Before the 1960s the training of ambulance personnel anywhere in Australia was sporadic. It varied in quality and quantity between communities and largely took place on the job.248 A meeting of the Victorian Ambulance Services Association in 1957 sought to resolve the issue regarding multiple training programs. A resolution was passed at that meeting that a request should be made to the local Hospitals and Charities Commission for a school to be established for the ‘preliminary training of ambulance officers to a defined standard’.249 In 1961 the first Ambulance Officers Training Course commenced in Geelong. Instruction was provided by nurses and doctors from the Geelong and District Hospital. Driving instruction was provided by ambulance superintendents.250 This was the first course specifically developed for ambulance officers, and not members of the public (as was the case with first aid training), that covered material specific to the unique nature of paramedic work.
By the 1960s there had been radical advances in medical knowledge and technology. In the US, Dr RA Cowley published a number of articles outlining the importance of an integrated and coordinated emergency care team that extended from pre-hospital to hospital. He developed a concept referred to as the ‘golden hour’, which claimed that trauma patients who received definitive care within an hour of injury had significantly better outcomes than those who did not.251 This type of medical research on the effect of ambulance intervention in the pre-hospital space was only just beginning to be undertaken in any organised way and with the objective of shaping paramedic practice. Although paramedics were not doing the research themselves, at least the environment in which they worked was being researched and the potential for paramedics to play a greater role in healthcare outcomes was being considered. The ‘golden hour’ concept became foundational in identifying the value of care provided in the pre-hospital space and raised awareness among the medical
248 Ibid. 249 Ibid. 250 Ibid.
251 E Brooke Learner and Ronald Moscati, ‘The Golden Hour: Scientific Fact or Medical “Urban Legend”?’
fraternity that ambulance officers were well placed to deliver that care provided they were properly trained.252
In Victoria, Dr Graeme Sloman became aware of advances in the US where ambulance attendants were taking a ‘quantum leap’ from applying first aid skills to becoming ultra- skilled ‘physician extenders’ qualified to administer advanced medical care in the field.253 He believed that a similar approach could be developed in Victoria. He won support from the College of Surgeons and funding from the Victorian minister of health to create a similar model referred to as a pre-hospital intensive care model. There was no formal emergency medicine speciality in Australia at this time but there were a number of doctors interested in emergency care and their work was informed by the experiences of doctors and medics during the Korean and Vietnam Wars.254 Strong links developed between those clinicians and the ambulance service who were the frontline for the majority of trauma at that time. The Ambulance Services Advisory Committee (ASAC) was formed and facilitated the clinical and professional development of paramedics. This was successful to the extent that Victorian ambulance officers had shifted from being essentially highly skilled first aiders with a restricted set of skills at the start of the decade, to administering pain relievers like the mild anaesthetic agent, trichloroethylene, which was previously only administered by doctors—a mere four years later.255
The extension of the role and practice of paramedics did not result from demands made by paramedics themselves; rather, it was a response to an increase in the number of traumatic incidents they were attending. Over the preceding 30 years or so car ownership had grown and with it the number of car accidents.256 Drink driving was common and seat belts were rarely worn; indeed seat belts and other safety features within cars were virtually non-
252 Ibid.
253 Ryan Corbett Bell, The Ambulance: A History (McFarland and Co, 2009) 254.
254 For example, it was observed that if a soldier was alive when ‘stretcher bearers’ reached him, it was
thought that he could be kept alive until he reached definitive care; See Sally Wilde, From Driver to
Paramedic: A History of the Training of Ambulance Officers in Victoria (Ambulance Officers Training
Centre, 1999) 86; Louise Reynolds and Madeleine O’Donnell. "The role of pre-hospital care and
paramedics: the emerging professionalisation of urgent care." Understanding the Australian Health Care System (2016): 271.
255 Sally Wilde, From Driver to Paramedic: A History of the Training of Ambulance Officers in Victoria
(Ambulance Officers Training Centre, 1999) 88.
256 From 1925 until 1979, over 100,000 road users were killed and 2.2 million injured prior to the
introduction of compulsory seat belts in 1971, see PW Milne, Fitting and Wearing of Seat Belts in
existent as authorities focused mitigation efforts on accident reduction rather than improved safety.257 As a result, ambulance personnel attended a large number of car accidents that resulted in significant trauma, well beyond that normally seen outside of a battlefield. Prior to this there were no specific accident and emergency departments in hospitals, but the increase in road users and subsequent road accidents necessitated their development. Emergency medicine developed as a specialty area and this contributed further to the clinical development of paramedicine working at the coal-face of road trauma. This move was supported by the head of the Standing Committee on Road Trauma, ESR Hughes, who wrote to the chair of the Hospitals and Charities Commission in Victoria stating ‘that there should be an increase in the standard of training of Victorian Ambulance Officers at all levels to enable them to fulfil an increased role’.258 This slow increase and expansion in training and scope of practice was contributing to the development of the profession beyond just being ‘drivers’. The expanded scope of practice meant that paramedics now had expanded professional responsibilities. The old approach of just turning up to the scene, loading the patient into the ambulance and letting someone else deal with the situation in hospital was changing. Ambulance officers were now required to know when to use these advanced skills and treatments and when not to. That is, they were required to use professional judgement and discretion and to consider how they could act in patients’ interests.
3.4.1Calls for Recognition
The flow-on effect of increasing road trauma for ambulance services and personnel was the recognition that the application of basic first aid and the ‘load ‘n go’ approach that had previously applied to pre-hospital care was now insufficient. The public health impact of road trauma was so great that in 1969 the Royal Australasian College of Surgeons held a seminar on the management of road traffic casualties. The seminar was significant and influential because it led to the Australian Medical Association’s (AMA’s) support not only for compulsory seat belts but, relevantly, for research to identify what greater role ambulance officers could play in providing care to road trauma victims.259 This point has
257 Ibid.
258 Sally Wilde, From Driver to Paramedic: A History of the Training of Ambulance Officers in Victoria
(Ambulance Officers Training Centre, 1999) 88.
further significance because it demonstrates that although the medical fraternity were driving the scope and development of knowledge and practice for ambulance officers at this time, they believed ambulance staff were only capable of delivering this type of care and treatment if they had the necessary training. A number of doctors who presented at the seminar, including Frank Archer—who was to become a seminal leader in the development of paramedicine in Australia—had worked as ambulance officers during their holidays.260 Archer identified that of all the practitioners in the care chain it was only ambulance officers, those right at the frontline who were ‘one of the few who deals with the life of the patient’, who had not undergone any type of intensive training. This situation prompted Archer to call for more and better training, recognising that this would only be possible if there was also a corresponding improvement in the ‘status of ambulance officers, and recognition of their skills and their value by the medical profession’.261
The second important clinical development that drove paramedics’ educational development and extension of their practice was an increased knowledge of and changes to the practice of cardiology. Ambulance personnel were frequently called to patients having cardiac episodes and there was some suggestion that early and effective treatment of these patients could also result in better outcomes.262 Cardiopulmonary resuscitation was developed in 1960263 and advances in technology such as the development of an affordable portable defibrillator, electrocardiograph monitors and research into the use of various pharmaceuticals including glyceryl trinitrate (trade name Anginine) also changed what could be done for cardiac patients in the pre-hospital setting. A three-month trial designed to assess if paramedics were capable of being trained and operating at this higher level was commenced; those paramedics who were selected underwent training that was previously thought to be only suitable for the higher status ‘trained nurse’.264
260 The title of Archer’s paper was ‘Care Before Casualty—Current Shortcomings;’ Frank Archer, ‘Dr.
Peter O’Meara-Ambulance to Academia and back again.’ (2003) Australasian Journal of Paramedicine 1.1.
261 Sally Wilde, From Driver to Paramedic: A History of the Training of Ambulance Officers in Victoria
(Ambulance Officers Training Centre, 1999) 87.
262 Michael F O’Rourke, ‘Reality of out of Hospital Cardiac Arrest’ (2005) 91 Heart 1505; Sally Wilde,
From Driver to Paramedic: A History of the Training of Ambulance Officers in Victoria (Ambulance Officers Training Centre, 1999).
263 Michael Criley, James T Niemann and John P Rosborough, ‘Cardiopulmonary Resuscitation Research
1960–1984: Discoveries and Advances’ (1984) 11(9)(Pt 2) Annals of Emergency Medicine 756.
264 Sally Wilde, From Driver to Paramedic: A History of the Training of Ambulance Officers in Victoria
In the late 1970s a Tertiary and Further Education (TAFE) course was prepared for the Victorian Ambulance Service’s Ambulance Officers’ Training Centre.265 It was titled the Certificate of Applied Science (Ambulance Officer). The course was developed by ambulance officers and doctors and reflected the unique work done by ambulance officers.266 The implementation of the Victorian TAFE program allowed an agreed standard of qualification for paramedics to be established. This program was later adopted by other state ambulance services.267
Ambulance officers had gradually been recognised by other members of the healthcare fraternity as providing a significant public health service. ‘Ambos’, as they were affectionately referred to, were recognised as working in a unique environment with a unique set of patients. This in turn required the application of a unique approach to healthcare. To achieve this, ambulance officers were now required to undertake a prolonged period of training to acquire specialised knowledge and skills. The St John First Aid certificate was no longer a sufficient qualification to perform the role. Ambulance officers now required a Certificate of Applied Science (Ambulance Officer), a qualification developed by the discipline for the discipline but with input from medicine. This shows the beginning of the development of paramedic professional autonomy. With regard to Wilensky’s trajectory of professional development, paramedics had achieved the first goal—the establishment of a training school.