AMBULANCE SERVICES IN IRELAND EVOLVE
Story by Vaughan Mason, NREMT-P, Advanced Paramedic - Ireland
Photos by Jeffrey Mayes
Used with kind permission of Elsevier Public Safety
As an EMT in Ireland in 1998, I decided to travel to Boston to embark on a paramedic course at Northeastern University in Burlington, Mass. During and after my course, I worked for a local company both as an EMT-B and as a paramedic before returning to take up employment with Dublin Fire Brigade (DFB) as a firefighter/EMT in late 2001.
I returned home to Ireland to find very little change in prehospital care, with ambulance personnel still limited in their scope of practice. Even as a nationally registered paramedic, I couldn’t use my advanced skills or knowledge of medications due to prohibitive legislation in Ireland. Also in a similar situation were six DFB personnel who had traveled to Boston in 1999 to complete the paramedic course and others who had funded their own trips from Ireland to take paramedic courses in Pittsburgh and Alabama.
In late 2004, however, things in the Emerald Isle finally began to change. It was during this time that the first two advanced paramedic classes began. I enrolled in the second course. The creation of an advanced paramedic course is just one of the many ways ambulance service in the Irish Republic is changing. Adding advanced paramedic training and moving to make EMS a nationalized industry is something that many prehospital providers have been waiting years—if not decades—to happen.
CHANGES IN DELIVERY OF CARE
By the start of 2006, an advanced paramedic service operating in limited areas of Ireland began allowing registered advanced paramedics to intubate with endotracheal tubes and laryngeal mask airways, start IVs and administer a range of medications. While no statistical data is available, the anecdotal evidence suggests that advanced paramedics are making a large improvement in the prehospital treatment of asthmatic, diabetic and epileptic patients because they now have the skills and medications to stabilize these patients. Survival to hospital discharge of cardiac arrests is also improving.
Previously, ambulance personnel in Ireland were known as EMTs, like many of their American counterparts. They were required to pass the National Qualification in Emergency Medical Technology (NQEMT), administered by the Pre-Hospital Emergency Care Council (PHECC), an independent agency that governs the industry by providing standards, education and training with exams, and produces clinical practice guidelines. Note: Northern Ireland Ambulance Service has successfully trained paramedics with advanced skills for many years.
Unlike EMS in the U.S. or the United Kingdom, the service in Ireland was not tiered until recently. If you called an ambulance, all providers who responded were EMTs with one level of training, which restricted them to the administration of aspirin, oral glucose, glyceryl trinitrate spray, Entonox (a mixture of nitrous oxide gas and air) and oxygen. EMTs were not authorized to intubate or initiate IVs, so patient care was behind most firstworld countries. Before the end of 2007, PHECC intends to authorize paramedics to use intramuscular (IM) Narcan, glucagon, and epinephrine for anaphylaxis, LMAs/LT airways, and nebulized salbutamol.
Although prehospital care in the Irish Republic was behind other countries, PHECC has been proactive in its efforts to make improvements. In collaboration with University College Dublin (UCD) and the National Ambulance Training School (NATS)—www.nats.ie—PHECC is funding and auditing the advanced paramedic courses.
Initiatives included changing the title of EMTs to “paramedic” and introducing a new level of providers called “advanced paramedics.” The advanced paramedic is similar in role and skills to an American paramedic and can intubate, cannulate via IV or use IO access, administer IM and SC injections, and decompress tension pneumothorax.
TRAINING
During their initial training, all DFB recruits complete a nine-week course to qualify as paramedics. To comply with the Department of Health’s requirements, each recruit becomes an intern and operates on the ambulance as the third person for familiarization and evaluation, followed by a period being assigned to ambulance duty every second day and night as part of their normal shift. After that, they’re rotated on the ambulance on a next-in-turn basis.
Two advanced paramedic vehicles now operate in Dublin on a part-time basis, with advanced paramedic interns from around the country joining as part of their internships.
The advanced paramedic course consists of 876 hours, divided into 21 modules and delivered in classrooms, laboratories, hospitals and in-service locations. Completion of a training record book is also an integral component of the course. The program structure includes six blocks:
Block I: Twelve weeks prior to the commencement of the course a one-day workshop is conducted for the participants that outlines the course content. The workshop will deliver Module 1, which prepares students for 200 hours of self-directed, distancebased learning activities, including tutorials and presentations.
Block II: Eighty hours of school-based learning in practical and theoretical components, and 80 hours of placement in a highdependency clinical environment (critical care unit or ICU).
Block III: Eighty hours of school-based learning in practical and theoretical components, and 80 hours of placement in a high-dependency clinical environment (accident and emergency department or operating theatre).
Block IV: Eighty hours of school-based learning in practical and theoretical components, 80 hours of placement in high-dependency clinical environments (pediatrics and obstetrics), and 16 hours of practice and evaluation prior to the internship.
Block V: A 160-hour internship with a paramedic supervisor, currently one from the U.K. and the other from Australia.
Block VI: A final panel assessment (including eight hours of pre-examination practice and 16 hours of practical and theoretical examinations).
Six modules are facilitated via distance education and are structured for the participants to complete the learning objectives at their own pace. Success in the modules is a prerequisite for progression to the remaining modules.
Thirteen modules will be facilitated in three off-the-job training blocks, requiring attendance at the NATS and/or additional venues nominated by UCD as required. Upon graduation, students receive higher diplomas in emergency medical technology.
NATIONAL CHANGES
The ambulance service is also changing its organization at a national level. Previously, the seven health boards and the Eastern Regional Health Authority provided ambulance services, with DFB providing 11 ambulances under contract. In 2004, the ambulance service and the southern health boards operated a fleet of 280 ambulances and responded to approximately 235,000 emergency and urgent calls and approximately 250,000 non-urgent patient transports.1
In addition to the health board ambulance service, DFB provides a dedicated emergency only ambulance service to the citizens of Dublin, similar to that provided by fire departments in many major U.S. cities, such as the Los Angeles Fire Department or Fire Department of New York EMS. However, the DFB ambulance service responds only to emergency 9-9-9 or 1-1-2 calls. The DFB covers most of Dublin in tandem with the Eastern Regional Health Authority, which also operates ambulances from four bases at Swords, Tallaght Hospital, Loughlinstown Hospital and St. James’s Hospital. The 11 full-time stations in Dublin, with the exception of Dun Laoghaire, share one ambulance, while the headquarters on Townsend Street operates two ambulances.
Another difference between the DFB and most American agencies is that it has been around for more than a century. It first operated an ambulance service for the people of Dublin in 1898, responding to 537 calls that year. It now responds to more than 90,000 with 11 ambulances, and the number of calls grows each year.
When the Health Act of 2004 passed in December, it dissolved the health boards and established a new authority, the Health Service Executive (HSE), to have authority over the national ambulance service. Many in the country’s EMS industry hope the establishment of the HSE will lead to the development of a condensed, national ambulance service.
SUMMARY
Until recently, Irish Repuplic didn’t provide different levels of prehospital care like Northern Ireland and other first-world countries. All ambulance personnel were considered to be EMT-Bs and unable to perform many skills common to U.S. paramedics, such as starting IVs or intubating patients. However, the emergency services industry in the Emerald Isle is evolving, with advanced paramedic classes creating an advanced level of care and a national shift in ambulance service organization. It’s a change many providers have been patiently awaiting.
Vaughan Mason, NREMT-P, is a full-time Firefighter/Advanced Paramedic with Dublin Fire Brigade. He instructs EMS and rope rescue courses, is a faculty member of the Wilderness Emergency Services Institute Europe and is a volunteer with the Dublin & Wicklow Mountain Rescue Team.
REFERENCE
1. HSE National Service Plan 2005, www.dohc.ie/news/2005/service_plan.html
Copyright 2007 Elsevier Public Safety