Going International

In 1999, Penny Price left Canada to become executive director of the National Ambulance Service of Qatar in the Middle East. Though there was limited ambulance service in the capital city, her role was to build an EMS system to serve the entire nation.

Over the course of a decade, she helped the national ambulance service grow from six ambulances and a staff of 60 to 60 ambulances, 25 interfacility transfer vehicles and a staff of more than 700. In the process of building a national EMS system from the ground up, Price sought out best practices from around the world and borrowed ideas from several countries.

“The United Kingdom was doing great things in quality assurance and integrating into the health system,” says Price, who is now back in Calgary working as health integration manager for Alberta Health Services EMS. “A result of EMS being embedded into the health system is that they’re able to look at outcomes better than the rest of us.”

She also points to advances in other countries. “South Africa is among the first to have a common registering body, the Health Professions Council, for all paramedics and is moving toward a standard, university-based curriculum,” she says.

Americans have a tendency not to look outside our borders for great ideas, and EMS is no different. But a collection of influential leaders from five countries says it’s time to change that. They’ve formed a new group, International Paramedic, with the goal of providing a forum for countries to learn from one another’s successes and mistakes and to provide resources for developing nations that are looking for guidance on starting their own ambulance services.

The idea for an international forum was hatched a few years ago by Gary Wingrove, director of strategic affairs for Mayo Clinic Medical Transport in Rochester, Minn., and past president of the National EMS Management Association, and Mike Nolan, president of the EMS Chiefs of Canada and paramedic service chief for Renfrew County in Ontario, Canada. At EMS events throughout North America and Australia, both were impressed by the need for some type of forum. “It struck both of us that there is a much larger community of paramedics and EMS professionals who are able to share their best practices and ideas,” Nolan says. And yet no such international forum for the exchange of ideas existed.

“Everybody seemed to be making progress, but internationally nobody was talking to each other, and people were starting from scratch when another country had already tried something,” Wingrove says. “We know some things are different, and we don’t necessarily know yet which are good and which aren’t, but there are some general themes that we see looking across various countries.”
Nolan and Wingrove reached out to fellow EMS leaders interested in joining forces. “We wanted to explore and identify common elements among paramedic services from around the world, to advance best practices and best ideas, and to create a forum where anybody in the world with an interest in paramedic services could contribute to a discussion, initiate a discussion, share ideas and build upon one another’s enthusiasm to create a new future for paramedics anywhere in the world,” Nolan says.

Fifteen participants from five countries met in Ottawa in April 2011 for two days of discussions that included developing a priority list of projects. One of the central issues that emerged: the need for a single name to describe people who do paramedicine around the globe.
“Nursing has evolved and has done a good job of establishing an identity. A nurse does relatively the same thing worldwide,” says Price, an International Paramedic member. “You don’t find the same thing in paramedicine.”

Instead, the group identified 36 different names used around the world for people who work within paramedicine. “From the reference point of the public, a nurse is a nurse is a nurse, and a doctor is a doctor is a doctor,” Nolan says. “But an EMT, EMT-paramedic, EMT-advanced and EMT-intermediate mean nothing to the public. We have become so skill-focused in our titling, we have missed the opportunity to create a public brand for paramedicine.”

The leaders also noted a trend in having paramedicine become a self-regulated profession, in which paramedics are independent practitioners, instead of functioning off the license of a physician/medical director. “The function of medical direction is largely a North American institution,” Wingrove says. Countries moving toward self-regulation include South Africa, Canada and Australia. “In Australia, physicians don’t have a role in ambulance work, and if they do, it’s to provide advice, not as somebody who makes decisions, sets protocols and decides who can practice or who can’t,” he adds.

In countries where paramedics are self-regulated, the educational requirements tend to be more extensive; in some places, paramedics are increasingly required to have college degrees. In Australia, the typical route to becoming a certified paramedic is to get a three-year bachelor’s degree in prehospital care or paramedical science, followed by a year or two of on-the-job training during an internship with an ambulance service.

The participants also developed a list of projects to get started on. Those include:

  1. Create a toolkit of support pieces for developing countries. “Some of the people at our session have done work in places where there is no ambulance system and no ambulances. When trying to set up an ambulance system, they need to know things as simple as how do you buy an ambulance? What do you put in it? Where do you access information about training courses?” Wingrove says. “Some of these countries, especially in Africa, are starting with very little.”
  2. Create a book of paramedic service best practices. “Best practices is not simply a list of things,” Wingrove says. “I see it as a topic area where lots of different ways of doing things have been explored and we know which ones are successful. We promote the best one or two that are best practices, such as taking STEMI patients to PCI-capable hospitals, taking trauma patients to trauma centers and doing those things that research shows to be effective.”
  3. Identify border issues. During major incidents, paramedics from one nation may be needed to cross international borders to provide mutual aid. With that comes obvious issues such as making sure paramedics have passports and can get past border checkpoints quickly. But there are other, less obvious, issues, too, such as who has liability for medical malpractice or workers’ compensation and which country’s protocols should be followed. The group wants to develop a manager’s tool kit that would explain each step, from the documents needed to a sample agreement for mutual aid.
  4. Partner with International Paramedic Practice to be the official, peer-reviewed publication of International Paramedic. The U.K.-based journal published its first issue in September 2011. The International Paramedic Forum will publish its position papers in the journal and encourage paramedics doing research on international EMS issues to submit articles for publication.
  5. Create an International Paramedic wiki and a reference document repository. A wiki enables people from countries around the world to submit information about EMS protocols, practices and regulations in their nations. Questions include things like how many levels of provider do you have? How many hours of education does each need? The end goal is to have a detailed picture of how paramedicine is practiced globally, which would be useful as a reference document but also to aid in research and figuring out how to develop best practices, says Price, who’s heading up the endeavor.
  6. Do the same for the forms medical direction takes internationally. Lately, there’s been a lot of discussion about the role of medical direction in paramedicine. Internationally, both the form and function of medical direction varies significantly, Wingrove says. What’s needed is a list of the various forms to inform the discussion.
  7. Encourage more exchange programs for paramedics and paramedic service chiefs. A few years ago, there was a good amount of student exchange between the U.K., Australia, Canada and the U.S., but that has slowed to a trickle recently, Wingrove says. Step one to reviving that is to come up with a list of current and defunct exchange programs. International study is a common feature of many higher-education programs and is used to expand and enhance a student’s educational experience and world view. Paramedics and EMS administrators could likewise benefit, he adds.


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