Ambulances aim to treat as well as transport

The HSE National Ambulance Service (NAS) has changed in many ways in the past few years. The most obvious change is structural. Until 2005, each of the former health boards had its own ambulance service, each with its own chief ambulance officer. After the HSE was formed, these eight areas merged into one national service. We now have a single service for the whole country, with a unified national management structure and more importantly, consistency in how things are done in every part of the country.

Clinical changes

An area of enormous change has been in the clinical aspect of the service. Traditionally, the ambulance service was perceived as being primarily about transport – if you were ill or injured, an ambulance came and took you to hospital, where the doctors and nurses provided your medical care. This has changed utterly. We now have the ability to provide sophisticated clinical assessment and intervention on scene and en route to hospital. This pre-hospital treatment is aimed at resolving high acuity illness or injury, or providing symptom relief. In many cases, this is not necessary, and the NAS still provides transport to hospital in all cases. However, the difference from what has gone before is that the service is about treatment and transport, rather than just transport.

Ireland has three levels of pre-hospital provider:

• Emergency medical technician (EMT)
• Paramedic
• Advanced paramedic. 

All must be registered with the Pre-Hospital Emergency Care Council (PHECC) in the same way that physicians must be registered with the Medical Council.

EMT qualification requires five weeks education, and this grade is used to staff intermediate care vehicles which carry out low priority inter-hospital transfer services. EMTs do not respond to 999 calls except in a first responder role to cardiac arrests.

Paramedic qualification takes two years – one year didactic education and placements, which is provided by the National Ambulance Service College (NASC) in the Phoenix Park in partnership with UCD. This is followed by a one year postgraduate internship. Paramedics currently make up 80% of the NAS workforce. Paramedic scope of practice includes oxygen, nebulised salbutamol, intramuscular glucagon, intramuscular epinephrine for anaphylaxis, 12 lead ECG acquisition and interpretation, and supraglottic airway insertion (such as the laryngeal mask airway, iGel or laryngeal tube). 

Advanced paramedics (APs) must be practising paramedics for two years before they can undertake AP education, which takes 10 months and again is provided by NASC/UCD. APs make up 20% of the NAS workforce. AP practice allows endotracheal intubation, intravenous/intraosseous access with administration of a wide variety of IV/IO drugs (morphine, cardiac arrest drugs, midazolam, IV fluids amongst others), manual defibrillation, needle cricothyrotomy and needle decompression of tension pneumothoraces. The NAS plans to double the number of APs over the next five to seven years.

What can’t paramedics/advanced paramedics do?

There are many things our clinical staff cannot do, and in these circumstances GPs who are present on a call can make a significant contribution.

Our clinical staff currently cannot determine that a patient does not have to go to hospital. Generally speaking, if we get a 999 call the patient usually requires some form of assessment or treatment in an emergency department (ED). However, this is not always the case. For example, a patient with well controlled epilepsy has his or her annual seizure in a public place and a passerby dials 999. In the absence of other comorbidities or seizure related injury, this patient does not need to go to an ED, but currently NAS staff have no option but to transport. The presence of the patient’s GP on that call allows a higher level of clinical decision making that may prevent unnecessary transport to hospital.

More importantly, GPs have the combination of clinical knowledge and experience combined with a knowledge of their own patients that our staff will never have. Paramedicine is protocol and algorithm driven. If a patient fits the algorithm, the paramedic can treat them. If they don’t fit the algorithm, the paramedic cannot treat them. For example, an advanced paramedic can administer IV fluids if a patient’s systolic blood pressure is below 90 mmHg, but cannot if it is above this level. GPs can make a more rounded clinical decision about patient management and guide the best treatment for their patient at that time.

Questions from GPs

I value interactions with GPs around the country. Here are some of the issues GPs have raised with me.

When I call an ambulance, I want them to come and take my patient to hospital. They spend ages with the patient in the back of the ambulance before they actually get going.

Once an ambulance crew take over a patient from a GP, the clinical responsibility for the patient passes from the GP to the crew. They need to familiarise themselves with the patient’s clinical condition, in particular the presenting complaint, relevant past history, meds, allergies, and a focused clinical examination, including vital signs and, if appropriate, a 12 lead ECG and blood sugar. In many cases this is facilitated by a hand over from the GP and/or the GP’s referral letter to the hospital. Some of the assessments may be done while the vehicle is moving, but some cannot, for example, 12 lead ECG acquisition. For safety reasons, the attending paramedic needs to be seated and restrained while the vehicle is moving, and some of this assessment may not be possible while restrained, so must be done before moving.

When I need an ambulance quickly, the control centre asks me a series of very basic questions about the patient’s condition. Why can’t they trust my clinical assessment that the patient needs an ambulance immediately?

We use a computer aided decision support system called Advanced Medical Priority Dispatch System (AMPDS) to prioritise all calls that we get every day. The NAS handles almost 900,000 patient interactions every year, from booked hospital transports to cardiac arrests, and we need to be able to triage these so we can send an emergency response to those that truly need it. If you need an ambulance for a patient immediately (for example for STEMI, respiratory failure, meningitis), the emergency medical controller may need to put you through the AMPDS question and answer algorithm so that your request can compete with all the other emergencies that come through the 999 system. This will allow the NAS to get your patient the nearest and best resource that we have available at that moment in time. In these situations it is best that you speak to ambulance control yourself. A small minority of GPs request an emergency ambulance via their receptionist, who generally won’t be able to answer any clinical questions about the patient’s status. This may result in your patient not getting an emergency ambulance in the timeframe that you feel is necessary.

When I request an ambulance why does it sometimes takes a considerable time to arrive?

While generally speaking we can anticipate ambulance demand, which has a discernible pattern over the 24 hour cycle, like any service which is demand-led, occasions occur where we have more calls than immediately available resources. In these situations, we will dispatch a resource every time, but on some occasions this resource may be coming from outside the immediate catchment area, and may take a little longer to arrive. There is always an ambulance available, sometimes it may be coming from a location that would not normally respond to your area. 

The last time I requested an ambulance, a rapid response vehicle (RRV) arrived before the ambulance did. If the RRV cannot transport patients, why is it dispatched?

All 999 emergency calls and all GP urgent calls will have an emergency ambulance dispatched. We will never send only an RRV to a call. However, the RRV may be considerably closer to the call, and may be able to do some assessment and treatment before the ambulance arrives, which will then cut down our scene time. The paramedic or AP in the RRV will also be able to give additional information to the control centre on the nature of the patient’s clinical status. 

Will paramedics ever be able to assess a patient and decide not to bring them to hospital?

The PHECC Medical Advisory Group is currently devising ‘treat and refer/treat and discharge’ protocols for both paramedics and advanced paramedics. There are a number of GPs on this group. When these are approved, paramedics and APs will be able to determine that a patient will not benefit from transport to hospital. These will be strictly under protocol and targeted at clinical conditions in which this is safe to do so; for example, the now well person with epilepsy post seizure, the person with diabetes post-hypoglycaemic episode with a normal blood sugar and no other issues of concern etc. If the patient or the patient’s GP wish for hospital transport, then we will always bring the patient to hospital. We hope to have these protocols approved and operational by the end of 2013.

Continuous change

The National Ambulance Service has changed and will continue to change. I am conscious that these changes impact on how GPs interact with us, and I hope this article brings some clarity to our interaction with GPs. I welcome feedback on this article to cathal.odonnell@hse.ie