As you walk through the various 2009 trade shows featuring new EMS products and services, there are a number of questions you ask yourself. Will the product or service lead to improved patient assessment and care? Is it affordable to implement? Is there evidence or research to support the product?...

As you walk through the various 2009 trade shows featuring new EMS products and services, there are a number of questions you ask yourself. Will the product or service lead to improved patient assessment and care? Is it affordable to implement? Is there evidence or research to support the product? Are there any patient or paramedic health and safety concerns? What is required to maintain and monitor the new product? Will the paramedics utilize the equipment or leave it on the shelf in the ambulance? You make eye contact with the sales person, and the sell is on! In Canada, there is a healthy competition amongst the ambulance vehicle manufacturers. With Crestline, Demers and Tri-Star leading the pack, the manufacturers are continuously being innovative to impress their clients. Crestline has introduced the new Driver Intention Lights that allows the paramedic to be aware of the vehicle’s motion when making decisions on patient care. And, Demers brings safety with the Obstacle Detection System, allowing the driver to be aware of obstacles when reversing the vehicle. All manufacturers are continuously improving space efficiencies in the patient compartment to maximize patient care and paramedic safety. Do you think your service is innovative with bicycle medics? Think again. The Xtreme Green Sentinel is an electric mobility vehicle designed to replace the bicycle and foot patrol with a reliable, state-of-the-art, and efficient urban and special event patrol. With speeds approaching 45 km/hr and a range of up to 128 km per charge, the Sentinel can support paramedic services (www.xgpinc.com) in a variety of urban environments. While the stethoscope allows you to hear what is going on inside the body, the new ACUSON P10 by SIEMENS provides the paramedic the opportunity to visualize what is going on. As the first pocket size ultrasound device, the ACUSON P10 provides the paramedic with instant images -- which are transferrable via the PDA type interface -- in confirming diagnostic assumptions in real time. In emergency medicine, the device assesses free fluid, cardiac activity, and AAA, as well as enabling critical care paramedics the ultrasound guidance for para/thora-centesis. In obstetrics, the device can provide a quick and comprehensive overview on fetal positioning, anatomy, heartbeat, fluid levels and placenta location during labour. There are various portable suctioning units available. A new product is the Laerdal Compact Suction Unit 3 (LCSU 3) that was designed specifically for the paramedic airway bag. Its unique 300-ml canister system, LED display and variable vacuum regulator gives the power and control needed to quickly clear a blocked airway. The unit comes with an AC/DC enabled, field changeable NiMH battery pack to get the job done. As an added feature, the LCSU 3 can be easily converted to an 800 ml configuration with the purchase of the appropriate canister and bracket. The LCU 3 receives honourable mention because it signifies the growing trend in EMS to make products lighter and effective. The LCSU 3 weighs in at 1.7 kg. Once the airway is cleared, there may be the need to intubate. However, it is a difficult airway due to poor lighting, challenging anatomy, or both. There are a number of laryngoscopes that offer white LED lighting to improve visualization of the airway. To improve the efficacy of the endotracheal intubation, the IntuBrite Laryngoscope Blade (www.intubrite.com) offers blacklight technology in order that the vocal cords will brightly phosphoresce during placement of the tube. With this improvement in larygoscopy, you can’t miss. The system also comes with a variety of blade sizes that are disposable. What’s next? An IV? Don’t worry about looking for that elusive vein. The AccuVein AV300 (www.accuvein.com) is a non-invasive and non-contact device that allows you the see veins on the skin’s surface. Just point and look. Regardless of skin tone or fat tissue content, the device will bounce infrared off the hemoglobin. As the veins appear, the paramedic can visualize which veins are curved and which veins are straight. All you need to do is pick the best vein to start your IV. The AccuVein AV300 comes with rechargeable batteries as weighs in at 10 ounces. And now my favourite: The Panasonic Toughbook H1. This sealed and fanless notebook is perfect for easy sanitation via a quick alcohol swipe. No more worries about collecting germs and transferring to your co-workers. The Toughbook H1 comes with a touchscreen or digitized display thereby removing the need for physical keys. The unit has a built-in camera, integrated wireless, GPS and Bluetooth to transmit information to ambulance systems and receiving hospitals. With long-life hot-swappable twin batteries, 80GB shock-mounted drive, and an integrated ergonomic handle, paramedics will grow to love this device that weighs in at 3.4 lbs. Overall, there is a trend with new EMS products. The innovative products emerging in EMS are increasingly lightweight in nature, portable and accessible. The products are meeting the needs of paramedics working in uncontrolled environments. The new products are striving to improve patient outcomes in addition to protecting the health and safety of paramedics. I can’t wait to discover what is new for 2010!

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In Ontario, after completing a two-year Ambulance and Emergency Care program from a recognized college, graduates are eligible to be employed by an operator of a land ambulance service. As per the associated legislation, the graduate may work...

In Ontario, after completing a two-year Ambulance and Emergency Care program from a recognized college, graduates are eligible to be employed by an operator of a land ambulance service. As per the associated legislation, the graduate may work with the EMS operator for up to 210 days after graduation. During this timeframe, the graduate is required to successfully pass the provincial Advanced Emergency Medical Care Attendant (A-EMCA) in order to continue employment. Levels of paramedic care Once hired by the land ambulance service, new employees typically receive additional training specific to policies and procedures of their new employer. During this orientation, new employees are also required to be certified by the medical director of a regional base hospital program. This certification allows the employee to perform controlled acts as a Primary Care Paramedic (PCP). The list of controlled acts that may be performed by a PCP includes: (1) administration of glucagon, oral glucose, nitroglycerin, epinephrine, salbutamol and ASA (80 mg form); (2) semi-automated external cardiac defibrillation; and (3) auxiliary protocols involving 12-lead ECG acquisition, diphenhydramine, gravol, taser probe removal and application of continuous positive airway pressure (CPAP). Paramedics who have completed a provincially recognized Advanced Care Paramedic (ACP) training program are required to successfully pass an ACP exam. Thereafter, the paramedic must be certified by the medical director of a regional base hospital program to perform the following skills: (1) administration of the drugs and acts similar to the PCP; (2) other drugs approved by the province on the recommendation of one or more medical directors of base hospital programs; (3) non-automated external cardiac defibrillation and monitoring; (4) peripheral intravenous therapy; (5) endotracheal intubation; and (6) auxiliary protocols involving emergency cricothyrotomy, adult intraosseous access, application of central venous access device, and patient sedation. Paramedics can also become Critical Care Paramedics (CCP). The list of controlled acts that a medical director can authorize a CCP to perform can be found in Ontario Regulation 257/00 at www.e-laws.gov.on.ca. Currently, only Toronto operates CCPs. Interestingly, a medical director can certify a PCP to perform one or more ACP acts, and certify an ACP to perform one or more CCP acts. Regional base hospitals A base hospital program in Ontario operates to (a) delegate controlled acts to paramedics (as described above); (b) provide the continuing medical education required to maintain the delegation of controlled acts to paramedics; (c) provide medical advice relating to prehospital patient care and transportation of patients; and (d) provide quality assurance information and advice relating to prehospital patient care. In 2009, the province completed a restructuring of the base hospital programs. The former 21 base hospital programs were consolidated into seven regional programs. The regional programs are now associated with Ontario's leading hospital systems. For example, the Centre for Paramedic Education and Research (western Ontario's regional base hospital program) is associated with Hamilton Health Sciences. A complete list of regional programs and their affiliated land ambulance service operators can be found at www.ambulance-transition.com/pdf_documents/contacts_bh.pdf. The restructuring offered new opportunities for both land ambulance service operators and paramedics. In a regional format, the new base hospitals were able to recruit expertise to develop programming in association with both neighbouring ambulance services and their paramedics. The new base hospitals have greater opportunities to share best practices and research with one another in an attempt to meet the ever-changing needs of the prehospital care community. And the dialogue between the base hospitals and the provincial regulator is more focused on providing services to their municipal EMS partners. There are critics of the new regional base hospital system. Critics would argue that a self-regulating Ontario College of Paramedics (such as the colleges in Alberta and Nova Scotia) is the answer in certifying and educating paramedics. The issue of a self-regulating college is now before the Health Professions Regulatory Advisory Council (HPRAC). The HPRAC is deliberating the issue in order to make recommendations to the Minister of Health and Long-Term Care. Continuing medical education In Ontario, to maintain certification, a PCP needs to complete a minimum of eight hours of education per annum and an ACP needs to complete a minimum of 24 hours of education per annum. It is not clear how the number of certification hours was developed. Are eight hours per PCP per annum a sufficient amount to ensure paramedics deliver quality prehospital emergency care? Given the scope of practice of an ACP, are 24 hours of education per year sufficient? Greater evidence is needed to establish an appropriate level of continuing medical education hours. The current trend among municipalities is to increase the number of ACPs in their operations. However, as you increase the number of ACPs, the number of emergency calls in which ACPs engage advanced skills declines. The number of calls is further reduced when placing ACPs in suburban and rural areas. In lieu of the call volume, educators have developed clinical placements at acute care hospitals, didactic sessions and medical rounds, and simulation laboratories. The other key issue is the actual curriculum delivered. Education needs to focus on the critical thinking and patient care skills that the paramedic requires in the field to produce positive patient outcomes. There is limited research in the area of prehospital emergency care to assist in continuous medical education for paramedics. Although there is limited research, municipalities are working towards promoting additional research initiatives. The Association of Emergency Medical Services of Ontario (AMEMSO) recently developed a research consortium in order to stimulate paramedic research. There is also the Canadian EHS Research Consortium that is dedicated in increasing paramedic research at the national level (see www.paramedicresearch.ca). Collecting the data Researchers need data. As technology develops in prehospital emergency care, data is becoming readily available to researchers. In Ontario, regulators are mandating the seven regional base hospitals to collect a minimum data set (MDS) for the purposes of providing quality assurance of paramedic care. The MDS also provides a comprehensive database for research. At the Centre for Paramedic Education and Research, a data warehouse is being developed to receive paper based paramedic documentation from six paramedic services and electronic paramedic documentation from three paramedic services. From the MDS and quality assurance initiatives, education curriculums can be developed to address systemic trends at both the local and regional level. The MDS can also be utilized for research purposes to assist in developing evidence-based paramedic practice. Overall, the paramedic education system in Ontario is off to a good start with the restructuring of the base hospital system. There is a viable alignment with the provincial regulators, base hospitals, EMS operators and paramedics in order to produce and maintain an effective education environment. The added value is promoting research initiatives that give credence to paramedic practice.

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This country we know as Canada is a place that is known to be quite diverse in so many different ways. Ethnically, religiously, culturally it is known worldwide as a place that people can come to and potentially have a chance to thrive with just...

This country we know as Canada is a place that is known to be quite diverse in so many different ways. Ethnically, religiously, culturally it is known worldwide as a place that people can come to and potentially have a chance to thrive with just a little hard work. The general consensus at this time seems to be that it's a harder life in this decade than it was, say 30 to 40 years ago. I tend to agree with that notion, to a point. When it comes to day-to-dayliving, things are certainly different. It costs more to own a home, a car, or anything really. The expenses needed to keep those material things are higher, as are medical expenses, property taxes, and anything and everything to do with keeping our children clothed, fed, healthy and happy. Of course in certain parts of the world they don't have the options we do here. No choices of where to shop, what school to send our children to, or whether to buy a hybrid car in order to save money because the price of gas continually goes "through the roof." We are fortunate to be Canadians. What about EMS? Has it changed? Has it evolved? Sure it has, and in a relatively short period of time. Does it take hard work to become involved with, and stay within the world of EMS these days? I'd sure say so. But did it always? What is great about these questions and others like them is that everyone is going to have a slightly different answer, depending on where you live within this country. Every single province and territory could have a book written about the beginning and subsequent growth of its EMS system. Of course some books would be longer than others as a few provinces are still just getting their feet wet when it comes to an organized system within them. However, there are a few who -- 30 to 35 years ago -- realized the importance of having the people who work in EMS receive a formal education of some kind in order to do the job. Ontario is one of those provinces. Let's have a quick look back and see what has happened over the past three or four decades in that province. The beginning What was the beginning? The beginnings of EMS itself are somewhat open for interpretation, but that isn't what we're discussing here. The first instance when a paramedic, or ambulance driver as we were known back then, required any formal education dates back to before 1975. The first thing that was ever required was what was known as a chauffeurs' licence. This was basically the class F of yesteryear and allowed someone to drive a vehicle the size of a hearse, which was the vehicle of choice for patient transport back then. As more and more privately owned patient transport companies came to be, some owners decided that in order to get a leg up on their competition they needed to do something. So they decided to have all of their employees trained in first aid and CPR. The companies that were the first ones to initiate this new level of training quickly gained a leg up in the industry and became the transport company of choice for their local communities. But as with most new things or trends, this training became the norm throughout all services so something else had to be done. When the competition between rival companies began to heat up, educators soon realized that they had an opening and developed what was considered to be an "enhanced" first aid course. More than one was available, but the most notable one was offered at Camp Borden. The option was for the employers to send their current and new hires to the Camp at the employer's expense to receive this training. College or bust In 1975, the government decided it was time to mandate formal education for ambulance attendants within the province and the first Ambulance and Emergency Care programs at the community college level were born. Unfortunately, I've been around long enough to say that I went through a one-year program at Conestoga College in Kitchener. It was a challenging ten months, with a strong curriculum that pushed myself and my classmates both academically and practically. The practical portion was the best part of these programs as they allowed us to see the real world outside of the classrooms. We were allowed to ride out with the local ambulance services and learn from those already on the job. As well, we were allowed to go into different departments in the hospitals such as obstetrical, surgery, emergency, palliative care and the burn unit to see what happens to people after they leave us and begin their road to recovery. EMCA Shortly after the launch of the college programs was the development of a provincial testing format for ambulance attendants to become formally licensed with the province and earn the title of emergency medical care assistant. This was a written test that took six hours and was divided into two three-hour segments. In the beginning,there was also scenario testing being done. However, during the mid-1980s it was decided to suspend the scenario testing and to this point in time scenario testing has not been reinstated in the province of Ontario. Along the way The entry level education process has remained virtually the same for over 20 years - one year at college followed by the provincial exam. Along the way, some new diagnostic tools and protocols were added to help enhance the working paramedic's skill set. The first thing to really change things was the advent of the defibrillator. The ability to, under certain conditions, electrically shock a person's heart and bring them back to life was considered a major medical breakthrough. Then, in the early 1990s, to take this new knowledge and equipment, intertwine it with CPR, and allow it to be put into ambulances to be used on the side of the road was considered somewhat radical for its time. But thanks to some forward thinking people, most communities now have a public access defibrillator program which gives the general public access to an automatic defibrillator to use in an emergency prior to the arrival of emergency services. The other thing that really changed the scope of practice for basic life support personnel was the grouping of six different medications and their administrative protocols into one bundle and calling them our symptom relief medications. These medications included nitroglycerin spray, ASA tablets, epinephrine nebules, glucagon mix, salbutamol nebules and oral glucose tablets or gel. Depending on where you work, many other medications may have been added to your box, but these were the original six. One year becomes two Only a couple of years after I graduated from my one-year college program in 1995, and due to the ever increasing scope of practise for what are now known as Primary Care Paramedics, the one-year program was expanded to two years. Basically, less became more. By that I mean, more of everything was now needed in order to become eligible to work in the EMS field. More time, more knowledge, more experience, more dedication, and perhaps above all else, more money all became required. However, it seems to have been a good move to make. Only the most dedicated, prepared, and organized students make it through both years, therefore creating the ripple effect of having a smaller number of students slipping through the cracks of the system. In years past, this just wasn't the case. Today...and tomorrow In today's modern world where a post-secondary education has become paramount, EMS in the province of Ontario has rolled with the flow of the times. It has gone from needing only a proper driver's licence, to needing a full two years of college education. Potentially there is more to come in this province. With self-regulation on the horizon, which some provinces already have, an increase in continuing education requirements is likely to in store, as well as the necessity to work a minimum number of hours each calendar year in order to keep your licence. A lot has changed over the past 35 years. What will the next 35 hold? There's only one way to find out. Tempest fugit. Writer's Note: Please remember that this article is intended as a general overview of the educational requirements that have been required by paramedics in the province of Ontario. The timelines given have come from my interviews with senior people that I know within the industry. I will take full responsibility for any inaccuracies found by the readers.

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