Editor's note: "Ambulance Australia" has been moved to Amazon Prime Video from Netflix.
If you tune into Netflix these days, you can view Ambulance Australia and see how the medics of the Queensland Ambulance Service respond to 0-0-0 calls as they perform EMS down under. How does EMS care in Australia differ from the United States? We spoke to Stephen Rashford, MBBS, FACEM, medical director of the Queensland Ambulance Service, to find out.
Rashford is an emergency physician and has been the medical director for QAS since 2005. During his time in this role, he has overseen a significant expansion in innovative paramedic practice, with particular interests in hemostatic blood product resuscitation, point-of-care ultrasound, airway management, procedural sedation, and the treatment of STEMI. Rashford is often in the field treating patients with his paramedics, looking to refine and optimize clinical algorithms. He also worked in the United States in the 1990s during his specialist training, so he knows about the U.S. EMS system as well.
The QAS is the busiest ambulance service in Australia, with a coverage area of 715,309 square miles served by 301 response locations. QAS responds to more than a million calls a year. Australia’s 0-0-0 dispatch centers parallel the American 9-1-1 system.
The QAS has about 5,000 employees, about 4,000 of whom are registered paramedics. Most are full time, with about 15% working part-time or per-diem. The QAS communications center consists of 500 emergency medical dispatchers. The QAS team also includes emergency medical physicians, infection-prevention nurses, EMS pharmacists, occupational therapists, and mental health clinicians. There are about 350 volunteer responders at the equivalent of U.S. EMTs in rural areas, but they are paired with paramedics for all responses. QAS has adopted the mobile health approach, rather than simply being an emergency medical response agency.
In the United States a two-tiered system typically means an agency provides both ALS and BLS service. QAS also has a two-tiered service, but with expanded capacity . Its baseline response is an ALS ambulance with two paramedics with bachelor’s degrees. They provide all the standard care expected of a paramedic-level response, similar to a nationally registered paramedic in the United States. Their second tier is critical care paramedic responders, who have more advanced sedation options, advanced RSI procedures, and multiple intubation options, similar to the skill set of a U.S. flight paramedic. In some areas QAS also has a third tier called “high-acuity response units” (HARUs), staffed by critical care paramedics equipped with whole blood products and ultrasound and able to perform advanced RSI, field amputations, and the like. These are similar to American EMS physician responders like those of New Jersey’s MD-1 program.
QAS has 11 helicopters, all staffed by critical care paramedics. Nine also carry critical care EMS physicians due to the requirements for occasional long-distance interfacility transports of very undifferentiated cases. QAS ground HARU providers have the same skill set as the flight teams.
Paramedics as Medical Professionals
In Australia paramedics are the fourth-highest-paid university graduates. Paramedic salaries include a base rate and guaranteed allowances. A new graduate will earn approximately $65,000 U.S. in their first year, and an experienced ALS paramedic approximately $90,000 per year working a typical 40-hour week. QAS critical care paramedics earn salaries north of six figures, and rural and remote paramedics receive further remuneration. Says Rashford, “Paramedics are appropriately paid for the expectations of care from a registered healthcare professional.”
An advanced care paramedic requires an undergraduate bachelor’s degree in paramedicine. A significant number of paramedics now also do dual degrees with nursing. A critical care paramedic requires a minimum of the bachelor’s degree and then a graduate diploma in critical care paramedicine, but most have master’s-level qualifications. The HARU and flight programs also undertake additional master’s programs. “Education is the key for us—something we value highly,” says Rashford. EMS in Australia is paid significantly more than firefighters and law enforcement.
Every paramedic level at the QAS has a scope of practice. If they need to go outside that scope, paramedics in the field can call a 24/7 clinical consultation line. The first point of call is a HARU critical care paramedic, and they can refer up to an EMS physician. Providing additional support is immediate access to Rashford or one of his two deputy medical directors. “We find the calls tend to be about very complicated cases or difficult decisions that challenge us as well,” says Rashford. “Ideally our paramedics consult by exception, not as a rule.”
The QAS has a detailed digital clinical procedure manual which it makes available online for free. Every paramedic in the QAS is issued a personal iPad that contains this manual but also allows for the digital clinical record, roster management, and dispatch information. Rashford takes special pride in the procedural section of the manual. “I have a full-time illustrator on my team,” he says. “We know people learn better from drawings than photos.”
On Netflix many of the QAS procedures can be seen on a regular basis. According to Rashford, the QAS used ketamine for procedural sedation well before most services in the U.S., starting in 2008. For acute behavioral disturbances it uses droperidol as its first-line medication, followed by ketamine. “We have published in this area widely,” says Rashford. “I know droperidol has an FDA black box warning in the USA, but there is overwhelming data that does not support that approach, which is a shame. Droperidol is effective and safer than midazolam or ketamine.”
QAS has some other unusual protocols that may not be common in the States. Examples include select intra-arrest thrombolysis for a proven STEMI or high likelihood of a pulmonary embolism. QAS data demonstrates better outcomes with selective use of intra-arrest thrombolysis in conjunction with online QAS physician approval. Physician EMS field units also undertake prehospital resuscitative thoracotomy.
QAS is involved in a research project involving blood product resuscitation, especially in busy urban areas. The QAS started using packed red cells on urban ground units in 2010, but helicopters have had them on board since the early 1990s. The HARU units now carry extended-life plasma and fibrinogen concentrate. Paramedic units all carry inhaled methoxyflurane, called the “green whistle,” for quick-acting nonopioid pain control in conscious trauma patients.
The Netflix Effect
Prior to coming to America, Ambulance Australia was a popular series in Australia. Of its various iterations, per Netflix, the QAS series rated the best. COVID has forced a pause on the next series, but QAS intends to participate early in 2021 with casting starting soon. “In general,” says Rashford, “the series showcases what a great job our paramedics do, and not just the high-acuity cases. It is a very professional production crew who are interested in a variety of stories.”
COVID has not affected Australia the way it has in the U.S. Says Rashford, “We have been very fortunate in Australia, especially Queensland. Our government closed Australia’s international borders very early, with our state government further adopting a very well structured approach centered on community safety. This has served us very well.” Vigorous contact tracing has also played a part, and the only significant COVID QAS has seen is in returning overseas travelers.
The QAS took a systemic approach to ensure the entire health system was prepared for a significant escalation, but Rashford says it hasn’t materialized. Overall workload dropped by 25% during the middle of the COVID outbreak; however, mental health calls increased by 20%. Overall workload is now exceeding pre-COVID levels.
Medical Director Role
Rashford forms part of an executive leadership team that reports directly to the Queensland Health Commissioner. His team also oversees the statewide education unit and research and performance team. “I do like getting out on road when I can,” says Rashford. “I used to get out quite a lot, about 1,400 cases per year, but now it is once or twice a week , usually to a complex trauma if HARU is unavailable or the patient may require a resuscitative thoracotomy in the setting of penetrating trauma.”
He has three EMS physician fellow positions he oversees. The fellows go into the field in addition to assisting with education and quality assistance. They are credentialed for specialist medical training in addition to the new Diploma of Prehospital Care and Retrieval Medicine. These physicians have usually completed their specialist training and come to the QAS for some advanced trauma work for 6- or 12-month rotations. QAS is the only ambulance service in Australia with these positions.
The QAS is always trying to innovate and identify areas for improvement. Leaders are rightfully proud of their staff, their commitment to technological innovation, and ensuring the best health outcomes for Queenslanders. Check them out on Netflix!
Barry A. Bachenheimer, EdD, NREMT/FF, is a career educator and college professor. With a fire and EMS career of over 34 years and counting, he is a frequent contributor to EMS World.