EM systems in different countries

[sihi]

Hi!

People from different countries please write about ambulance service in your countries.

1. who works in ambulance? (paramedic teams?, phisician teams? Nurses? nurse=paramedic?)

2. What drugs do you have and which drugs you can use without a doctor (especially write about sedative/anestetics, muscle relaxants,....)?

3. Are there any drugs that you can administer only after "call" to a doctor?

4. Which procedures can you do without doctor (intubation, cardioversion,...)?

5. EM studies - paramedic studies (years?), team leader-ambulance nurses (EM?/anestesia? specialisation?), phisician (specialisation?)

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I write example about EM in my country - Estonia, European Union.

1. We have 3 kinds of teams: nurse-teams ~65% (nurse+nurse+technician), phisician teams (doctor+nurse+technician), intensive care team/reanimobile (EM doctor or anestesiologist+nurse+technician)

2. Mostly all teams have the same drugs. (injections, tablets...) Inj.: Adrenaline, Dopamine, Noradernaline, Phenylephrine, Diazepam, Midazolam, Propofol, Sodium Oxybutyrate (anesthetic), relaxants (optional), Fentanyl (optional, some teams have in the north, and intensives), Morphine, Pethidine, Tramadol; Diclofenac/Ketoprofen, drotaverine, Metoclopramide, Clemastin, Prednisolon, Dexa., Salbutamol (inhal, inj.), Aminophylline, Metoprolol, Digoxin, Verapamil, Adenosine, Amiodarone, Propafenon, Enalapril, clonidin, Nitroglycerine, phenytoin etc....

3. Usually relaxants for intubation are not used by nurses, some nurses or phisicians use propofol. In some regions it is possible to call to intensive care team - they come and help to stabilise patient.

4. Mostly all teams can do most of procedures - cardioversion with sedation, in CRP - intubation or LT-tube, live patient airway control with LT or intubation (with sedation or anesthesia). And usually we treat at homes (also nurse teams) - Atrial fibrillations, high BP-s, simple abdominal pains, we assess ECG and put diagnoses - if needed hospitalise.

5. to be team leader nurse must to pass EM exam or to study 1,5 years in EM and intensive care specialisation cource and get intensive care nurse specialisation. Doctor - it can be doc. with different or without specialisations.

Thanks!!

[ChaseZ]

I will comment on the nurse aspect in the US. The minimum educational requirement is an associate degree (ADN) which takes 2 years to complete. The next level of education is a bachelors degree (BSN) which takes 4 years. Both associate and bachelors prepared nurses take the same licensing exam and have indentical clinical roles. There is a push for bachelors to become the mimumium entry and many large academic hospitals will only hire BSN new grads. Also, many managment positions require a BSN. Once a RN there are various speciality certifications you can acquire in ICU, Cardiac, Neuro, etc which usually require a year of experience and an exam. RNs are rarely used on ambulances. Some states allow RNs to practice within their scope on ambulances but that is rare outside of hospital to hospital critical care transport. RNs do have presence in helicopter EMS. This requires multiple (5+) years of ICU/ER experience and multiple extra certifications. Fight nurses have a broad scope including all the drugs you mentioned, intubation, central lines, and chest tubes. Our CRNAs require a 2 year master degree with an option of adding a 1-2 year doctorate after your 4 year BSN. CRNAs in some states are able to function as independent provides and manage patients autonomsly.

[MariB]

Wait! My daughter graduates with her LPN in May. That was forgotten.

Granted she will never use it, will not even work as one, it is part of the program she is in for her RN.

I think in most bigger areas Lpns are beginning to be less and less. My mother is retired as an LPN, but she was nursing home.

[island emt]

LPN's are a assisted living and nursing home level skill for the most part now .

A few hospitals still hire them but nowhere near as many as in the past.

Ambulances in the US are staffed primarily by EMT's of the various license levels. Basic , Advanced & Paramedic.

There are some specialty transport teams that have RN's and other hospital staff such as respiratory therapist or DR's for critical care or pedi neonate teams. There are also Paramedic Flight Nurse positions in rotary wing EMS and fixed wing air transport.

[chbare]

I do not see two year nurses going anywhere. The BSN required in ten (years) statements have been around before I went to nursing school. There has been a bigger RN presence in contemporary times, but I suspect it is still somewhat limited to specialty transport. Nurses are not uncommon on flight teams and the assumption that they have massive amounts of experience and specialty certification is incorrect. In recent years, I've seen a change in the industry and now it's not uncommon to find RN's with 1-3 years of experience making the flight transition. Even when I started flying HEMS in 2006, I had over four years of ER experience and no specialty certifications aside from NREMT credentials. That changed when I started flying, but I still wanted to dispel the myth that all flight nurses have exceptional amounts of experience and extensive credential lists when they start flying.

[paramedicmike]

I noticed the same things as CHBARE noted with the nurses I flew with. I also noticed the same thing with the paramedics hired to fly.

In the area I'm currently living a two year nurse cannot get a job. Anywhere. The minimum education needed for hire locally is a BSN. And this is a pretty big local area.

[fab]

I actually considered studying in Estonia, to be honest I still do...

To answer your question:

1. BLS-Ambulance (patient transport, sometimes used as first responder on emergency calls): EMT-B (2 months training) + EMT-I (4 months)

ALS-Ambulance (responds to 911-calls): EMT-I + Paramedic (2-3 years)

physician's chase car (responds to critically ill, severly injured patients): Paramedic (additional training concerning mass casualty incidents) + physician

MICU (critical care, interfacility transport): Paramedic + Critical Care Paramedic + Physician (consultant, experienced in intensive care)

neonate ambulance: Paramedic + Critical Care Nurse + Physician (nurse and physician experienced in neonate intensive care)

HEMS same as physician's chase car (the doctors there are usually more qualified and experienced)

2. everything you could possibly need... propofol, sodium thiopental, etomidate, ketamine, fentanyl, morphine, succinylcholine, vecuronium... here's the neighbouring state's drug list: http://www.google.de/url?sa=t&rct=j&q=&esrc=s&source=web&cd=5&ved=0CFMQFjAE&url=http%3A%2F%2Fwww.aelrd-rlp.de%2Faelrd%2Fcontent%2Fcommon%2Fdownload%2FNotfallmedikamente_Rheinland-Pfalz.xls&ei=72TgUJCEGY6RswbYroGQDQ&usg=AFQjCNGTSo1IjWRm2z5unZDlmhqgmEVFMA&bvm=bv.1355534169,d.Yms

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.

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

[chbare]

I noticed the same things as CHBARE noted with the nurses I flew with. I also noticed the same thing with the paramedics hired to fly.

In the area I'm currently living a two year nurse cannot get a job. Anywhere. The minimum education needed for hire locally is a BSN. And this is a pretty big local area.

This varies. The ADN has a big share of the nursing jobs in my area of the country. I think the biggest change that I've seen is that you can no longer expect a job wherever you want upon getting out of nursing school. As a new grad I was able to walk into an ER and I had several other offers around the country. Now, I think that kind of flexibility is limited even among four year nurses. As a two year nurse, there are jobs, but you will have to be willing to relocate and take a "less" desirable position. The same is true with LPN's. There is a market for the LPN but it's limited and you have to be willing to travel. The old glory days of nursing are over IMHO, but it's still a viable career pathway.

Edit: As somebody who has been a CNA, LPN, ADN and a BSN, I would strongly recommend people tough it out and get the BS degree. You will likely spend the same amount of time getting an ADN due to pre-requisites and waiting lists. You may as well find a decent, accredited four year programme and maximise your options in this economy.

[island emt]

In this area ADN's can find work in the hospitals, but the upward mobility is limited to those with a BSN.

[Kiwiology]

Ambulance Officers in New Zealand operate at one of three Practice Levels. In the olden days it was possible to get hired (especially in Auckland) with no qualification above a first aid certificate and complete all training “on the job” over a number of years however that is no longer the case.

All drugs and procedures are autonomous without the need to consult with a Doctor (the way it should be!)

Emergency Medical Technician (Diploma – one year)

OPA, NPA, LMA, automated defibrillation, automated cardioversion, 12 lead ECG acquisition (automated interpretation), tourniquet, oxygen, PEEP valves, entonox, methoxyflurane (where used*), paracetamol, aspirin, GTN spray, glucose, glucagon, salbutamol, ipratropium, nebulised adrenaline, oral ondansetron, oral loratadine

Paramedic (Degree – three years)

All of the above plus manual defibrillation, manual cardioversion, IV cannulation, NaCl 0.9%, IV glucose 10%, 12 lead ECG interpretation, morphine, fentanyl, adrenaline, amiodarone (cardiac arrest), naloxone, ondansetron (IM and IV), midazolam (seizures), ceftriaxone

Intensive Care Paramedic (Post Graduate Certificate – one year)

All of the above plus endotracheal intubation, intraosseous needle access, cricothyrotomy, pacing, atropine, ketamine, midazolam (sedation), adenosine, vecuronium, suxamethonium (selected Officers only)

All Intensive Care Paramedics can sedate and paralyse an already intubated patient (i.e. dead person) but only selected Intensive Care Paramedics can anaesthetise and paralyse to intubate (rapid sequence intubation) – the difference is subtle but important.

It is strongly rumoured that by 2015 the Ambulance Service will only, wherever possible, hire Degree graduates.

Most ambulances have at least one Paramedic and either another Paramedic or a Technician. Intensive Care Paramedics will be joined up with a Paramedic wherever possible but sometimes with a Technician. It is still possible to get an ambulance with two Technicians, particularly in in rural areas or where there is a shortage of staff because they are e.g. sick, on leave, on courses etc; this seems to be somewhat problematic in Auckland which was traditionally well staffed.

From October a new model is being introduced over the next 2-3 years which will see calls colour triaged as either purple (immediate life threat), red (serious but not life threat), green (no life threat) or grey (telephone triage appropriate). Purple calls will get a lights and siren response, red calls will be responded to at normal road speed, green calls will get the Sierra jeep instead of an ambulance (solo responder) and grey calls will get telephone advice. Wherever possible patients who are responded to will not be transported to ED but rather referred to their GP, A&E clinic or an alternate resource.