AmboFOAM’s Toys: Training, Education and Equipment.

I was going to add a note on the bottom of my last post about gear to let people know what drugs and toys I carry, but I thought it deserved a post of it’s own with a brief run down on some of our education requirements as well.

Victoria, like most Australian services, runs a two tier system of paramedics (we used to have ambulance officers, but we all got “promoted” to paramedic some time ago)

In Victoria our entry level paramedics are known as Advanced Life Support (ALS) Paramedics.  They make up the bulk of the service and do most of the work.  To become an ALS paramedic one has to first be accepted into one of the Bachelor Degree programs that many Australian universities offer.  The standard Bachelor degree is three years full time study, and if successful you graduate with a Bachelor of Health Science or a similar bachelor level degree.  Some universities also offer a 4 year option that includes nursing subjects, and candidates graduate with a nursing degree as well.

If you are then offered a position within Ambulance Victoria there are still further requirements before ultimately qualifying as an ALS paramedic.  A year is spent working with clinical instructors and qualified paramedics, with various competencies to be achieved along the way.  Finally, after 4 years of study and supervised practice you get to be a qualified ALS paramedic, which gives you the authorization to use/do the following things:

  • Airway adjuncts: Oral and nasal airways, and LMA
  • IV access (in patients > 14 years of age only)
  • Oxygen
  • CPAP (for acute cardiogenic pulmonary oedema)
  • Aspirin
  • Glyceryl trinitrate
  • Methoxyflurane
  • Salbutamol (nebulised)
  • Ipratopium (nebulised)
  • Misoprostosol (for PPH; off-label I believe)
  • Normal saline
  • 10% dextrose
  • Glucagon
  • Naloxone (IM only)
  • Morphine (Restrictions in place on how much can be used without consulting with the senior MICA Paramedic who oversees clinical stuff on a day to day basis from the control room)
  • Fentanyl (Primarily intranasal, but can be used as alternative to morphine, also with restrictions)
  • Adrenaline (IM for anaphylaxis, IV for cardiac arrest, nebulised for croup)
  • Midazolam (IM only, for status seizures or management of the drug affected patient who is a risk to self or others)
  • Antiemetics: Metoclopramide and prochlorperazine (stemetil) – restricted to adult patients only.
  • Ceftriaxone (For treatment of meningococcemia, but can be used for other etiologies of sepsis on consultation)

One can then decide whether to continue to MICA paramedic, or to follow other career options within ambulance.

To become a MICA Paramedic one then has to apply and sit a gamut of tests including clinical exams, scenario assessments and interviews.  If successful a place is offered in the Graduate Diploma course which is currently only offered by Monash University in Melbourne.  This course takes another year of education, training and mentoring. Placements are undertaken in adult and paediatric anaesethesia, adult and paediatric emergency departments, ICU and CCU.  The course culminates with a viva voce, and upon passing this the candidate is now a qualified MICA paramedic.  BUT WAIT!  It’s not over yet.  Whilst qualified, the MICA paramedic spends another 12 months working with more senior MICA Paramedics, and in this time is not authorised to carry out rapid sequence intubation unless with a suitably qualified MICA paramedic.  At the end of this 12 month period the MICA paramedic then sits another assessment in order to be allowed to carry out RSI themselves.
(This education process is currently being streamlined and may differ from this description, however this is the process I followed.  The overall time-frame and requirements remain essentially the same)

Finally, 6 to 12 months after this, the MICA paramedic can become a single responder (previously they will have continued to work on an ambulance with a second MICA paramedic, junior MICA paramedic or perhaps MICA paramedic student)
A three month probation period is in place before they are let loose on their own.

Phew!  So after all this, the MICA paramedic gets to use the following (in addition to ALS drugs/equpiment)

  • Morphine and fentanyl for analgesia can be used at discretion of the paramedic, with no upper limit.
  • Adrenaline – IV as push dose pressor and via infusion.
  • Amiodarone
  • Atropine
  • Adenosine
  • Dexamethasone
  • Frusemide (far too much, far too often)
  • Midazolam (IV)
  • Salbutamol (IV)
  • Syntocinon
  • Sodium Bicarbonate
  • Suxamethonium
  • Pancuronium
  • Intubation
  • Sedation to enable intubation (horrible and scary)
  • Rapid Sequence Intubation
  • Needle thoracostomy
  • Cricothyroidotomy

Given the years of training and education, it’s actually a fairly short list of stuff.  I like to think that it’s not what we’ve got, but how we use what we’ve got that is important, but there are certainly a number of things that I personally think we are lacking.

Analgesia is probably where we fall behind the most.  Essentially we have an opioid, or a different opioid (methoxyflurane is being de-emphasised and has limited utility anyway).
Obviously not everyone needs an opiate, and some need more than an opiate.  I look with envy to our Kiwi colleagues who have ketamine for the worse stuff and paracetamol for the less worse stuff (along with morphine, fentanyl, and nitrous oxide or methoxyflurane) which I think is superb.  A multi-factorial approach to analgesia is superior to just pushing more of the same repeatedly.

We recently lost metaraminol from our bags which is a shame.  I think it was probably under-utilised anyway, and would love to see an alternative such as phenylephrine available.  Another pressor that is also missing is noradrenaline, although I hope there is a chance that this may be considered for inclusion in our bags as it has been used by airwing safely and effectively for a long time.

A ventilator would be a very welcome addition to our equipment.  Whilst we have an excellent program for RSI, and carry out a large number with (currently) 100% success, I believe we let our patients down after the tube goes in.  We currently have simple bag-valve-masks with no ability to adjust FiO2 and no PEEP valves.  Patients are ventilated with this set up for significant lengths of time (sometimes many hours) which can be doing their lungs no good at all.

Of course, effecting change in such a large, widespread organisation is no easy task.  There are many layers of bureaucracy and oversight for new things to have to filter through, and thus change can seem slow in coming.  Additionally, to roll out a decent ventilator to the all the MICA units in the state would require an enormous outlay of money, and money is something most government services are short of.

Thus I don’t intend this to be a criticism of the people who work tirelessly to improve patient care in my organisation; it is merely a wish list of stuff I reckon we should have. Fortunately there are some improvements trickling down as we speak: ketamine will “soon” be available for both analgesia and for induction (replacing the fentanyl/midazolam cocktail we currently use) and we will also be getting ondansetron which will be great. There may be other things coming, if anyone knows of any, feel free to let me know!

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7 Responses to AmboFOAM’s Toys: Training, Education and Equipment.

  1. kiwimedic says:

    Have started printing your stuff off and leaving it on the mess table at our (rural) branch. Couple of the old school guys were all over it until they found out you were a kiwi and then shuffled off mumbling something about wide tooth shearing combs and the 1970’s. Never mind. What are your thoughts on external pacing post unsuccessful pharma? Or even in combination? I know it’s used with reasonable effect in other services, even on the dreaded Mrx. Given the history of MICA being stood up with cardiac care in mind I wonder if it is another tool to be added. Also coming from NZ, paracetamol is a big miss for AV, or anyone who doesn’t carry it. For the febrile or taking the edge off a longer term pain, given ramping or long rural transport times, it can keep the wolves at bay in conjunction with our other tools. Keep it going and let us in on your thoughts.
    Rich

  2. Best not to get them started on the 2013 International Woodchopping Championship win by the Kiwis…

    I have to admit I have no first hand experience with transcutaneous pacing for symptomatic bradycardia. We also treat very few bradycardias these days. Essentially if you have perfusion, are not having a STEMI or have active pain we leave generally leave you alone.

    With that said,the AHA and ILCOR state that pacing may be no more effective than 2nd line pharmacotherapy (adrenaline in our case). The Australian Resuscitation Council words it slightly differently with the preference for pharmacotherapy with pacing as a rescue measure if this fails.

    So I can’t say whether we are missing anything, but we are certainly operating within accepted standards. In my experience it is a rare bradycardia who does not respond to an adrenaline infusion (but of course this doesn’t mean much)

    I agree that something like paracetamol would be fantastic. I would love to be able to take a patient with even a simple fracture, start them with some methoxyflurane while we faff around, a couple of paracetamol, and some morphine and/or ketamine for extrication or splinting and movement to the truck. With a combined approach we could limit the amount of any one drug we have to use and provide more appropriate ongoing analgesia instead of having to just crack amp after amp of morphine ad nauseam (quite literally!)
    Obviously there are risks associated with NSAIDS or paracetamol, but I would hope that with the years of education and training we have that we might be able to manage giving them safely.
    It certainly seems a little absurd that we are trusted with RSI, but not with good analgesia, especially given how often we would use one as compared to the other.

    ILCOR Website: http://www.ilcor.org/home/
    ARC Guideline: http://www.resus.org.au/policy/guidelines/section_11/managing_acute_dysrhythmias.htm

  3. KIdoc says:

    ….can buy paracetamol and many NSAIDs off the supermarket shelf, unlike opiates (at least, not in my local supermarket)
    Shouldnt be TOO long a bow to get these onto the MICA service.
    I see needle thoracostomy is on the list – how about FINGER throacostomy? You can always practice on a sheep on one of my EMST courses if that helps the inner KIwi feel more comfortable

  4. BambalanceDriver says:

    I have noticed some sarcastic distaste for the MRx on this site. Do you have a post that outlines its problems? My service is about to purchase these to replace our current (disliked) Zoll E-series. There is nothing I can do about it, as our service voted them in, but I would like to know what I am in for.

    • Hi.

      What can I say about the MRx? Two things to remember: One, these are merely my opinions and are not representative of my organisation (etc etc). Two, We are using the older version of the MRx and I have not had an opportunity to play with the new one.

      With that said: I find the MRx to be very heavy and cumbersome. It only prints on narrow, rhythm strip paper, which makes deciphering 12 lead ECGs very difficult. It has very poor filtering (some of this may be user changeable I guess) so alarm fatigue sets in very early. It will alarm at any movement, because it is hot, or cold, because a stray zephyr wafted past the cables, or because it is Tuesday. Fortunately it often doesn’t seem to alarm at little things like critical desaturation or VT…
      The screen is also not an accurate representation of what is actually happening. You can’t glance at the oscilloscope and say “Aha! VF!” because it is likely to be sinus rhythm. (Well, ok, that may be overdoing it, but the point remains, you can’t actually trust what you see on the screen)
      Interestingly, in conversations with paramedics around the world, I have never come across anyone who does like the MRx.
      I hope it is an improvement over your E-Series. I believe our airwing have just gone the the X-Series Zoll and I understand that they like them so far.
      Good luck with the change!

      • BambalanceDriver says:

        Thank you for the fast and thorough reply. We looked at the Zoll X, and that one had my vote. I am hopeful that we can overcome some of those issues, and I will let everyone know my brief thought on them once they have been in service for a bit. Philips reps are coming to “educate” us this week. I will be sure to ask about alarm adjustments and the like.

  5. Nathan Haynes says:

    what is the minimum RSI’s and ETT’s per year to maintain competency ?
    Cheers mare

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