What Skills Do Ambulance Crews Have?

tallaght01

So, it has been said that the Irish ambulance service is essentially a glorified first-aid service.

IN particular the ones that are staffed by firemen.

They don't give drugs, rely on automated defibrillation, dont intubate....and essentially perfom the same roles as an experienced first-aider.

what do you guys think.


These are not neccesarily my opinions. This is what I've been told by colleagues. I'm a doctor who's worked in the UK and New Zealand for the past few years.

In both places the paramedics give drugs and can intubate.

I haven't worked in Ireland in a long time, so don;t know what the reality is nowadays.

Can anyone shed some light on what I can expect if I'm picked up by an ambulance in Ireland in status epilepticus, or status asthmaticus, or in VF arrest?

cheers guys.

civdef

Hopefully someone more qualified then I can comment further, but to summarise the current situation:

Advanced Paramedics - New grade, small but increasing numbers, scope equivalent to that of other countries.

Paramedic - Previously called EMT here, the majority of ambulance service crews are at this level. Similar scope of practice to EMT-Bs in other countries, but more extensive training. Additional skills being added gradually.

EMT - New grade, principally envisaged for patient transport services and voluntary organisations operating ambulances. Equivalent to EMT-Bs in other parts of the world.

The ambulances staffed by DFB are all crewed by Paramedics with some Advanced Paramedics, same as HSE ambulances, all DFB firefighters are trained as paramedics.

tallaght01

so they've just started calling EMTs paramedics? Coz they should be two different grades, no?

I guess what I'm wondering is what they can do that skilled first-aiders can't.

I've been teaching first aiders for a long time, and the good ones can do the following....

use neck collars, splints, scoop stretchers, chairs etc

they can use oxygen and entenox

they can use an AED

They can use a guedel airway, and a bag+mask

They can use a sats monitor

They've completed moving and handling modules

They can take a BP

This is in the UK. But can our crews in Ireland do any more?

What drugs can our advanced paramedics give? How competent/confident are they at advanced airway management? Where are they learning to put lines into people?

timmywex

paramedic; former emt, they have been upskilled and this is on going,they can give drugs but not sure on what, the skills are a lot more than first aid,

advanced paramedic, as said, new grade, can intubate, give a wide area of drugs, iv im etc etc

www.phecit.ie for details on drugs etc,,,

the dfb have all paramedics, with a number of advanced in response cars also,

you may have got the idea of first aiders from people getting mixed up with the voluntary ambulances which just cover certain events and give first aid, privates are gloriifed taxi men basically, rarely using lights or sirens, doing routine transfers

any more questions, just ask, cant think of more to post, dont be afraid to ask, alternatively, you can go to www.irishambulance.net and ask there, thats full of current paramedics and advanced paramedics



edit: ok, i thought i had aloada stuff on the drugs and guidelines etc, but theyve been taken offline, and the ambulance training school website doesnt seem to want to respond either.

Dave!

Out of interest, are you in the fire services yourself timmywex?

timmywex

no, i just want to be a paramedic in a few years and know a fair bit about it as a result, im trained first aid and defib and prob know higher than that.

tallaght01

timmywex wrote: »

paramedic; former emt, they have been upskilled and this is on going,they can give drugs but not sure on what, the skills are a lot more than first aid,

advanced paramedic, as said, new grade, can intubate, give a wide area of drugs, iv im etc etc

www.phecit.ie for details on drugs etc,,,

the dfb have all paramedics, with a number of advanced in response cars also,

you may have got the idea of first aiders from people getting mixed up with the voluntary ambulances which just cover certain events and give first aid, privates are gloriifed taxi men basically, rarely using lights or sirens, doing routine transfers

any more questions, just ask, cant think of more to post, dont be afraid to ask, alternatively, you can go to www.irishambulance.net and ask there, thats full of current paramedics and advanced paramedics



edit: ok, i thought i had aloada stuff on the drugs and guidelines etc, but theyve been taken offline, and the ambulance training school website doesnt seem to want to respond either.

so where do they learn to intubate? took me ages to be able to do it. Plus there's some pretty funky drugs you often have to give when ur tubing someone.

Would be interested to know what drugs they can give though.

Can they intubate babies?

Del2005

tallaght01 wrote: »

So, it has been said that the Irish ambulance service is essentially a glorified first-aid service.

IN particular the ones that are staffed by firemen.

They don't give drugs, rely on automated defibrillation, dont intubate....and essentially perfom the same roles as an experienced first-aider.

what do you guys think.


These are not neccesarily my opinions. This is what I've been told by colleagues. I'm a doctor who's worked in the UK and New Zealand for the past few years.

In both places the paramedics give drugs and can intubate.

I haven't worked in Ireland in a long time, so don;t know what the reality is nowadays.

Can anyone shed some light on what I can expect if I'm picked up by an ambulance in Ireland in status epilepticus, or status asthmaticus, or in VF arrest?

cheers guys. QUOTE]

I was doing first aid training with some DFB men and they had recently done the paramedics course, this was a couple of yeards ago now. They where sent to the US to the full US paramedic course and also sent to the UK to get trained on the things the we do different to the US. Our paramedics have the same levels as the UK and US and can also dispense the same drugs. They started with 12, and these are now providing training to the rest and I assume they are still sending some away.

MartinC2006

I have a friend who has worked an EMT in Cork for around ten years.
I have a friend who has worked as an EMT in Belfast for about the same.

We all came through St Johns together and they took it further with careers etc.

It just so happens the friend from Belfast Finishes his Paramedic course next week.
The friend from Cork finished his advanced paramedic course a while ago.

From a lay persons observation the consensus seems to be;

UK > Ireland EMT grades in every way, driving, equipment, training etc.

However the advanced paramedic course in Ireland seems to be much better than the UK version. Training takes 3 times as long (I think), more drugs, more skills, just that little bit ahead in every aspect apparently.

The main problem being there’s not that many advanced paramedics yet.

I’ll be sure to ask my friends for a more detailed response on the differences.

Martin.

tallaght01

Was just out for a jog there and met a guy on my street who's in the fire brigade, and used to be on the ambulances.

He's semi-retired now, but his son is a paramedic (not an advanced paramedic).

He reckons his son "can give drugs".

I don't know what drugs these are, but I presume they're the cardiac arrest drugs, like adrenaline and atropine.

There's no good evidence that these drugs make a huge difference, but they probably do. So, i think it's a good idea that most paramedics can use them.

So, that's progress. This guy was telling me about how years ago when he was on the ambulances, people were just dying in the back, coz all they could do was cardiac massage.

I wonder how good these new paramedics are at getting IV access in somebody who's arrested, in order to get the drugs into the vein.

I know many many times in the UK, people came in flat, but with no IV access because the paramedic couldn't get a drip in. That's no criticism of them, getting a line into somebody with no cardiac output is often a real nightmare.

From my own biased paediatrician point of view, I still think one of the big problems in the UK/new zealand/south africa where I've worked in the A+E environment is that children's emergency care is poor. Paramedics never spend any time in a childrens ward (except the guys in johannesburg spent 5 days in a neonatal unti doing nothing). Very often, the most imprtant, and yet the most difficult thing to do, in a baby/small child is to get a drip in. It's hard enough when they're well, let alone when they're unwell. I think an advanced paramedic should have put lines into chubby toddlers in emergency situations before being let loose.

When these kids go off, they nearly always come in having had no drugs because nobody could get a drip in. Some paramedics are obsessed with intubating these kids, and spend a lot of time trying to acquite this competency, because it's one of the cooler things that you can be seen to do at an arrest. But good airway control without an ETT tube will nearly always suffice. I'd rather a kid came to A+E with a line in, having had drugs and fluid, than with an ETT tube in situ.

It's all very well to walk around with huge belts on, with cool looking equipment hanging off them, but we need to make sure we can do the basics.

MartinC2006

I think your being harsh there, you can't tar everyone with the same brush.
I for one think Paramedic's are hugely under appreciated for what they do.

I've no idea what the procedure is called but if a child was that closed down I beleive they can gain access through the neck some how?

Also from what I've gathered from my friend and he's the first to admit kids scare the hell out of him. Its very much so lift and run, no messing about just get to the advanced car asap. If theres time to tube etc on the way so be it.

Martin.

tallaght01

c'mon dude, read the post. I specifically underlined the word "some".

I don't think I'm being harsh.

I'm pointing out that I've very rarely seen a child arrive in A+E with a line in. Most of the unwell adults that come through the door have one in place.

I think that's because paramedics don't spend enough time training with kids.I think most paramedics would disagree with this.

I think you've proved my point when you say that paramedics just scoop and run with the kids. This, in my experience, happens, even when they would benefit from some on-site treatment.

You can put a line into a kid's neck if they're shut down. You just stick a cannula into a neck vein. I wouldn't really expect a paramedic to do this, though.

What would normally be used is an introasseous needle (which is a needle straight into a leg bone). I have never, ever seen or heard of a paramedic putting one of these into a kid. Of course, that doesn't mean it has never happened.

This is my point, though. There's lack of paediatric training for paramedics.

But I do have to say that the general consensus in hospitals is that the amount of kit hanging off a paramedic is inversely proportional to their competence

Fyr.Fytr

As far as i know paramedics can give gtn, glucogel, asprin, enthonox and some others. AP's can give a whole lot more they can intubate aswell

Not sure what, but i have colleagues who are paramedics and advanced parsmedics so will find out more

tallaght01

Fyr.Fytr wrote: »

As far as i know paramedics can give gtn, glucogel, asprin, enthonox and some others.

That's a pretty decent start, though.

I presume they can give adrenaline/atropine at an arrest too?

!!!!!conor!!!!!

Here's a quick overview of the current standards in Irish EMS:

Voluntary Ambulances: Currently highest level is EMFR which can use AED, OPA, BVM, O2, Entonox, KED, collars, longboard, BP, O2 sats, frac packs, can't think of anything else!

This is soon changing to new EMT being the highest voluntary standard. The standard is here http://www.phecit.ie/Documents/Education%20&%20Training/SectionE%20Edu%20&%20Train%20Standards.pdf

The drugs they will be able to give after this 4 week and 1 week clinical placement course are Asprin, GTN, Glucose Gel, Glucagon, Adrenaline, Salbutamol, Morphine, Cyclizine, Naloxone, Oxygen, Entonox and Paracetamol (some require doctor's order I believe)

Statutory/Private Ambulance: The next level is the old EMT now called paramedic. Drugs that can be given by current EMTs are GTN, aspirin, oxygen, entonox and glucose gel. The EMT/paramedic are due to be upgraded with new skills via CPD such as LMA, salbutamol, glucagon, etc.

The new skills are here: http://www.phecit.ie/Documents/Education%20&%20Training/SectionF%20Edu%20&%20Train%20Standards.pdf

The highest level is Advanced Paramedic which was known as EMT-A for a short period. This includes et tube placement, LMA, IV access, manual defib, sorry can't think of anything else off the top of my head!!

Advanced Paramedic guidleines: http://www.phecit.ie/Documents/CPG%20-%20As.pdf

Meds: http://www.phecit.ie/Documents/Medication%20Formulary.pdf

The training levels can be viowed here: http://www.phecit.ie/DesktopDefault.aspx?tabindex=7&tabid=427

timmywex

ah cool conor, i knew them yokes were on that site somewhere, just couldnt find them

tallaght01

I'm impressed witht he advanced paramedic stuff.

My concerns lie with their diagnostic skills though.

What hospitals are training these guys?

It will be a great service if they pull it off though.

sunnyjim

Some of the Advanced Paramedic lads went abroad to do a Diploma. I think that UCD are accrediting something too.

EDIT

http://www.ucd.ie/genpract/preview/cicsemta.htm

http://www.ucd.ie/pgstudy/news/2006_april/042706_paramedics.htm

Some reading on the UCD side of things.

Tango Alpha 51

tallaght01 wrote: »

I'm impressed witht he advanced paramedic stuff.

My concerns lie with their diagnostic skills though.

What hospitals are training these guys?

It will be a great service if they pull it off though.

Tallaght01,
Let me put your mind to rest. To become an advanced paramedic takes the guts of another 9mths on top of your basic training. Also you have to be 5yrs post qualified as a paramedic before you're even considered to be able to go forward for training. They spend alot of time in theatre & various hospitals in Dublin, Limerick etc learning how to intubate, cannulate etc. The list of drugs that we (Paramedics & Advanced Paramedics) give is undergoing review every year. Yes, years ago, people were loaded into ambulances & taken to hospital without much intervention but things have changed drastically for the better. I can also assure you that my partner (an Advanced Paramedic) would have no problem cannualting a paed if neccessary & he is more than competent to do so. For long enough we had the medical profession holding back our development because "they didn't want us playing" with their toys. We as in Paramedics & Advanced Paramedics don't profess to be doctors but personally I found your colleagues comments about us as a "glorified first aid svce" to be offensive & unprofessional to say the least. Both ourselves(HSE National Ambulance Service) & the DFB Ambulance Service are professional in every respect & you can't equate our role to a first aider. Lastly I can assure you that if you do ever have an arrest in Ireland or a status epilepticus or indeed any other ailment that if an ambulance does come for you, that you will be treated with the upmost respect & professionalism & treated to the best of the crew's ability.

tallaght01

buzzman wrote: »

Tallaght01,
Let me put your mind to rest. To become an advanced paramedic takes the guts of another 9mths on top of your basic training. Also you have to be 5yrs post qualified as a paramedic before you're even considered to be able to go forward for training. They spend alot of time in theatre & various hospitals in Dublin, Limerick etc learning how to intubate, cannulate etc. The list of drugs that we (Paramedics & Advanced Paramedics) give is undergoing review every year. Yes, years ago, people were loaded into ambulances & taken to hospital without much intervention but things have changed drastically for the better. I can also assure you that my partner (an Advanced Paramedic) would have no problem cannualting a paed if neccessary & he is more than competent to do so. For long enough we had the medical profession holding back our development because "they didn't want us playing" with their toys. We as in Paramedics & Advanced Paramedics don't profess to be doctors but personally I found your colleagues comments about us as a "glorified first aid svce" to be offensive & unprofessional to say the least. Both ourselves(HSE National Ambulance Service) & the DFB Ambulance Service are professional in every respect & you can't equate our role to a first aider. Lastly I can assure you that if you do ever have an arrest in Ireland or a status epilepticus or indeed any other ailment that if an ambulance does come for you, that you will be treated with the upmost respect & professionalism & treated to the best of the crew's ability.

I think you're taking this all very personally.

The medical profession are the ones teaching the bulk of the courses listed above. I doubt we ever used the phrase "don't want you playing with our toys".

I think we have to be careful who we let use potent drugs. I'm in favour of first responders being able to give drugs. I've spent most of my career working in countries where paramedics are the norm.

I do, however, understand from the above that you guys spend 6 weeks in hospital. I'm not sure if that's "a lot of time".

I also have always worried about the over-confidence of some paramedics. To say your colleague would have no problem in cannulating a kid is a good example of this.

I'm a paediatric registrar, and have worked loads in neonates and ITU and A+E. My consultants and I would never ever say we would "have no problem" cannulating a kid. If you have ever tried it during a resus, you'll realise what a nightmare it can be. I have taken up to 45 mins getting IV access into a newborn (not even during an arrest!).

The remark about first-aid people having a similiar skill set was probably a reasonable comment, considering the pre-hospital situation at the time. there were no drugs, and no intubations/cannulas a few years ago. Therefore, I don't see the difference.

What drugs can your basic paramedic give (ie not the advanced guys, coz ther'es only like 20 of them in the country isn't there?). We've seen lots of lists about advanced paramedic drugs here. But what about the guys who I'm most likely to meet if I go into status?

Dave!

Might be just my good self, but I'm detecting quite alot of hostility from most of your posts in this thread so far tallaght01... Again, might just be me.

tallaght01

well, you might think I'm being hostile, but I'm in favour of pre-hospital drug admin.

People are easy to accuse others of hostility, when difficult questions are being asked.

All I want to know is...

1) what drugs an I likely to receive if I keel over now. ie what can the current paramedics give me?

2) Why is there not more than 6 weeks of clinical placement in the training course?

3) Why is there not a paediatric placement that last longer than a few days, because a lot of the A+E depts where they do their placements won't see kids presumably.

4) Why don't we focus more on some of the more problematic procedures, such as cannulating babies/toddlers/infants

When people can answer these questions, then they can accuse me of hostility.

Shield

DaveMcG wrote: »

Might be just my good self, but I'm detecting quite alot of hostility from most of your posts in this thread so far tallaght01... Again, might just be me.

Hi tallaght01.

I see where DaveMcG is coming from but I think I know why.

You are obviously very experienced in your field. Perhaps even an expert.

I don't think there's hostility in your posts, but I am detecting some frustration.

In my opinion, questions 2, 3 and 4 can't be objectively answered unless the person/people who designs the course(s) comes in here and answers you directly. Some people who have done the course(s) may be able to suggest answers to you, but I'm starting to think that suggestions are not acceptable to you at your level, or what you're looking for.

tallaght01

Totally agree psni.

I am frustrated about what's coming through the door in other countries.

I don't blame paramedics one iota for this.

The course design is obviously outwith their control.

What annoys me sometimes, though, is that when I raise any kinds of issues like this with paramedics where I've worked, the same replies crop up again and again....

"we provide a VERY prfessional service"

"medical professionals feel threatened by us"

"We can intubate/canulate easy"

I think they should be responding by saying they'll audit how many kids come in with IV cannulas successfully placed (obviously not including those who don't need one) etc etc

I think they should be challenging themselves and looking at their own performance constantly, like the rest of us have to do.

Having said that, it may well happen in Ireland. It may be a great service. i hope it will.

But we have to be open to questions and scrutiny, or else standars slip.

Shield

Yeah you don't have to tell me about being open to standards and scrunity. I'm in one of the most scrutinised police forces in the world. Scrutiny is good, but you can be over-scrutinised too.

Back to your topic - I'm in no way qualified to even speculate. Just as long as you're aware that your frustration is coming through in your posts, and those who are in the job may see that as an affront and go on the defensive as a knee-jerk reaction.

Having said that, I do hope someone can provide you with directions to the answers you're looking for.

tallaght01 wrote: »

Totally agree psni.

I am frustrated about what's coming through the door in other countries.

I don't blame paramedics one iota for this.

The course design is obviously outwith their control.

What annoys me sometimes, though, is that when I raise any kinds of issues like this with paramedics where I've worked, the same replies crop up again and again....

"we provide a VERY prfessional service"

"medical professionals feel threatened by us"

"We can intubate/canulate easy"

I think they should be responding by saying they'll audit how many kids come in with IV cannulas successfully placed (obviously not including those who don't need one) etc etc

I think they should be challenging themselves and looking at their own performance constantly, like the rest of us have to do.

Having said that, it may well happen in Ireland. It may be a great service. i hope it will.

But we have to be open to questions and scrutiny, or else standars slip.

Tango Alpha 51

Tallaght01,
Let's start again. Your right in that standards do have to be maintained.

1) There is over 100 Advanced Paramedics in the svce at the moment out of a total staff complement of 1300 or thereabouts.

2) The AP program has only been up & running for the last 2-3 yrs

3) As for paramedics, upskilling etc, the following is by no means an exhaustive list of drugs:

a) oxygen
b) entonox
c) aspirin
d) glucopaste
e) glucogel
f) salbutamol
g) diazepam pr
h) IM Morphine

+ others. I'm on nights at the moment & have been working for the last 18hrs already so am tired but will dig out the material & post it for you.

The PHECC have decided that cannulating & intubating along with the frontline cardiac drugs are the standard that they want us at in the next yr or so. Personally can't see that happening due to budgetary restraints but we are trying.

I never stated that cannualting or intubating was easy & trust me try to cannulate someone in car that's on it's roof in a mangled condition is far from easy but we do the best we can & yes we are human & miss from time to time.

In relation to my posting about my partner's ability, I can only speak from personal exp of watching this person do their job. The paed placement for paramedics was only 1wk but we are led to believe that the whole paramedic syllabus in Ireland is changing for new entrants into the svce where figures of up to a 1yr in clinical placements are being bandied about.

We are audited here in Ireland by the PHECC inrelation to our PCR's etc & FTP committees are in the process of being set up.

You might have your performance monitored where you work but I can tell you that up to very recently once you qualified as a doctor & if you set up a GP practice in Ireland, there was no further accountability on your part either.

We are advancing the Pre Hospital Emergency Care side of things in the svce in Ireland & like everything else it takes time but we will get there.

I understand your frustrations at times with paramedics but equally we're frusrated by some of your colleagues totally dismissing us out of hand as not knowing what we are talking about. We have the exp of working the road in sometimes very hostile & difficult situations & unlike yourself who has the support of nursing,medical,trauma teams with a full range of diagnostic equipment & ancillary support svces withing the hospital setting, we have only each other with limited equipment to do our job.

tallaght01

I'm sure it will get there, buzzman.

IN fact, it has the beginnings of a good early drug delivery service.

I think the framework for serving adults is already in place,and will be effective.

I'm still concerned about the paediatric side of things. I don't think it's neccesarily a disaster waiting to happen or anything, but I think you'll agree that 1 week of paediatrics isn't sufficient. Presumably we can agree on that much? I'm glad they're talking of extending it.

I've cannulated people in ambulances and in car wrecks (even in a lift with no lights and a pothole :P). But this is all the more reason to have trainee paramedics in A+E literaly doing every cannula in the place for a number of weeks. I even think paramedic trainees should go on-call in hospitals out of hours, whereby they're the ones called when a cannula needs to be replaced on a ward...coz they're often tougher cannulas than A+E cannulas. I know you guys have no control over that side of things though.

Also the argument that GPs haven't been audited over the years cannot be used in this context. You have to be your own advocates here. What would you audit in a GP surgery? It's difficult to know. Hospital docs have always been audited. Many of us meet every month and discuss every patient who has died or has been seriously ill in the previous 4 weeks. We have to stand up and present the case, while a team of our peers question us.Not many health professionals do that.

Paramedics will be easier to audit, as they have a more easily definable role compared to that of a GP.

I'm not sure why you think many of my colleagues dismiss you out of hand. All docs have the golden hour concept drilled into them from medical school. I have to say I've never had the chance to dismiss a paramedic out of hand, because the only time I meet paramedics is when they're handing over a patient at resus, when we're usually not arguing about the skills of paramedics. Other than that, you guys usually hand over your patients to the nurses. But if you look at the paramedic discussion fora in some of the UK sites you will see that there is a cohort of paramedics who think they know more medicine than doctors.

I hear there's now a motorbike in Dublin? Great idea. We need more. We've been using them in the UK for years. Great way of getting a defib to the scene quickly. I was once at a hotel in the UK when a guy arrested. Within minutes the bike was there. Coldn't believe how fast it was. He was had the AED on, and I had the line in and the tube ready within minutes of the fonecall, despite there being crazy traffic outside. It was a great service.

emedd

tallaght 01 - there is a tone in your posts which is confrontational. maybe you don't mean it to be there, but it is.

all the information you want is on the phecc website. only APs an give ACLS drugs at present.

all pre-hospital clinical practice guidelines are drawn up by phecc and continuing professional development (including audit) is becoming a part of this.

audit is important in the context of a GP as any other health professional. if you think the role of a GP can't be audited, you need to go back to college.

do you audit your paediatric cannulations?

it is not possible to train pre-hospital practitioners for every eventuality. a balance has to be struck between what commonly needs to be treated and what is rare enough that it is not worth spending resources and time on.

the majority of paediatric presentations are not life threatening (in contrast to adults) this may reflect the bias towards adult rather than paediatric experience in the AP course.

tallaght01

emedd wrote: »

tallaght 01 - there is a tone in your posts which is confrontational. maybe you don't mean it to be there, but it is.

all the information you want is on the phecc website. only APs an give ACLS drugs at present.

all pre-hospital clinical practice guidelines are drawn up by phecc and continuing professional development (including audit) is becoming a part of this.

audit is important in the context of a GP as any other health professional. if you think the role of a GP can't be audited, you need to go back to college.

do you audit your paediatric cannulations?

it is not possible to train pre-hospital practitioners for every eventuality. a balance has to be struck between what commonly needs to be treated and what is rare enough that it is not worth spending resources and time on.

the majority of paediatric presentations are not life threatening (in contrast to adults) this may reflect the bias towards adult rather than paediatric experience in the AP course.

When you ask tough questions, you're always acused of hostility.

When I present at our mortality and morbidity meeting, the tone taken is somewhat similiar, but I don't keep telling people how hostile they are, I get on with it.

If you think me saying that it's difficult to audit the overall practise of a GP is the same as saying GPs can't be audited, then you need to join me back at college. I've been involved in GP audits. But GPs patient demographics are widely different, and the co-morbidity of their patients are too. A GP in north innner city dublin will loose a lot more patients every year than a GP in Blackrock. How do you audit Gps when they deal with people having emotional crises etc. I just said it was more difficult than auditing the role of the paramedic. I stand by that.

Yes, I have been involved in/been at the presentation of several audits about cannulas and central lines. It's big business in paediatrics. I personally haven't been audited since I was very junior. But it's very rare that a child on a ward who needs a cannula doesn't get one at all. The same can't be said for the pre-hospital environment.

The majority of paediatric nor adult presentations are probably not life threatening. BUT you would honestly be amazed at how sick a baby can be without many symptoms. The signs can be very subtle. My last meningitis case was in a 5 month old baby. Ity was missed by everyone...paramedics...A+E staff...would have been missed by me if I wasn't a paediatrician. I am constanly sent children (babies in particular) who nobody thinks are sick.

Traumadoc

The ambulance service in Ireland has improved in leaps in a very short time,
The service in Australia and Newzealand is very impressive, it is difficult to get into, two years in college followed by a further 2 years training.
Emts are paid very well, and are superb.

The Irish system is changing very rapidly despite huge obsticles placed by various vested interests. It is largely driven by the enthuaism of the ambulance staff to advance the service.

BeardyGit

I attended some medical training recently in the UK that's specifically designed for mountain rescue personnel. The purpose of the training is to enable MR team members administer drugs when appropriate. The course syllabus is decided upon and taught by A&E registrars and consultants from a number of hospitals in the UK where they're only too familiar with the consequences of inadequate pre-hospital care. Unfortunately, this training and certification from the RCS isn't recognised in Ireland, and we're unable to give ANY drug, even if it can make a big difference to casualty care and outcome. We attend the training to ensure we're staying right at the top when it comes to our speciality - It's unfortunate that the training can only be put to use if we're assisting on a job in the UK (incl. NI of course) The drugs I can administer IN THE UK ONLY include Diazepam, Difene/Voltarol, IM Morphine, GTN, Glucogel, some Athmatic meds etc.

Here in Ireland, we can't even legally give an asprin for a suspected MI.

The pre hospital emergency care in this country leaves a lot to be desired to be honest. Unfortunately, until hospital doctors and consultants get off their arses and start making some noise about the widespread restrictions placed on those of us who actually pick up the pieces before bringing them to the A&E, we'll never get anywhere.

Your own interest in paediatrics is distracting you from the bigger picture I fear - and I believe you're getting caught up in your own interests instead of trying to do the most, for the most. I would say that consultants and hospital doctors spend more energy chasing better conditions and contracts for themselves instead of demanding better training and less restrictions at the pre-hospital stage. Sorry if that offends you, but I really believe many of your peers get caught up in the little details and their own circumstances, rather than actually going out of their way to help improve the situation for ALL.

With respect Tallaght01, your replies on this whole thread simply highlights the contempt with which 'the rest of us' are treated by the medical professions. You show little knowledge of what it's like to actually work on the ground in a multi-disciplined unit, in a REAL frontline environment, yet you appear to believe you're qualified to judge the service provided by paramedics and so on. If you disagree, I'd love you to actually state your professional experience, so we may decide ourselves if you're qualified enough to judge. Your credentials alone are insufficient to protect your comments from legitimate and well reasoned criticism, so put aside your ego for a while and actually explain how your professional experience leads you here.

Right now, all I'm seeing in you is arrogance and contempt.

Gil

tallaght01

I've really no idea what I've said to cause such umbrage here. If anyone cold quote it (in context) I'll take it on board. Usually we just get "well, it's your tone" etc. If you think I'm grilling anyone here, you should see what those of us who work in hospital have to put up with

But very doc in the world hears tired comments about arrogant docs every day, whenever we question any other health professionals. This isnt a new thing. And yoiur stereotypes aren't new.

People can say what they want about us, with free abandon though.

If anyone can highlight what Ive said that's offensive then fine. I've tried to highlight the poor pre-hospital situation, then I'm told we're self interested because we're not interested in the pre-hospital situation.

All my research is in public health, which is, by definition, the attempt to do the most for the most. Improved paramedic care is far from the most pressing issue if we're trying to "do the most good for the most people" to be honest.

It doesn't take away from the fact that paediatric pre-hospital care leaves a lot to be desired.

I'm not all that up to date with how things are in the world of adult pre-hospital care. So, I confine myself to paeds.
Having said that, If it makes everyone feel better, I'll agree that one week's paeds training is enough, and that the lack of practical skils is acceptable.

And I'll leave you guys to it.

Take care, and good luck with your respective careers.

dfbfirerescue

couple of points for you tallaght01.
drugs as stated above at advanced paramedic level are published on phecc.ie website. same goes for paramedic level ect.
airwaymanagement at paramedic level now includes Lma.S
at advanced level its intubation.
cardiac arrest protocols for advanced are same as for doc s in resuss. epi. atropine amiodorone ect. the pre hospital care profession face innumerable obstacles both in the field and as regards training opportunities. as a reg. you will understand the godlike feeling consultants exude at times and we feel it especially when there is major resistance to advancing our profession pre hospital. as a member of dublin fire brigade i am trained both as fire/rescue, and as emt-p (currently called paramedic) we have the only fully integrated fire / ems system in europe where all members rotate from ambulance to fire duties. when dfb ambulances respond to cardiac arrests / major trauma ect you have at least 1 fire truck responding also, for patient handling and extra manpower. to refer to us as first aiders is i feel a little harsh. ask any advanced paramedics who have spent some of their internship on dfb responce car what they think. for difficult arrest i.v. drug access and for difficulty with paed s i.o. is the option. it happens in hospitals regularly which is a controlled setting . . a little run for a night out on a frontline hse ambulance , or a dfb ambulance might not be a bad idea if you have a free night ?????????

emedd

Ive really no idea what I've said to cause such umbrage here. If anyone cold quote it (in context) I'll take it on board. If anyone can highlight what Ive said that's offensive then fine.

Ok... here goes...

So, it has been said that the Irish ambulance service is essentially a glorified first-aid service.

Who said this? Why do you say it? Your opening line is already getting people's back up. If i'd opened a thread saying paediatricians are just glorified GPs you might understand.

IN particular the ones that are staffed by firemen.


Same again.

They don't give drugs, rely on automated defibrillation, dont intubate....and essentially perfom the same roles as an experienced first-aider.

You are misinformed - as previous thread have shown.

So where do they learn to intubate? took me ages to be able to do it. Plus there's some pretty funky drugs you often have to give when ur tubing someone.

In hospital! "Funky drugs"... whatever, displays a lack of respect for paralysing agents if you ask me. Besides, prehospital drug assisted intubation has not been shown to be beneficial so why be worried about it?

He reckons his son "can give drugs".

Why the Quotes?

I wonder how good these new paramedics are at getting IV access in somebody who's arrested, in order to get the drugs into the vein.


Why be pessimistic? Why not assume they are good at it? I/O is a fairly failsafe back up.

I know many many times in the UK, people came in flat, but with no IV access because the paramedic couldn't get a drip in. That's no criticism of them, getting a line into somebody with no cardiac output is often a real nightmare.

It's no criticism. I have failed to get a line into cardiac arrest patients too. If it's no criticism, why bring it up?

Paramedics never spend any time in a childrens ward


Wrong.

because it's one of the cooler things that you can be seen to do at an arrest


Maybe you think so. I think the "coolest" thing you can do is save a life, but perhaps your priorities lie elsewhere.

It's all very well to walk around with huge belts on, with cool looking equipment hanging off them, but we need to make sure we can do the basics.

Deroggatory statement.

c'mon dude, read the post. I specifically underlined the word "some".


Patronising.

Most of the unwell adults that come through the door have one in place.


Eh... not they don't. Only 100 APs in the country, so most adults don't get a line. Just showing your ignorance of pre-hospital care in Ireland.

But I do have to say that the general consensus in hospitals is that the amount of kit hanging off a paramedic is inversely proportional to their competence


Not in any hospital I've been in. In fact, the best place for your kit is in your bag not on your belt. Most Paramedics keep the bare minimum on their belt. But obviously it suits your argument to gloss over this.

My concerns lie with their diagnostic skills though.


Why? Have you any experience of this. In my opinion, their diagnostic skills are excellent and his is a reflection of the AP course which encourages a broad foundation in physiology and anatomy, not rote-learning.
[B[/B]


What drugs can your basic paramedic give (ie not the advanced guys, coz ther'es only like 20 of them in the country isn't there?). We've seen lots of lists about advanced paramedic drugs here. But what about the guys who I'm most likely to meet if I go into status?

Again, this is on the PHECC website you've been directed to already. There aren't about 20 of them either. "Coz"

Thats why you've got my back up. I tried to find some positives, but there weren't any.

tallaght01

I know I've left this forum, but if I've offended you with the statements you've highlighted, then I should explain their context, so as to reduce any offence.

emedd wrote: »

Ive really no idea what I've said to cause such umbrage here. If anyone cold quote it (in context) I'll take it on board. If anyone can highlight what Ive said that's offensive then fine.

Ok... here goes...

So, it has been said that the Irish ambulance service is essentially a glorified first-aid service.

Who said this? Why do you say it? Your opening line is already getting people's back up. If i'd opened a thread saying paediatricians are just glorified GPs you might understand.

IN particular the ones that are staffed by firemen.


Same again.

I never said any of the above. People had raised concerns with me about the pre-hospital service in Ireland run by the DFB (as opposed to the EHB one) so I quoted what they'd said and put it to you guys for opinion.

emedd wrote: »

They don't give drugs, rely on automated defibrillation, dont intubate....and essentially perfom the same roles as an experienced first-aider.

You are misinformed - as previous thread have shown.

The drugs issue is what I was asking about. One of the reasons I started the thread. The rest is true, except for 100 of your 1300 ambulance personell as far as I can make out.

emedd wrote: »

So where do they learn to intubate? took me ages to be able to do it. Plus there's some pretty funky drugs you often have to give when ur tubing someone.

In hospital! "Funky drugs"... whatever, displays a lack of respect for paralysing agents if you ask me. Besides, prehospital drug assisted intubation has not been shown to be beneficial so why be worried about it?

I've a lot of respect for paralysing agents, and sedating agents. I use them all the time. How you equate a turn of phrase with a lack of respect for a drug is beyond me. But fair enough.

The fact that something hasn't been show to be of benefit doesn't mean paramedics wouldn't do it. Adrenaline and atropine haven't been shown to be of benefit at arrests, and you still give them. I wasn't aware that you only did non-drug intubations. I am now. It doesn't change the big picture.

emedd wrote: »

He reckons his son "can give drugs".

Why the Quotes?

Because I was quoting him?? I was also highlighting that was exactly what he said to me...ie he didn't know what drugs his son could give....in the context I was asking what drugs firemen can give.

emedd wrote: »

I wonder how good these new paramedics are at getting IV access in somebody who's arrested, in order to get the drugs into the vein.


Why be pessimistic? Why not assume they are good at it? I/O is a fairly failsafe back up.

You can't just assume people are good at things. You have to question. That's all I did. Maybe it's a cultural difference betwen hospital and pre-hospital medics. Nobody ever "assumed" I was good at practical procedures in hospital. I had to prove it.I will definitely continue to question. I have never seen an IO put in by a paramedic at a paeds arrest. They can do it, but it's scary. If you've ever had to reduce a fracture in order to give the drugs after you've broken a tibia with an IO (like I have) then you'll know it can go wrong.

emedd wrote: »

I know many many times in the UK, people came in flat, but with no IV access because the paramedic couldn't get a drip in. That's no criticism of them, getting a line into somebody with no cardiac output is often a real nightmare.

It's no criticism. I have failed to get a line into cardiac arrest patients too. If it's no criticism, why bring it up?

I think this was one of the simpler-to-understand-points that I made.

Like I have said several times, I think it's a good idea that you guys can give drugs. Then I said I wondered about IV access training. I didn't say it was crap, I said I wondered about the training. The point was that drugs are no use unless you can get them into the patient. As paramedics spend 6 weeks in hospital, I quite justifiably questioned how competent they are at difficult IV access. I think it's a fair question. It wasn't an accusation, it was a question.

emedd wrote: »

Paramedics never spend any time in a childrens ward


Wrong.

Yes, it appears they spend a week in a childrens ward. I am suitably chastised

emedd wrote: »

because it's one of the cooler things that you can be seen to do at an arrest


Maybe you think so. I think the "coolest" thing you can do is save a life, but perhaps your priorities lie elsewhere.

Yea, that's the obvious conclusion

emedd wrote: »

It's all very well to walk around with huge belts on, with cool looking equipment hanging off them, but we need to make sure we can do the basics.

Deroggatory statement.

I think it's a statement most people would agree with. But fair enough,

emedd wrote: »

c'mon dude, read the post. I specifically underlined the word "some".


Patronising.

Maybe you need to be patronised. I specifically underlined the word "some" and was then treated like I'd accused all paramedics of genocide through incompetence.

emedd wrote: »

[Most of the unwell adults that come through the door have one in place.


Eh... not they don't. Only 100 APs in the country, so most adults don't get a line. Just showing your ignorance of pre-hospital care in Ireland.

The context was the UK. I haven't worked in Ireland in years. I've said that several times. It doesn't change the point. The point was a general one about competencies in cannulating adults vs cannulating small kiddies.

emedd wrote: »

But I do have to say that the general consensus in hospitals is that the amount of kit hanging off a paramedic is inversely proportional to their competence


Not in any hospital I've been in. In fact, the best place for your kit is in your bag not on your belt. Most Paramedics keep the bare minimum on their belt. But obviously it suits your argument to gloss over this.

Most paramedics do, but some don't. I accept that was something I shouldn't have said to paramedics. But, whether you like it or not, it's a standing joke in many A+E departments/retrieval teams. But it's probably not so relevant to the overall bigger picture, so fine.

emedd wrote: »

My concerns lie with their diagnostic skills though.


Why? Have you any experience of this. In my opinion, their diagnostic skills are excellent and his is a reflection of the AP course which encourages a broad foundation in physiology and anatomy, not rote-learning.
[B[/B]

A lot of paramedic paediatric diagnoses are wrong. That's becuase they don't spend enough time doing on-call paediatrics. I would suggest that paramedic trainees should go on-call with the paeds reg/SHO in a hospital, except I'd be afraid of offending you guys.

The other thing that's often wrong is the grading of severity. I get called a lot to "code 2 " emergencies, where the ambulance radios in and we're expecting somebody pretty sick. But, they're often not particularly unwell. Having said that, I have no problem with erring on the side of caution. I'm just making the point that, in my experience, paediatric training may not be what you think it is. Part of the problem too is lack of feedback for paramedics.

emedd wrote: »

What drugs can your basic paramedic give (ie not the advanced guys, coz ther'es only like 20 of them in the country isn't there?). We've seen lots of lists about advanced paramedic drugs here. But what about the guys who I'm most likely to meet if I go into status?

Again, this is on the PHECC website you've been directed to already. There aren't about 20 of them either. "Coz"

so, there's 100, rather than 20. Fine.

emedd wrote: »

Thats why you've got my back up. I tried to find some positives, but there weren't any.

I'm sorry I offended you. I think I just asked questions. You shouldn't take quotations out of context.

I still think my concerns are valid. That makes me an arrogant doctor.

You think I have no right to question. I don't think that makes you arrogant, but I believe it makes you less professional.

But this wil degenerate into an argument, and my questions about experience with IV access in kids/experience doing on-call paeds are never going to be answered here.

So, I'm definitely out of here now.

Happy xmas, and I hope you're not too busy over the next few weeks.

emedd

i could reply to you again tallaght01, but i don't think were going to agree. you're right of course in everything you said. it's paramedics that are silly for giving adrenaline and atrpine at arrests despite the evidence base (oh wait - that's what doctors do too).

you have an idea that paramedics have to be as competent in all scenarios as hospital staff - that's not realistic. Similarly I would argue that most hospital staff would be out of their depth pre-hospital. Paramedics don't have to make the diagnosis, they treat the patient. The two don't necessarily go together.

I'm not a paramedic, I'm a doctor. I take offence at what you said because I know it to be untrue for the vast majority of my paramedic colleagues. If you really care about prehospital care in Ireland try to have a positive influence rather than sit on the sidelines criticising.

Bye

BeardyGit

emedd wrote: »

....I'm not a paramedic, I'm a doctor. I take offence at what you said because I know it to be untrue for the vast majority of my paramedic colleagues. If you really care about prehospital care in Ireland try to have a positive influence rather than sit on the sidelines criticising.

Bye

Oh dear. I think we just found your kryptonite Tallaght01

Traumadoc

I too am a Doctor, and I find your posts , offensive.

faceman

emedd wrote: »

i could reply to you again tallaght01, but i don't think were going to agree. you're right of course in everything you said. it's paramedics that are silly for giving adrenaline and atrpine at arrests despite the evidence base (oh wait - that's what doctors do too).

you have an idea that paramedics have to be as competent in all scenarios as hospital staff - that's not realistic. Similarly I would argue that most hospital staff would be out of their depth pre-hospital. Paramedics don't have to make the diagnosis, they treat the patient. The two don't necessarily go together.

I'm not a paramedic, I'm a doctor. I take offence at what you said because I know it to be untrue for the vast majority of my paramedic colleagues. If you really care about prehospital care in Ireland try to have a positive influence rather than sit on the sidelines criticising.

Bye

I think some people have taken comments very personally here and have taken some of the OP's comments very selectively. But if you re-read the thread, you will see from post 1 that the OP has asked questions in a constructive manner while voicing his support of the paramedics in general.

Not questioning one's standards and work practises is a receipe for for failure. But then again, we irish do that in many professions. There has been very little direct response to the OP's questions other than to call him arrogant.

FlutterinBantam

Is that a true and UNBIASED reflection of your feelings FM?

Are you tallaght01's pimp or something 'cos it sure looks that way;)

faceman

Call it what you want, it doesnt change the responses (or lack thereof) to the OP's questions.

then again, maybe tallaght01 has a grudge against paramedics because one of them stole his orthapedic girlfriend. But sure they're only pretend doctors anyway!

faceman

Just to also point out, no one has responded to disagree with tallaght01 directly and say the standards are fine.

BeardyGit

Okay Faceman, I'd suggest you re-read the posts made by Tallaght01 subsequent to the original thread-starter before you make an arse out of yourself. His 'question' WAS answered. Moving on from that as he did, he started to offend.

From singling out fire service operated ambulance crews to having a go at winding up all paramedics out there, Tallaght01's been nothing but a big wooden spoon trying to stir a pot of sh** since he rambled in here.

If the man hasn't worked here in many years, has no idea what to expect from paramedics/ambulance crews in Dublin (Tallaght being a clue)/Ireland and is clearly more interested in provoking responses than paying attention to the detailed responses to his initial mumblings, what else can he expect at this point? He's been discourteous at every juncture and still thinks he holds the high ground in some sense.

Fair play to Emedd for sounding out with the following:

"If you really care about prehospital care in Ireland try to have a positive influence rather than sit on the sidelines criticising"

That's the crux of the matter really. Tallaght01's asked questions, ignored the answers, and now deliberately tries to move on instead of dealing with the question this thread should have posed for him, and his stinking attitude.

Gil

faceman

Gil_Dub wrote: »

Okay Faceman, I'd suggest you re-read the posts made by Tallaght01 subsequent to the original thread-starter. While he openly disclaimed these as his own opinions (at least, not necessarily), his follow ups were the ones where he really rubbed people up the wrong way.

From singling out fire service operated ambulance crews to having a go at winding up all paramedics out there, Tallaght01's been nothing but a big wooden spoon trying to stir a pot of sh** since he rambled in here.

If the man hasn't worked here in many years, has no idea what to expect from paramedics/ambulance crews in Dublin and is clearly more interested in provoking responses than paying attention to the detailed responses to his initial mumblings, what else can he expect at this point? He's been discourteous at every juncture and still thinks he holds the high ground in some sense.

Fair play to Emedd for sounding out with the following:

"If you really care about prehospital care in Ireland try to have a positive influence rather than sit on the sidelines criticising"

That's the crux of the matter really. Tallaght01's asked questions, ignored the answers, and now deliberately tries to move on instead of dealing with the question this thread should have posed for him, and his stinking attitude.

Gil

As far as i can see he has responded to every comment made. How has asking questions rubbed people up the wrong way? Where has he ignored answers? Asking the questions which question standards and expectations is the start of striving for best in class or even world class. I fail to see how his attitude has been offensive. Perhaps someone can make it clearer.

To me, at it is of course only my opinion, none of his comments were personal.

Tango Alpha 51

Faceman,
Am just curious. Are you an emt/paramedic/advanced paramedic working either for the HSE National Ambulance Service or the DFB Ambulance Service.

boomer_ie

tallaght01 wrote: »

The other thing that's often wrong is the grading of severity. I get called a lot to "code 2 " emergencies, where the ambulance radios in and we're expecting somebody pretty sick. But, they're often not particularly unwell. Having said that, I have no problem with erring on the side of caution. I'm just making the point that, in my experience, paediatric training may not be what you think it is. Part of the problem too is lack of feedback for paramedics.

In defense of the DFB lads who I have worked with on a regular basis and from my own experiences the interventions they do / give on scene and while transporting can make a huge difference to the patient. Personally I have had patients go from completely unresponsive, fitting etc to being fully alert in the space of 5 - 10 minutes (while waiting for a DFB ambulance to arrive). What I am trying to say is that when they make the initial call that they have X, then I would believe them, they arent monkeys they are highly trained individuals, granted there may be issues with one or two here and there but that exists in EVERY organisation/level of training including Doctors, consultants etc. As pointed out earlier there is a lot that the Paramedics can do and quite frankly your comments towards them are offensive and uncalled for.

PS Stay safe everyone and enjoy your Christmas.

faceman

buzzman wrote: »

Faceman,
Am just curious. Are you an emt/paramedic/advanced paramedic working either for the HSE National Ambulance Service or the DFB Ambulance Service.

no im not and while my opinion is limited to what i do know, i am a tax payer concerned about the treatment and health of our children. Its about time someone asked the difficult questions of the vested interest groups.

Anyway, it christmas day. No more arguments today.

dfbfirerescue

i personally found a lot of tallaght01 comments generalised and unhelpful. if you really want to improve things tallaght01 there is a direct link on this site to www.phecc.ie. give them a call and offer your advice services re paeds.. it would be most welcome. there are a number of very brave and diligent doctors involved with phecc to move prehospital care forward in ireland. there is to my knowlage no paediatric doctors involved with phecc so your comments/time/skills and knowlage would be of immense benefit to everybody..
put your money where your mouth is... share your skills!

BeardyGit

faceman wrote: »

....no im not and while my opinion is limited to what i do know, i am a tax payer concerned about the treatment and health of our children....

That old chestnut, eh? :rolleyes:

I'm not looking to pick a fight, but you'd do well to educate yourself a little more before trying to get into this little discussion. This isn't the type of discussion in which the taxpayers point of view will be considered a contribution. This is a thread dealing with a doctors approach and comments (second hand or not) regarding the professionals who deliver pre-hospital care.

I'm not trying to be a pratt, so don't get annoyed, it's just what it is. You're not a professional, so you can't play right now with the big boys as such.

Sorry, and happy christmas!

Gil

Tango Alpha 51

Faceman,
You stated that no one has directly answered Tallaght's questions/criticism of the Ambo Svce in Ireland. Those of us who work in it, have done so. I trained hard for my chosen profession. I received my diploma from the medical faculty in UCD as did the rest of my colleagues working in the svce be they HSE or DFB. To equate us as being nothing more than "glorified first aiders" was extremely offensive considering the amount og work & commitment it takes to train as a paramedic ( no one forced me into this career I know). I personally have no problems answering any questions any taxpayers asks of me. Paeds is a problem in Ireland but not just for us. Hospitals around the country if you don't live in DUblin have the same problem. There is a greater emphasis put on the Adult side of things pre hospital care wise for the simple reason that we deal with Adults alot more often then we do paeds.
The old "ambulance driver" monocle is something we're trying to get rid of for years. We are trained professionals, doing a difficult job in difficult circumstances. I treat everyone with the respect. I expect the same back.

But you are right, it's christmas so I wish you, Tallaght & everyone else on the board a very happy christmas & a peaceful new year. Think of me whilst I'm working these days.