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)
- CPAP (for acute cardiogenic pulmonary oedema)
- Glyceryl trinitrate
- Salbutamol (nebulised)
- Ipratopium (nebulised)
- Misoprostosol (for PPH; off-label I believe)
- Normal saline
- 10% dextrose
- 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.
- Frusemide (far too much, far too often)
- Midazolam (IV)
- Salbutamol (IV)
- Sodium Bicarbonate
- Sedation to enable intubation (horrible and scary)
- Rapid Sequence Intubation
- Needle thoracostomy
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!