A history of ambulance
practitioners and services in SA
Curriculum Vitae
Gerald Dalbock graduated at UCT. He subsequently obtained bis Ouiation M e d i c a l E d x a m i n e r ' s c e r t i f i c a t e , Diuing and Submarine Medicine cer- tificate and his DIP PEC. He is also ATLS, ACLS, APLS Instructor certified.
Preuiously Gerald was Principal M e d i c a l O f f i c e r o f t h e A m b u l a n c e
Training College, but be is currently Medical Director for UCB Criticare - Cape. He also bolds bonorary appoint- m e n t s w i t b M e t r o R e s c u e a n d t b e Prouincial Administration'Western Cape Ambulance Training College.
P O B o x l l l T , Parow 7500 C P
Summary
A short history is gi,aen of the ambu- Lance seruices uhich haae changed remarkably especially ouer th,e past two decad,es. Today sui,tabl,e candidntes can undergo three leuels of traini,ng swer- ai,sed by a Nati,onal Professional Board for emergencA cdre personnel, as well as a three year diploma course (full time) at aari,ous techni,cons. These are all registered with th,e SAMDC, making the ambulance practitioner part of the h.ea\th teu,rn.
lntroduction
Ambulance services in South Africa have undergone remarkable changes over the past 20 years.
T h e c o n c e p t o f a n u n e q u i p p e d b o x - t y p e a m b u l a n c e a r r i v i n g a t a s c e n e with an unqualified attendant acting as a driver, relying on the goodwill of the public to help him load the patient and subsequently rushing off to hospital w i t h o u t b e i n g a b l e t o p r o v i d e a n y advanced Iife support, are thanldully in the distant past.
As part of the Act of Union (1910) the provision of health and hospital ser- vices became a Central and Provincial Government responsibility. The provi- sion of ambulance services was desig- nated to third tier government and thus fell under the local authority.
Town clerks (in the interest of their ratepayers) combined firefighting and ambulance services into one service, thus presenting us with the Fire and Ambulance Service.
With notable exceptions, and because of a lack of medical control and input,
Dr G Dalbock MBChB; DipPEC.
S Afr Fam Pract 1996;17:1 18-121
KEYWORDS History;
Ambulances;
Mobile emergency services;
Education, professional.
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the ambulance component of these ser- vices tended to lack support and thus p r o b l e m s w e r e e x p e r i e n c e d w i t h equipment, training and standards.
I n t h e l a t e 1 9 6 0 s t h e W e s t e r n C a p e Ambulance Services were regionalised and placed under the control of a me- dical director. The far-sightedness of this director led to numerous improve- m e n t s w i t h r e g a r d s t o a m b u l a n c e design, training standards and ambu- Iance equipment.
In the 1970s the responsibility for the provision of ambulance services was changed under Section 16 of the Health Act of 1977. This now placed responsi- b i l i t y d i r e c t l y w i t h t h e H e a l t h D e p a r t m e n t s o f t h e P r o v i n c i a l Administrations. Promulgation of this act was delayed until October 1981.
Subsequent to this Act, development of ambulance services on a national level w a s d e p e n d e n t o n t h e P r o v i n c i a l Administrations.
By the 1980s the different Provinces had:
established Provincial Ambulance Ttaining Colleges;
- trained personnel to an intermediate life support level;
- upgraded ambulance design and equipment levels;
- implemented rescue training and the strategic placement of adequate- ly placed rescue squads;
- begun upgrading communication networks;and
- begun investigating the concept of advanced life support training.
By the latter 1980s in the four largest urban centres:
- advanced life support trained per- sonnel were in place;
- standards of patient care had improved dramatically;
- clinical control was via supervising medical officers; and
- ambulance and rescue services
were compatible with international norms.
T h e s e i s l a n d s o f p r e - h o s p i t a l e x c e l - l e n c e . h o w e v e r . e x i s t e d i n a s e a o f mediocrity and large areas of the coun- try had rudimentary if any, ambulance s e r v i c e s w i t h s t a n d a r d s v a r y i n g tremendously - depending on which service one inspected.
Each of the then four Provinces had by this stage establishe d at a Provincial level:
norrns and standards for ambulance practitioners;
a scope of practice for ambulance practitioners;
a m b u l a n c e c o u r s e c u r r i c u l a a n d examination standards; and
s t a n d a r d i s a t i o n o f a m b u l a n c e design and equipment.
The problem that now existed was that t h e r e w e r e n o N a t i o n a l n o r m s a n d standards for ambulance practitioners and the different Provinces each had their own approach to training, scope of practice, course curricula, ambu- lance equipment and operational mat- ters.
This state of affairs led to tremendous fiustration amongst ambulance person- nel who found their qualifications were not recognised in different Provinces a n d t h e s t a n d a r d s o f c a r e l s c o p e o f practice differed from Province to Pro- vince.
As a result of continued lobbying by v a r i o u s o r g a n i s a t i o n s s u c h a s t h e S o u t h A f r i c a n A s s o c i a t i o n f o r A m b u l a n c e a n d E m e r g e n c y C a r e Personnel and the Metro Permanent Workgroup, the Minister of Health and Population Development established the Professional Board for Emergency Care Personnel on the 10 Januar 1992.
This move meant that ambulalrce prac- titioners within South Africa were now g o i n g to be recognised for the first
Remarkable changes over the past 20 years.
A National Professional Board was established in 1992 - allowing
registration with the SAMDC.
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time on a national level as a profes- sional group of people registrable with the South African Medical and Dental Council.
Subsequent to the establishment of the P r o f e s s i o n a l B o a r d , t h e f o l l o w i n g results have been achieved:
a n a t i o n a l s c o p e o f p r a c t i c e f o r ambulance practitioners;
conditions of practice;
ethical rules of practice;
nationally standardised training and course content;
- nationally standardised medical treatment protocols;
nationally standardised capabilities;
establishment of a register for para- medics;
e s t a b l i s h m e n t o f a r e g i s t e r f o r ambulance emergency assistants;
establishment of a register for basic ambulance assistants; and
a c c r e d i t a t i o n o f t r a i n i n g i n s t i t u - tions.
There are three registrable levels of professional ambulance practitioners:
B a s i c A m b u l a n c e A s s i s t a n t , A m b u - lance Emergency Assistant and Para- medic. These titles are to be used by qualified and registered persons only.
All ambulance practitioners are bound to practice according to protocols and a specific scope ofpractice (dependent o n l e v e l o f t r a i n i n g ) . N o a m b u l a n c e practitioner may treat apatient for gain w i t h o u t b e i n g r e g i s t e r e d w i t h t h e SAMDC.
Training of ambulance practitioners results in three levels of patient care:
basic, intermediate and advanced life supports.
Summary of capabilities of ambulance practitioner levels
l. Basic life support (BLS):
Post successfully completing a three week course the candidate qualifies as
a Basic Ambulance Assistant (BAA).
Q u a l i f i e d t o u s e a l l s t a n d a r d a m b u - lance equipment, but may not do inva- sive procedures on a patient. Entitled to administer oxygen, entonox and oral glucose when needed.
2. Intermediate life support (ILS):
E n t r a n c e r e q u i r e m e n t : B A A , w i t h acceptable on-road experience.
Post successfully completing an eight week course, the candidate qualifies as an Ambulance Emergency Assistant (AEA)
Over and above BAA capabilities he may also:
- perform defibrillation;
i n i t i a t e i n t r a v e n o u s i n f u s i o n s (according to protocol);
perform needle thorocentesis;
perform needle cricothyrotomy;
use anti-shock garment (leg sections only);
administer intravenous dextrose;
and
administer nebulised 82 stimulant.
3. Advanced life support (ALS):
Entrance requirements: AEA, with acceptable on-road experience.
Post successfully completing a four month course, the candidate qualifies as a Critical Care Assistant (CCA) and is entitled to register as a paramedic.
Over and above AEA capabilities he may also:
perform synchronised cardiover- sion;
perform open cricothyrotomy;
use full anti-shock garment;
make use of 26 therapeutic pharma- cological agents to treat all forms of medical, paediatric, obstetric, gynaecological and surgical emer- gencies; and
By the late 1980s our services in urban centres were compatible with international norms.
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- continue therapy of intensive care unit Patients in transit'
An ambulance practitioner may also obtain a National DiPloma in ambu- lance and Emergency Care Technology' This is a three year full time diploma course offered by the Witwatersrand and Natal Technicons'
A national diplomate is also registrable as a paramedic upon successfully com- p l e t i n g t h e d i P l o m a ' b u t h a s a f a r g r e a t e i t h e o r e t i c a l a n d p r a c t i c a l lrounding than a CCA' The diplomate i s a l s o e x P o s e d t o a w i d e r a n g e o f other emergency related topics during the training, inclusive of rescue and m a n a g e m e n t p r i n c i p l e s ' T h i s m a k e s t h e d i - P l o m a t e a f a r m o r e b a l a n c e d ambulance Practitioner'
I n o r d e r f o r a p a r a m e d i c t o p r a c t i c e according to SAMDC protocols there must be a supervising medical practi- tioner available to give radio or tele-
p h o n i c a d v i c e w h e n n e e d e d ' M o s t ambulance services today thus have a f l e e t o f w e l l e q u i P P e d a m b u l a n c e s m a n n e d b Y B L S a n d I L S P e r s o n n e l ' with a paramedic available on an ALS ambulance (or response car), to back- up the staff when needed' A doctor is aLo required to be available for consul- tation and clinical control'
We are Proud to welcome the ambu- lance practitioner into the realm of the medical Professional.
Bibliography:
1. Pre-hospital care for road accidenl casual- t i e s i n t h e R e p u b l i c o f S o u t h A f r i c a ' Automobile Association of South Africa SurveY, 1985.
2. Keenan JP' Ambulance seryices in SA - past' present and future' Hospital Supplies' March
1990:4-10.
3. Ambulance & Emergency Medical Services:
Natal internal circular No' 60/94
4. SAMDC Professional Board for Emergency Care Personnel: policy documents' August 1994.
Three levels of training as well as a National Diploma.
The Resuscitation council of southern Africa has produced 44' and other size' posters on the toPics of:
. Cardio-Pulmonary resuscitation of adult$ and children' . Choking
. n J u u n ' 1 d t i f e s u p p o r t f o r a d u | t s a n d c h i | d r e n .
They also run courses for medical and paramedical people to get these qualifica- tions.
More information is available from:
UCB Criticare E.M.S., PO Box 31036, Braamfontein, 2017
South Africa.
Tel: (011) 642-7510 Fax: {011) 643-6906
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