DEAR PHYSICIANS, ALL OF YOU IN HEALTHCARE ARE PARAMEDICS EXCEPT THE MED LAB SCIENTIST

I have always read with keen interest all your publications about all that happens in the health sector in Nigeria. I have concluded that you are a verbose writer lacking the substance of truth; full of a self-styled ideology. I also concluded that you are like a website watchdog for pathologists (those who have lost the sense of direction of their professional career). I write with every sense of seriousness to avail fellow Nigerians the opportunity to know who paramedics are, how they are trained, what they do or employment structure, where they are found and where are they found in Nigeria?

WHO IS A PARAMEDIC?
The paramedic is a healthcare professional who works in emergency medical situations. A paramedic may be more formally defined as a medical professional who provides medical care to sustain life in the pre-hospital environment, usually in an emergency, at the point of illness or injury. This includes an initial assessment of the patient after a particular health crisis. Treatment can also be continued en route to a hospital if more definitive care for the patient is required. Paramedics provide advanced levels of care for medical emergencies and trauma. The majority of paramedics are based in the field, in ambulances, emergency response vehicles, or in specialist mobile units such as cycle response. Paramedics provide out-of-hospital treatment and minor diagnostic services, although some may undertake hospital-based roles, such as in the treatment of injuries.

TRAINING OF PARAMEDICS.
In the United States, paramedic training is considered vocational. Paramedic education programs typically follow the US Department of Transportation’s Emergency Medical Technician-Paramedic: National Standard Curriculum. While many regionally accredited colleges and universities offer paramedic programs, only a handful require a formal degree component prior to completion. Course minimum required hours vary from state to state but range between 700 – 1300 didactic and clinical hours. Calendar length can vary from between six months to upwards of two years.

The disparity of educational requirements and lack of an academic degree contribute to overall lower wages and less respect amongst other allied health care providers in the US.

In the United Kingdom, ambulances became largely municipal services shortly after the end of World War II. Training was frequently conducted internally, although national levels of coordination led to more standardization of staff training. As of 2010 public ambulance services were operated by regional entities, most often trusts, under the authority of the National Health Service, with significant standardization of training and skills. The UK model utilizes two levels of ambulance staff: internally trained Ambulance Technicians, which are similar to EMTs in the US, and paramedics with advanced life support skills.

Initially paramedics were mainly trained internally, with experienced ambulance technicians often progressing to the role of paramedic. Increasingly, however, university qualifications are being expected for paramedics, with the entry level being an Honours Bachelor of Science degree in Pre-Hospital or Paramedic Care. Some British paramedics have gone on to become Paramedic Practitioners, a role that practices independently in the pre-hospital environment in a capacity similar to that of a nurse practitioner, but with more of an acute care orientation.

Canada, for example, attempted a pilot paramedic training program at Queen’s University, Kingston, Ontario, in 1972. The program, which intended to upgrade the then mandatory 160 hours of training for ambulance attendants, was found to be too costly and premature. The program was abandoned after two years, and it was more than a decade before the legislative authority for its graduates to practice was put into place. An alternative program which provided 1,400 hours of training at the community college level prior to commencing employment was then tried, and made mandatory in 1977, with formal certification examinations being introduced in 1978. Also in Canada, Advanced Care Paramedics were not introduced until 1984, when Toronto trained its first group internally, before the process spread across the country. By 2010 the Ontario system involved a two year community college based program, including both hospital and field clinical components, prior to designation as a Primary Care Paramedic, although it is starting to head towards a university degree-based program.

WHAT DO PARAMICS DO? OR WHAT IS THEIR EMPLOYMENT STRUCTURE?
Paramedics are employed by a variety of different organizations, and the services provided by paramedics may occur under differing organizational structures, depending on the part of the world. A new and evolving role for paramedics involves the expansion of their practice into the provision of relatively basic primary health care and assessment services.

Some paramedics have begun to specialize their practice, frequently in association with the environment in which they will work. Some early examples of this involved aviation medicine and the use of helicopters, and the transfer of critical care patients between facilities. While some jurisdictions still use physicians, nurses, and technicians for transporting patients, increasingly this role falls to specialized senior and experienced paramedics. Other areas of specialization include such roles as tactical paramedics working in police units, marine paramedics, hazardous materials (Hazmat) teams, Heavy Urban Search and Rescue, and paramedics on offshore oil platforms, oil and mineral exploration teams, and in the military.

The majority of paramedics are employed by the municipal emergency medical service for their area, although this employer could itself be working under a number of models, including a specific autonomous public ambulance service, a fire department, a hospital based service or a private company working under contract. There are also legions of paramedics who volunteer for backcountry rescue teams, small town rescue squads, and the like.

The provision of municipal ambulance services, and paramedics, can vary by area, even within the same country or state. For instance, in Canada, the province of British Columbia operates a province-wide service (the British Columbia Ambulance Service) whereas in Ontario, the service is provided by each municipality, either as a distinct service, linked to the fire brigade, or contracted out to a third party.

SKILLS OF PARAMEDICS IN THE HOSPITAL SETTING.

It will interest Nigerians to know the following: While there are varying degrees of training and expectations around the world, a general set of skills shared by essentially all paramedics and EMTs (EMERGENCY MEDICAL TECHNICIANS) includes:
Advanced cardiac life support, or ACLS, treats areas involving cardiac injury or compromise; the most common is cardiac arrest. Since the heart and nervous system begin to degrade in as little as 4-6 minutes, early recognition and treatment in the prehospital setting is very effective in life saving treatments. Using many devices and treatment modalities, such as Cardiac Monitors, Defibrillators, and cardiac medications, the chief objective is to stop and reverse the effects of lack of cardiac output.
Spinal injury management, including immobilization and safe transport. Fracture management, including assessment, splinting, and use of traction splints where appropriate. Obstetrics, including assessment, assisting with uncomplicated childbirth, and recognition of and procedures for obstetrical emergencies such as breech presentation, cord presentation, and placental abruption.
Management of burns, including classification, estimate of surface area, recognition of more serious burns, and treatment.
Advanced airway management techniques including surgical airways.
Triage of patients in a mass casualty incident.
Assessment and evaluation of general incident scene safety.
Effective verbal and written reporting skills (charting).
Routine medical equipment maintenance procedures.
Routine radio operating procedures.
Emergency vehicle operation.

MEDICATIONS ADMINISTERED BY PARAMEDICS.
Paramedics in most jurisdictions administer a variety of emergency medications. The specific medications they are permitted to administer vary widely, based on local standards of care and legal restrictions, and physician or medical director preferences. For an accurate description of permitted drugs or procedures in a given location, it is necessary to contact that jurisdiction directly. A representative list of medications may commonly include:

Analgesic medications such as aspirin, ketorolac and paracetamol, used to relieve pain or decrease nausea and vomiting.
Narcotics like morphine, pethidine, fentanyl, and dilaudid, used to treat severe pain, such as with burns and fractures.
Adenosine, calcium channel blockers Diltiazem and Verapamil used to slow down excessively high heart rates.
Parasympatholytic drug such as Atropine, used to speed up slow bradycardia heart rates.

Sympathomimetics[6] such as dopamine, dobutamine, norepinephrine, and epinephrine used for severe hypotension (low blood pressure), cardiogenic shock and septicemia.

D50W (a solution of 50% dextrose in water), used to treat hypoglycemia (low blood sugar).
Sedatives like midazolam, lorazepam, and etomidate, used to reduce the irritability or agitation of patients.
Paralytics such as succinylcholine, rocuronium, and vecuronium, used when an emergency procedure such as rapid sequence intubation (RSI) is required.

Antipsychotics like haloperidol or ziprasidone, used to sedate combative patients.
Respiratory medications such as salbutamol, Ipratropium bromide and methylprednisolone, used to treat conditions such as asthma and acute bronchitis.

Cardiac medications such as nitroglycerin, aspirin, and morphine, fentanyl used to treat cardiac ailments such as angina and heart attacks.

Antiarrhythmics such as amiodarone, lidocaine and magnesium sulfate used to treat cardiac arrhythmias such as ventricular tachycardia and ventricular fibrillation.
Antiemetics such as promethazine or ondansetron used for nausea and vomiting.
Naloxone used to treat opioid drug overdose and flumazenil.

In the Nigerian health system, the fight for superiority, and the fear for the sudden emergence of the Medical Laboratory Scientist has evolved into unbridled calumny and the use of such words as mediocrity, paramedical as a weapon of PROFESSIONAL WARFARE by the NMA and her allies to attack other noble professions in the health sector in Nigeria. It is pertinent to note that a close look at the history of paramedical professionals, shows that every other health professional like doctors, nurses, pharmacists, radiographers can function perfectly well as a paramedic, EXCEPT the MEDICAL LABORATORY SCIENTIST. The evidence is clear as stated above based on the duration of training, certificate obtained, general skills as well as medications administered by paramedics. So in Nigeria, the term PARAMEDICAL is misinterpreted and misapplied because of selfishness and arrogance. In Nigeria today, based on what happens in the UK, US, Canada, Australia, I cannot see any form of paramedical activity established by law through the act of legislation in our hospitals. It is very important to mention that NEMA is in the fore front of coordinating paramedical activities in the case of emergency responses.

For clarity’s sake, based on history and on the realities on ground in Nigeria:

Para medics are pre-hospital in function, they are community, district or state based. They perform some procedures that physicians are supposed to do if their workload allows. According to the Britannica, “these paramedical workers perform routine diagnostic procedures such as the taking of blood samples and therapeutic procedures such as administering injections, or suturing wounds; they also relieve physicians of making routine health assessments and taking medical histories”.

A Medical Laboratory Scientist in Nigeria is not a paramedic, he/she is a medical degree holder and is licensed to practice independently without interference and is said to be medically qualified. The NICN judgment is very clear.

The functions of a Medical Laboratory Scientist cannot be undermined as a key player in the health industry, whether as a private practitioner or a government staff. For those calling for the use of private laboratory practitioners in government hospitals; they should realize that it is still one and only MEDICAL LABORATORY FAMILY, regulated by MLSCN established by Act 11 2003.

The Nigerian Medical Association NMA, must realize that it is highly criminal to take clinical decisions without medical laboratory investigations.

NMA should realize that it is an act of quackery and stealing punishable by law for another professional to append his/her signature on a piece of work done by another professional, Pathologists take note.

NMA should quickly withdraw the statement and apologize to Nigerians for the statements that imply that they intend to treat Nigerians without LABORATORY INVESTIGATIONS; this is medical genocide, the Judiciary should take note.

NMA should stop crying over spilled milk, the NICN judgment has come to stay and there is no going back.

Nigerians should know that the core departments in healthcare are not Para medicals. For reference check Britannica which says Paramedical Personnel also called Paramedics are healthcare workers who provide clinical services to patients under the supervision of a physician. The term generally encompasses nurses, therapists, technicians and other ancillary personnel involved in medical care but is frequently applied specifically to highly trained persons who share with physicians the direct responsibility for patient care. This category includes nurse practitioners, physician’s assistants, and emergency medical technicians… For the record, these are not established disciplines in Nigeria. Perhaps, the time has come for the training of paramedical personnel like nurse practitioners, physician assistants et al to start.

Finally, I call on all comrades across the nation to stand their ground, because MLSs are here to improve and modernize medical practice and not to be subdued by it while we also inform and educate the people.

Com. Anyanwu, Francis E. 08030907860.08180082590, lamour_aug11@yahoo.com