulsory Treatment Order under the Mental Health Act and I dare say the equivalent flavour exists in your respective jurisdiction, hell hole or other such locality as may be expressed from time to time, batteries not included, no refunds, large is an extra $1 and not valid on Sunday. The Medical Council of New Zealand, the Royal New Zealand College of General Practitioners, the Health and Disability Commissioner, the Health Practitioners Disciplinary Tribunal, the College of Kiwiologists and the Centre for the Advancement of Kiwiology in Medicine (1) have all agreed that a doctor-patient relationship may only be ended by the Physician if they are incompetent to treat the patient. General Medical Council of the United Kingdom in Good Medical Practice (2,3) also states it is ethical only end a relationship with a patient when doctor-patient trust has been broken and only then in rare circumstances, specifically citing theft, assault or violence as specific appropriate examples; it goes to to specifically state that a patient must not be denied access to medical care or discriminated against based on their religion or beliefs. Doctors' and Patients' Rights and Responsibilities as published by the South African Medical Association (4) also takes the same view; that a doctor has the right to choose their patients but must not discriminate against or decline medical care to a patient because their beliefs differ from their own and that a patient has the right to refuse any treatment if competent. The Code of Ethics of the American Medical Association (5,6) supports the view taken by the funny-talking, national regulators mentioned previously. Specifically it states a patient may refuse any recommended health-care or treatment but here is where it gets interesting! It states that a physician has a right to end a doctor-patient relationship and does not specify the same cautionary notes as others. The Australian Medical Council and the Canadian Medical Association both in their respecitve Codes of Ethics (7,8) have the same view; that the patient can refuse any treatment or care, the doctor must respect the patients wishes but can also exercise the right to cease being that patients' physician if a suitable alternate is arranged; the Canadian document warns such termination must be for a "legitimate" reason. I am not arguing that a Physician should be able to end the relationship with a patient if it is truly necessary for reasons the UK GMC specifies and those like it i.e. assault, theft from the practice or clinic, if the patient is being threatening or if the doctor is retiring etc. Canada warns that such termination again must be "legitimate" and the natural test of such interpretation will come down to the disciplinary bodies or perhaps an additional civil suit in the US and a reasonable person, and indeed a reasonable Physician or at least all the ones I know, would say the reason "Little Molly's mommy didn't want her vaccinated" is not legitimate. Sorry Doc I have to disagree with you on this one, now excuse me while I nick off to the Resident Medical Officer lounge to eat the House Surgeons lunch, he died from fatigue and will not be requiring it (1) http://www.mcnz.org.nz/portals/0/publications/2011%20-%20Ending%20a%20Relationship.pdf (2) http://www.gmc-uk.org/guidance/good_medical_practice/good_clinical_care_decisions_about_access.asp (3) http://www.gmc-uk.org/guidance/good_medical_practice/relationships_with_patients_ending_relationships.asp (4) http://www.samedical.org/patients-corner/doctors-and-patients-rights-and-responsibilities.html (5) http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion1001.page? (6) https://ssl3.ama-assn.org/apps/ecomm/PolicyFinderForm.pl?site=www.ama-assn.org&uri=%2fresources%2fdoc%2fPolicyFinder%2fpolicyfiles%2fHnE%2fE-8.115.HTM (7) http://ama.com.au/codeofethics (8) http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD04-06.pdf

Wendy this is exactly the problem that many people miss and some can't understand there needs to be a balance between theory and practical and that one is enhanced by the other. I am a true believer in education being the great liberator; it doesn't necessarily mean we are going to administer more treatment to a patient at the time we consult with them but physical examination and pathology knowledge are areas where huge gains can be made from a solid knowledgebase to allow alternate referrals, leaving at home etc You are showing you are truly a person who understands how education enhances ones practice, well done! Not bloody likely indeed I mean he hasn't even offered us any hot Florida beach and roller blade chicks, bro, seriously

The Carolinas seem to have very aggressive standing order based protocols; but in many protocols from across the US it is standard to see something like "contact medical control prior to ... " which ranges from cardioversion to adrenaline to more than x mg of morphine. For example the Georgia Statewide Protocol has "contact medical control" at damn near every second paragraph; in Los Angeles a whole double sided page of standing orders. I know there are places where you never or almost never have to contact medical control but it shouldn't be part of practice; I can understand there are numerous co-factors influencing why it is and am not passing judgement on anybody for it but y'know .... Now Jake I will have to fire up the pick up truck, pop on some contemporary country rock music, pin up the Confederate flag in the rear window and come haulin my ass down your way; we can go fishin' and watch NASCAR (... I don't believe it Bob they're making another left turn!), roast some sort of animal on the BBQ, drink cheap beer, hate on Obama and go to the gun range, perhaps we can do the last two at the same time. Oh, and we're not bringing Dwayne, he's liable to end up at a rough biker bar and in the county jail Yeah, I am sort of taking the piss but not really; I am a conservative pro-gun ownership, Christian Republican trapped in a Kiwi's body; know any single chicks who like guys with funny accents? lol

Is this not what "online" medical control is? For example you may have IV adrenaline as part of your scope of practice (not that common in the US I've seen btw) but it may be a "medical control option" only. You lying bastard you should have stayed at the casino man I won up large and could have paid for a better hooker for you but you horny bugger couldn't wait .... what would James say? never mind I think he was at the bar down the street ....

Yes we have an evidence based scope of practice that is defined by the National Ambulance Sector Clinical Working Group and reviewed every two years. Over the last ten years our scopes of practice have been aggressively widened to ensure the delivery of the most appropriate care to the patient, create a more efficient system of operation and reflect international best practice. A good example is ten years ago only specially selected Paramedics who "[the ambulance service had] absolute faith in" were allowed to be further educated and authorised to carry adrenaline and morphine because it was always to remain "selected" Officers only. Now that the Paramedic Upskilling program has matured and these Officers have proven themselves capable (and with the Bachelors Degree being now required for this level) has led to a substantial upskilling of Paramedic level Officers with a variety of drugs (see my last post) Rather than "teaching the test" or "teaching the scope" (not saying anybody does this, rather contrasting that methodology) we teach broadly; Ambulance education is more on-par with nursing e.g. anatomy, physiology, health care systems, research and statistics, pathophysiology, risk management etc You get muppetmedicsTM who are idiots regardless of whatever system you have; it is not that we have a lack of oversight or accountability quite the opposite but rather we do not have to seek permission from an on-line physician to provide treatment. We do not want to be held up as being "better" or "more intelligent"; we operate differently because the context of our practice is different and that does not mean anybodies is worse than anybody else. Again, there are muppetmedicsTM regardless of nationality; nobody here thinks they are smarter than anybody else; many of the smartest Paramedics I know come from the US, Canada, South Africa, the UK, all over. But it stands to logic that we could reasonably equate increased competency with increased autonomy? Yes I have heard that Kiwi doctors and nurses can be real douchebags; I see it here and I've heard of it when they go remote as well. I think NZ/UK doctors/nurses are very good at the biological or theoretical but perhaps not so good at the doing; I've also heard this from colleagues locally who say their American Consultant is much more "hands on" focused than the New Zealander. This I think comes from that we are perhaps have a bit of so-called "tall flower syndrome" where it's not seen as acceptable to sprout above the rest and take charge I'm not sure. Again you are confusing the two concepts; professional accountability ("oversight") is very important and something we have a lot of here; locally speaking within Ambulance there are the Clinical Coaches, Clinical Development Team, regular mandatory CCE, audit, QA/QI etc etc; we have a very strong culture of being held accountable. Having to seek permission to use your scope of practice however what we do not have to do and is fairly common around the world as I have pointed out before. That doesn't mean somebody who has autonomy is not a douchebag, come on mate, you should know, King Douchebag, I mean fuck you ditched me at the casino and went off with some cheap hooker and got wasted on coke and I found you at a cheap motel naked covered in faeces wrapped in a blanket with a vegetable collander on your head to keep the space ships away with your hoe no where to be found; just like your credit cards and identity The things your ole pal Kiwi does for you .... I don't think having to ask permission to use your parts of your scope of practice should be considered anything other than a benchmark especially when I can name significantly more places where it is the standard than where it is not. You raise a valid point; one must balance theory with application of said theory.

By American standards yes, by international standards such a level of education is becoming the standard. Australia requires a Bachelors Degree and Graduate Certificate, just like we do as they do not have the Technician grade UK requires a two year FdSc for State Registered Paramedic Canada requires three years of education for Advanced Care Paramedic South Africa has a two year CertTech educated Emergency Care Technician and a four year BTech educated Emergency Care Practitioner Rettungsassistent ("Paramedic" loose translation) in Germany is two years of education 150mg as a drip given over 30 minutes Again, such a standard is increasingly common around the world; We do not have any online control i.e. do not have to "seek permission" to do anything, neither do Australia, nor South Africa, nor the UK, in Canada there is some which was a real surprise given the high standard of education.

Welcome to our community, mind the Kiwi and please, no flash photography, keep your hands, arms and cameras inside the vehicle at all times and listen to the instructions from your waiter. I wouldn't consider many of those drugs necessary pre-hospital to be honest; quality (how you can use what you have) is almost, if not more important, than what you have, but that's just in my readings. More is not always better; beta blockers and calcium channel blockers I don't think are something useful to Paramedics; certainly I understand the rationale behind it but I am not aware of any evidence that shows improvements in morbidity and mortality in the pre-hospital environment. Flumazanil is not necessary, its nasty evil muck that we carried very briefly in the 1980s I believe and quickly threw it away Thiamine falls into the same category as flumazanil; I really can't see a role for it in the pre-hospital setting Naloxone is probably not necessary either; ensure adequate oxygenation and transport to hospital. It may have some role in chronic pain patients who have accidently scoffed down a few too many oromorph and can be left at home once we wake them up. Etomidate, suxamethonium, rocuronium and vecuronium; good to see somebody doing RSI but I am concerned if you are doing it properly or just dishing it out to everybody who only gets 2 tubes a year anyway and letting them have at it Fentanyl and midazolam are standard drugs carried most places in the world If you have plavix and tenecteplase you must be doing thrombolysis/ reperfusion, interesting There are much better analgesics than hydromorphine, like ketamine, which can also be used instead of etomidate for RSI In case you are interested, here is what each of our levels can do; we have unlimited drug dosages in line with prudent professional practice and work autonomously with no "online control" Emergency Medical Technician (mostly volunteers, some paid - one year course) LMA, 12 lead ECG acquisition, tourniquet, PEEP, oxygen, aspirin, GTN, salbutamol, ipatropium, oral glucose, glucagon, nebulised adrenaline, oral ondansetron, paracetamol. entonox (or methoxyflurane where carried), loratadine Paramedic (Bachelors Degree) EMT + 12 lead ECG interpretation, cardioversion, sodium chloride 0.9%, D10, adrenaline, amiodarone (cardiac arrest), morphine, fentanyl, IV ondansetron, naloxone, ceftriaxone, midazolam (seizures) Intensive Care Paramedic (Graduate Certificate) Paramedic + intubation, intraosseous access, pacing, atropine, adenosine, ketamine, midazolam (sedation), amiodarone (fast AF/VT), suxamethonium, vecuronium Thrombolysis is coming nationwide at some point too, some areas have it

You could get him a Littman Master Classic II SE stethoscope; I think over your way they're about $70 Might also think of getting him a copy of Marieb Human Anatomy and Physiology so he can understand what he is listening to with that stethoscope I wish my brother was as nice as you .... he's a poo poo head (like Dwayne! )

I'm not sure who makes our hip pouch but it's not too dissimilar from the one you mention Paramedics carry fentanyl 2x 100mcg and 4x morphine 10mg/1ml and an Intensive Care Paramedic also have 2x ketamine 200mg/2ml Midazolam, suxamethonium and vecuronium are carried in our standard drug roll-up

I am going to also say sympathetic nervous system dysfunction from heavy metal or other form of poisoning from where he works Hmm but if that were the case you would think others who works where he does would have it Case closed, I'm going to the beach

Like I said we are autonomous practitioners responsible for our own actions, if somebody identities themselves as a physician we have no legal obligation to do anything they request, there is however professional respect due and the acknowledgment of collegial support which should be taken into account Many of the physician I know are well aware they are not experts in the management of out of hospital acute events and will leave it to the ambos but if they offer to help then where possible I will put them to work holding fluid or doing CPR etc Because we are autonomous practitioners with our own guidelines a doctor can not legally direct us to provide care nor would I accept such a request unless made in collaboration but I doubt such a circumstance has ever occured here Again, our medicolegal system is much less complex

In the last decade we've removed 50% dextrose, stesolid, lidocaine, metaclopramide, promethazine and frusemide (I suspect also nubain and/or foratol may have been lurking in one or two places i.e. ex DHB (hospital based) services) In the last decade we've added 10% glucose, paracetamol, methoxyflurane*, ipatropium, ondansetron, fentanyl, ketamine, ceftriaxone, amiodarone, adenosine, suxamethonium, vecuronium and loratadine as completely new medicines Also since 2002 GTN, glucagon, ipatropium, ondansetron, methoxyflurane* and loratadine have become Technician (EMT) medicines, Paramedics have gotten adrenaline, morphine, fentanyl, midazolam, ceftriaxone, amiodarone and 10% glucose; Intensive Care Paramedics have been upskilled with all other medicines not already listed at Technician or Paramedic level plus ketamine, adenosine and paralytics. I strongly suspect the removal of adrenaline from cardiac arrest guidelines here come 2015 should there be no additional evidence of benefit between now and then * methoxyflurane is carried by staff working in limited space (Motorcycle Response Unit and Rapid Response Unit) where entonox is not practical or in very rural areas where resupply of entonox is problematic

There seems to be a great fear over your way about emergence syndrome and ketamine; I have only seen it once and the benefit of ketamine is far outweighed by the small chance of some hallucinations so, we do not routinely give midazolam to those who have had ketamine and only give it if the hallucinations are particularly severe. Ketamine is just the bees knees its the most awesome stuff ever I love it to bits its totally freaking awesomeness wrapped in made of win Interestingly it seems Intensive Care Paramedics may have been under-dosing people on ketamine so the new Guidelines encourage larger dosages of ketamine if required. This one bloke got 80mg of ketamine one night, hell 80mg of ketamine would damn near anaesthetise me, which we are also using ketamine for now too Oh and it's really awesome for giving House Surgeons the shits followed by "what on earth did you give him?" Gosh you blokes really are missing out by not having House Surgeons ....

All y'all are hilarious ... I love my crazy internet family ... except Dwayne

If you want hot weather and reasonably comparable clinical autonomy/scope look at Texas re Australia Ambulance Victoria are excellent, as are the QAS and ASNSW, I'd personally recommend QAS because all the beaches are there!

Sounds like my last shag

sucks for you living in a land with so many dangerous creatures not like this side of the dutch we still use it as a first-in treatment for symptomatic bradycardia

you know i can finally sound cool and say i need a "bus on a rush" when im late for work and the first bus is full?

You understand me well; shame you're not younger, hotter and female

DIE WORDS DIE! Oh dear that looks like some sort of stirring instrument in my hand Hmm um, hey look over there while I run away .....