CHAPTER 18 The professionalisation of paramedics: the development of pre-hospital care
An ambulance service is a system organised to deliver patient care in the pre-hospital situation. This chapter addresses the emerging professional identity of the paramedic as an independent and essential component of the health care system. While paramedics act independently, they provide a vital conduit for patients requiring medical assistance between out-of-hospital care and formal care settings. Despite this, the standing of the paramedic is still considered as an associate profession (ABS 2006i) with their inclusion into the health system yet to be fully realised (Reynolds 2004).
The role and the work of the paramedic in Australia is defined through state and territory legislation — Ambulance Service Act (Tas) 1982; Ambulance Services Act (Vic) 1986; Health Services Act (NSW) 1997; Ambulance Service Act (Qld) 1991; Ambulance Services Act (SA) 1992; Emergencies Act (ACT) 2004). While the term paramedic has been adopted in recent time, paramedics were formally known as ambulance officers. Across Australia paramedics work in a voluntary capacity or are employed by ambulance services to treat and transport patients to and from hospital and are able to instigate various forms of medical treatment. The nature and type of this medical treatment is dependent on their qualifications and training. Table 18.1 outlines the various grades of paramedics in Australia with their associated qualifications and duties.
The emergence of paramedic as a profession is a recent development in Australia, but history is scattered with examples of emergency care. For example, early accounts of resuscitation described in the Christian Bible provide examples of emergency care. The prophet Elisha noted that:
… he went up, and lay upon the child, and put his mouth upon his mouth, and his eyes upon his eyes, and his hands upon his hands: and he stretched himself upon the child; and the flesh of the child waxed warm.
Several hundred years later, in 960 Avicenna, a Muslim philosopher stated: ‘…When necessary, a cannula of gold or silver is advanced down the throat to support inspiration’ (Avicenna 1970). In 1767 the Dutch Humane Society described methods of resuscitation to include: ‘…keep the victim warm, give mouth-to-mouth ventilation, and perform insufflation of smoke of burning tobacco into the rectum’ (Varon & Fromm 1993). In 1914 Dr Crile described the use of adrenaline in resuscitation (Crile 1921) and in 1920 Hooker and Kouwenhoven were able to treat the life-threatening cardiac event of ventricular fibrillation with the application of electrical current to the heart (Hooker, Kouwenhoven & Langworthy 1933).
Modern developments in emergency care and transport in pre-hospital care have their origins in the theatres of conflict and wars. Napoleon’s chief military surgeon, Dominique Larrey (1776–1842), developed a system to initiate emergency medical treatment for wounded soldiers on the battlefield, prior to transportation to a medical receiving post (Richardson 1974). Larrey identified that delay of treatment resulted in needless deaths. In response to this, he designed a purpose-built carriage that was able to access all parts of the battlefield; he then staffed the carriage with medical personnel. The carriage was known as ‘ambulance volante’ (flying ambulance) (Efstathis 1999).
Despite the work of Napoleon’s surgeon, the development of ambulance transport services was slow to take form. For several decades after the turn of the 20th century, many hospitals did not have emergency rooms or departments. As recently as the 1960s, people would often have to find their own way to hospitals, or, when available, seek the assistance of the ‘ambulance driver’. The ‘ambulance driver’ was usually the local undertaker as he had a sizable vehicle to accommodate patients lying down. He would bring the patient to the back door of the hospital and ring the doorbell for attention. The nurse would assess the condition of the patient, and then call for a physician if she thought the patient really needed one (Mustalish & Post 1994).
Both World Wars One and Two were significant events in advancing pre-hospital care clinical practices and procedures. However, while technology and telecommunications improved as a result of lessons learned during the two great wars, the emergency care for military troops during the Korean War was still regarded as inadequate. Lessons were learned from Korea and, as an outcome of these lessons, the war in Vietnam honed the skills of trained medical personnel with medical activity focused on four Rs: rapid assessment, rapid intervention, rapid response, and rapid transportation to hospital (Austin 2002; Efstathis 1999). These skills were then transferred to the civilian context.
The origins of the paramedic workforce can be found in the Most Venerable Order of the Hospital of St John of Jerusalem (Order of St John) founded in the decade following the 1099 invasion of Jerusalem by the Christian Crusaders (Howie-Willis 1985; Mustalish & Post 1994). Under the leadership of Raymond du Puy, a French nobleman who served as the Grand Master, the Order of St John extended its mission to the charitable function of assisting the injured with medical care as well as taking up a military role during the Crusades. The Order of St John declined in the centuries following the Crusades, but emerged again in the 1800s when support for the teaching of first aid principles in an increasing industrialised workforce became essential (Howie-Willis 1985).
In some states and territories, such as South Australia, Western Australia and the Northern Territory, the Order of St John was instrumental in the early development and organisation of the first ambulance services. In other states the government assumed early control over the operations relegating the Order of St John solely to first aid training (Wilde 1999). St John remains the primary ambulance service in Western Australia and the Northern Territory.
The work of medical personnel — nurses, doctors and paramedics — is similar. Each uses the same life-saving tools, provides patient care, and each promotes actions to preserve human life. However, the paramedic profession provides a service that is unique; paramedics’ work is usually undertaken by a team of two, with minimal equipment, and away from the high-tech support of hospitals or well-equipped clinics. Paramedics work ‘on-road’, transporting sick or injured patients via car, helicopter, boat or plane from their homes or accident sites to the safety of hospitals. The work of paramedics is not limited to transport; vital treatment is provided to the patient once the paramedic arrives on the scene. However, where doctors and nurses in hospitals are supported by back-up teams of staff and specialists, have ready access to an extensive range of diagnostic equipment, and work in controlled environments, paramedics deliver health care wherever the patient is; on the side of the road, under a bridge, at sea, and in all temperatures.
In terms of provision of emergency patient care, the relationship between paramedic and medicine is intrinsic. Both professions have preservation of human life as their prime tenet and both professions rely on each other in order to stabilise and salvage life. While paramedic treatments are implemented autonomously in the field, medical governance is not far from those treatments. The guidelines and protocols governing paramedic practice arise primarily from research done by medical doctors (American College of Emergency Physicians [ACEM] 1997), although increasingly this is changing as more paramedics engage in research. In the event of paramedics attending a patient in a life-threatening situation, radio communications provide the conduit for them to convey essential information to doctors at the hospital so that preparations can be made in advance, ready for the patient’s arrival. In turn, when the paramedic describes the patient’s symptoms that differ from the norm, doctors may offer suggestions or alterations to standard treatment regimes.
The formal relationship between paramedics and the medical profession may differ from country to country. For example, in the US and UK paramedic practices are governed by medical doctors and permission is required to administer base-line life-saving drugs. This may be done following radio description of the patient’s symptoms. In Australia, the criteria and policies for administration of life-saving drugs are determined by a medical advisory committee, allowing the paramedic to take the initiative when retrieving a patient.
While most Western countries have a separate organisation delivering pre-hospital care, some countries have yet to develop a central emergency communications system and service and rely on hospital personnel to retrieve patients with the assistance of a ‘driver’. Some international charitable agencies (such as St John, Red Cross, Red Crescent) provide this essential service either solely or supplementing civil defence and hospital-based services.
Unlike a number of other health professional groups, paramedics are not currently required to be registered with a regulating body, nor do they require a licence or registration to practise. However, they do require an authority to practise. This is usually achieved at the end of a formal internship which varies in duration from state to state and territory, and according to the type of education; for example, VET or university-based. In response to the 2005 Australian Productivity Commission report into Australia’s Health Workforce, the Coalition of Australian Governments (COAG) has recommended that health professionals who are required to be registered do so under a single national body. Such a move would cater for health professionals such as paramedics to move into special needs areas or to extend their scope of practice through role substitution (COAG 2007). The Council of Ambulance Authorities is currently exploring the COAG recommendations.
The relationship between paramedic, nursing and medicine offers unique opportunities for collaboration for 21st century health care and we outline some of these developments below. Many nurses train as paramedics and increasingly universities are offering combined nursing/paramedic degree programs. Interestingly, many paramedic academics see the development of a body of professional knowledge and research as closely aligned with medicine. Unlike nursing they are not seeking professionalisation through a strong separation from medicine. This may well be a result of the youthfulness of the profession, the close control still exercised by medicine over paramedic practice, or simply a pragmatic response to power. There are parallels between paramedic, nursing (see Chapter 16) and midwifery (Chapter 17) in their relationship to medicine.
Pause for reflection
The role and scope of practice of health professionals is not always consistent. For example, in the USA and UK it is common for paramedics to work in hospital emergency departments alongside nurses. In remote locations across Australia it is common practice for nurses to function as a paramedic in the event of a vehicle accident. Despite this crossover of roles, paramedics in Australia do not undertake the standard activities of the general nurse, such as working in an emergency department. Nor can nurses trained as paramedics use their time practising as a paramedic towards maintaining their registration as a nurse. What is your view on these anomalies?