AN INVESTIGATION INTO THE NON-COMPLIANCE OF ADVANCED LIFE 
SUPPORT PRACTITIONERS WITH THE GUIDELINES AND PROTOCOLS 
OF THE PROFESSIONAL BOARD FOR EMERGENCY CARE 
PRACTITIONERS 
 
LLOYD DENZIL CHRISTOPHER 
(Student Number: 18701600) 
 
A dissertation submitted in fulfilment of the requirement for the degree of 
Master in Technology: Emergency Medical Care 
 
Durban University of Technology 
Faculty of Health Science 
 
Department of Emergency Care and Rescue 
 
 
 
 
 
 
 
 
 
Supervisor: _________________ 
L.D. Grainger (PhD) 
 
 
Date: _________________ 
 
 
 
ABSTRACT 
 
Purpose 
The Professional Board for Emergency Care Practitioners (PBECP), a division 
of the Health Professions Council of South Africa, regulates the scope of 
practice and publishes guidelines and protocols that advanced life support 
(ALS) practitioners are required to follow. These define an acceptable, 
standardised approach to each commonly encountered emergency. Non 
compliance with the guidelines and protocols regularly occurs, which could 
impact on the quality of care delivered and may result in further injury or death 
of the patient. This study investigated the reasons for non-compliance by ALS 
practitioners and explored how compliance could be improved. 
 
Methodology 
The study was conducted in the interpretive paradigm using a grounded theory 
approach. The population was ALS practitioners in the Western Cape. 
Purposeful sampling was used to select the sample. Focus group discussions 
and interviews were used for data collection. The data was analysed using 
interpretative methods of analysis, in order to achieve the research objectives.  
 
Findings  
The health system focus on delivering health care to the community as part of 
the Primary Health Care focus has created new challenges for the ALS 
practitioner. The PBECP guidelines and protocols do not accommodate the 
unique circumstances of rural ALS practice and this disjuncture between the 
guidelines and protocols and the realities of rural health care contribute to the 
eventual non-compliance.  
 
The EMS organisation's inability to provide clinical supervision consistent with 
the PBECP guidelines and protocols; ensure adequate support for practitioners 
in rural services and effectively monitor and evaluate ALS clinical practice has 
created a fertile environment for non-compliance.  
 
The processes used by the PBECP to develop and implement guidelines and 
protocols are regarded as non-scientific, lack consultation and conflict with 
other universally accepted guidelines. The delayed implementation of 
continuous professional development as a requirement for continued 
registration and the absence of clinical updates prior to the release of revised 
guidelines and protocols, contribute to non-compliance.  
 
Significant changes are underway to address the quality of education and 
training of emergency care practitioners. The introduction of the mid-level 
worker, the professional degree and continuing professional development bode 
well for the future of the profession and emergency medical services. A strategy 
to develop the existing practitioners, who will continue to be the backbone of 
emergency medical services for the foreseeable future, is needed.  
 
The ALS practitioner is at a critical stage in the evolution to becoming a 
professional. The immaturity of the profession is evidenced by the absence of 
local research and publications, the lack of inward reflection, desire for self 
improvement and genuine concern for adopting best practice 
recommendations. The formation of an association to further the interests of 
professionalism is urgently required. 
 
Conclusions  
Non-compliance is as a result of several interrelated factors that influence the 
ultimate decision of the ALS practitioner not to comply with the PBECP 
guidelines and protocols. A multi-factorial approach, spearheaded by the all 
stakeholders is required to improve compliance. 
 
DECLARATION 
The author hereby declares that the content of this research project is the 
author‟s own unaided original work, except where specific indication is given to 
the contrary (by reference). This work has not been previously submitted to the 
Durban University of Technology or any other University. 
Signature: __________________________ 
Date:  
 
DEDICATION 
I would like to dedicate this work to: 
 My mum Caroline and late dad Desmond, for their inspiration, love and 
example. 
 Lynnell and Daniel Christopher for their love, understanding and support. 
 
ACKNOWLEDGMENTS 
The author is grateful to the following people without whose assistance; this 
endeavour may not have been possible: 
 
 Dr Linda Grainger for her expert supervision, guidance, and academic 
inspiration 
 Mr Navindhra Naidoo, for his guidance and assistance 
 
TABLE OF CONTENTS PAGE No. 
ABSTRACT   ii 
ACKNOWLEDGEMENTS   vi 
ACRONYMS AND ABBREVIATIONS   xii 
LIST OF FIGURES   xiii 
LIST OF TABLES   xiv 
LIST OF APPENDICES   xiv 
 
CHAPTER 1 
1.0. Introduction         01 
1.1.     Background to this research   01 
1.2. The purpose of the study       02 
1.3.     Objectives of the study       02 
1.4.  Motivation for the study       03 
1.5.  Assumptions of the study       03 
1.6.  Reflection on the study       04 
 1.6.1. Researcher‟s perspectives      05 
1.7.  Definition of terms        06 
1.8.  Overview of the dissertation      08 
 
CHAPTER 2 
2.0.  Literature Review         09 
2.1.  Background literature       09 
2.1.1. The health system in South Africa     09 
2.1.2. Emergency medical services     12 
2.1.3. Professional Board for Emergency Care Practitioners  14 
2.1.4. EMS education and training     
 15 
2.1.5. Quality of care in EMS      18 
2.2. Literature on compliance with guidelines and protocols   20 
2.2.1. Guideline and protocols use in EMS    23 
2.2.2. Studies on non-compliance with guidelines and protocols 24 
2.2.3. Reasons for non-compliance with guidelines and protocols 28 
2.3.  Summary         30 
   
CHAPTER THREE 
3.0  Methodology                 31 
3.1  Introduction         31 
3.2.  Study design         31 
3.3  Study setting         33 
3.4  Population         33 
3.5.  Sampling strategy        34 
 3.5.1. Sampling method       34 
 3.5.2. Criteria for selection       36 
 3.5.3. Characteristics of the sample     36 
 3.5.4. Sample size        37 
3.6.  Data collection        38
  
 3.6.1. Focus group discussions      39 
  3.6.1.1. Pilot study focus group discussion   39 
  3.6.1.2. The data collection tool     39 
  3.6.1.3. Moderator and observer     41 
  3.6.1.4. Place and time of the focus group discussions 42 
 3.6.2. Individual interviews       42 
  3.6.2.1. The data collection tool     42 
  3.6.2.2. Place and time of interview    43 
3.7.  Data analysis and interpretation      43 
3.8.  Trustworthiness        45 
3.9.  Ethical issues        47 
3.10.  Conclusion         49 
         
CHAPTER FOUR 
4.0.  Findings as to the reasons for non-compliance    50 
4.1.  The Health system factors that influence non-compliance  50 
4.1.1.  Inadequate clinical and resource support   
 51 
4.1.1.1. Inadequate support of ALS practitioners by medical  
practitioners         51 
4.1.1.2. Personnel and equipment shortages   52 
4.1.1.3. Limited ALS scope of practice and non-compliance 54 
 
4.1.2.  Lack of access to continuing professional development 55 
4.1.3. Conclusion        56 
4.2.  The role of emergency medical services in non-compliance  58 
4.2.1.  Poor communications      58 
4.2.2. Long distances to hospital      60 
4.2.3.  Medical Practitioner advice to ALS practitioners may  
not conform with guidelines and protocols   
 60 
4.2.4.  Limited drug issue       62 
4.2.5. Conclusion        65 
4.3.  PBECP Guidelines and Protocols       
 67 
4.3.1. Confusion about the understanding and use of guidelines  
and protocols        
 67 
4.3.2.  Legitimacy of PBECP guidelines and protocols   69 
4.3.3. Use of guidelines and protocols     71 
4.3.4. Problems related to the process of protocol development   
and implementation       72 
4.3.4.1. Lack of consultation     72 
4.3.4.2. No updates of ALS practitioners    73 
4.3.4.3. Lack of face credibility     73 
4.3.4.4. No scheduled review date    
 74 
4.3.5. Conflict with other guidelines      74
   
4.3.5.1. Conflict with hospital practice    75 
 4.3.6. Preference for other guidelines     76 
4.3.6.1. Preference for South African Medicines Formulary 77 
4.3.6.2. Preference for American Heart Association  
guidelines       78 
4.3.6.3. Errors in the PBECP guidelines and protocols 
reduce their credibility     79 
4.3.7. Inappropriate drug use or dosage in guidelines and 
protocols        80 
4.3.7.1. Midazolam and diazepam use in sedation  80 
4.3.7.2. Morphine protocol      82 
4.3.7.3. Adrenaline protocol     83 
4.3.7.4. Specific problems with drugs in other protocols 
 85 
 4.3.8. Conclusion        86 
4.4.  Education and training       89 
4.4.1. Type of qualification of the practitioner    89 
4.4.2. Emergency care training      91 
4.4.3. Regional variation in training     96 
4.4.4. Insufficient pharmacology knowledge    97 
4.4.6. Lack of participation in continuing professional development 99 
 4.4.7. Conclusion        102 
4.5.  The evolution of ALS practice as a profession    104 
4.5.1. Characteristics of a Profession     104 
4.5.2. Independent ALS practice      105 
4.5.3. Trust of the ALS practitioner     
 108 
4.5.4. ALS practitioner use of consultation    109 
4.4.5. Conclusion        109 
4.6. Summary         111 
 4.6.1. Interrelated categories      113
     
CHAPTER FIVE 
5.0.  Findings on how to improve compliance     116 
5.1.  Introduction         116 
5.2. Heath system improvements to increase compliance   117 
5.3.  The role of EMS to improve compliance     119 
5.4.  The PBECP role in improving compliance    123 
5.5.  The role of ALS education in improving compliance   127 
5.6.  The role of the ALS practitioner in improving compliance  130 
5.7.  Summary         133 
      
CHAPTER SIX 
6.0. Conclusion and recommendations     
 134 
6.1.  Conclusion         134 
6.2.  Recommendations        137 
6.2.1. Recommendations for PBECP interventions   137 
6.2.2. Education, training and CPD     138 
6.2.3. Role of the PBECP in guideline development    138 
6.3.  Area for future study       
 139 
6.4.  Closing statement        139 
 
REFERENCE LIST         141
        
            
ACRONYMS AND ABBREVIATIONS 
ACLS:  Advanced Cardiac Life Support 
AIDS:  Acquired Immune Deficiency Syndrome 
AHA:   American Heart Association 
ALS:   Advanced Life Support 
BMJ:   British Medical Journal 
CME:   Continuing Medical Education 
CPD:   Continuous Professional Development 
CPR:   Cardiopulmonary Resuscitation 
ECP:   Emergency Care Practitioner 
EMS:   Emergency Medical Service 
HIV:   Human Immunodeficiency Syndrome 
HPCSA:  Health Professions Council of South Africa 
ILCOR:  International Liaison Committee on Resuscitation 
NCEMS: National Committee on Emergency Medical Services 
PALS:  Paediatric Advanced Life Support 
PBECP:  Professional Board for Emergency Care Practitioners 
SAMF:  South African Medicines Formulary 
SARC:  South African Resuscitation Council 
WHO:  World Health Organization 
 
LIST OF FIGURES         PAGE NO. 
Figure 1. Sampling method used in study     
 35 
 
Figure 2. The health system factors that influence non-compliance   57  
 
Figure 3. The role of EMS that leads to non-compliance    66  
 
Figure 4. The factors influencing PBECP guideline and protocol usage  87  
 
Figure 5. Learning cycle showing the growth after review and reflection  93  
 
Figure 6. ALS practitioner training and education factors that  
influence compliance        103  
 
Figure 7. Factors influencing the evolution of ALS practice    111  
 
Figure 8. The context of the emergency care profession    113  
 
Figure 9. Categories that interrelate across the themes    115  
 
Figure 10. The health system mechanism to resolve resource provision  118  
 
Figure 11. EMS organisational role in improving compliance    122  
 
Figure 12. Roles and responsibilities of PBECP and the criteria    
 for the development of guidelines and protocols    126  
 
Figure 13. The role of ALS education in improving compliance   129  
 
Figure 14. Factors that influence the professional development of ALS  
 practitioner         132  
 
Figure 15. The interrelated role of the themes to improve compliance,  
 showing the ALS practitioner as central to the process   136 
 
LIST OF TABLES  
Table 1. Characteristics of the population sample     37  
Table 2. Personal leadership and organizational change in relation to  
method of training and education.      92  
 
 
LIST OF APPENDICES  
APPENDIX 01: Discussion guide for focus group discussion    149 
APPENDIX 02: Information given to participants     
 150 
APPENDIX 03: Informed consent document      152 
APPENDIX 04: 2003 PBECP guidelines & protocols (extracts)   154 
 
 CHAPTER 01: INTRODUCTION  
 
1.1. Background to this Research  
 
There has been a rapid evolution of the paramedic profession since the 
establishment of the Professional Board for Emergency Care Practitioners 
(PBECP) under the jurisdiction of the Health Professions Council of South 
Africa (HPCSA) in 1992. The days when firemen, cross trained as ambulance 
drivers, delivered sick and dying patients to hospital in the back of unequipped 
vehicles are behind us. Ambulance drivers have gradually been replaced by a 
growing body of emergency care practitioners. On-the-job training has been 
substituted with nationally regulated training and education that allows 
registration with the HPCSA as a Basic, Intermediate or Advanced Life Support 
practitioner. The PBECP regulates the scope of practice of emergency care 
practitioners by means of guidelines and protocols, which it approves. The 
guidelines and protocols undergo periodic revision in keeping with international 
best practice. The current guidelines and protocols were issued in 2003. These 
guidelines and protocols describe the authority and responsibility of the ALS 
practitioner in performing emergency clinical procedures and administering 
approved medications in commonly encountered emergencies. Non-compliance 
with the guidelines and protocols may cause further harm and suffering for 
patients.  
 
The researcher qualified as an Advanced Life Support (ALS) practitioner in 
1989, and is the present Chairperson of the PBECP and the Head of 
Department of the Department of Emergency Medical Care at the Cape 
Peninsula University of Technology. The non-compliance of ALS practitioners 
with the 2003 guidelines and protocols had been discussed at the PBECP 
which became aware of the problem by the evidence presented in complaints to 
the Board. Consequently the PBECP identified the need to explore the reasons 
for non-compliance and seek ways to improve compliance.  
  
The extent of non-compliance with the PBECP guidelines and protocols was 
established in a pilot study undertaken by the researcher. The study used a 
questionnaire to gather data on non-compliance from National Diploma: 
Emergency Medical Care students, who where witnessing ALS practice whilst 
undertaking service learning with qualified ALS practitioners. The pilot study 
confirmed that non-compliance regularly occurred. The students estimated that 
they had witnessed ALS practitioners transgress the PBECP guidelines and 
protocols in 35% of calls during 2005. The most common transgression related 
to incorrect drug usage and dosage administration.  
 
Based on the discussions at PBECP level and the findings of the pilot study, it 
became clear that non-compliance with the guidelines and protocols was a 
problem which needed to be investigated.  
 
 
1.2. Purpose of Study  
 
The purpose was to determine why advanced life support practitioners do not 
comply with the Professional Board for Emergency Care Practitioners 2003 
guidelines and protocols and to explore how compliance could be improved.  
 
 
1.3. Objectives of the Study  
 
The first objective was to describe ALS practitioners' perceptions as to the 
reasons for non-compliance with the 2003 PBECP guidelines and protocols.  
  
Based on the findings, the second objective was to determine how compliance 
with the 2003 PBECP guidelines and protocols by ALS practitioners could be 
improved.  
 
 
1.4. Motivation for the Study  
 
The study was motivated by a request from the PBECP that specifically sought 
to gain insight into the, hitherto undocumented, ALS practices of non-
compliance with the guidelines and protocols, without accusing the practitioners 
of misconduct.  
 
The second motivation was to identify strengths and weaknesses in the current 
guidelines and protocols and in so doing inform the future development of 
PBECP guidelines and protocols.  
 
The third motivation was to find out how compliance could be improved and in 
so doing identify areas of risk, as this may decrease patient morbidity and 
mortality, limit inappropriate practice and ensure cost saving by better utilisation 
of resources.  
 
1.5. Assumptions of the Study  
 
The first assumption was that all practitioners are aware of the existence of 
PBECP protocols by virtue of their registration with the PBECP.  
 
The second assumption was that all practitioners are duty bound and legally 
obligated to comply with the PBECP guidelines and protocols and that 
guidelines and protocols are needed for ALS practice.  
 
The third assumption was that the PBECP has a responsibility to determine and 
approve ALS guidelines and protocols.  
 
 The fourth assumption was that guidelines and protocols are necessary to 
regulate scope of practice of the ALS practitioner.  
 
1.6. Reflection on the Study  
 
The investigation did not compare the differences in perceptions between 
compliant and non-compliant practitioners in respect of the research question. 
Whilst this could have been valuable from a research point of view, it would 
have created ethical problems. The reason for this is that it would have 
necessitated acknowledgement of non-compliance by the practitioners. As this 
is ethically and legally unacceptable, and especially as the researcher is the 
Chairperson of the PBECP, practitioners may not have participated voluntarily 
in the study. It is therefore unlikely that it would have obtained approval by the 
Faculty Research Committee.  
 
The ALS practitioners, who participated in the study, reside and practice in the 
Western Cape Province. Their experiences of health care are within this 
particular socio-economic context. The Western Cape Province is unique in that 
it has the lowest South African unemployment rate (18.4%); poverty rate 
(19.9%) and infant mortality rate (8.4%) when compared to the other eight 
provinces in South Africa. In comparison the Limpopo Province has the highest 
unemployment rate (36.1 %) and the Eastern Cape has the highest poverty rate 
(64%), and the highest infant mortality (61.2%) (Pelser, 2004:206-210). It is 
therefore possible that participants that practice in a different socio-economic 
context may have provided different reasons for non-compliance and 
approaches to improving compliance than those obtained in this study. 
However, the researcher, as Chairperson of the PBECP interacts frequently 
with practitioners from other provinces and based on this experience believes 
that the findings would not be significantly different. Furthermore, the ALS 
practitioners that participated in the peer review of the recommendations of the 
study reside and practice in two other provinces. They agreed that the 
recommendations were applicable nationally.  
 
1.6.1. Researcher's Perspectives  
 
In order to make explicit my perspectives at the beginning of the study, I 
present the following:  
 
As the researcher, I am myself an ALS practitioner. I also serve as the 
Chairperson of the PBECP and I am the Head of Department an Emergency 
Care Department at an academic institution.  
 
The emergency care profession is fragmented and divided as a result of 
historical differences between private and public health delivery systems, CCA 
and National Diploma qualified practitioners and practitioners from different 
provinces. These divides present an obstacle to the professional development 
of the practitioner.  
 
The independence of ALS practice is undermined by the historical vestiges of 
the paramilitary style EMS systems that employed, trained and clinically 
controlled ALS practitioners with little opportunity for independent practice.  
 
The short course training has been perpetuated by the private sector EMS 
training organisations, the motivation for which is largely financial. The tertiary 
institutions, Emergency Care Departments have had capacity limitations and 
have not been able to sufficiently address the EMS under-graduate 
requirements. In turn, even the public sector institutions who are not financially 
motivated have contributed to the perpetuation of short course training and the 
resultant delay in the attainment of professionalism in EMS.  
 
The PBECP as an organ of the HPCSA has demonstrated questionable levels 
of efficiency and effectiveness in executing its mandate to protect the public and 
guide the profession.  
 
1.7. Definition of Terms 
 
1.7.1. Advanced Life Support (ALS) Practitioner:  
A health care professional that has completed the Critical Care Assistant course 
or the National Diploma in Emergency Medical Care and whose name appears 
on the ALS Emergency Care Practitioner register of the Health Professions 
Council of South Africa .  
 
1.7.2. Emergency Care:  
The rescue, evaluation, treatment and care of an ill or injured person in an 
emergency care situation and the continuation of treatment and care during the 
transportation of such person to or between health establishment(s).  
 
1.7.3. Guideline:  
Systematically developed statements to assist practitioners make patient 
decisions about appropriate health care for specific clinical circumstances.  
 
1.7.4. Paramedic:  
This term is synonymous with the term ALS Practitioner. Within the profession, 
an ALS practitioner may also be referred to as "ALS", "CCA" or "NDip".  
 
1.7.5. Protocol:  
A protocol is a precise, detailed plan for administering a regimen or therapy.  
  
1.7.6. Independent practice:  
A practitioner registered with the HPCSA who is an independent practitioner 
and is therefore permitted by law to provide care and services, without direction 
or supervision, within the scope of the practice as approved by the HPCSA.  
 
1.7.7. Supervising medical practitioner:  
A medical practitioner, usually employed by emergency medical services, who 
may provide direct or telephonic clinical support and advice to ALS 
practitioners.  
  
1.7.8. Scope of practice:  
A list of capabilities and approved medications that are authorised for use by 
practitioners whose names appear in the corresponding register of the HPCSA.  
 
1.7.9. Non-compliance:  
A failure to adhere to a prescribed guideline and protocol.  
 
1.7.10. Rural/Urban Areas  
Within the context of this study, the West Coast, Cape Winelands, Overberg, 
Eden and Central Karoo are rural areas. Although rural areas may include 
densely populated towns such as George, there are fewer hospitals and the 
average ambulance mission time (time call received until ambulance is 
available for next call) is estimated at 110 minutes with an average travel 
distance of 49km (Provincial Government Western Cape, 2006). The 
metropolitan city of Cape Town and the adjacent towns, bordered by Strand, 
Stellenbosch, Paarl and Melkbosstrand are defined as an urban area. The 
mission time in the urban area is 60 minutes.  
 
1.8. Overview of the Dissertation  
 
Chapter 1 introduces the study and includes a background to the study, 
purpose, objectives, motivation, assumptions and definitions. The literature 
review that contextualises the study is found in Chapter 2. Chapter 3 addresses 
the study methodology with regards to design, population choice, sampling, 
data collection, data analysis and ethical issues. Chapter 4 describes the 
findings in respect to the reasons for non-compliance with the PBECP 
guidelines and protocols. Chapter 5 presents the findings in respect of the 
second objective, which deals with how compliance can be improved. Finally 
the conclusion, critical review and recommendations can be found in Chapter 6. 
References and appendices follow.  
  
Chapter 2 
 
2.0. Literature Review 
 
Any investigation into the reasons for non-compliance with clinical guidelines 
and protocols must examine the environment in which Advanced Life Support 
practice occurs. The following literature review will provide the background that 
will contextualize the current health system in South Africa, and against this 
backdrop examine the role and function of Emergency Medical Services (EMS) 
and the Professional Board for Emergency Care Practitioners (PBECP) in 
relation to Advanced Life Support (ALS) practice. The literature review will then 
focus on the development and use of guidelines and protocols. Finally, 
documented reasons for non-compliance with guidelines and protocols and 
studies on non-compliance with guidelines and protocols are presented. 
 
2.1. Background Literature 
 
2.1.1. The Health System in South Africa 
 
The World Health Organisation defines a health system, as all the people 
whose actions have as their primary purpose to promote, restore or maintain 
health (World Health Organisation, 2000:5). It encompasses the total network or 
system of services and the provision of care in a country, including all particular 
health care or health services such as Emergency Medical Services (van 
Rensburg, 2004).  
 
The health system in South Africa is embodied in the South African Constitution 
(Act 108 of 1996). Section 27 of the Constitution states that the people of South 
Africa must have access to health care services and that no one may be 
refused emergency medical treatment. Prior to the promulgation of the 
Constitution, health care services were deemed a privilege rather than a right.  
 
Government policy documents such as the Constitution, the National Health 
Plan (1994), the Reconstruction and Development Programme, Policy 
Framework document (1994), the National Health Bill (2002) and the White 
Paper on Transformation of the Public Service (1997) all give direction to the 
transformation of health services in South Africa (van Rensburg and Pelser, 
2004:110-115). The Health Act (Act No. 61, 2003) aims to establish a health 
system based on decentralised management, principles of equity, efficiency, 
sound governance, internationally recognised standards of research and a spirit 
of enquiry and advocacy which encourages participation (South Africa. Health 
Act 2003:3).  
    
Prior to the first democratic elections in 1994, the resources within the health 
system, such as the location and distribution of hospitals, catered mainly to the 
needs of the minority white population (Nicholson, 2001:24-27). Nicholson 
further explained that the apartheid health system was unequal, fragmented 
and wasteful and had as its focus the curing of disease rather than the 
prevention of disease. To correct the previous fragmented and inefficient health 
system, the Department of Health adopted the District Health System as a 
model for delivery of equitable, efficient and effective health services based on 
the principles of Primary Health Care. The District Health System supports the 
principles of community involvement, integrated holistic health care delivery, 
inter-sector collaboration and a grass roots approach to planning, policy 
development and management.  
To create an equitable health system with a Primary Health Care focus, Central 
hospitals are being downsized and resources are being relocated to support 
Primary Health Care facilities that have been established in disadvantaged 
areas (Perrott, 2003:325). Despite this the burden of third-world diseases such 
as HIV/AIDS, tuberculosis, and periodic endemics of measles and other 
childhood illnesses are still prevalent, according to Perrott. He also notes that 
the lack of immunization, poor sanitation, malnutrition, poor education, and the 
social climate of unemployment and poverty have resulted in high infant 
mortality.  
There are three levels of hospitals in South Africa. A District hospital that is 
Level 1 employs General Practitioners, Medical Officers and Primary Health 
Care nurses. The Regional hospitals receive referrals from Level 1 hospitals 
and provide specialist services that include general surgery, orthopaedics, 
general medicine, paediatrics, gynaecology, radiology and anaesthetics. A 
Level 3 or Central hospital functions as highly specialised referral unit and 
employs highly trained specialists (Department of Public Service and 
Administration, 2006). 
Trauma injuries resulting from interpersonal violence accounted for between 
1.25 million and 1.5 million cases that were reported to state hospitals in 1999. 
As a result Primary Health Care facilities are required to provide trauma and 
emergency health services and are required to have an appropriate number of 
emergency health staff to give trauma victims appropriate emergency care 
(Redelinghuys and van Rensburg, 2004:264). Accordingly, the facilities are 
expected to have emergency „boxes‟, equipment, drugs and supplies. 
Van Rensburg and Pelser (2004:162-165) note that the factors influencing the 
health system are complex. Environmental determinants such as 
demographics, geography, political, economic, religious factors all play a role. 
The South African health care landscape has a unique blend of western, 
traditional and alternative medicine with western health care provided in 
hospitals, clinics and by private medical practitioners. Traditional medicine is 
provided by traditional healers called Isangomas, or diviners and Inyangas, or 
herbalists. Complementary and alternative medicine, such as homeopathy, is 
provided by a wide range of allied health practitioners.  
 
The White Paper for the Transformation of the Health System in South Africa 
(1997) presented a set of policy principles and objectives that defined the 
structure of an integrated health system, according to Clarke (1998:367). It 
established the functions at a national, provincial and district level. The 
provision of Emergency Medical Services is a provincial competency in terms of 
the South African Constitution and the provision of emergency care has been 
identified as a health priority. Although EMS is not considered Primary Health 
Care, it is seen as integral to a comprehensive health care system. This is 
principally because adequate emergency facilities and pre-hospital care have 
not been available in many disadvantaged areas.  
 
2.1.2. Emergency Medical Services 
Emergency Medical Services (EMS) has developed rapidly since 1977 when a 
decision was taken that made the provision of ambulance services a provincial 
government competency (MacFarlane, van Loggerenberg and Kloeck, 
2004:145). Pre-hospital care has since transformed from a transport service 
that provided a basic level of care for the sick, operated by isolated 
municipalities to a fully fledged emergency service. Today EMS is a complex, 
sophisticated system that provides advanced life support care to mainly urban 
and certain rural parts of the country. The pockets of sophistication that exist 
are equal to those of any first-world EMS. Further strides in the evolution of 
EMS were made when, in 1992, regulations were passed that made it 
compulsory for all emergency care practitioners to register with the then South 
African Medical and Dental Council.   
The nine provinces in South Africa are not equal in terms of how their 
communities are served and resources are distributed (Clarke, 1998:368). 
Individual provinces fund their EMS from nationally allocated funds. EMS‟s in 
the Gauteng, Western Cape and KwaZulu-Natal provinces are generally better 
funded and well resourced. Private EMS‟s are distributed throughout South 
Africa and are primarily located in the more economically viable metropolitan 
regions. Ambulance services in the former apartheid created homelands used 
ambulances with unqualified staff and little equipment to transport patients 
between hospitals. The amalgamation of these homeland ambulance/transport 
services into the provincial EMS‟s created imbalances that still exist today.  
The Department of Health in the Eastern Cape, as an example according to 
Clarke (1998:368), has begun to redress the imbalances in recent years. Until 
1996, services in this and other provinces, were duplicated and fragmented 
because municipal governments did not want to cede the autonomy and control 
that they had over the services since before 1994. The Eastern Cape 
Department of Health combined all municipal and homeland services and 
created the Eastern Cape Emergency Medical and Rescue Service. The vision 
of the Eastern Cape EMS encompasses seven goals: improved communication 
systems; coordination of services; development of human resources; equitable 
distribution of resources; community involvement; community education in first 
aid, accident prevention, proper accessing of the ambulance service; and 
respect for all citizens.  
MacFarlane, van Loggerenberg and Kloeck, (2004:147) explain that the EMS 
system serves two functions; emergency response and inter-hospital patient 
transfers. All provinces experience problems associated with the use of 
emergency services to transport out-patients between hospitals or from clinics 
to hospitals. This demand is as a result of the reorganization of the Primary 
Health Care system. As the mandates of state hospitals change to a Primary 
Health Care focus, some hospitals are expanding while others have diminished 
their level of service based on rationalization of resources and community 
needs. These changes have been too rapid for many communities to adapt. 
The transition has placed a burden on EMS as there is an increase in the 
number of patients being transferred from one health facility to another. To 
remedy this situation, public education, improved public transport or a basic 
medical transport service is required.   
Emergency Medical Services is usually the patient‟s first point of contact with 
the health system (Provincial Government Western Cape, 2006:156). 
Emergency care can include a variety of services that vary in complexity such 
as: telephonic advice; basic, intermediate and advanced life support; rescue 
services; and aero-medical services. Agreement must be reached regarding the 
appropriate standards of care for each service. The lack of close coordination of 
EMS services impacts on the efficiency of the entire service.  
Nationally, EMS can be activated by calling a toll-free emergency number, 
10177 or from the 112 number from a cellular telephone (Clarke, 1998:368). 
The Department of Communications is currently implementing the 112 toll-free 
emergency telephone number for all emergencies.  Emergency calls to the 
emergency communications centre are triaged according to severity of the 
emergency. The dispatcher uses this information to determine the priority of the 
emergency and then allocates EMS resources depending on their availability 
and seriousness of the incident. Advanced Life Support (ALS) practitioners are 
a scarce resource and are usually only assigned to respond to emergency calls 
that are deemed to be immediately life threatening.  
Clarke (1998: 372) noted that because of the distances to clinics in rural areas, 
adequate communications are needed between ambulances, clinics, secondary 
and tertiary hospitals to ensure the efficient transport of the critically ill or 
injured. The shortage of medical practitioners in the Trauma and Emergency 
units of rural hospitals is a concern. Due to limited resources in rural areas, ALS 
practitioner skills may need to be altered, to include immunizations and the 
provision of community education on emergency care prevention. This will meet 
the needs of the communities and is in keeping with the Primary Health Care 
approach. 
 
2.1.3. Professional Board for Emergency Care Practitioners  
The Health Professions Council of South Africa (HPCSA) is a statutory body, 
established in terms of the Health Professions Act (Act No. 56 of 1974) as 
amended (Amendment Act 1 of 1998). Its mandate is to protect the public, all 
consumers of health care services, and to provide guidance on educational, 
professional and ethical issues to health practitioners (Health Professions 
Council of South Africa, 2004). The HPCSA provides guidance to twelve 
professional boards in setting health care standards for training and discipline in 
the professions registered with the Council; ensuring ongoing professional 
competence; and fostering compliance with those standards. The HPCSA is an 
autonomous organization that is funded entirely by the health care professions 
it represents.  
The Professional Board for Emergency Care Practitioners was established in 
terms of regulations published under Government Notice (Notice No. R 173 of 
10 January 1992) (Health Professions Council of South Africa, 2004). As with 
the other Professional Boards, the PBECP operates as a Standards Generating 
Body (SGB), developing policy documents to guide the emergency care 
profession, as well as overseeing education and training outcomes. The 
Professional Boards are responsible for formulating the rules and regulations of 
conduct and professional practice, as well as conducting preliminary and 
professional enquiries. Regulations that govern the scope of practice of 
practitioners and on which guidelines and protocols are based are published by 
the HPCSA. These regulations legally bind the practitioner to comply with the 
guidelines and protocols of the Professional Boards.    
 2.1.4. EMS Education and Training  
 
The regulation of emergency care training falls under the jurisdiction of the 
HPCSA and the PBECP (Health Professions Council of South Africa, 2004). In 
this regard the Professional Boards generate education and training outcomes 
and accredit education and training providers  
  
Emergency medical care training in South Africa follows two streams, these 
being the short course training undertaken at any one of 57 Colleges nationally 
or the 3-year National Diploma in Emergency Care offered at four Universities 
of Technology situated in Durban, Cape Town, Johannesburg and Bloemfontein 
(Health Professions Council of South Africa, 2006).  
The vast majority of practitioners follow the short course route of training that 
starts with a one month Basic Ambulance Assistant (BAA) course (Clarke, 
1998:369). After having completed several months of on the road experience as 
a BAA, a further four month training programme will qualify the practitioner as 
an Ambulance Emergency Assistant (AEA). Following at least six months 
experience as an AEA the practitioner may enter the nine month Critical Care 
Assistant (CCA) course that qualifies him/her as an Advanced Life Support 
practitioner. The CCA practitioner and the National Diploma qualified 
practitioner share the same scope of practice which is embodied in the 
protocols published by the PBECP.  
 
A review of the South African nursing colleges found that they have under-
qualified staff, lack management capacity and have developed a particular 
culture and ethos (Mekwa, 2000:278). She explains that the colleges are run 
like schools with crammed timetables and a strong emphasis on “practice”. 
College personnel are not expected to produce research or generate new 
knowledge. For similar reasons the PBECP‟s October 2006 newsletter 
mentions the need to improve the Colleges of Emergency Care (E.C. News, 
2006:3).  
 
In contrast to nursing and ambulance colleges, nursing and emergency 
education at the Universities of Technology is comparatively more theory-
orientated and uses predominately a learner centred problem-based learning 
approach (Mekwa, 2000:278). Problem-based learning is an appropriate 
pedagogical technique for health learners. It allows the learner to explore 
options and gain the capacity for developing strategies based on reflective 
decision making. The development of critical thinking and reflective skills, in 
learners and practitioners, can influence change and equip practitioners to cope 
with diversity in a more creative way. Clinical tutors serve as important role 
models and should encourage students doing experiential learning to analyse 
and respond flexibly to individual patient‟s problems.  
 
For the reasons given by Mekwa (2000:278) and in the E.C. News (2006:3), the 
PBECP is concerned that the present format of short course training is 
inadequate to meet the future health needs of the country and has proposed 
terminating short course training in favour of formal education. 
 
The move towards formal higher education training and the use of clinical 
protocols is not unique to EMS in South Africa. Black and Davies (2005:24) in 
their description of EMS systems in the United Kingdom (UK) speak of a 
growing trend of Universities developing a 3-year modular course. In the UK, 
clinical care is delivered by paramedics adhering to national clinical protocols. 
Ambulance practitioners are expected to undertake refresher training every 3 
years (Black and Davies, 2005:24). 
 
Education should take place every time a standard, such as the protocol, is 
changed in order to reinforce high quality patient care, update the practitioner 
regarding newer treatment modalities and equipment, and remedy perceived 
deficiencies (Schneider, et al. 1994:134). At present, recertification of 
Emergency Care Practitioners is not required in South Africa, although the 
PBECP does encourage practitioners to engage in Continuing Professional 
Development (CPD) activities (Health Professions Council of South Africa, 
2004). Such activities have been shown to be beneficial, especially in terms of 
learning the latest practice guidelines and protocols, and ensuring skills 
retention (Schneider, et al. 1994:134). CPD is recognised as necessary to 
improve clinical practice through activities like reflection, evaluation and 
consideration of the evidence base (O‟ Sullivan, 2004:174). It is envisaged that 
CPD for emergency care practitioners will become compulsory in 2007 (E.C. 
News, 2006).  
 
The Advanced Cardiac Life Support (ACLS), Paediatric Advanced Life Support 
(PALS) and the Advanced Trauma Life Support (ATLS) courses are available to 
ALS practitioners and have been shown to be beneficial especially in terms of 
the encouraging the use of the latest practice guidelines according to 
Schneider, et al. (1994:129). They also note that retention of skills is ensured by 
continuous practical training. 
 
2.1.5. Quality of Care in EMS 
 
The Institute of Medicine, in a report titled “To Err is Human: Building a Safer 
Health System”, used data from several large studies, to conclude that between 
44 000 and 98 000 deaths a year are the result of medical injury in the United 
States. This would rank medical error as the eighth leading cause of death in 
the United States (Burstin, 2002:1074). Through rational conjecture, by 
complying with an accepted standard of care, not only is quality assured but 
lives are saved and human suffering alleviated.   
 
The inference that compliance with internationally accepted standards of care is 
linked to quality of care is not disputed. The core business of EMS is to improve 
the quality of emergency medical care provided to the people in the provinces, 
decrease morbidity and mortality and revitalise EMS. Organisational issues to 
support the above, include improving resource mobilisation and management of 
resources, without neglecting the attainment of equity in resource allocation 
(Harambe Institute, 2002). Also, human resource management and 
development must be improved, as must communication and consultation 
within EMS, and between the service and the communities served.  
 
The quality of EMS care was described in the KwaZulu-Natal: Emergency 
Medical and Rescue Service (KZN-EMRS) quality improvement policy 
development report, compiled by Naidoo (2002). It investigated healthcare 
users‟ perceptions of levels of performance in KZN-EMRS and perceptions of 
quality amongst the KZN-EMRS staff. The questionnaire probed 16 different 
areas, of which, in the area of technical competence, 37 % of the respondents 
indicated that the levels of technical competence were unacceptable. Naidoo‟s 
(2002) questioning of the competence levels of the emergency care 
practitioners is in relation to their psychomotor clinical skill which is not within 
the scope of this study (Naidoo, 2002). 
 
There are several measurable dimensions of quality according to Cook and 
Sinclair (1997:890). Safety - how safe is one‟s practice from causing potential 
harm to one‟s patient? Provider competence - does one have the necessary 
knowledge, skills and attitude to provide competent care? Acceptability - does 
one‟s care meet the expectations of the patient and other health workers? 
Accessibility - how easy is it to obtain one‟s service? Efficiency - does one‟s 
service perform with minimum wastage? Appropriateness - is one doing the 
right things and providing the correct and proper care? Effectiveness - is one 
doing the right things right and does the care that one provides meet with 
expected results. Non-compliance with guidelines and protocols may 
compromise patient safety, raise concerns about practitioner competence, be 
unacceptable to patients and other health workers, be inappropriate, and 
reduce the efficiency and effectiveness of the care provided.  
The frequency and nature of complaints from patients, public and other health 
professionals may be used to measure the quality of service provided and 
identify areas of weakness in the organization. There are numerous areas 
within EMS that carry the potential to generate complaints. The three most 
common originators of complaints were: patients (53%), medical personnel 
(19%) and family member or friends (12%). Interestingly, Colwell, Pons and Pi 
(2003:405), in a retrospective study conducted in Denver, USA found that there 
were no instances of paramedic partners filing complaints against each other. 
Rude behaviour or the use of excessive force accounted for 27% of the 
complaints, reinforcing the notion that not everyone knows what constitutes 
good or bad medicine, but nearly everyone is aware of the difference between 
good and bad behaviour. Complaints by other medical personnel related to poor 
medical judgement or technical skills, emphasises quality of patient care. 
Internal complaints generated from sources such as the EMS crews and 
receiving and referring hospital staff receive less attention than do complaints 
from the public. This study is limited by its retrospective design that depended 
on finding complaints in the paramedic division achieves. Importantly the 
authors found from previous studies that the majority of dissatisfied clients do 
not register complaints and therefore their reasons for dissatisfaction are not 
reflected in the results. 
MacFarlane and Benn (2003:189) found that pre-hospital care is a difficult area 
to monitor and evaluate because of the multitude of variables. Accurate data is 
emphasised as being necessary to describe customer needs, evaluate 
performance, establish goals for improvement, and monitor progress. Sources 
of data can include; patient return form data, stakeholder data (e.g., from 
medical aid companies, road accident fund, etc.), satisfaction data are used to 
determine how well the EMS system is meeting the needs of patients and other 
stakeholders, process data are important for identifying and managing local 
needs, such as, vehicle use, age, kilometres, maintenance status and reliability; 
provider training, education data; financial data; and other administrative data. 
Process data can be used to determine the root cause of problems and to 
compare performance against quality indicators.  
 
Monitoring and evaluation of performance indicators and reviewing data such 
as the patient report form data are important to track the progress that EMS is 
making towards delivering a quality service. Importantly the patient report form 
data may reflect the non-compliance of ALS practitioners with the PBECP 
guidelines and protocols.  
 
2.2. Literature on Compliance with Guidelines and Protocols 
 
An internet search using Google Scholar and Medline did not reveal any South 
African studies on compliance with guidelines and protocols. Prospective 
randomised studies on the topic were found to be uncommon in a review of the 
international literature.  
   
One method of improving the quality of care is the use of guidelines and 
protocols. An American study concluded that their use by medical practitioners 
could reduce the high degree of morbidity and mortality associated with 
preventable iatrogenic injury (Burstin, 2002:1074).  
 
Confusion can arise as to how a guideline is defined and is to be used as is 
illustrated by Scott (1996 as cited by Schwartz, et al. 1999) in the following 
extract:  
 
“Lady Thatcher: „They are exactly what they say, guidelines, they are not the 
law‟. „They are guidelines‟. Ms Baxendale: „Do they have to be followed?‟ Lady 
Thatcher: „Of course, they have to be followed, but they are not strict law‟. „That 
is why they are guidelines and not law; of course, they have to be applied 
according to circumstances.”  
 
Schwartz et al. (1999:1153) concludes that the U.S. Institute of Medicine 
definition of a guideline is the simplest to understand and use. The definition 
states that guidelines are: “Systematically developed statements to assist 
practitioners to make patient decisions about appropriate health care for 
specific clinical circumstances”. 
A protocol is defined as a precise, detailed plan for administering a regimen or 
therapy (American Society for Testing and Materials in Clawson, Martin and 
Hauert, 1994).   
A protocol stipulates a precise dose and therefore does not allow the 
practitioner any deviation whereas a guideline allows for the practitioner to use 
clinical judgment and administer a drug until the desired effect is achieved or 
the maximum dose is reached. 
A review of cases brought before English courts concludes that the mere fact 
that a protocol or guideline exists for the care of a condition, does not of itself 
establish that compliance with it would be reasonable in the circumstances, or 
that non compliance would be negligent (Schwartz, et al. 1999:1154-1155). As 
guideline use becomes increasingly popular, so acting outside guidelines could 
expose practitioners to the possibility of being found negligent, unless they can 
prove a special justification in the circumstances. 
 
Morris (2003:236) concludes that excess information in complex intensive care 
environments exceeds human decision-making limits so increasing the variation 
in clinical care and clinical errors.  This study places importance on 
distinguishing guidelines and inadequately explicit protocols from adequately 
explicit protocols concluding that only adequately explicit protocols will lead 
different practitioners to the same decision when faced with the same clinical 
scenario.  
Moody-Williams, et al. (2002:409) do not differentiate between a guideline and 
a protocol. When writing on their use, noting that they: 
o are used to assist practitioners to make decisions regarding appropriate 
health care for specific clinical circumstances; 
o are especially useful in emergencies where the luxury of time to consult 
on best practice is rare; 
o should be evidence-based; 
o counter the tendency for medical practice to be anecdotal and parochial; 
o can decrease unnecessary variations in care and improve quality; 
o must be flexible and be used as a tool together with sound clinical 
judgment; 
o should avoid undue complexity; 
o should be well researched; 
o should be widely distributed after development; and 
o should be continually updated.  
In the South African EMS context these criteria for protocols and guidelines 
are relevant and applicable. 
2.2.1. Guideline and Protocol use in EMS 
MacFarlane, van Loggerenberg and Kloeck (2005:148), note that basic, 
intermediate and advanced emergency care practitioners in South Africa are 
required to register with the Professional Board for Emergency Care 
Practitioners (PBECP), in order to practice their profession. In addition, their 
scope of practice is governed by guidelines and protocols that are determined 
by the PBECP. The scope of practice of ALS practitioners allows them to 
practice advanced clinical skills and administer up to Schedule seven 
medications within the PBECP stipulated protocols and guidelines (MacFarlane, 
van Loggerenberg and Kloeck, 2005:148). Section 22A (9) of the Medicines and 
Related Substances Control Act (Act 101 of 1965, amended Act 90 of 1997) 
stipulates that Schedule seven and eight drugs are prohibited substances. No 
person may acquire, use, possess, manufacture or supply Schedule seven 
substances unless he or she has been issued with a permit by the Director-
General of Health (South Africa. Medicines and Related Substances Control Act 
1965:10). 
 
In 2003 the PBECP published and circulated a revised basic, intermediate and 
advanced life support scope of practice that prescribed the approved 
medications, protocols, capabilities, regulations and ethical rules (Health 
Professions Council of South Africa, 2003). They describe the authority and 
responsibility of the emergency care practitioner and they provide an 
acceptable, standardised approach to each commonly encountered emergency. 
Deviation from the PBECP guidelines and protocols may result in further injury 
and suffering to the patient and could result in a disciplinary inquiry (See 
Appendix 4:3 for extracts from the PBECP guidelines and protocols). A notice in 
the ALS practitioner 2003 guidelines and protocols, states that the practitioner 
must familiarise himself/herself with the contents of the document and that the 
inherent recommendations and guidelines replace all previous versions and 
publications issued under the authority of the Professional Board (Health 
Professions Council of South Africa,  2003).  
The PBECP 2003 guidelines and protocols are based on the 2000 International 
Liaison Committee on Resuscitation (ILCOR) Guidelines 2000 for 
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. These 
guidelines were finalised after a decade of international, scientific collaboration 
between seven international resuscitation organizations including the 
Resuscitation Council Southern African (Cummins, 2003:2).  The PEBCP 
guidelines and protocols were developed in consultation with stakeholders that 
included educational institutions, emergency societies and associations, and 
subject experts. Drafts were circulated for comment prior to their approval and 
publication (Justus, 2006).  Schwartz et al. (1999:1156) noted that the 
development of guidelines requires the correct interpretation of current scientific 
knowledge, contribution from all important groups, the use of precise definitions 
and a transparent process.  
 
The use of guidelines and protocols in emergency care are not unique to South 
Africa. In the United Kingdom, clinical care is delivered by paramedics adhering 
to national clinical protocols (Black and Davies, 2005:25). 
 
2.2.2. Studies on Non-compliance with Guidelines and Protocols 
 
In spite of the apparent value of guidelines and protocols, health care 
practitioners do not always use them. There have been several international 
studies on the non-compliance of guidelines and protocols. A survey conducted 
by the American Academy of Paediatrics demonstrated that guidelines were 
only used by 35% of 600 Paediatrician respondents (Moody-Williams, et al. 
2002:405).   
 
The literature points to numerous examples of how quality of care may be 
compromised by poor clinical practices and not following internationally 
accepted guidelines. Katz and Falk (2001 cited in Sanders 2002:1065) found 
that 25% of patients studied had endotracheal tubes improperly placed by 
Advanced Life Support practitioners. The use of secondary confirmation 
devices have been shown to reduce the incidence of improperly placed 
endotracheal tubes. Clinical guidelines could be used to good purpose to 
introduce the use of secondary confirmation devices in emergency medical 
services. 
 
Aaron, Smith and Litchy (2004:404) note that placement verification of any 
intubation is of vital importance as an unrecognised non-tracheal intubation can 
be rapidly fatal. Their study into intubation confirmation techniques associated 
with unrecognised non-tracheal intubations by pre-hospital providers found that 
in 35 of the 1643 cases evaluated, patients had misplaced endotracheal tubes 
and that the use of secondary confirmation devices was not universal. This 
study was a retrospective review of provider self reports. This proved to be a 
limitation of the study as details of the course of intubation could have been 
under-reported and not all cases were captured on the quality assurance 
database. Despite the low incidence, this result is significant because a 
misplaced endotracheal tube will almost certainly result in death.  
 
A study on how effectively hospital personnel perform cardiopulmonary 
resuscitation (CPR) found that their practice did not conform to the CPR 
guidelines (Abella, Alvarado and Myklebust, 2005:305). Although the sample 
was small and specific to in-hospital resuscitation, the study emphasises the 
need for effective CPR that has been shown to improve chances of survival to 
hospital discharge. CPR effectiveness can be significantly compromised by 
using poor technique. This aspect of resuscitation has come under close 
scientific scrutiny in the last decade. Early and effective CPR has proven to be 
a significant indicator of the success of the resuscitation attempt and 
international guidelines have been published on the best CPR technique. 
 
Hodgetts, et al. (1995:51) conducted a retrospective audit by analyzing the 
ambulance service report form and found that pre-hospital endotracheal drug 
dose was inadequate in 37.9% of cases and differed from the recommendations 
in a total of 43.2% of cases. Furthermore, Atropine was given in less than the 
recommended dose in 53.7% of cases and Adrenaline was given in twice the 
recommended dose in 20.5% of cases. No explanations are presented in this 
study as to the reasons for non-compliance with the recommended dosages.  
A review of 5944 patient report forms collected over a three-year period from 
the King/Drew Medical Centre revealed deviations from pre-hospital 
management protocols  established by the Los Angeles Paramedic Training 
Institute, and from standard medical practice. The overall compliance to the 
protocols of 94% was found. Compliance to standard medical care was 97%. 
The most common deviations were failure to administer prophylactic Lignocaine 
to cardiac patients with chest pain and failure to apply cervical spine 
stabilisation in patients with suspected head trauma (Wasserberger, et al. 1986: 
868). 
Advanced life support calls during a two-month period were examined for 
protocol deviations by the University of Rochester, School of Medicine, New 
York (Stephan, Wrenn, and Slovis, 1991:1319). Of 1,246 calls examined, 16% 
had deviations. Approximately 55% of these deviations were minor, 38% were 
serious, and 7% were very serious in  nature. The effects of the errors were 
evaluated using hospital records. Results showed that 89.5% of patients were 
unaffected, 5.0% improved, and 5.5% suffered complications from deviations. 
The report concluded that protocol deviations committed in  pre-hospital 
environment does not usually cause direct harm to patients. A review of these 
deviations, revealed misconceptions in  the use of intravenous therapy, a 
number of serious deviations in  advanced cardiac life support protocols . The 
report further recommended studies of quality  assurance to help identify 
areas of strength and weakness in an EMS system. 
According to Cline et al. (1995:5-57) despite biannual Advanced Cardiac Life 
Support training of doctors and nurses in a rural hospital in North Carolina, non-
compliance with Advanced Cardiac Life Support guidelines was noted in 35.2% 
of treatments. This study reviewed two hundred and seven cardiac arrests and 
found that synchronised cardioversion, calcium chloride and sodium 
bicarbonate were used with significantly higher non-compliance. The authors 
admit that the retrospective method used in this study may have increased the 
overall non-compliance reported due to inaccurate documents. Although this 
study was based on the 1992 resuscitation guidelines and protocols, it is likely 
that these findings could be extrapolated to non-compliance with current 
guidelines and protocols as it was found many deviations were as a result of 
last-ditch efforts in somewhat futile cardiac arrest situations.  
 
The incidence of non-compliance with a blood transfusion algorithm was found 
to be 23% in a study conducted by Boralessa et al. (2002:213). In this 
prospective observational study, the authors observed patients undergoing 
knee surgery and requiring blood transfusion. The authors concluded that a 
transfusion algorithm together with staff education is effective in reducing both 
the number of patients transfused and inappropriate transfusions. A 77% 
compliance with guidelines and protocols that have little impact on mortality and 
morbidity may be regarded as a success. In the context of emergency 
resuscitations such statistics may be viewed negatively. 
 
The most recent guideline regarding the management of patients surviving an 
acute myocardial infarction advocate the use of aspirin, beta blockers and 
angiotensin-converting enzyme and discourage the use of calcium-channel 
blockers. Axtell, Ludwig and Lope-Candales (2001:114) recorded that 
previously collected data from the National Registry in New York showed dismal 
compliance with these guidelines. To improve compliance a cardiac and 
pharmacy steering committee was formed. The pharmacist made 
recommendations to the physician if the physician had not prescribed 
adjunctive medication with no apparent contraindications. This interdisciplinary 
approach improved compliance with the percentage of patients receiving the 
adjunctive medications increasing significantly. The interdisciplinary approach 
may not be an option for the pre-hospital environment. However the doctor 
receiving from the ALS practitioner in hospital may encourage compliance by 
evaluating the pre-hospital patient management. 
   
2.2.3. Reasons for Non-compliance with Guidelines and Protocols 
 
Non-compliance can be as a result of non-competence for one can argue that a 
competent independent practitioner would not only be one that is legally 
qualified to perform acts within a specific ranges of skill, knowledge and ability 
but, would assume responsibility for ones own skills, knowledge and ability. 
Competence and compliance are related. A definition of competence refers to a 
condition of being legally qualified to operate to an adequate, safe standard 
(Clements and Mackenzie, 2005:516). The definition of compliance as it applies 
in medicine is a willingness to follow a prescribed course of treatment (The 
American Heritage, 2000). Non-compliance with the guidelines and protocols 
may be in part due to poor competence. 
 
A systematic review of the literature to identify barriers to physician guideline 
compliance was undertaken by Cabana et al. (1999:1458). This review found 
that barriers in one setting may not be present in another. Included in this 
review were seventy six articles that had investigated 293 potential barriers to 
guideline compliance. The barriers affecting compliance were classified into 
seven general categories: the barriers that affected physician knowledge (lack 
of awareness or lack of familiarity), attitudes (lack of agreement, lack of self-
efficacy, lack of outcome expectancy, or the inertia of previous practice), or 
behaviour (external factors such as patient factors, guideline factors and 
environmental factors).  
 
Reluctance to use guidelines and protocols may occur because the practitioner 
perceives that they were developed in a vacuum, are overly complex, are 
outdated, are too prescriptive or are not scientifically based (Moody-Williams, et 
al. 2002:405). A lack of research on pre-hospital emergency care has required 
EMS systems in the United States of America to write many clinical protocols 
based on little more that what is described as “guesses, anecdotes, gut 
feelings, and vendor-pushed gee-whiz technology” (Garza, 2006:24). Graff, et 
al. (2002:1093) also found that the higher the level of evidence the more likely it 
is that there will be compliance with the guideline. It is important therefore that 
guidelines should enhance the appropriateness and effectiveness of health care 
by narrowing the gap between what is known from research and what is 
actually practiced in health care setting (Moody-Williams, et al. 2002:405). The 
ILCOR guidelines addressed these concerns in the manner in which they were 
developed and are therefore internationally accepted as they have been shown 
to enable practitioners to provide care with consistent quality (Cummins, 
2003:2). 
 
One of the conclusions reached in a study conducted by Marco and Schears 
(2003:87) on pre-hospital resuscitation practices was that practitioners with 
more than ten years experience were more likely to withhold resuscitation 
attempts in the presence of verbal "do not resuscitate" orders and were more 
likely to not start resuscitation if they considered the patient's condition futile. 
This finding may indicate that the years of experience of the practitioner may 
influence compliance with guidelines and protocols. 
 
The effectiveness of monthly educational meetings to improve compliance with 
EMS patient transfer protocols in Turkey were evaluated by Armagan et al. 
(2004:857). The results of this observational study showed more appropriate 
care in some respects, such as the presence of cervical collar and proper 
airway management. However other parameters were not significantly different 
after the monthly educational meetings. The authors concluded that greater 
effort was required to increase compliance with other aspects of the transfer 
guidelines. This study highlights the importance of regular, focused continuing 
professional development of practitioners. 
 
 
 
2.3. Summary 
 
Notwithstanding the importance of investigating compliance with guidelines and 
protocols in emergency medical services in South Africa, a thorough search of 
the literature failed to reveal any such published studies. Emergency medical 
services are for many the first point of contact with the health system. 
Emergency care practice lends itself to the use of protocols and guidelines 
developed for use in this unpredictable, often complex environment. The 
reasons for non-compliance with the protocols and guidelines have not been 
adequately identified and addressed in the current world literature. By exploring 
and trying to better understand the reasons for non-compliance with the PBECP 
guidelines and protocols, this study could assist the profession in improving 
compliance. It could inform future protocol and guideline development and 
implementation with the ultimate aim of improving the quality of emergency care 
rendered to the South African public. 
 
CHAPTER 3 
 
3.0 METHODOLOGY 
 
3.1. Introduction  
In this chapter the methodology employed in this study with regards to study 
design, sampling, data collection, data analysis and interpretation, data 
trustworthiness and ethical issues will be presented.     
 
3.2. Study Design 
 
The study was conducted in the interpretive paradigm and used Strauss and 
Corbin's grounded theory method. Strauss and Corbin (1990 as cited in Brink, 
1999:121) describe grounded theory as a research method that uses a 
systematic set of procedures to develop an inductively derived grounded theory 
about a phenomenon. In line with Strauss and Corbin's approach, a literature 
review is provided to contextualise and explore the research problem (Polit,and 
Hungler, 1999). The study used exploratory and explanatory research questions 
with the purpose of understanding what is going on, what the processes are 
through which non-compliance is experienced and how it could be improved. In 
so doing, an appreciation of the full nature of non-compliance was developed. 
As explained in Chapter 1, there has not previously been an investigation into 
the reasons for non-compliance of Advanced Life Support (ALS) practitioners 
with the guidelines and protocols of the Professional Board for Emergency Care 
Practitioners (PBECP) in South Africa. In fact, there has been little international 
research on this problem amongst emergency care practitioners. Therefore, 
since this is a study on a human phenomenon about which little is known, it is 
appropriate that it should be conducted in the qualitative paradigm (Mouton, 
2001 :162).  
 
The design of the study was based on the assumptions of the naturalistic 
paradigm as described by Polit and Hungler (1999:240). The researcher 
regards the ontology or nature of reality as being revealed by the practitioner's 
subjective experiences of non-compliance and constructed in their complex 
world of lived experiences. The epistemology that is the relationship between 
the enquirer and those being researched, was based on an empathetic 
interaction between the researcher, the research assistant and the participants, 
the researcher and the research assistant both being ALS practitioners. This 
"relativistic" study collected data from a group of practitioners and was based 
on their perceptions, experiences and understanding of their practices as it 
relates to the research question. The researcher accepted that there is no one 
"truth" in the description of ALS practice. The axiology of the study was that the 
subjectivity of the results was inevitable and desirable. Methodology associated 
with the qualitative paradigm was used. The design was flexible and capable of 
being adjusted during the data collection. The focus was on understanding non-
compliance as a whole in the context of ALS practice. Interpretations were 
grounded in the experiences of the participants. Narrative data was collected. 
This data was analysed and categories were identified based on the views and 
experiences of ALS practitioners as to the reasons for non-compliance with the 
PBECP guidelines and protocols. Through inductive reasoning relationships 
between the categories were identified to build a full conceptual description of 
the phenomenon. These were tested against the literature, refined and then 
checked against the data therefore a cyclical process of inductive and deductive 
reasoning was used.  
 
The theoretical framework for grounded theory is based on sociology and 
derived from symbolic interactionism (Holloway and Wheeler, 1996:99). There 
is a focus on the processes of interaction between people and the behaviour 
and social roles that result when people interact with one another. A person in 
symbolic interactionism is active, creative and modifies social roles based on 
societal influences. Grounded theory places emphasis on the societal context 
within which people function.  
 
The unit of analysis for this study was non-compliance of the ALS practitioner 
with the PBECP guidelines and protocols.  
 
3.3. Study Setting 
 
The setting for the study was the Western Cape Province of South Africa. The 
researcher and research assistant work in this area, and it therefore made 
access to the participants easier. Chapter 2 provides an overview of the health 
system in South Africa. There are both private and public ALS practitioners in 
the province that provide advanced life support to the 4.5 million people in the 
province (Benagh, 2005:83). The provincial government receives on average 40 
000 emergency calls per month, the majority of which are for indigent patients. 
Patients with access to medical aid provide the bulk of the emergency calls to 
private ambulance services. There is no overall coordination of public and 
private services. Often both private and provincial services would attend motor 
vehicle accidents and major incidents together.  
 
Emergency care training is provided by four private colleges. In 2003, the 
provincial government entered into an agreement with the Cape Peninsula 
University of Technology that resulted in the introduction of the National 
Diploma: Emergency Medical Care. Previously the provincial college conducted 
short course training up to advanced life support. The majority of practitioners 
that have the National Diploma: Emergency Medical Care qualification would 
have qualified and have worked in either Gauteng or KwaZulu-Natal provinces. 
 
3.4. Population 
 
The study population was the ALS practitioners residing within the geographical 
boundaries of the Western Cape Province of South Africa. There are 124 such 
HPCSA registered male and female ALS practitioners practicing in the public or 
private sector of this region.   
 
3.5. Sampling Strategy 
 
3.5.1. Sampling Methods 
 
The selection process for the initial focus group discussion was purposeful in 
order to seek rich sources of information and included participants that may 
have alternate views to that of the researcher (Polit and Hungler, 1999:298). 
The experience gained from the pilot focus group discussion as well as the 
researcher and the research assistant's knowledge of the population guided the 
selection of the initial participants. These participants included practitioners that 
were known to be experienced and knowledgeable in pre-hospital care. In 
selecting the sample, the researcher sought to achieve a sample that would be 
reflective of the ALS practitioners in the rest of the country so that the findings 
could be transferable to them. The researcher was able to do this as he has an 
understanding of the practitioners as a result of his work experience in two 
other provinces and of being the Chairperson of the PBECP, which involves 
regular interaction with ALS practitioners from all over South Africa.  
 
Following the initial focus group discussion, snowball-sampling referral was 
used to identify other participants for further focus group discussions, who 
would provide rich and varied data (Polit and Hungler, 1999:297). The 
researcher specifically asked the initial participants to help identify other 
practitioners that they felt may provide insight on the research question. The 
intention was to include practitioners that were key informants and specific 
referrals as this would increase the scope and depth of the data obtained. 
Although the population size is small, the researcher and the research assistant 
do not personally or professionally know each member of the ALS population in 
the Western Cape. As Polit and Hungler (1999) note, a weakness of this 
snowball approach is that the eventual sample might be restricted to a rather 
small network of acquaintances. Moreover the quality of the referrals may be 
affected by whether the referring sample member trusted the researcher and 
truly wanted to cooperate.  
Upon the completion of the focus group discussions, two semi-structured 
individual interviews were conducted. The sampling method for selecting the 
interviewees was also purposeful. Figure 1 illustrates the sampling process. 
 
Figure 1. Sampling methods use in study. 
 
3.5.2. Criteria for Selection 
 
Selection criteria for inclusion in the study were registration as a paramedic with 
the HPCSA and current employment in either public or private sector 
emergency medical services. In addition, the researcher specified the preferred 
characteristics of the participants, these characteristics may have included one 
Criteria: 
Qualification, Experience, Private/Public sector, 
Rural/Urban  
Purposeful Selection 
 
Snowball Sampling 
 
Criteria: 
Key informants referred from participants in Focus 
Group 1  
Snowball Sampling 
 
Criteria: 
Key informants referred from participants in Focus 
Group 1& 2  
Criteria: 
Subject experts to confirm and provide insight into 
findings from focus group discussions   
Purposeful Sampling 
 
Focus Group 1 
 
Focus Group 2 
 
Focus Group 3 
 
Interviews 
or more of the following: an exposure to local, rural, national and international 
EMS experience; a range of ALS qualifications, practitioners closely associated 
with higher education programmes, those with short course qualifications who 
are not interested in further career development; and private and public sector 
experience. The sample was selected serially as the focus group discussions 
progressed. The two interviewees, for the individual interviews were selected, 
based on their knowledge, experience and positions in which they are currently 
employed, to confirm and provide insight into the findings that were emerging 
during the data collection and analysis. 
 
3.5.3. Characteristics of the Sample 
 
In keeping with the grounded theory approach, theoretical sampling was used 
(Terre Blanche and Durrheim, 1999). Therefore, decisions about what to collect 
and from whom to collect were determined by the emerging theory. Initially, 
maximum variations sampling was used to obtain the broadest range of 
information and perspective on non-compliance, hence the identification of the 
characteristics mentioned in 3.5.2. Thereafter, the two individual interviewees 
were selected to confirm or disconfirm the interpretative account.  
 
Of the total group of twenty three participants in the focus group discussions, 
there were nine practitioners from rural services, nine from private Emergency 
Medical Services, thirteen practitioners hold the Critical Care Assistant 
qualification and seventeen have more than five years post qualification 
experience.  
 
Table 1. The characteristics of the focus group discussion sample 
Sector Setting Qualification Length of Service 
 Rural Urban CCA N.Dip: EMC > 5yrs < 5yrs 
Public 6 8 11 7 9 7 
Private 2 7 2 3 6 1 
TOTAL 23 23 23 
 
Two discussions were conducted in two separate sites in the Cape Town 
metropolitan area. This is the area with the highest number of ALS practitioners 
and participants from Cape Town would provide an urban perspective on ALS 
practice. The town of George in the Southern Cape was selected as the third 
venue, as this town is in a rural area and participants were expected to provide 
a rural perspective on ALS practice.  
 
The first interview was with a senior ALS practitioner that held the position of 
national EMS manager. The interview was used to clarify the categories that 
were emerging from the focus group discussions. The second interview was 
with a senior trauma surgeon that is the head of an accident and emergency 
unit. The second interview was conducted after the data analysis and sought to 
clarify the recommendations on how compliance could be improved. 
 
3.5.4. Sample Size 
 
Brink (1999: 131-145) explains that larger sample sizes do not necessarily 
result in a better result especially in qualitative studies where the type of sample 
is purposive or theoretical. Too many participants could have clouded the 
issues and overcomplicated the complex analysis process. For these types of 
research, the sample size is adequate when the meanings are clear and the 
data are fully explored.  
 
Three focus group discussions were held in which a total of twenty three ALS 
practitioners participated. There were six participants in the first discussion and 
eight in the second discussion in Cape Town. Nine participants attended in 
George. As Burns and Grove (2001:425) explain, the ideal size of each group is 
between six and eight participants so as to encourage participation from all. Too 
many participants may limit the opportunities for 'quiet' participants to express 
their opinions. Too small a group may not stimulate discussion and obtain 
varied opinions.  
 
It was evident after the third focus group discussion that little new information 
was emerging and the researcher and the research assistant arrived at the 
conclusion that further focus group discussions were unlikely to reveal further 
new information. The findings of pilot focus group discussion were similar, and 
although these findings were not used, they did confirm what was said in the 
other focus group discussions.  
 
In this regard it was strongly felt by the researcher that theoretical data 
saturation for this unit of observation had been reached by the end of the 
assigned data collection period. This data saturation was gauged by category 
development which appeared to be dense and rich and relations between 
categories were well established (Kelly, 1999:424).  
 
In addition to the participants in the focus groups, two individual interviews were 
conducted. Therefore, the sample for the study was 25 participants. 
 
3.6. Data Collection 
 
There is a wide selection of data collection instruments available. Polit and 
Hungler (1999:312) identify self reports, observation and biophysiologic as 
three types data collection that are most frequently used in social research.  
 
Primary data, in the form of self reports was used for the study. This was 
appropriate since the purpose of the study was to understand the reasons for 
non-compliance and ways in which it could be improved based on the views of 
the ALS practitioners themselves. Two methods were used to gather these self 
reports, namely focus group discussions and individual interviews. 
 
3.6.1. Focus Group Discussions 
 
3.6.1.1. Pilot Study Focus Group Discussion 
 
A pilot study took place in KwaZulu-Natal on 2 September 2005. This 
discussion with six ALS practitioners drawn from the educational and 
operational sectors was moderated by the researcher and conducted under the 
supervision of the research supervisor. In addition to allowing the practical, 
administrative aspects to be checked, the pilot study also demonstrated that the 
proposed method of data collection and tool were likely to yield the required 
data. In fact, the results of the pilot study were very similar to those of the actual 
study. However, they were not included in the findings. The pilot study was also 
used to ensure that the researcher had the necessary skills to conduct focus 
group discussions. 
 
3.6.1.2. The Data Collection Tool 
 
Focus groups were chosen as a method of data collection because according to 
Knodel (1993:36) the interaction between participants enables them to express 
their view of the world, beliefs and attitudes using their own words. During the 
discussion participants ask questions, which provide an opportunity for them to 
re-consider or re-evaluate their own understanding of their experiences they are 
particularly useful when a researcher wants to explore the degree of consensus 
on a given topic. 
 
The discussion guide (Appendix 1) was developed and used by the moderator 
during the focus group sessions. It was pre-tested by having it checked by the 
supervisor and obtaining the approval of the Faculty Research Committee. It 
was further tested during the pilot study (see 3.6.1.1.). The discussion guide 
focused on four broad areas related to the research questions. Some of the 
questions were intended as a guide, so the order did not need to be followed 
and other questions could be asked to clarify what was being said or to probe 
further. The questions were based on the study undertaken by Moody-Williams 
et al. (2002) on the attributes of guidelines and protocols which were developed 
by a panel of experts in managed health care, quality improvement and 
emergency medical services. The panel used recommendations from the 
Institute of Medicine 2001 report in the formulation of the questions. The study 
was deemed to be relevant and applicable and therefore used to inform the 
discussion guide. Open-ended questions were used to stimulate useful trains of 
thought in the participants with the aim of establishing why non-compliance was 
occurring and how it could be improved. At no stage were participants directly 
asked about their own behaviour or situation with respect to non-compliance, as 
this would have been unethical. Participants were encouraged to draw on their 
own experience which was useful in grounding the discussion in reality and 
served as a concrete referent when asked about what is typical or common. A 
participatory approach was taken during the discussions so the participants 
where made to feel valued in terms of their perceptions and experiences and 
they believed their contribution would play an important role in improving the 
situation.  
 
In using the tool, both the researcher and the research assistant independently 
noted key points during the discussion. The key points were discussed privately 
with the research assistant after the focus group discussion and agreement was 
reached on the main points that had emerged.  
 
The focus group discussion method and the guide were effective as lively 
discussion with a free flow of ideas occurred in each of the discussions. 
Furthermore, participants were clearly stimulated by the contribution from other 
participants in the group. During the focus group discussions some participants 
initially tended to dominate the discussions. However, the moderator intervened 
to minimise their influence without being prejudicial or partial to any particular 
participant.  
 
Each of the focus group discussions were digitally recorded with the permission 
of the participants. These recordings were transcribed by the researcher and an 
electronic copy was emailed to each participant to check for correctness. Only 
two participants responded with corrections. These corrections were added to 
the transcripts. 
 
3.6.1.3. Moderator and Observer 
 
The research assistant, acting as the moderator, conducted the focus group 
discussions with ALS practitioners, whilst the researcher attended as an 
observer. The researcher's experience from the pilot focus group discussion 
was that it was difficult to observe and closely listen to what was being said 
while at the same time moderating the discussion. It is for this reason that the 
research assistant acted as the moderator after being briefed by the researcher 
on the preferred technique to employ, as described by Knodel (1993). The 
researcher did ask clarifying questions where appropriate, that added to the 
discussion. The Faculty Research Committee had approved the use of a 
research assistant to act as a moderator should the participants object to the 
researcher because of his position as Chairperson of the PBECP. In fact, this 
was not necessary.  
 
The research assistant is an educator in the Academy of Emergency Care at  
Cape Peninsula University of Technology and has passed a research 
methodology course as part of a Masters in Public Health degree. He was 
therefore regarded as being suitably skilled to act in this capacity. In addition, to 
moderating the discussion, the research assistant took brief notes as a further 
back-up to the digital recordings. There were no objections to the presence of 
the researcher, or the research assistant. 
 
3.6.1.4. Place and Time of the Focus Group Discussions  
 
The focus group discussions and interviews were held at mutually suitable 
times and venues. The discussions lasted an average of one hour and ten 
minutes. The venues were selected on the basis of suitability, availability and 
proximity of the venue to the participant's place of employment. Each venue 
had a circular boardroom configuration with the moderator seated at the head. 
This seating arrangement allowed maximal participation. The objective of the 
focus group discussion was achieved in that there was an in-depth examination 
of the issues stated in the objectives of the study. 
 
3.6.2. Individual Interviews 
 
The focus groups were complimented by semi-structured individual interviews 
which were used to explore and clarify findings that had emerged from the 
focus group discussions with individuals who have vast experience with ALS 
practice.  
 
Two individual focused interviews were conducted by the researcher. Interviews 
involve verbal communication between the researcher and the interviewee, 
during which information is shared with the researcher (Baker, 1992:207). The 
semi-structured interview is more fluid and allows the interviewer discretion to 
move in productive directions (Seaman, 1987:290). The interviewer's function in 
the semi-structured interview is to encourage participants to talk freely about 
the topics on topic guide. The interviews were selected as a method to explore 
and probe findings that emerged during the data collection and analysis. 
 
3.6.2.1. The Data Collection Tool 
 
With the above in mind, and in preparation for the interview, the researcher 
made brief notes on the findings from the focus group discussion that needed 
further exploration. These notes formed the topic guide. The topic guide 
questions were open-ended and prepared so as not to be restrictive. The 
interview was seen as an interaction between the interviewer and the 
interviewee in which the interviewer has a general plan of inquiry but not a 
specific set of questions that must be answered.  
 
All the formal interviews were digitally recorded. The recordings of the 
interviews were used to make transcriptions of the interviews. A copy of the 
transcripts was e-mailed to the interviewee to ensure transcript correctly 
reflected the responses of the interviewee. 
 
3.6.2.2. Place and Time of Interview 
 
An appointment was made with the interviewees and it was agreed that the 
researcher's office would be the best location for the interview to take place as 
it was quiet and allowed for privacy. The researcher provided the interviewee 
with the information guide and the consent form. The interviews lasted twenty 
minutes. 
 
3.7. Data Analysis and Interpretation 
 
The data was analysed using grounded theory methods of analysis, in order to 
produce a full conceptual description from the data. The researcher used the 
editing analysis style as described by Polit and Hungler (1999:574). The 
transcripts were read through several times in search of meaningful segments 
and units. The scrutiny of the data continued until the researcher was familiar 
with the content and had a good comprehension of the data. The transcripts 
were also read by the research assistant to obtain an alternate view. During this 
process, the research assistant identified a particular bias in the initial 
interpretation of the data by the researcher. The researcher had a bias in favour 
of the PBECP. After a discussion with the research assistant, and a careful 
critical review of the data, the researcher agreed with the observation of the 
research assistant which is reflected in the findings.  
 
In synthesizing the data, categories were identified. The data was organised by 
key words and phrases followed by groupings of concepts into categories and 
then identifying major categories. In putting the pieces together the researcher 
got a sense of what was common and what were obvious variations. The 
categories and core categories were discussed with the research assistant. The 
hermeneutical circle (Kelly,1999:424) became evident as the relation of 
meanings of individual experiences and the meanings of categories that 
reflected the coherent ordering was revealed (Holloway and Wheeler, 1996). 
The meaning of the parts were considered in the relation to the meaning of the 
whole, which in itself can only be understood in respect of it's constitute parts. 
Initially eight major categories were identified.  
 
The process described by Holloway and Wheeler (1996:101) was used. A 
schematic tree diagram of categories and subcategories was drafted. The 
schematic tree had topic headings linked to sub-headings. Brief summaries 
were made for the content of the discussion for each group concerning each 
topic, indicating, for example the extent of consensus regarding the topic and 
the direction of this consensus. Common subcategories were then regrouped 
and the categories revisited. There was immersion with the data that lead to 
open coding by constant comparison across the data until major categories 
emerged with their properties and dimensions. Five major categories eventually 
emerged and a core category was identified. The coding of the data was done 
using colour highlighters with a corresponding code in the margin of the 
transcript. Microsoft Word® was used to cut and paste the text  
 
Theorising of each category to seek alternative explanations was done with the 
assistance of the research assistant. The schematic tree was adjusted until the 
'best fit' for the data could be found. The recontextualizing of the data was done 
during an interview with the trauma surgeon. The surgeon as the head of the 
accident and emergency unit develops and implements guidelines for this unit. 
The core findings and recommendations of the data were discussed in relation 
to use of guidelines in hospital accident and emergency unit and the researcher 
used inductive reasoning to identify patterns, threads and associations that 
were similar with the findings of the focus group discussions (Polit and Hungler 
1999:575). A final revision of the major categories was undertaken with 
collaboration with the supervisor.  
 
The accuracy of the interpretative analysis is enhanced if the analysts are 
intimately involved with the actual data collection (i.e. involved as moderators) 
as was the case in this study. This considerably reduced the distance between 
the analyst and subject being studied (Knodel, 1993:34-50). 
 
3.8. Trustworthiness  
 
Lincoln and Guba (1985 as cited in Polit and Hungler, 1999:426) suggest that 
there are four criteria for establishing trustworthiness of qualitative data. They 
include credibility, dependability, confirmability and transferability.  
  
The data is credible when there is prolonged involvement, data triangulation 
and peer debriefing and member checks. The research supervisor checked the 
data and then the analysis and interpretation in order to protect against bias 
that may have arisen because the researcher is an ALS practitioner, the 
Chairperson of the PBECP and the Head of Department an Emergency Care 
department at an academic institution. Further checks were done by the 
research assistant who also assisted with the proof reading of the dissertation. 
By virtue of the researcher's position, prolonged involvement has taken place. 
Data triangulation occurred when the findings of the focus group discussions 
were supported by the findings in the interviews. The findings on how 
compliance could be improved and the draft recommendations that arose out of 
the study were emailed to three colleagues that are situated in Johannesburg 
and Durban and who are responsible for the current review of the PBECP 
guidelines and protocols. The transcripts were emailed to participants of the 
focus group discussions and the interviewees to ensure that the discussion was 
accurately reflected.  
 
Dependability refers to the stability of data over time and conditions. The data is 
confirmable if it is neutral and objective and there is agreement between two or 
more people about the data's relevance and meaning. The audit process 
fulfilled by research assistant and supervisor, reflective notes detailing 
decisions and conclusions during the data analysis support the dependability 
and confirmability of the data.  
 
Transferability is the extent to which the findings can be transferred to other 
settings and groups. Ten of the twenty three participants have ALS experience 
in the other provinces in South Africa. In addition, the setting in the Western 
Cape Province can be replicated in any of the other eight provinces in South 
Africa. The sample is representative of the general South African ALS 
population, and peer review was undertaken by ALS practitioners that are 
located in Gauteng and KwaZulu-Natal. 
 
According to Cormack (1991:161) reflexivity is an important concept with critical 
science as it recognises that the researcher is a part of the research process 
and there is therefore a need for the researcher to reveal their own beliefs and 
attitudes. Methodological openness was ensured when the raw data was made 
available and discussed with the research supervisor who acted as a second 
analyst. The researcher was aware of the social setting of the research and the 
potential for bias. The researcher, the research assistant and the research 
supervisor constantly strived to ensure that the researcher‟s position as Chair of 
the Professional Board did not influence the findings. There was at all times 
awareness that the wider social context of the findings would be made available 
to the Professional Board with the purpose of improving emergency care 
practice. 
 
3.9. Ethical Issues 
 
There are three basic ethical principles that provide guidance to researchers: 
respect for persons, beneficence and justice (Brink, 1999:38).  
 
The principle of respect requires that there must be respect for a person‟s right 
to self determination. Self determination means that individuals have the right to 
decide whether or not to participate in or withdraw from a study, without facing 
the risk of prejudice.  
The principle of beneficence involves “doing good” for the participant and above 
all do no harm. Researchers must ensure that the person is not harmed 
physically, emotionally, spiritually, socially, economically or legally.   
 
The principle of justice involves the person‟s rights to fair selection and 
treatment and their rights to privacy. Data must be collected with the 
participant‟s knowledge and consent. They also expect information collected 
from or about them to remain private. This can be done by making sure that the 
confidentiality of informants and the data that they provide is protected.  
 
The major ethical issue with this study related to the researcher's position as 
Chairperson of the PBECP. It was essential that prospective participants not 
feel pressured to participate and that they believe that information that was 
divulged during the study would not be used against them or their colleagues. A 
participatory approach was adopted during the focus group discussions. 
Participants understood that the purpose of the study was not to identify deviant 
practitioners. To this end, the procedures for ensuring that participant rights 
were protected in this study included obtaining informed consent (principles of 
human dignity and justice), maintaining privacy through ensuring confidentiality 
(principle of beneficence and principle of justice) and a risk/benefit assessment 
(principle of beneficence). 
 
Informed consent has three major elements: the type of information required, 
the degree of understanding required to give consent and the fact that the 
person has free choice in giving consent. To receive consent, the researcher 
provided participants with a written information sheet (Appendix 2), which 
contained a full explanation of the study and what was being requested of them. 
Participants were also informed that they were not obliged to participate and 
could withdraw at any stage. They were given an opportunity to read the 
information sheet and ask any questions before signing the consent form 
(Appendix 3) and participating in the study. None of the participants withdrew 
during the study and none of the participants declined to participate when 
approached to do so. Mechanisms to ensure privacy included the use of code 
names instead of real names and reporting group data only. Participants in 
focus group discussions also signed an undertaking to keep all information 
confidential. The digital recordings are stored in a password protected folder on 
the researcher‟s computer and will be destroyed after completion of the study to 
ensure confidentiality. 
 
A risk-benefit analysis was conducted (Brink, 1999:37-51). The benefit of the 
study was its potential contribution of knowledge for the profession, and 
practical value to society to improve compliance. Participants benefited by 
gaining a better understanding of guidelines and protocols that will ultimately 
change through improved development and implementation processes. The 
potential risks relate to breaks in confidentiality. This was avoided through 
measures to ensure privacy. The benefits were regarded as outweighing the 
risks.  
 
3.10. Conclusion 
 
There was considerable debate, amongst colleagues at the initial Masters student 
meeting, on what methodology to employ to answer the research question. The choice 
of methodology and design was successfully tested during the pilot focus group 
discussion. Participants were eager to share their experiences and readily identified with 
the research question. 
 
The methodology worked well as ALS practitioners that took part in the study all 
participated very willingly and openly admitted non-compliance even though this 
practice is not legal as it deviates from PBECP guidelines and protocols. The 
participants saw the study as an opportunity to add value to the ALS profession. 
 
Chapter 4 
 
4.0 Findings as to the Reasons for Non-compliance 
 
The following chapter presents the findings for the first question of this study: 
the reasons why ALS practitioners are non-compliant with the PBECP 
guidelines and protocols.  The data for the analysis was derived from the 
transcripts of the focus group discussions and interviews. Extracts from the 
transcripts were used to ground the discussion to the purpose of this study and 
explore the patterns that became apparent. Five major categories emerged 
from the analysis, namely the health system factors that influence non-
compliance; the role of Emergency Medical Services; the PBECP guidelines 
and protocols; ALS practitioner education and training and evolution of 
Advanced Life Support practice. Each major category and its related categories 
and subcategories will be discussed separately. Thereafter, linkages between 
the different major categories and their categories will be explained.  
 
The findings of the focus group discussions and interviews in so far as the 
views of rural versus urban practitioners, private versus public sector 
practitioners, the qualifications and experience of practitioners are similar and 
therefore are discussed collectively.  
 
4.1. The Health System Factors that Influence Non-Compliance  
 
As noted in Chapter 2, a health system includes all the components and 
activities, whose primary purpose is to promote, restore and maintain health 
(van Rensburg, 2004:2; World Health Organisation, 2000:5). This major 
category concerned a number of factors that were related to the components 
and activities of the health system as a whole. Many of them are linked to the 
fairly recent establishment of Primary Health Care clinics and the provision of 
EMS to previously underserved rural communities.  
 
4.1.1. Inadequate Clinical and Resource Support  
 
There is inadequate clinical support provided by EMS medical practitioners to 
rural ALS practitioners. A disparity exists, in the provision of equipment and 
human resources, between the urban and rural health facilities. Although there 
may be shortages of equipment and personnel in urban areas, the availability of 
clinical support by medical practitioners and the shorter distances to hospitals 
minimise the effect of inadequate clinical and resource support. ALS 
practitioners that practice in the city identified the difficulties of rural areas. 
Occasionally practitioners from urban services undertake inter-hospital transfers 
from rural clinics and hospitals and it is on these occasions that urban 
practitioners are exposed to the inadequate resources that exist in rural areas.  
 
4.1.1.1. Inadequate Support of ALS Practitioners by Medical Practitioners 
 
EMS systems in Europe, the USA and Australia are dependent on medical 
practitioners to provide either on scene assistance or verbal radio directives to 
the attending Emergency Medical Technicians (Paramedics). The international 
resuscitation guidelines, that form the basis for South African practice, were 
developed for the context of direct clinical supervision by medical practitioners. 
The 2003 PBECP protocols and guidelines, however, no longer require the 
South African ALS practitioner to obtain prior approval from a medical 
practitioner to administer scheduled medications, terminate resuscitation 
attempts and/or perform invasive procedures. The move away from direct 
medical practitioner supervision is in favour of professional autonomy of the 
ALS practitioner and has been sanctioned largely due to the scarcity of medical 
practitioners to fulfil a clinical supervision role to ALS practitioners across South 
Africa. This change to independent practice occurred in 2001 (Justus, 2006). 
Despite this change, most EMS‟s still have a medical practitioner on 24-hour 
call to provide clinical support to the ALS practitioners, yet ALS practitioners 
practicing in rural areas still felt unsupported in their practice.  “In town the 
Doctor will meet you half way…, here [rural region] if the protocol says intubate 
the patient… you must decide” (P4). (Note: P4 is a reference to Participant 4)  
 
In the following example described by Participant 13, the lack of specialist care 
in rural hospitals impacts on the pre-hospital use of the PBECP guidelines and 
protocols: “If you really go up to the Northern Cape or wherever, they don‟t 
really have specialists and when you get there it is basically a primary call and 
you need to initiate the treatment and decide what you are going to do with this 
patient for the next 3-4 hours”.  
 
The failure in the health system to provide adequate medical practitioner 
support to the practitioner creates a medico-legal and ethical dilemma for the 
ALS practitioner. The practitioner may reach the limitation of a guideline or 
protocol and would need permission from a medical practitioner to exceed the 
prescripts of the guidelines and protocols, as is required by the regulations 
governing the use of the PBECP guidelines and protocols. If there is no medical 
practitioner available to grant permission then the ALS practitioner is faced with 
a medico-legal and ethical dilemma.   
 
4.1.1.2. Personnel and Equipment Shortages 
 
Rural referring hospitals and clinics do not routinely have medical specialists 
and therefore these health facilities need to transfer the critically ill or injured to 
hospitals where specialist care can be provided. As a result of poor support 
systems in rural clinics and hospitals, patients are poorly prepared for 
transportation and it is not uncommon to find that the referring medical 
practitioner at the rural hospital is a junior, inexperienced community service 
practitioner. The ALS practitioner faced with this reality has to assume control, 
stabilise and transport the critically ill or injured to tertiary health care facilities 
that may be many kilometres away. An unstable patient will require close 
monitoring and possible drug infusions for pain or sedation for the duration of 
the road transfer that may last several hours.  
Resuscitation equipment, such as ECG/defibrillators, is not universally available 
at hospitals. Although the vast majority (97%) of hospitals do have resuscitation 
equipment, it does not mean that these essential items of equipment are 
available in sufficient quantities when required. Neonatal resuscitation trolleys 
are less available in rural hospitals (15%) as compared to urban hospitals 
(10%) (Edwards-Miller, 1998:164). The rural ALS practitioner, because of the 
scarcity of resuscitation equipment in rural hospitals, may be called upon to 
resuscitate patients in the hospital using their own equipment, prior to 
transferring the patient to a receiving facility. The limitation of the drug dosages 
and indications for use of the PBECP guidelines and protocols may not 
accommodate these special circumstances of care.  
 
Rural hospitals may not have a medical practitioner on duty 24-hours a day: 
“There is not always a doctor on duty at the rural hospitals” (P21). The medical 
practitioner will usually be on call. Poor communications from the scene of the 
incident may delay notification of the hospital of an incoming emergency 
patient. The ALS practitioner has in this instance to continue to resuscitate and 
care for the patient while waiting for the medical practitioner to arrive at the 
hospital.  
 
Human resources are a critical component of the health system and account for 
two-thirds of the national heath care budget. Problems in this area include the 
mal-distribution of personnel and insufficient and inappropriate training and 
education (Edwards-Miller, 1998:167). Organisations such as the Rural Doctors 
Association of South Africa actively recruit doctors to fill vacancies in rural 
hospitals and clinics in an effort to address these shortages. The availability of 
medical practitioners, that is the percentage of clinics visited by a medical 
practitioner to consult patients at fixed clinic facilities showed a decline in the 
Western Cape from 77% in 1997 to 66.7% in 2000 (Centre for Health Systems 
Research and Development, 2003: 49). Participants 13 and 21 suggested that 
the dosages in the PBECP guidelines and protocols are inadequate to support 
prolonged patient care that may be required due to the lack of resources within 
the health system. 
 
4.1.1.3. Limited ALS Scope of Practice and Non-Compliance 
 
The delay in clinical treatment of critically ill patients by medical practitioners 
prompted Participant 21 to present an argument for rural paramedics to be 
permitted to perform additional procedures. For example: “…we are taught … 
pericardiocentesis – we should be allowed to do it because … a lot of times that 
you get that [cardiac tamponade] on the scene”. “…a tamponade does not take 
long to kill a patient. There is some of the stuff that we are taught that I think 
should be allowed on protocol”. The practitioner in the above example has been 
taught a procedure that is not within the scope of practice as it is published in 
the PBECP guidelines and protocols (Appendix 4:93). The practitioner is faced 
with an ethical dilemma when confronted with a patient with a cardiac 
tamponade. Performing the procedure may save the patient‟s life but to do so is 
illegal as the practitioner will be non-compliant with PBECP guidelines and 
protocols.    
 
The PBECP regulates the scope of practice of emergency care practitioners. 
The Basic, Intermediate and Paramedic practitioner‟s scope determines the 
procedures that may be performed by a practitioner holding a particular 
qualification. Basic non-invasive procedures, such as the recording of a blood 
pressure are within the scope of practice of a Basic practitioner. Procedures 
that are invasive and that carry to significant risk of complications are limited to 
practitioners holding an ALS practitioner qualification. Additions to the ALS 
practitioner‟s scope of practice, such as that proposed by Participant 21, may 
be considered by the PBECP if there is scientific evidence to support its 
beneficial use in the pre-hospital environment.   
 
The ALS practitioner is taught to identify the signs and symptoms of a cardiac 
tamponade. This injury, which is most often caused by penetrating chest 
trauma, can rapidly become fatal. A pericardiocentesis (aspiration of blood from 
the pericardial sac) is advocated until such time that the patient can receive 
definitive care in an operating theatre. This skill is currently outside the scope of 
practice of a paramedic because the condition is difficult to diagnose in the pre-
hospital environment and procedure is associated with dangerous 
complications such as the laceration of the coronary blood vessels (Sanders, 
2001:695). Participant 21 was the only participant that made the suggestion to 
include this skill into the ALS scope of practice. 
 
The teaching of advanced skills to rural EMS practitioners proved unsuccessful 
in a study conducted to evaluate whether rural Basic Emergency Medical 
Technician‟s could be taught to perform out-of-hospital orotracheal intubation 
after didactic and mannequin training. The average success rate was 49%, 
(range 40% - 75%). Because the success rates were much lower than the 
historical success rates for paramedics (range 77% - 91%) the study was 
terminated early. The likely reasons for the poor success rate included 
inadequate training and inadequate skill retention with fewer than 1.5 
intubations per year (Bradley, et al. 1998:27). It is likely that similar problems 
would occur if ALS practitioners were taught to perform pericardiocentesis.     
 
4.1.2. Lack of Access to Continuing Professional Development   
 
Rural practitioners have fewer opportunities to access continuing professional 
development (CPD) programmes as is clearly stated in the following extract: 
“The 2003 protocol has new drugs and I have not been updated because I‟m in 
a rural area,  I therefore don‟t have the insight to use the drugs” (P3). Similarly 
only 75% of rural hospitals in South Africa provide CPD programmes for their 
staff (Edwards-Miller, 1998:157). ALS practitioners that are employed in rural 
areas are not supported by the health system with regards to providing CPD 
programmes or access to internet based programmes. The distances that need 
to be travelled to access CPD programmes are great and can therefore be 
costly in terms of time and money. There could be an adverse impact on 
service delivery if several ALS practitioners simultaneously left a rural area to 
undergo CPD. However, the need for service delivery must be balanced against 
the potential harmful long term consequences of the attrition of knowledge and 
skills. The concern about the lack of access to CPD activities was shared by the 
majority of participants. 
 
4.1.3. Conclusion 
The health system creates a platform upon which delivery of services takes 
place. The health department has the challenge to deliver equitable, effective 
and efficient health care to all areas of the country. The participants identified 
lack of medical and infrastructure support and poor access to continuing 
professional development in rural areas as examples of how the challenges 
facing the health system influence the ALS practitioner‟s compliance with the 
PBECP guidelines and protocols.  
 
Figure 2 below illustrates the influence of the health system as a whole on non-
compliance. Inadequate resources and clinical support at the rural hospitals and 
clinics creates a need for an expanded ALS scope of practice. There is 
insufficient clinical support provided by medical practitioners to ALS 
practitioners in rural areas. The shortage of equipment and personnel in rural 
clinics and hospitals impacts on their practice and the PBECP, ALS scope of 
practice does not accommodate the specific needs of rural ALS practice. Health 
Professionals that work and live away from the metropolitan cities have fewer 
opportunities to access continuing medical education.  
 
  
Figure 2. The health system factors that influence non-compliance 
 
Health System 
Shortage of 
doctors  
Personnel and 
equipment 
shortages  
Shortage of 
equipment  
Inadequate 
support of ALS 
practitioners by 
medical 
practitioners 
Lack of access to 
continuing 
professional 
development 
 
Inadequate 
clinical and 
resource support  
 
Limited ALS scope 
of practice  
(Note: In diagram, the major category shape is shaded, the categories have a 
double outline and sub-categories have a single outline. This also applies to all 
diagrams that follow.) 
 
4.2. The Role of Emergency Medical Services in Non-compliance 
 
As explained in Chapter 2, Emergency Medical Services (EMS) must receive 
and respond to emergency calls, provide emergency medical care and rescue 
services and transport the ill or injured to appropriate medical facilities. EMS is 
responsible for the development of policy, protocol, clinical governance and 
quality management as it applies to the provision of emergency care and 
rescue services. ALS practitioners are employed by EMS to provide advanced 
life support care to the critically ill or injured. In this regard, factors related to 
EMS influence non-compliance with the protocols and guidelines. The 
categories identified within this major category concerned communications, 
distances to hospital, medical practitioner advice and limited issue of drugs. 
These are explained hereafter. 
 
4.2.1. Poor Communications 
 
Voice communication is the essential lifeline for any modern EMS, particularly 
with respect to obtaining clinical support. “Because of the rural geography there 
are no cellular phone and radio communications and whatever actions you take 
there will determine the outcome of your patient” (P21). Radio and telephone 
communications to get advice from the medical practitioner on call may not be 
possible because of a lack of blanket two-way radio or cellular phone coverage 
in the Western Cape Province. Essentially practitioners are isolated and faced 
with caring for critically ill or injured patients who may require some sort of 
clinical intervention that is specifically not covered by the protocol. This is 
reflected in the reference by Participant 4 to being the “alpha and omega”, 
implying that in these conditions the patient‟s life is in the hands of the 
practitioner.  
 
“If there is a problem with the patient or the patient needs medication…. It 
complicates your work because a lot of times you decide what to do, that is, go 
above your protocol” (P4). Under these circumstances where communication to 
get advice is not possible, practitioners are forced to exceed PBECP guidelines 
and protocols in an attempt to continue to provide the best possible care under 
these circumstances. ALS practitioners may encounter situations in which the 
recommended maximum dosage is not efficacious because the patient has 
developed a tolerance to the drug and the half life of the drug is reduced 
(Hassan, 2006).  
 
The sentiment of the participants is endorsed in the 1998 South African Health 
Review that identified that communications essential for the management of 
emergencies is an ongoing problem, especially for rural clinics. Nationally, 62% 
of clinics have working telephones while 30% reported two-way radios not 
working (Edwards-Miller, 1998:162).  
 
Similarly, de Villiers (2006) reports that approximately 90% of the Western 
Cape Province has EMS two-way radio coverage. The private sector coverage 
is limited to the large metropolitan regions and private sector ALS practitioners 
are dependent on cellular phone communications to obtain medical direction. 
Cellular coverage is limited to the national road routes and towns. 
 
Access to a telephone is essential to ensure that rural clinics can summon the 
assistance of an ambulance to transport critically ill or injured to hospital as well 
as obtain clinical advice and facilitate the day to day administration that is so 
essential for any health facility. The ALS practitioner may arrive at a clinic 
located outside two-way radio coverage and be unable to get medical advice 
from the EMS medical practitioner because the clinic does not have access to a 
two-way radio or telephone. EMS, in executing its mandate to provide quality 
emergency care, is responsible to ensure that effective communication systems 
are in place to support the ALS practitioner. 
 
4.2.2. Long Distances to Hospitals 
 
Distances to hospitals in rural Western Cape are vast. These distances, 
coupled with poor road conditions and poor mechanical condition of 
ambulances, can compound the travelling time to an emergency call and from 
the place of the incident or clinic to hospital. The average distance from a fixed 
clinic to the nearest hospital in the Western Cape is 14 kilometres as compared 
to the national average of 29 kilometres (Centre for Health Systems Research 
and Development, 2000: 41). The distances from the patient to the clinic are 
unknown. The majority of clinics, 88% of urban clinics and 77% of rural clinics, 
do not have their own transport and rely on ambulance services to transport 
patients in an emergency (Edwards-Miller, 1998:164).  
 
The national emergency average response time is significantly greater for rural 
clinics (1.6 hours) as compared to urban clinics (0.9 hours). In the Western 
Cape, 77% of clinics had an emergency response time of less than one hour in 
1998 (Edwards-Miller, 1998:164).  
 
The greater the distance from hospital, the longer the period of time that the 
Emergency Care Practitioner (ECP) has to provide care to the patient in the 
ambulance. The following statement by Participant 4: “…here you are 500km 
away from a doctor” illustrates the additional burden placed on rural 
practitioners who have to provide sustained care to patients who may be hours 
away from a Level 2 or 3 hospital.  
 
4.2.3. Medical Practitioners Advice to ALS Practitioners May Not Conform 
with Guidelines and Protocols  
 
Medical Practitioners have been involved in EMS since its inception. Prior to the 
establishment of the Professional Board, the medical practitioner as the head of 
Emergency Services assumed medico-legal responsibility for the practice of 
ALS practitioners. Since the establishment of the Professional Board and of 
ALS practitioners subsequently becoming independent practitioners, the role of 
the medical practitioner has become that of clinical supervisor (MacFarlane, 
Van Loggerenberg, and Kloeck, 2005:145).  
 
What emerges from the participants is that the advice given by the supervising 
medical practitioner does not always conform to the PBECP guidelines and 
protocols and encourages non-compliance as is the case in this extract: 
“Lasix®… there is a max dose: how many times you call the medic and they 
[medical doctor] will say give him double that…” (P21). This suggests that the 
medical practitioner that is issuing the instruction may not be familiar with the 
PBECP guidelines and protocols or is not concerned with the side effects that 
may result, as in this example, hypotension from the Lasix®  administration 
(Health Professions Council of South Africa, 2003).   
 
The medical practitioner that gives advice to the ALS practitioner assumes 
medico-legal responsibility for the clinical instruction that is issued. However, a 
concern raised by Participant 4, is that the advice given by the supervising 
medical practitioner is outside that of the PBECP guidelines and protocols and 
is not recorded for medico-legal and quality purposes: “…what bothers me 
sometimes is the doctor may be busy with another patient and he says: yes, do 
that… and how does that cover you? None of that conversation is recorded”. 
This practice exposes a possible medico-legal risk if the conversation between 
the medical practitioner and the ALS practitioner is not recorded.  
 
Participant 18 highlights the inconsistency of how different medical practitioners 
in different parts of the country interpret the PBECP guidelines and protocols. 
“Dr X in Pietersburg will say you must comply with the protocol and a Doctor in 
Cape Town will say you will exceed your protocol as long as it‟s the best 
outcome for your patient”. This inconsistency encourages differing practice 
standards that may not only vary geographically but also vary between medical 
practitioners employed in the same EMS.  
 
In the following example, the advice of the medical practitioner although outside 
the recommendations has a positive outcome: “Even [with] Soda Bic [Sodium 
Bicarbonate] there seems to be a lot of controversy around its use.” “Recently I 
had a resuscitation and the patient was hypoxic for a while before CPR was 
started”. “One of the doctors was on scene [advised to administer Sodium 
Bicarbonate]”. “…it reversed the acidosis and was quite effective: we did get the 
patient back” (P12). In this instance, Participant 12 noted the controversy 
around the use of Sodium Bicarbonate. This experience, without careful 
reflection, could have caused future indiscriminate use of the drug even though 
the literature clearly states that there is no data that confirms that treatment with 
buffer agents improves outcome, and in fact, intravenous bicarbonate may 
produce intracellular acidosis that damages cardiac or cerebral tissue (Vincent, 
2003). 
 
There is no evidence to suggest that the clinical advice offered by supervising 
medical practitioners in EMS has worsened the outcome of the patient as is 
mentioned by Participant 19: “…the doctors haven‟t read our protocol so their 
advice might be outside of the protocol”. “But I think it is seldom to the patient‟s 
detriment”. This statement by Participant 19 was corroborated in an interview 
with Participant 25, senior medical practitioner, who stated that in the case of 
certain drugs non-compliance would not necessarily be detrimental to the 
overall outcome of the patient. The repeated disregard for the PBECP 
guidelines and protocols by EMS medical practitioners may diminish the 
credibility of the guidelines and protocols contribute to the ALS practitioner‟s 
non-compliance.  
  
4.2.4. Limited Drug Issue 
 
Participants practicing in both the public and private sector EMS said that their 
employer did not issue all the drugs listed in the PBECP guidelines and 
protocols. “… they only started to give Morphine at the beginning of the year 
and they still don‟t have Amiodarone…” (P11). The drugs that are unavailable 
commonly include Amiodarone, Flumazenil and Morphine. 
 
Limited access to drugs may encourage practitioner non-compliance as 
alternative, possibly less effective drugs are administered or drugs are used for 
inappropriate clinical conditions. “The employer is a major cause for non-
compliance because you don‟t have what your protocol stipulates for you to use 
or you have a different drug to what the hospital is going to use then they [the 
hospital] complain why did you start with the Lignocaine we want to give the 
patient Amiodarone”(P10). 
 
When asked about having had patients that needed an unavailable drug, the 
response was in the affirmative and in reply to how that made the practitioner 
feel, the response was: “Nothing, it‟s something I accepted, that it‟s not 
available” (P6). Participant 7 in response said: “But we also carry alternative 
drugs”. In part the blame and responsibility for the practitioner using „less 
effective‟ drugs is apportioned by the practitioner to the EMS organization. 
  
Access to drugs such as Amiodarone and Annexate® [Flumazenil] is limited 
both in the public and private sector and encourages theft of drugs from 
hospitals by ALS practitioners. “…we have one ampoule of Annexate ®”. “I don‟t 
know how we get it but we have it” (P15). This suggests that the drug was 
illegally or improperly obtained. Participant 11 admits to the unauthorised 
acquisition of drugs from hospitals: “I just get it from the doctors or the 
hospitals, the drugs that I needed”. Participants 6 and13 also cited Flumazenil 
as the drug to which they do not have access. 
 
The concern of Participant 16 is that this practice amounts to theft of drugs from 
hospitals: “It does bring about a negative side and I picked up on scavenging, 
unfortunately we‟ve had one or two instances…”. “You take an ampoule of 
Etomidate out of a hospital is actually stealing, it‟s a criminal offence and its 
leaves your service liable which at the end of the day leaves you liable…”.  
 
The primary reason given by Participants 6 and 13 for not having Amiodarone is 
the cost of the medication: “Amiodarone is not available due to expense” (P6). 
Another reason offered by Participant 4 is that the person responsible for 
purchases does not see the clinical need “The people in charge of the service 
and of making a decision are not paramedics so they don‟t see the need for it”.  
Strategies of expenditure control in the public services and profit growth in the 
private sector influence the culture within the EMS organization and may 
negatively impact on quality of care.  
 
Limited access to schedule seven medications, that is prohibited substances 
such as morphine, may have to do with a lack of trust by management or fear of 
management that the drug would be abused by the practitioner: “I think that 
they don‟t trust us” (P15). “Services don‟t want to buy it because of previous 
bad experience”. “They might have someone abusing the drug” (P18). Morphine 
is derived from opium and can be synthesised to form heroin (Narconon, 2006).  
 
Participant 16 understood the context of limited access to drugs across the 
health sector: “…it is a generic problem across the entire medical services in 
this country”. “You find …that ICU [Intensive Care Unit] doesn‟t run on a certain 
drug it‟s too expensive…”. A survey of the availability of d rugs in South African 
hospitals showed that of a sample of 25 drugs listed on the Essential Drug List, 
not all the drugs are universally available in the majority of hospitals (Edwards-
Miller, 1998:171). For example, only 85% of hospitals surveyed had Morphine 
Sulphate although it is relatively cheap. 
 
The employer can be held vicariously liable should a patient come to harm 
because of non-compliance. The principle of vicarious liability is an anomaly in 
South African law because it imposes strict liability on an employer for the 
derelict of its employee in circumstances in which the employer is not itself at 
fault (Deneys Reitz Case Law Update, 2003). Participant 21 felt that non-
compliance would be viewed as a serious offence by the employer and that it 
would lead to dismissal: “I‟ve seen the things that people were fired for in the 
last month and that [protocol deviation] is not even going close”. 
 
4.2.5. Conclusion 
The core business of the EMS is to improve the quality of emergency care 
delivered to the population of South Africa thereby decreasing morbidity and 
mortality (Harambe Institute, 2002). Organisational issues that support this 
purpose include improving resource mobilization and management of resources 
without neglecting the attainment of equity in resource allocation. Human 
resource management and development must be improved, as must include 
communication and consultation within EMS and between the service and the 
communities served.  
 
EMS is the environment where ALS practice occurs and therefore has a direct 
influence on ALS practice. This major category concerns the role that EMS 
plays in ALS non-compliance with the guidelines and protocols. Figure 2 depicts 
its categories and subcategories.  
 
 
 
 
Figure 3. The role of EMS that leads to non-compliance 
 
In conclusion, there is a strong suggestion that emergency medical services do 
not support practitioners practicing in rural areas. The delivery of high quality 
emergency care in the rural setting requires an infrastructure quite different 
from urban or suburban environments given the limited resources in that 
setting. Practitioners may face environmental obstacles in the form of distance 
and terrain, as well as a lack of resources that makes communication and 
primary access to the patient difficult. Application of the latest evidence-based 
emergency medical practice may not be possible because of a lack of 
resources and infrastructure. Limited access to drugs based on perceptions 
about potential drug abuse by practitioners, advice of medical practitioners that 
is inconsistent with the PBECP guidelines and protocols and inadequate clinical 
quality control, all contribute to non-compliance. 
 
Limited issue of 
drugs 
EMS 
Distance to 
hospitals 
Poor radio 
communications 
 Inconsistent 
medical advice  
Morphine, 
Amiodarone, 
Flumazenil 
Adenosine 
Advice outside 
PBECP protocol 
Medico-legal 
responsibility 
4.3. PBECP Guidelines and Protocols 
 
The PBECP regulates the scope of practice and publishes protocols and 
guidelines to which ALS practitioners are required to adhere. The protocols and 
guidelines list the capabilities, the protocols and ethical rules that govern ALS 
practice. Not surprisingly, issues associated with the PBECP guidelines and 
protocols emerged as a strong category in relation to the reasons for non-
compliance. Specific drug protocols were identified as being problematic. 
 
 4.3.1. Confusion about the Understanding and Use of Guidelines and    
Protocols 
An important finding concerned the use and understanding of the terms 
'guideline' and 'protocol'. This confusion exists in the PBECP documents, and 
the terms appear to be used interchangeably. In addition, and probably as a 
consequence, participants were unclear on the difference between a guideline 
and a protocol and if and when they could deviate from the guidelines and 
protocols.  
 
The Minister of Health has, in terms of section 50(2) of the Medical, Dental and 
Supplementary Health Services Professions Act, 1974 (Act No. 56 of 1974) as 
amended (Amendment Act, No. 1 of 1998), approved the rules that state that a 
performance by a paramedic of any professional act other than those set out in 
protocols approved by the professional board and the council, except at the 
written direction or responsibility of a registered medical practitioner, is 
otherwise illegal. However, the introductory notes in the PBECP guidelines and 
protocols state that the document serves as a guideline and does not replace 
sound clinical judgment (Health Professions Council of South Africa, 2003).  
 
The PBECP guidelines and protocols are not clear as to what a protocol is and 
what a guideline is. The words „protocols‟, „standards‟ „recommendations‟ and 
„guidelines‟ are used in the notice on pages two and three of the booklet without 
explanation (Appendix 4:3). The front cover says: “Protocols” and on page 3 the 
statement reads: “These documents are intended to serve as guidelines…” 
(Health Professions Council of South Africa, 2003). In the general discussions it 
was apparent that practitioners were unclear as to if, how and when deviation, 
from the prescripts contained in the PBECP guidelines and protocols, was 
permitted. Participant 21 reflects that a lot of ALS practitioners do not see the 
document as a guideline: “Let the protocol be a guideline - lot of practitioners 
don‟t see it as a guideline, they see it as this is the law; the Bible says you will 
give 40[mg] and no more”. In the view of Participant 21 the dosages stipulated 
in the guidelines and protocols are just a guide to be followed at the discretion 
of the practitioner. 
 
Regulation 1379 (Appendix 4:115), pertaining to the ALS practitioner, does 
clarify when a practitioner may deviate. It states that the performance of 
professional acts by a paramedic practitioner other than those set out in the 
protocols approved by the professional board and council is not permitted, 
unless at the written direction and under the responsibility of a registered 
medical practitioner or in the case of oral conditions, a registered dentist (Health 
Professions Council of South Africa, 2003). Therefore, the PBECP guidelines 
and protocols, in so far as the regulations are concerned, are protocols as they 
prescribe the maximum dose, indications, contraindications and precautions for 
the drugs within the scope of practice of the ALS practitioner. An algorithm for 
common emergencies, that essentially contains a detailed plan on how the 
medications should be administered, is also provided. The independent 
practitioner can independently decide to implement the protocol and can only 
deviate from the protocol under the direct instruction of a medical practitioner 
(Health Professions Council of South Africa, 2003).   
 
Participant 13 understood that a court of law would measure practice against 
what is stipulated in the PBECP guidelines and protocols but was unclear as to 
how much deviation would be acceptable: “…if something goes wrong, you‟ve 
treated your patient and …that ends up in court”. “You have now under your 
independent practice, protocol is a guideline, whole story, deviated a bit from 
the protocol and now the attorney is pulling you to pieces, now how does that 
stand in court?” “Do they go strictly according to these are the protocols, these 
are the guidelines you have to do it according to that…?” “…I‟ve spoken to a lot 
of people…. [they are] scared to deviate out of their protocol…”. This again 
points to a lack of clarity about how to interpret the guidelines and protocols.  
 
The Regulations (Regulation 1379 of 1994) published in the PBECP guidelines 
and protocols provides the legal basis for the use of the PBECP guidelines and 
protocols yet Participant 18 was unclear as to what the legal ramifications would 
be if the protocols were breeched and suggests his professional actions may be 
covered by the Good Samaritan legislation (Health Professions Council of 
South Africa, 2003). “…what will the HPCSA use to counsel you”? [In Sout h 
Africa the] “…Good Samaritan law still applies”. “… in the USA paramedics 
apply it [guidelines and protocol] to the tee otherwise they run the risk of been 
sued”. Good Samaritan legislation affords protection to the public that come to 
the assistance of a fellow citizen in need and does not afford protection to a 
professional person whose duty it is to render emergency care. ALS 
practitioners are specifically excluded from this protection by the HPCSA, 
Ethical Rule 28 which makes provision for any other health professionals to 
perform any act in an emergency situation (Health Professions Council of South 
Africa, 2003). 
 
4.3.2. Legitimacy of PBECP Guidelines and Protocols 
 
The practitioners acknowledge the legitimacy of the Health Professions Council 
of South Africa and the PBECP as a statutory body with a legal mandate to 
regulate ALS practice. Twelve Professional Boards, including the Medical and 
Dental Professions Board and the Professional Board for Emergency Care 
Practitioners operate under the jurisdiction of the HPCSA (Health Professions 
Council of South Africa, 2004).   
 
The statement by Participant18 is an example of how the legitimacy of the 
PBECP guidelines and protocol is used by practitioners to support their 
practice: “… because the protocols he lp to give credibility to my actions…, for 
example by insisting on the patient being intubated prior to transportation”. “It‟s 
a written document from the HPCSA and therefore supports the paramedic‟s 
actions and/or requests”. Annexure 15 of the Ethical Rules (Health Professions 
Council of South Africa, 2003) states that the ALS practitioner must follow the 
protocols approved by the PBECP and HPCSA, except under the written 
direction and responsibility of a medical practitioner. PBECP guidelines and 
protocols provide algorithms for commonly encountered emergencies. The 
step-by-step sequence of the algorithms lists airway management as the third 
step in the sequence, following scene safety and patient responsiveness. In the 
example above, tracheal intubation is necessary to secure the patient‟s airway. 
It is within the ALS practitioner‟s rights, as stated in the ethical rules, to request 
a written instruction from the medical practitioner if his proposed management 
conflicts with that of the medical practitioner. The medical practitioner in issuing 
a written instruction then assumes medico-legal responsibility for the patient.  
 
The PBECP guidelines and protocols are used to defend their clinical decisions 
when questions are raised by other health care professionals, as is stated: “We 
did show - look it is in our protocol - and that also helps in a way but after a long 
argument” (P15). What also emerges is the obvious tension that exists in the 
environment in which the practitioner practices. The practitioner has to defend 
the clinical decisions and choice of patient management when handing over the 
patient to medical practitioners and nurses at hospital. The HPCSA will 
arbitrate, should the need arise, in disputes between Professional Boards that 
fall under its jurisdiction (Health Professions Council of South Africa, 2004). To 
avoid confrontation with other health professionals the practitioner may be 
inclined to ignore the PBECP guidelines and protocols in favour of local 
guidelines.   
 
 
4.3.3. Use of Guidelines and Protocols  
 
Carefully written and properly used, the PBECP guidelines and protocols may 
limit and control the risk of liability. They provide an expectation that is known in 
advance of any patient encounter and therefore are used to keep the patient 
and the practitioner safe.  
 
The following statement reiterates the benefit of having PBECP guidelines and 
protocols: “I think the protocol is an excellent tool to keep the practitioners safe”. 
“The dosages and drugs, some say we don‟t have enough drugs others say we 
have too much, but it keeps us safe”. “It‟s a recommendation and guideline” 
(P7). This statement is supported by Participant 10, who, in response to the 
dosages states: “…that‟s like a cockroach dose”. “… Made to protect us from 
being sued… [and] lends a bit of safety as well”. The reference to „cockroach 
dose‟ implies that the dosage was only enough to work on a cockroach. It 
shows insufficient knowledge of the therapeutic index of the drugs in use, where 
the therapeutic index measures the therapeutic value of the drug by measuring 
the useful dose to the toxic dose. (Penn, 1980:36.)  
 
This view is contested by Participant 2: “In my view they are too simple to add 
value”. “It‟s safe but very limiting”. Participant 2 has the view that there is 
insufficient information provided to keep the practitioner safe. Clinical situations 
are by their very nature complex. To deal with all the levels of complexity in a 
guideline and protocol would be impractical, but on the other hand to 
oversimplify it would not represent the reality and therefore prove it to be 
irrelevant (Cantrill, 1992: 507). 
 
The protocol is seen to benefit the practitioner, for if a practitioner meticulously 
follows the guidelines and protocols the patients would be safe from harm and 
the paramedic would therefore be protected from litigation. Although the 
dosages are safe to use, that is the possibility of severe side effects are 
minimised, the experience of the practitioners is that the dosages are not 
effective. Non-compliance occurs when practitioners administer higher „unsafe‟ 
dosages to obtain the desired effect; for example Midazolam for sedation. 
 
4.3.4. Problems Related to the Process of Protocol Development and 
Implementation 
 
Guideline and protocol development requires that the information contained 
therein is correctly interpreted and translated (validity); that another group of 
developers given the same information would produce a similar result 
(reproducibility); that there has been consultation across the profession 
(representativeness) and that the process used must be transparent (Schwartz, 
et al. 1999:1155-1156). Subcategories in this category indicate problems 
related to these criteria. The development of the PBECP guidelines and 
protocols using these criteria may result in greater acceptance of the standard 
and an added benefit should include a greater degree of compliance.  
 
4.3.4.1. Lack of Consultation  
 
Participant 3 acknowledges the benefits of consultation in this extract: “…there 
needs to be some sort of projected changes so that when new guidelines are 
released it doesn‟t come as a surprise”. “Then everyone knows that this book is 
going to change given sufficient evidence and research”. The value of 
ownership and buy-in to the process and outcomes cannot be underestimated 
according to Schwartz, et al. (1999:1157). They explain that to be effective the 
consultation must be both narrow and wide. Narrow consultation will include a 
group that is respected within the ALS practitioner community for their 
expertise. Wide consultation will include not only the practitioners but also 
subject specialists and organisations that play a role in the provision of 
emergency care. The use of electronic media such as the internet, as a tool to 
undertake wide consultation, is advocated by Participant 1: “…when there is a 
protocol change…the profession should have changes discussed in…an 
interactive website where all practitioners can have input and not only pre-
hospital care practitioners but [also] the doctors”. The major limitations to 
consultation would include the cost of the exercise and the time it would take to 
consult extensively. 
 
4.3.4.2. No Updates of ALS Practitioners  
 
For the guidelines and protocols to impact on clinical practice the PBECP would 
need to disseminate information on the changes. “If they [PBECP] are changing 
the protocol, set up meetings or send out brochures to the base, if you don‟t 
have time to come this is what is going to change” (P12). 
 
4.3.4.3. Lack of Face Credibility  
 
The credibility of the PBECP guidelines and protocols is called into question by 
Participant 22 when an attempt was made to reference a statement: “We 
challenged one of the statements and could not find the answer and that 
became a problem”. “Credibility is important”. 
 
The importance of referencing within the document is emphasised by 
Participant 22: “…we do need a line saying were the information comes from, a 
reference or website with additional information that adds value to the credibility 
of the document and so it really just empowers us to say if you want to 
challenge my protocol, this is were I got it from”. Participant 1 supports the need 
for the PBECP guidelines and protocols to be referenced: “…the development 
of the protocol itself, I‟m not sure that we are actually empowering the 
practitioner with enough information… coupled with a change in the protocol 
they should [provide] adequate [reference] reading where the practitioner… 
[can] substantiate why we are using this infusion”. “This doesn‟t come through 
with the protocol changes”. 
 
The suggestion of referencing the PBECP guidelines and protocols is useful as 
it grounds the document in a scientific context and provides opportunities 
further reading and insight on the recommendations contained in the PBECP 
guidelines and protocols (Schwartz, et al.1999:1156). 
 
4.3.4.4. No Scheduled Review Date  
 
To cope with the ever changing landscape, Participants 6 and 15 identify the 
need for an annual review of the PBECP guidelines and protocols: “Protocols 
need to be revised every year” (P6). “…the people that write the protocol don‟t 
update the changes… I‟m stuck with the protocol that Amiodarone is 
contraindicated in children”. “In some literature it‟s not”. “They haven‟t changed 
anything” (P15). 
 
This view is shared by Participant 15: “They [the Professional Board] haven‟t 
changed anything [in the protocol]. When I was taught at the college I was 
taught differently”. 
 
4.3.5. Conflict with Other Guidelines  
 
Participants' experiences showed that the PBECP guidelines and protocols 
conflict with what is practiced in hospitals, with clinical advice that is provided by 
medical practitioners in hospitals, and with the content of nationally and 
internationally recognised literature. Participants would witness drugs being 
administered in hospitals without consideration for the maximum dosages 
prescribed in the PBECP guidelines and protocols.  
 
The PBECP guidelines and protocols are not supported by what is contained in 
the drug package insert (Sanofi-Synthelabo, 2004). In this instance the 
concurrent use of two anti-anti arrhythmia agents is not supported in the 
PBECP guidelines and protocols but no mention of this exclusion is contained 
in the drug package insert (Health Professions Council of South Africa, 2003). 
“The protocol says you can‟t give Amiodarone because it is another anti-
arrhythmia drug …the protocol says to you that you must continue with 
Lignocaine despite what the evidence says to the contrary”. “The protocol is not 
supported by even the manufacturer‟s notes” (P19). 
 
In instances where there are varying opinions, as is the case with fluid 
replacement, the PBECP guidelines and protocols do not provide sufficient 
evidence to support their recommendations: “I just think the protocols should 
look more in-depth at fluid challenges because everywhere you go there are 
different thinking and regimes around permissive hypotension” (P8). 
 
The PBECP guidelines and protocols appear as a rigid inflexible document for 
some of the drugs and this inflexibility impacts on the clinical decision making of 
the practitioner. An example is the contraindications of Aspirin, provided by 
Participant 19 (Health Professions Council of South Africa, 2003).  “Aspirin [is] 
contraindicated for asthma…[but] has proven benefit if the patient is having an 
MI [myocardial infarction] and it‟s not uncommon for a patient to have asthma in 
his medical history, so … we might withhold the aspirin when that is not really a 
problem”. “The protocol doesn‟t make any allowance for that”.  
 
4.3.5.1 Conflict with Hospital Practice 
 
There is a difference in the hospital recommended drug regimes and dosages 
and those in the PBECP guidelines and protocols: “…a colleague came under 
fire for giving Dormicum®.” “She wanted to know how you can give this dosage 
of Dormicum®” (P15).  
 
In the following extract Participant 13 faced humiliation by hospital staff for 
following the recommended PBECP guidelines and protocols for adrenaline 
infusion: “…you put  up an adrenaline infusion post cardiac arrest and you get to 
hospital the doctors are laughing at us, with your 1mg in your 200ml saline, they 
really are laughing at us”. 
 
Guidelines practiced by individual specialist medical practitioners within a 
hospital setting may differ not only with the PBECP guidelines and protocols but 
with other guidelines such as those contained in the SAMF: “[I] went to Dr R 
and told him that we give 6mg, 6mg and 12mg of adenosine.” [He said” …they 
will use much less and 6mg in his opinion 6 mg is a hell of a lot”. “So in that 
instance you are overdosing in his opinion as a cardiologist, yet the SAMF also 
recommends 6mg,6mg,12mg, so that doesn‟t leave us anywhere” (P19). 
 
Participant 13 expressed concern that other health care providers did not know 
what the scope of practice of the ALS practitioner was and particularly what was 
contained in the PBECP guidelines and protocols: “…the people in the hospital 
and the casualty have got no idea what we can and can‟t do…”.“…the 
anaesthetist was absolutely gob smacked that we could intubate and use 
Dormicum®”. “Every time I‟ve done an ACLS [Advanced Cardiac Life Support] 
or PALS [Paediatric Advanced Life Support] course with doctors and nurses 
they were flabbergasted that, that was our protocol, they couldn‟t believe it”. 
“After that they would see me and treat me with so much more respect”.  
 
It is accepted that to effectively manage emergencies requires a coordinated 
approach within the hospital. Clinical guidelines for good resuscitation practice 
are needed, to ensure that the equipment is functioning, drugs are available 
and that hospital staff are trained to maintain and upgrade their knowledge and 
skills in resuscitation. A significant proportion of hospitals, 25% rural and 14% of 
urban hospitals did not have a protocol on resuscitation (Edwards-Miller, 
1998:45). 
 
4.3.6. Preference for Other Guidelines 
 
Information that the practitioner reads in other literature such as the South 
African Medicines Formulary may differ from the information in the PBECP 
guidelines and protocols: “It is confusing reading. A lot of the information given 
is contraindicated in other books” (P7).   
The integrity of the PBECP guidelines and protocols are questionable in the 
view of Participant 22: “…the influences that we have in emergency medicine 
are the AHA [American Heart Association], the SARC [South African 
Resuscitation Council], the SAMF [South African Medicines Formulary] and 
then we get our protocol book. You are then bound by these guidelines as a 
safety measure but the integrity is so challenged it forces people to go beyond”. 
The examples cited by the other participants do support this statement but not 
to the extent described by Participant 22. 
 
4.3.6.1. Preference for South African Medicines Formulary 
 
The foreword of the South African Medicines Formulary (SAMF) states its 
purpose as being to bring clear and accurate guidelines for safe, rational and 
cost-effective use of drugs commonly used by health professionals in South 
Africa. The SAMF has become a benchmark of good practice and is cited in 
courts of law and by those responsible for drug policy (Gibbon, 2003). 
 
The use of the SAMF is repeatedly advocated by the participants in the focus 
group discussions. Participant 15 was of the opinion that the universal use of 
the SAMF would reduce conflict amongst health professionals. “…there are 
sometimes slight differences with the protocol and the SAMF”. “The SAMF is 
used universally across … health [depart ments] and it‟s [use] will help us 
because it will reduce the arguments and fighting”. This would support the need 
for a nationally standardised practice guideline document.  
Participants 15 and 7 would trust the information in the SAMF above that of the 
PBECP guidelines and protocols. When asked which drug information they rely 
on, the response was: “I use the SAMF and this would supersede the protocol” 
(P15). “The extended reading of it is in the SAMF which offers more 
information. I would trust more what the SAMF says than what the protocol 
says” (P7). 
 
When asked, Participant 18 agreed that the SAMF should replace the PBECP 
guideline and protocol and reiterates that the protocol is a guideline implying 
that the SAMF information is more precise and accurate. “Yes, the [PBECP] 
protocol is a guideline”.  
 
The SAMF is regarded as being more comprehensive by Participant 2, 22 and 
11 “…read SAMF it‟s got all the information” (P2). “It [protocols] contrasts all the 
other documents such as the SAMF that is used in hospitals now days and we 
pre-hospital practitioners are bound by this [protocol]”. “The SAMF covers the 
range of medications” (P22).  
 
The additional information provided in the SAMF could influence clinical 
practice by helping the practitioner to identify and eliminate contradictions to the 
drug use: “…the protocols have contraindications, indications and absolute 
contraindications, … [the] SAMF and …BMF [British Medicine Formulary] they 
say you can give it …the contraindications you can [rule out] …but  they don‟t 
make provision in the protocol book for those things” (P11). 
 
4.3.6.2. Preference for the American Heart Association Guidelines 
 
The American Heart Association (AHA) is closely associated with the 
development of CPR and cardiac emergency care guidelines that are used by 
millions of health care providers around the world. The AHA Scientific Sessions 
2005 that informs guideline development was attended 17662 delegates from 
more than 57 countries (American Heart Association, 2006). These guidelines 
are based on a systematic, evidence-based review of resuscitation science. 
The PBECP guidelines and protocols are founded on the latest AHA 
recommendations yet do not carry the same recognition in the view of 
Participant 2: “The document will have more credibility if it makes reference to 
the latest AHA recommendations”. Note that because the derivation is not 
acknowledged, their credibility is called into question. 
 
The AHA management of specific conditions such as anaphylaxis differs from 
the PBECP guidelines and protocols: “The [AHA] resuscitation guidelines talk 
specifically about anaphylaxis to the escalating dosages in prolonged 
resuscitation, the protocols talk about the normal standard doses” (P3). 
 
The AHA recommendations provide comprehensive information that supports 
the algorithms as is confirmed in response to a question on whether the AHA 
Resuscitation Guidelines offer more guidance than the PBECP guidelines and 
protocols, the response was: “By far” (P17). 
 
Participant 2 also accepts that the AHA guidelines may differ from those 
recommended by the European Resuscitation Council, which may again differ 
from the recommendations of the South African Resuscitation Council: “The 
AHA guidelines were the CPR guidelines have changed… the AHA says [a ratio 
of] 2:30 [for CPR] now which one is right …the BMJ [British Medical Journal 
published European] guidelines says [a ratio of] 2:50…”.  
 
4.3.6. Errors in the PBECP Guidelines and Protocols Reduce their 
Credibility 
 
Participant 3 mentioned that there were errors in the PBECP guidelines and 
protocols. The errors impacted on the credibility of the document: “…so many 
faults that leads them to doubt the document”. “If the document [protocols] is 
foolproof it will result in more compliance”. However, the general consensus 
was that there were few errors and that these did not significantly influence non-
compliance. As an example, Participant 7 mentioned that the milligram per 
kilogram dose and the maximum dose of Atropine would only work for a patient 
weighing a maximum of 60 kilograms. When questioned which dose would be 
used Participant 7 responded: “I go for the dose per kg and sometimes go for 
the maximum depending on the circumstances”. 
 
 
4.3.7. Inappropriate Drug Use or Dosage in Guidelines and Protocols  
 
In response to the question as to which drugs were problematic, participants 
identified Midazolam, Morphine and Adrenaline as the most controversial. Other 
drugs mentioned include Aspirin, Furosemide, Sodium Bicarbonate and 
Diazepam.  
  
 The drug dosages stipulated in the PBECP guidelines and protocols are 
consistently raised as an area of concern by the participants. The dosages are 
regarded as too small to be efficacious or inadequate to cater for the clinical 
picture of the patient in the emergency setting. The dosages do not 
accommodate the length of time it takes for the patient to reach hospital. The 
practitioner can administer the maximum recommended dosage and then find 
the effects of the drug wearing off and would be forced to administer an 
additional dosage effectively exceeding the maximum recommended dose. 
  
Participants 6 and 7 identified a conflict with the stipulated maximum dose: 
“…the protocol dosages, it will say the maximum dose and the recomme nded 
dose per kilogram are in conflict” (P7). “…say this is you max dose, then I can 
go now but when it is per kilogram what do I do now?” (P6).             
 
A less frequently mentioned problem is that the drug may not be the most 
appropriate one for the situation and patient.  
 
Subcategories of the specific drug protocols which were problematic were 
identified, and are described hereafter. 
 
4.3.7.1. Midazolam and Diazepam Used in Sedation 
 
The following comment supports the predicament created by the PBECP 
guidelines and protocols: “…the sedatives in the rural areas, the transfers and 
the limited dosages are not adequate so you have to step outside your protocol 
to get your patient to the other side”. “I think the new protocols need to look at 
the max dosages and the transfer distances or get stronger sedatives” (P8). 
 
This limitation in the protocol was identified by several participants, including 
P13, P18, P12, P15, P3, P8 and P9 who essentially relayed the same message 
that the limitations on the drug dosages did not accommodate the sustained 
care of the patient (Appendix 4:54).  
 
The following extract illustrates the appropriate use of a drug but also how 
uncomfortable the practitioner is when being forced to exceed the maximum 
recommended dose: “The dose issue, if you are 160km to hospital, if you have 
convulsions you stopped it with 10mg of Valium® but after 20 minutes you again 
have convulsions again and repeat the dose”. “You‟ve now administered the 
maximum dose, but the patient has again a fit, you too have exceeded the 
protocol” (P15), (Appendix 4:33). When asked about their feelings when 
exceeding the dose, the response was: “What now must a do, but as I add 
another 5mg then the patient stops fitting”. 
 
It may also be that the drug is being used incorrectly. Midazolam is used to 
sedate patients for intubation at a recommended dose of 0.1 to 0.3mg/kg. 
However, in one study it was only used as the sole induction agent in 16% of 
cases (Sagarin, et al. 2003: 329). In effect, Midazolam as it is used in the pre-
hospital setting in South Africa may not be the drug of choice and may need to 
be used in conjunction with other sedative agents to provide prolonged sedation 
required for long distance transfers. 
 
The maximum dosage for Midazolam in the guideline and protocol is 0.3mg/kg. 
This would translate to 24mg of Midazolam for an 80kg patient. Participant 12 
recorded exceeding the recommended maximum dose: “Dormicum® [dose of] 
15mg to sedate a patient for intubation just doesn‟t work, you have to give much 
more than that”. When questioned how much more, the response was: “You got 
to give up to 30mg because most of the patients that we do actually sedate are 
alcoholics or being exposed to drugs and sometimes you can give up to 45 mg 
and it doesn‟t work…”. Large dosages of Midazolam are being administered by 
paramedics to obtain the desired level of sedation for oral intubation. The 
habitual use of alcohol and/or other narcotic drugs will influence the half-life of 
drugs administered to patients (Hassan, 2006). The guidelines and protocols do 
address the concern raised by Participant 12 by stating that doses must be 
calculated according to each patient‟s individual requirements and that drug 
doses must be titrated against effect (Health Professions Council of South 
Africa, 2003). In instances where the maximum dose is reached without the 
desired effect, the practitioner is required to obtain permission from a medical 
practitioner before administrating a higher dose. 
 
In an interview, the medical practitioner responsible for a hospital emergency 
unit acknowledged that patients arriving at the unit had on occasion received 
higher dosages on Midazolam. The net effect of this higher dose was a longer 
period of stay on a ventilator. The medical practitioner recommended that the 
Board consider alternative sedative drugs for pre-hospital use. 
 
4.3.7.2. Morphine Protocol 
 
The time spent on the scene of an emergency should ideally be kept to a 
minimum to ensure that the patient reaches definitive care in hospital 
expeditiously. The „Golden Hour‟ concept is commonly understood as starting at 
the time the incident occurred to when the patient reaches definitive in-hospital 
care (Mattox, 1997). Paramedics continue to use this concept as a reference 
even though population-based studies from several centres have demonstrated 
that it is not a fact but a concept. As time becomes a critical factor, the 
practitioner may not allow sufficient time to elapse for the maximal effect of the 
drug to take effect before administering a higher dose.  
 
The peak onset of action of morphine may be too long for it‟s effective use in 
the pre-hospital environment: “…the resuscitation guidelines says that morphine 
takes 15-20 minutes to reach peak onset, we want to give it before we splint a 
fracture femur or to extricate” (P19). This concern is shared by P13: “…it 
doesn‟t help the situation if the patient is entrapped and it‟s taking 15 minutes 
for the drug to work”. (Appendix 4:57) 
 
The delayed effect of the drug may result in a number of problems: initial 
overdosing in an attempt to achieve the dose against effect result; omitting to 
administer any analgesia; carrying out the procedure aware that the patient may 
not have the full effect of the drug or using an alternative analgesic agent such 
as nitrous oxide.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
 
4.3.7.3. Adrenaline Protocol 
 
Adrenaline use in cardiac arrest is universally accepted due to its potent alpha 
effects, although when investigated in clinical trials its use does not appear to 
be beneficial in significantly improving survival to hospital discharge (American 
Heart Association, 2005). In addition, non-compliance with recommended 
dosages appears to be a common problem. A study was conducted in Sweden 
to determine whether adrenaline was administered in accordance with 
advanced cardiac life support guidelines during cardiopulmonary resuscitation. 
It found that in 68% of cases, the average time between dose intervals was 
longer than the recommended 3-5 minutes and the adherence to the 
recommended guideline was lower in out-of-hospital cardiac arrest (Johansson, 
et al. 2004). The reasons for non-compliance with the advanced life support 
guidelines were not established in this study. 
 
Similarly, several participants indicated that they were non-compliant with the 
recommended adrenaline administration dosage. In spite of several studies that 
show that initial or escalating high-dose adrenaline has only occasionally 
improved initial return of spontaneous circulation and therefore did not impact 
on early survival rates. In eight randomized clinical studies involving more than 
9000 cardiac arrest patients, high-dose adrenaline produced no improvement in 
survival to hospital discharge rates or neurological outcomes when compared 
with standard doses. The American Heart Association recommends a standard 
dose of 1mg of adrenaline every 3 to 5 minutes during adult cardiac arrest 
(American Heart Association, 2005). 
 
The participants base their practice on their own experience and outdated 
knowledge: “I don‟t have those successes with normal 1mg” (P18). When 
questioned as to whether the practitioner was comfortable with that practice, the 
response was: “Yes, my success rate is higher with mega-dose”. In response to 
the question: "Is mega-dose still your current practice"? The participant said: 
“Yes, that‟s the way I was taught”. (See Appendix 4:12) 
 
This practice was common to Participants 12 and 18, both of whom hold the 
CCA qualification: “…giving 1mg adrenaline as a starting dose for CPR, I‟ve 
tried the 1mg route and by word of mouth you listen to the older paramedics 
who have been in the game for a long while they say start with a mega-dose”. “I 
found that the mega-dose works much more effectively” (P12). “Yes, I‟ve had a 
few people walking around that have been successfully resuscitated with mega-
dose” (P18). 
 
The teaching and more especially the status or reputation of the teacher 
reinforces the practice. Participant 18 continues to use larger doses because of 
the teaching of two influential medical practitioners: “I was taught mega-dose by 
[Dr] K and [Dr] D and we got a few people back [successfully resuscitated]” 
(P18). Interestingly one of the medical practitioners mentioned, today teaches 
and practices the new recommendations. However, Participant 18 is still 
influenced by what was taught many years ago. 
 
Participant 16 alluded to using alternative doses when the recommended dose 
failed: “I don‟t know what the issue is with the mega-dose at the moment. My 
personal opinion is once the guideline hasn‟t worked that you need to try 
something else…” (P16).  
Participant 13 concluded that there is no significant difference in the outcome 
between standard one milligram and five milligram dose regimes: “…final 
outcome of the patient; to me there is no difference whether you use a mega-
dose or whether you use your 1mg every 3 minutes” (P13). Without any 
significant changes to the outcome, practitioners are more likely to continue 
with their traditional practice despite scientific evidence to the contrary. The 
period of time that the practitioner is engaged with the patient is relatively short 
in the pre-hospital phase. The scientific evidence is based on the entire 
spectrum of care that includes pre-hospital, in-hospital and survival rates after 
hospital discharge. 
 
The non-compliance with regards to adrenaline doses is not universal as 
suggested by Participants 7 and 17: “On the contrary I‟ve had success with the 
standard 1mg dosages.” “I gave a lot of adrenaline in total but it was in 1mg 
dosages” (P7). “Likewise” (P17).  
 
Despite evidence to the contrary it would appear that high dose adrenaline 
administration is common practice in cardiac arrest.  In a 1995 trial in Australia, 
researchers found that higher Adrenaline use in resuscitation showed 
significant (P= 0.01) change to beneficial ECG rhythm when 10mg of adrenaline 
was used compared to a 1mg dose. However this change did not reflect in 
improvement in survival to hospital discharge (Woodhouse, et al.  1995:249). 
The ALS practitioner using higher dosages may successfully resuscitate the 
patient to the point of the hospital casualty unit but may not be aware that the 
patient does not survive to be discharged from hospital.   
 
4.3.7.4. Specific Problems with Drugs in Other Protocols 
 
Practitioners specifically identified problems with other PBECP guidelines and 
protocols associated with the use of Adrenaline, Midazolam, Morphine, Aspirin, 
Furosemide and Diazepam.  
 
Participant 19 found that the PBECP guidelines and protocols stated that 
Aspirin administration was contraindicated in patients with asthma but its use in 
patients with asthma is listed as a precaution in the SAMF. The experience of 
this participant is that often myocardial infarction patients, who may benefit from 
Aspirin, have a history of asthma and that the benefits of Aspirin administration 
would outweigh the potential risk of an asthma episode. (Appendix 4:6) 
 
The dose of Diazepam was identified by Participant 15 as insufficient to 
successfully terminate epileptic seizures: “… if you have convulsions again and 
you repeat the dose… you now administered the maximum dose, but the 
patient has a fit again…”. (Appen dix 4:33) 
 
Participants 3 and 22 advocate the use of escalating Adrenaline doses in 
anaphylaxis as they found is recommended by the AHA Resuscitation 
Guidelines. (Appendix 4:12)   
 
In the experience of Participant 21 the dosage of Furosemide in the PBECP 
guidelines and protocols was inadequate because many of the patients that 
required Furosemide are using the tablet form of the drug. “ … Lasix ® there is a 
max dose, how many times you call the medic and they will give him double 
that because they would already be on Lasix®”. (Appendix 4:38) 
 
4.3.8. Conclusion 
 
Figure 4 shows the major category and its categories and subcategories.  
 
 
Figure 4. The factors influencing PBECP guideline and protocol usage. 
 
The credibility of the PBECP guidelines and protocols is questioned by 
practitioners who participated in the study: “…why would we want compliance to 
something that we have established is flawed?” (P19) There is obvious 
confusion as to what a guideline and protocol is. The process of developing 
guidelines and protocols comes under scrutiny as does the differences that 
exist with other guidelines.  
 
The key issues that emerge in relation to the role of the PBECP are the lack of 
clear definitions with regards to what a guideline is and what a protocol is. 
Practitioners have conflicting views and interpretations of how they are 
permitted to use the guidelines and protocols. Specific examples are given of 
how the PBECP guidelines and protocols are not congruent with other 
PBECP 
Guidelines & Protocols 
Benzodiazepines 
Morphine 
Adrenaline 
other drugs HPCSA Act 56 & 
regulations 
Legal document 
  
Supports safe 
practice 
Conflicts Guideline & protocol 
development 
SAMF 
AHA 
hospital practice 
Crediblility, 
Consultation and 
review 
 
 
What is a 
guideline / 
protocol? 
Problem drug 
protocols 
guidelines, such as the SAMF, that are commonly used by other health 
professionals. 
 
The participants were able to identify several protocols that they had 
encountered problems with. These specifically related to the drug dosages, 
indications and contraindications for use.   
 
4.4. Education and Training  
Compliance or non-compliance with the PBECP guidelines and protocols by 
ALS practitioners, in relation to education and training is informed by factors 
such as: differences in education and training; use of outdated teaching 
methods; lack of participation in continuing professional development and 
insufficient pharmacology knowledge.  
It would be reasonable to conclude that education cannot take place without 
training, and vice-versa however for the purpose of this chapter, education is 
viewed as the acquisition of knowledge, skills and behaviour in a manner that 
encourages problem solving and inculcates ways of thinking that are 
productive, effective and rewarding thus preparing the leaner to deal with an 
solve a broad range of problems, and to choose which problems are important 
and which are not (Moore, 1998). Training, according to Moore, facilitates the 
effective use of certain techniques, places emphasis on rote learning, minimises 
analysis of their theoretical presuppositions and reducing teaching to the 
application of the formulas without consideration to their learning process.  
 
4.4.1. Type of Qualification of the Practitioner 
 
The type of qualification appears to be a factor in non-compliance. To register 
as an ALS practitioner with the PBECP one would need to have successfully 
completed either the three year National Diploma in Emergency Medical Care 
or the nine month duration Critical Care Assistant (CCA) course. Entry to the 
CCA course is permitted after successful completion of the Basic Ambulance 
Assistant (BAA) and Ambulance Emergency Assistant (AEA) short course and 
at least one year‟s clinical experience in an ambulance service. The curriculum 
of the BAA, AEA and CCA courses is based on technical skills as compared to 
the curriculum of the National Diploma: Emergency Medical Care (EMC). The 
short course curriculum does not place emphasis on evidence based practice 
and clinical decision making. The following statement: “According to our 
training, or ability and what we see and have to do out there, the protocol is not 
sufficient” (P18). This illustrates the dependence by CCA qualified practitioner 
on the PBECP guidelines and protocols because of their perceived inability to 
be able to make independent clinical decisions.  
 
During the focus group discussions it became apparent that participants 
distinguished between the CCA qualified practitioners and the practitioners 
holding a National Diploma: EMC qualification. Participants also distinguished 
between ALS practitioner‟s who qualified pre and post 2000 as is evident in this 
extract: “…you will have o ld school CCA‟s and new school and you have 
National Diploma qualified paramedics [all trained differently]” (P18). 
 
The short course mode of ALS practitioner training that exists today is not 
unique to EMS in South Africa. Paramedics in the United States of America 
(USA) and the United Kingdom (UK) are also trained in this manner however 
there is a growing trend in the USA and UK towards formal education. Fourteen 
Colleges and Universities in the USA offer a Bachelors Degree in EMS. In 
2000, the Joint Royal Colleges Ambulance Liaison Committee published a 
discussion document on the concept of the practitioner in emergency care. This 
paper suggested that the non-degree paramedic training programmes have left 
paramedics lacking in key attributes such as clinical judgement and limited in 
other areas, such as patient assessment (Kilner, 2003:378). 
 
At a meeting with training stakeholders in September 2006 the PBECP, 
together with the National Department of Health, announced that the future 
professional qualification structure would comprise of a two-year National 
Diploma and a four-year Professional Degree. It is envisaged that the current 
short course system of education will cease in 2010 and that by 2015, 80% of 
the workforce in the public sector would hold professional qualifications. The 
move to formal education as opposed to the informal, short-course training 
route is supported by Participants 13 and 2: “I personally think that all the short 
courses should be done away with”. “I‟m a firm believer in the Diploma course… 
[it] has been out of reach for some of us…” (P13). “I don‟t think that the 
[education and training] system is good enough to continually educate the 
advanced life support practitioners out there” (P2). None of the participants 
objected to this suggestion. The National Department of Health, Human 
Resources Directorate concurs and suggests that the emergency care 
practitioner make-up must include aspects such as personal wellness, 
communication, basic science, life orientation and applied technology 
(Department of Health, 2006).  
 
4.4.2. Emergency Care Training 
 
The traditional method of instruction encouraged a cycle of experience and 
practice after the initial training. With little or no continuing medical education, 
reflection, consultation and critical thinking the practitioner is unlikely to use 
experience wisely or adapt to change in practice. As is illustrated in Table 2, 
skills focused training is a quick fix solution to correct a problem with low 
personal involvement on the part of the learner. To achieve transformational 
change requires a sustained period of educational development of the learner 
with a high level of consciousness and personal leadership.  
 
Table 2 and Figure 5 illustrate the pitfalls of EMS short course training in South 
Africa. This type of training may have been an acceptable solution to meet the 
needs of EMS at the time the EMS started but as emergency care began to 
evolve and mature, deficiencies in this educational approach become apparent 
as practitioners are slow to adapt to challenges of new knowledge and the 
resultant changes to protocols and guidelines.  
Table 2. Personal leadership and organizational change in relation to 
method of training and education (adapted from Wills, 2006:10). 
 
 
Type Primary Focus focus strategy 
level of 
conscious
NESS 
PERSO
NAL 
leaders
hip 
develop
ment 
Highe
r 
Educa
tion     
 
 
 
 
                                                       
Short 
Cours
e 
Reactive 
change 
Fix the 
problem 
Outsi
de-In, 
Local 
Quick fix How Low 
Trained to 
perform 
tasks 
Operational 
Change 
Continuo
us 
improve
ment 
Outsi
de –
In, 
Area 
Structure
d 
training, 
skill 
develop
ment 
What, How Low 
Trained to 
meet new 
requireme
nt 
Transitional 
Change 
Short to 
medium 
term 
survival 
Outsi
de- 
In, 
Syste
m 
Wide 
Redesig
n 
strategy, 
systems 
and 
processe
s 
What, How, 
Why 
Low/Hig
h 
Build 
Capacity 
for change 
Transformat
ional 
Change 
Long 
term 
sustaina
bility 
Inside
-Out 
Emergen
t 
process, 
changing 
culture 
and 
mindset 
What, How, 
Why,  
Caring 
Why, 
Caring For 
High 
Prepare 
mind for 
transforma
tion. 
Capacity 
for 
continuou
s learning, 
Learner 
centred  
 
What is evident from the statement by Participant 18 is that experience is 
occurring without critical reflection: “It is also what you feel comfortable with, 
your previous experience, I‟ve been a paramedic now for 12 years and you 
always go back to what you feel comfortable with, I‟ve seen the results, I‟ve 
seen patients recover and you always tend to go back to your previous 
experiences”. “The protocol will say this, but you have a gut feeling that this is 
not what is needed”. Illustrated in Figure 5 is how practitioners, when given the 
right tools, during their training and education, can use their experience to 
improve their practice by review and reflection. 
 
 
Figure 5. Learning cycle showing the growth after review and reflection 
(adapted from Wills, 2006:13).  
 
The absence of ongoing review of clinical practice by the practitioner further 
encourages poor practices. Reflection enables practitioners to look at their 
actions, thoughts and feelings and is considered to be a means of learning from 
practice which is a cornerstone for professional development and growth. If the 
practitioner fails to challenge their own practice there is a risk that it will become 
habitual and routine (Moloney and Hahessy, 2006:50). 
 
To prepare practitioners who are able to think critically and solve problems in a 
variety of clinical practice settings, requires teaching strategies that promote 
meaningful learning, instead of using traditional methods that depend on  
memorisation as the learning method (Moore,1998). The frequent use of 
adjectives, such as “drum”, “hammer” and “indoctrinate” confirms the use of 
outdated teaching practices in earlier paramedic training. Practitioners were 
expected to memorise the PBECP guidelines and protocols and respond 
verbatim in order to pass the final examination. The method of teaching, led to 
Training Experience 
Review 
Conclude 
Action 
Learning 
Enhancement of capacity 
for effective action 
Observation/Feedback 
What happened and 
Why? 
Reflection 
How do I feel/think 
about it now? 
Adapting 
What processes, 
practices, behaviours 
will I change? 
  
Practice 
 
Future 
the „indoctrination‟ of the learner and when changes were later made to the 
PBECP guidelines and protocols it was inevitable that practitioners were then 
unable to modify their practice to accommodate these changes. Participants 12, 
18, 5 and 16 identify with this methodology: “…it‟s just that the way you where 
examined and … t aught, your lectures will drum into you, this is the way it‟s 
going to be…”. “… the way you are trained that actually makes the big 
difference”. “You have a great deal of experience but your protocol that you 
learnt in 1986, it is like parrot fashion, it is stuck in you and that is what you 
going to do”. “You‟ll change only if you tried it and it works” (P12). “Its also the 
way that it‟s forced into your brain, the training, its going to make you exceed or 
not exceed your protocol” (P18). “It‟s a question of me being more comfortable 
with things that I learnt 10 years ago because they got drilled in” (P5). “We have 
been taught and have drummed into us remembering dosages as opposed to 
learning what it actually does” (P16). 
 
Very few of the instructors involved in providing short course education have 
formal educational qualifications. The outcome of this is evident in the 
description of the outdated teaching methods employed to ensure the 
transmission of knowledge. “It all depends on who was your instructor, (did 
he/she give) …you the freedom of thinking for yourself or is it someone who 
said you will do this according to protocol”.” It depends on your instructor, are 
you too scared to step outside your protocol or treat clinical signs and 
symptoms”. “I would prefer treating the clinical signs and symptoms of the 
patient” (P18). Participant 12 recommends a method: “You should have lateral 
thinking and you should have an open mind”. 
 
The introduction of a standard CCA curriculum in 1994 did improve the way in 
which CCA training was done. However, after undergoing revision in 1998 no 
further curriculum changes were made by the PBECP. “…you had people 
[paramedics] here from 1986 … in those years there was never a curriculum”. 
“These guys were trained based on how a person felt the curriculum should be”. 
[They] “… indoctrinated people into a certain way of thinking”. “But since 1994 
when they introduced the first curriculum things have changed, the problem 
however is that Mr A or Mr B has not changed with the system, he has been left 
behind”. “…the training that he had…was most probably two or three 
months…which is insufficient” (P2).  
 
When questioned on the difference in practice between pre and post 2003 
qualified paramedics and whether differing practices are still happening, the 
response was:   “Yes, …mainly with the paramedics that qualified a long time 
ago, … that‟s never been or had the opportunity or never really cared to go for 
refresher courses and just jack up their skills and see what the new protocols 
are about” (P13).  
 
Not all the practitioners who were trained in this era fit this profile. Participant 10 
defends this category of practitioner: “…you‟ll actually be surprised of how 
many of the older guys that did the two to three month paramedic courses are 
current…”.  
 
Participant 19 reflects on the current educational approach that is used at the 
Universities of Technology: “…the institution where I trained …we weren‟t ever 
given protocol tests… instead we were given big essay  topics; like discuss high 
dose adrenaline versus standard dose adrenaline and make use of so many 
references within a time period”. This educational approach is in keeping with 
the outcomes based education approach, adopts a learner-centred approach. 
Learners are expected to construct their own knowledge, skills and values; the 
lecturer is the facilitator to the learner‟s self driven search (Parker, 2002). The 
lecturer creates an environment for learners to build their knowledge.  
 
The PBECP guidelines and protocols are at the very foundation of the CCA 
course. The entire course is focused on the student mastering and applying 
these standards in simulated patient scenarios. In the statement: “The teaching 
emphasizes the book as the gospel while the book is not the gospel” (P2), one 
becomes aware of the PBECP guidelines and protocols are being associated 
with the Bible, that is it contains prescriptive „commandments‟.  
 
Conflict arises when actual practice is not always supported by the PBECP 
guidelines and protocols. The narrow method of teaching that limited 
interpretation and understanding of the PBECP guidelines and protocols 
encourages non-compliance when the „one size fits all approach‟ fails to work in 
practice. “If we accept that the protocol is …justi fies being called a Bible then 
compliance is a given and there is no negotiation about it, but when there is still 
some debate and some of the issue are not clarified then the guy‟s compliance 
will be lacking, and they would rather use other methods or ideas and maybe 
not comply with the protocol step by step” (P10). This is  supported by 
Participant 19: “In my view the initial methods  or ways we did things in the 
emerging stages of the profession was a very cowboy, non-thinking, closed 
approach were the protocol was seen as the Bible, it was a series of events that 
would take place one after the other”. 
 
4.4.4. Regional Variations in Training  
 
The PBECP guidelines and protocols may be interpreted and taught differently 
at different colleges and regions in South Africa: “…there is too much deviation 
in training as it is at the moment. Institute X is doing this and institute B is doing 
that” (P16). 
 
The experience from Participant 3 after meeting paramedics and medical 
practitioners from other regions during a paramedic competition, is that different 
provinces have different practices despite what the PBECP guidelines and 
protocols may say: “…this case that required a cardiac infusion and we put in 
1mg but then Dr B from Durban… said but we are using 5mg for an infusion 
and Wits [Technikon Witwatersrand] were using 10mg”. “But I said the protocol 
says 1mg and they had a problem with me using the 1mg...”. “So your own 
experience is that the protocol is implemented differently in different parts of the 
country”.  
 
Training institutions may interpret and introduce changes to the PBECP 
guidelines and protocols either to suit local practice guidelines which may vary 
from the PBECP recommendations. As an example there would be less 
emphasis during ALS training on drugs such as Amiodarone because these 
drugs are not issued by EMS to ALS practitioners in the region: “The different 
places of training also impacts on how people see the protocol”. “Every college 
has its own way of training” (P18).  
 
4.4.5. Insufficient Pharmacology Knowledge 
 
Pharmacology is taught as an annual subject in the third year of the National 
Diploma programme. The pharmacology curriculum equips the student with 
broad knowledge and it is not limited to the drugs listed in the PBECP 
guidelines and protocols. The drug information taught on the CCA course, on 
the other hand, is limited to the drugs in the current PBECP guidelines and 
protocols and provides limited information on general pharmacology. This is 
supported by Participant 9: “…this is how I  was trained, you know about the 
drug, you know your protocol and you get to know additional information about 
the drug… [Earlier qualified paramedics] will say no… that not what the protocol 
says”. 
 
CCA qualified participants identified the gap in knowledge as an obstacle that 
hindered their understanding of the drugs listed in the PBECP guidelines and 
protocols and therefore influenced the degree of compliance as is evidenced in 
the following extracts: “I believe the core understanding of the pharmacology is 
not there [ in the protocol book]” (P22). “With the new National Diploma: 
Emergency Care, National Certificate programme surely the guys [practitioners 
with these qualifications] do more pharmacology” (P18).  
 
Participant 21 would prefer that the education and training of paramedics be of 
such a nature that it would provide the ALS practitioner with sufficient 
knowledge to allow for the unrestricted and judicious use of drugs: “…if you 
qualify as a doctor you get to use the drug as you see fit”. “Yes, give a protocol 
with certain medications but then you are allowed to use that medications as 
you see fit, use the medications to its full extent, like a doctor”. “Adapt the 
training in such a way that we are allowed a drug”. “We must be taught and use 
it to the full extent”. “They should state that yes, you are allowed these drugs 
but you are allowed their full extent”. “You still must be limited, but you are not 
limited to small petty things that the book says 40mg [laughter]”. This statement 
reflects the infancy of the profession as it evolves towards autonomous 
practice, which is discussed later in this chapter. 
 
The statement by Participant 3 that medical practitioners do not follow 
guidelines and protocols is incorrect: “Doctors don‟t have a protocol book what 
makes us different”. Practice guidelines exist for most health care professionals 
(Schwartz, et al. 1999:1152).  
 
The statement by Participant 10 illustrates how his teaching and experience 
differs with regards to the pharmacokinetics of the drug Midazolam and how this 
impacts on clinical practice. “There is maybe one occurrence of a side effect 
and that is in the protocol but somebody that works with it on a daily basis may 
contradict what is being said”. “I am talking about Dormicum® and inducing 
hypotension”. The isolated experience of the practitioner may override the 
evidence presented during the training.  
 
A side effect is an unwanted effect that occurs in the course of the normal 
action of a drug, for example Morphine produces constipation. A drug would 
typically undergo extensive clinical trails before it is used on humans. The 
incidence and severity of side effects differs from patient to patient. A 
practitioner may not see side effects in a hundred patients but then have one 
patient that has severe side effects to a drug. Some of the side effects are overt 
and may not readily present during the brief and acute phase of treatment, for 
example, hypotension (Hassan, 2006). This may be due to the practitioners‟ 
expectation that patients with severe injuries deteriorate and not attribute the 
changes to the side effects of drugs that have been administered. As an 
example, hypotension due to blood loss is a common sign in patients with 
trauma. However several drugs, including Morphine, Midazolam, Adenosine, 
Glyceryl Trinitrate, Lignocaine and Furosemide also can produce severe 
hypotension (Health Professions Council of South Africa, 2003). The ALS 
practitioner may be mistaken and attribute the hypotension just to the blood 
loss.  
 
4.4.6. Lack of Participation in Continuing Professional Development 
 
The need to introduce continuing professional development (CPD) was raised 
by fourteen of the participants during the focus group discussions.  None of the 
participants had reservations on CPD: “…bring that one rule that every 
paramedic that has been trained must be updated” (P14). 
 
There is no current requirement for emergency care practitioners to participate 
in continuing education or recertification. This will change in 2007 when 
continuing professional development will be compulsory for every practitioner 
registered with the Health Professions Council of South Africa (E.C. News, 
2006:6). Points towards professional development can be accumulated in any 
one of three ways; the first being non-measurable outcomes like conferences, 
the second being measurable outcomes in the form of interactive skills 
workshops, and the third centres on activities associated with structured 
learning. Practitioners that do not comply could face penalties in the form of 
practicing under supervision, be required to undergo a remedial programme of 
continuing education, an examination, suspension from practice or being struck 
from the roll of practitioners.  
 
CPD is recognised as a part of professional responsibility and accountability, 
and is fundamental to professional and therefore organizational success. CPD 
can be described as a planned process that enhances professional 
performance. A practitioner, by improving practice through activities such as 
reflection, evaluation and consideration of evidence, will ultimately provide good 
quality patient care (O‟ Sullivan, 2004: 174). 
  
Participants 8, 12 and 11 were concerned that practitioners had been practicing 
for years without having undergone any updates: “They did the course in 1989 
or 1990 and we are currently in 2006, it‟s been forever and they never went 
back [for update or training]…” (P8). “…on the road you actually stagnant, there 
is no refresher courses, paramedics that qualified in 1986/7 … have n‟t been 
back to the college” (P12). “…they not used to change so they just stick to their 
protocol because its been working for them for 20 years, 10 years, that‟s why 
they stick with it instead of using the 2003 guidelines” (P11). “The protocols 
change but who changes the mindsets of the dinosaur” (P8).  
 
Participant 18 suggested an annual re-examination. When asked if an update 
and re-examination would be likely to change practice, the response was: “Yes, 
I think it will”. “You will be more up to date as to what is happening”. “If you do 
an exam every year it will help you to keep up to date with the changes and the 
new protocols”. 
 
The voluntary participation in CPD is regarded as ineffective by Participant 2: “I 
don‟t think that the system is good enough to continually educate the advanced 
life support practitioners out there”. The proposed CPD system is based on trust 
and relies on the individual practitioner to keep documented proof of their CPD 
activities (E.C. News, 2006:6). 
 
The dependency on guidelines and protocols and less use of sound clinical 
judgement can be to the detriment of the patient. The absence of opportunities 
for practitioners to regularly review of their knowledge and update their clinical 
skills and decision making abilities may negatively impact on their practice: 
“Unless we have CME programmes in place we run the risk of very sound 
knowledge withering away and all that is left is that [protocol] book, and that is 
why [I] place value on that book” (P22). (CME is the acronym for continuing 
medical education.) 
 
There is an acknowledgement by the participants that there will be attrition of 
knowledge over time, however there is a lack of personal accountability to 
ensure that knowledge and skills are maintained at an acceptable level: “(It) 
…goes about your training”. “Unfortunately this is where we lack a lot”. “All over 
the world, every year you are expected to rewrite an exam in order to practice”. 
“In South Africa, not”. “I‟ve lost a whole lot knowledge since I did exams 1994” 
(P18). 
Clinical meetings and updates be used to clarify the PBECP guidelines and 
protocols and improve compliance: “There was a clinical meeting at which an 
anaesthetist came and gave us a talk on Dormicum® and he said that in order 
for it to work we should use it with morphine and we‟ve been using Dormicum® 
and Morphine on patients where we have difficult intubation and it works quite 
well” (P12). 
The extent of non-compliance may be minimised by CPD as Participant 18 
describes in response to the question on whether training will change practice. 
The answer was: “Yes, it will change my practice”. “I will then ask why this has 
worked for me in the past but the reason why it‟s changed now is because „a‟, 
„b‟, „c‟ and „d‟ has changed and that also enlightens you and brings you up to 
date with new investigations and things that have happened in the world”. 
While ALS practitioners may currently be officially regarded as being 
„competent‟, they may become incompetent due to the failure to keep up with 
constant changes in the art and science of medicine (Stoy, 1998). Non 
compliance can be as a result of non-competence for one can argue that a 
competent independent practitioner would not only be one that is legally 
qualified to performs acts within a specific ranges of skill, knowledge and ability 
but would assume responsibility ones own skills, knowledge and ability. The 
practitioner‟s non-competence may result in non-compliance with relation to the 
lack of in-depth general pharmacology knowledge, the ability to self-develop 
oneself, to recognise the benefit of peer review and consultation and to adopt 
universal accepted best practice recommendations that would improve 
compliance.  
Continuing education must be designed to keep up with the rapid changes in 
medicine and to fill voids that are identified by quality improvement 
programmes. Technical and professional practitioners are at significant risk of 
becoming outdated in their skills and their knowledge. It is not enough for them 
to maintain the competence acquired in the years of formal education. In the 
emergency care profession, information is not static; perpetual change is the 
norm (Stoy, 1998). 
4.4.7. Conclusion 
 
Figure 6, depicts the categories, subcategories and their linkages. It illustrates 
how the dual ALS training and education impacts on ALS practice. The CCA 
short course training follows an outdated curriculum that is taught by ALS 
practitioners who do not have formal teaching qualifications and tend to use 
outdated teaching methods. This system of training does not encourage 
transformational change and provides inadequate pharmacology content. The 
regional variations in training and absence of CPD also negatively influence 
practice.  
 
 
Figure 6. ALS practitioner training and education factors that influence 
compliance 
 
Significant changes are underway in an attempt to address the quality of 
education and training of emergency care practitioners. These changes include 
the phasing out of the short course training system and the introduction of a 
two-year mid-level worker qualification and a four-year professional degree. 
Not outcomes 
based education 
ALS practitioner 
qualifications 
NDip /BTech EMC 
Learning cycle 
Education & 
training 
Pharmacology 
knowledge 
CPD 
Outdated 
curriculum 
No teaching 
qualification  
Outdated teaching 
methods 
CCA Short 
Course 
Regional 
variations 
However well these changes may bode for future development of emergency 
medical services, it does not address the need to update the current practicing 
practitioners who will continue to be the backbone of emergency medical 
services for the foreseeable future. It is envisaged the CPD may address this 
concern. 
 
 
4.5. The Evolution of ALS Practice as a Profession 
 
The fifth major category that emerged from the data analysis was the evolution 
of ALS practice as a profession. Non-compliance was clearly related to this 
process. 
 
“There was an article in the newspaper about a paramedic doing some 
wonderful work. Her dream was to become a Doctor, but she was dyslexic so 
she decided to be a paramedic [laughs]” (P1). 
 
The term professional is ambiguous and what constitutes a profession has been 
a source of debate in the last century. Medicine has been described as a 
prototypical example of a profession and the medical practitioner has 
traditionally been seen as the pre-eminent authority over all health                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
matters. Freidson (as cited by Margolis, 2005) concluded that autonomy, self 
regulation and self determination are central characteristics of a professional. 
Other characteristics include that the work of a professional must be of such a 
nature as to be of significant public interest; the professional must undergo a 
prolonged period of training in abstract and complex knowledge, the profession 
must help create knowledge; and a service orientation must exist (Margolis, 
2005:41).  
 
4.5.1. Characteristics of a Profession 
 
ALS practice has yet to be given full recognition in terms of the status of the 
profession. In many quarters the ALS practitioner is still seen as an ambulance 
driver: “The doctors and nurses think we are ambulance drivers…” (P13). More 
than 80% of the current workforce holds a Basic Life Support qualification which 
is obtained after four weeks of training. Fewer than 2% are ALS practitioners 
(E.C. News, 2006:1). The profession is responsible to ensure that it meets the 
criteria to qualify for professional status.   
 
The ALS profession in South Africa currently finds itself in the process of 
achieving the status of a profession as shown when the achievements in 
relation to the characteristics of a profession are considered. The establishment 
of the PBECP and the status of independent practitioner do afford the 
practitioner a degree of autonomy and self regulation. The establishment of a 
professional association would allow a degree of self determination. The 
termination of short course training will over time address the education and 
training shortcomings and with the growth of post-graduate qualifications and 
research, profession specific knowledge will be created.  
The key responsibilities of an ALS practitioner would include treating patients in 
accordance with the PBECP guidelines and protocols, to maintain best clinical 
practices in accordance with quality standards and to respond to opportunities 
that enhance professional development. An ALS practitioner would have 
associations within the organisation, with management, administration and 
fellow operational crews. External stakeholders are patients, other health 
professionals, the public and other emergency service personnel and providers. 
In meeting these responsibilities there is still no guarantee that the ALS 
practitioner would be appreciated: “…they [Doctors] start afresh a s if the patient 
was picked up from the road and brought straight in”. “All your interventions are 
taken off and thrown to the side”. “That gap has not been bridged enough for us 
to get a foot in the door in terms of getting the profession recognised” (P1). 
There is progress towards the achievement of specific characteristics of a 
profession from the following categories. 
4.5.2. Independent ALS Practice 
 
The HPCSA defines independent practice as a practice where a registered 
health profession is conducted by a health practitioner without supervision of 
another health practitioner (Health Professions Council of South Africa, 2004). 
In 2001, the Professional Board and the HPCSA declared all ALS practitioners 
registered on the Paramedic register as independent practitioners (Justus, 
2005). Prior to this resolution, emergency care practitioners fell into the 
category of supervised practice. This meant that clinical decisions, such as the 
declaration of death and the administration of medication above schedule five  
had to be authorised by a supervising medical practitioner (South African 
Medical and Dental Council, 1998). The training and education of ALS 
practitioners prior to 2001 was based on the premise that ALS practitioners 
were the eyes and hands of the medical practitioner at the scene of an 
emergency and would therefore not require any clinical decision making 
knowledge and skills in their education and training.  
 
The change of status to independent practitioner should have been 
accompanied by updating the knowledge and clinical skills of existing 
practitioners. Essentially, practitioners found themselves in a void, having to 
fend for themselves with the PBECP guidelines and protocols as their only tool: 
“…the new one [protocol] brings us a lot of friction  in our situation…”. “…in the 
previous one it was stated that you had to make contact with a medical officer” 
(P20).  
 
Practitioners encounter other health care professionals that are not aware of the 
ALS practitioner‟s scope of practice and would question their use of schedule 
seven drugs as is illustrated by Participant 15 and 21: “The experience has 
been of queries from doctors about who gave the morphine and what makes 
you qualified to do this” (P15). “…the doctors are not aware of the capabilities of 
what paramedics can and cannot do” (P21).  
 
Many practitioners continue to practice in the previous paradigm: “I don‟t have 
to phone the doctor to give morphine but I would rather phone the doctor to give 
an „up‟ dosage … and safeguard myself…” (P21).  
 
The responsibility for ensuring that practitioners are updated lies with the 
individual practitioner. The role of the HPCSA would be to provide the 
framework for continuing professional development. When asked who is 
responsible to ensure that practitioners are updated, the responses were: “As 
independent practitioners it is up to us”, “…it‟s our responsibility, its our patients 
that we are treating, as a recent graduate this is how I feel at the moment” (P7). 
“… with doctors it‟s their individual responsibili ty to update themselves, why 
can‟t we paramedics be the same” (P3). “I feel the independent practitioner 
should try his best, but also from the HPCSA side” [they should provide enforce 
CPD] (P17). “I spend thousands every year with my CME [Continuing Medical 
Education], it‟s up to the individual…” (P16). These statements reflect a growth 
towards personal self development that is found in a professional. 
 
Historically the PBECP guidelines and protocols were developed by medical 
practitioners employed within emergency medical services as supervisors of 
ALS practitioners. Graduates from the Universities of Technology, having 
completed the four-year Bachelor of Technology: Emergency Medical Care 
qualification, are frustrated with the constraints of the PBECP guidelines and 
protocols which can result in non-compliance because they perceive their own 
clinical knowledge to exceed the constraints of the PBECP guideline and 
protocols: “There is a sense that the protocol makes me feel that I am not 
trusted to make that clinical judgement” (P19). 
 
Practitioners that have undergone tertiary education want to practice 
independently of the guidelines and protocols: “…give us that trust, that we can 
use the drug to its full extent as we see fit and as the patient responds, but state 
it in the protocol so there is no risk of a big stick” (P21). 
 
This view is not universal, the CCA qualified ALS practitioners are cautious: 
“There could be a danger in that because in the pre-hospital setting where 
things go wrong you are not in a safe environment”. “There are factors where 
you must be cautious” (P4). “I don‟t want to say that they must just give us a 
carte blanche”. “For some drugs I want to see where I can exceed… when I can 
help the patient”. “Not when there is a side effect to the drug then you 
continuously give it like carte blanche” (P15). This difference in opinion may be 
linked to the lack of self confidence that stems from inadequacies of the short 
course training focus on narrow skills content, and begs the question "how 
independent are the practitioners‟ with regards to the provision of emergency 
care?". 
 
4.5.3. Trust of the ALS Practitioner 
 
Limited access to Schedule seven medications, such as morphine, may have to 
do with a lack of trust by management or fear of management that the drug 
would be abused by the practitioner: “I think that they don‟t trust us” (P15). 
“Services don‟t want to buy it because of previous bad experience”. “They might 
have someone abusing the drug” (P18). According to Gilson, Palmer and 
Schneider (2005:1428), relationships of particular importance to health care 
provision are those that exist between practitioner and the patient, and 
practitioner and the employer. Trust is linked to personal behaviours; the 
immediate supervisors‟ actions may affirm or undermine trust in the employing 
organization. Trust in the organization is linked to the style of organizational 
leadership and the nature and practices of human resource management 
functions. Trust offers an ethical frame for understanding health system 
organisation and performance.  
 
Related to the issue of trust, is the perception that the paramedic profession 
attracts people with an extroverted personality. There is little evidence to 
support a distinct personality type that is reflective of emergency service 
workers as a whole (Wagner, 2005). However, this perception is alluded to by 
Participants 21 and 4 “You do get cowboys out there”. When asked whether the 
practitioner‟s personalities did impact on practice, the response was: “Yes we 
are „A‟ type personalities” (P4). “Over the years the PBECP guideline and 
protocol has changed but the mentality and the practitioner‟s attitude has not 
changed” (P3).  
 
 
4.5.4. ALS Practitioner Use of Consultation  
 
Consulting with peers and other health professionals is universally regarded as 
good practice. Participants 16 and 9 were of the opinion that this was not 
universal practice amongst paramedics: “It is the ego effect that people are 
afraid to consult first and then secondly afraid to whip out a book” (P16). 
“People are scared to consult one another” (P9).  
 
Participants 16 and 20 acknowledges the importance of consulting: “It is often 
that the protocol itself is lacking in certain issues where it guides you to a 
certain position, where you are then left literally on your own and therefore 
consultancy plays a huge role to fill those gaps”. “I think that consultancy is the 
key…” (P16). When asked who one would consult, the response was: 
“Colleagues, doctors, nurses, whichever other health care professional” (P16). 
“Sometimes you need to consult in certain cases just as a safety measure” 
(P20). 
 
In my own experience there is an attitude and image that is fostered within the 
profession that rewards speed of action, bravado and quick autocratic decision 
making whilst caring for critically ill patients. Referral to books and consultation 
are viewed as a sign of weakness.  This attitude may inadvertently be 
encouraged in the education and training of paramedic students. During 
classroom practical patient care simulations emphasis is placed on memory 
recall of the PBECP guidelines and protocols and unrealistic time restrictions 
are enforced. 
 
4.5.5. Conclusion 
 
Medical science is evolving at a phenomenal rate. Annually billions of Rands 
are spent on research that informs clinical practice (Polit and Hungler, 
1999:688-689). Emergency care practitioners are not immune to these 
influences and Participant 19 identifies this information growth:  “…when you 
treat your patients you have some sort of evidence to support that… information 
is changing all the time so you have to keep up to date” (P19).  
The immaturity of the profession is evidenced by the lack of local conferences 
and symposiums in emergency medical care. There are no opportunities for the 
development and sharing of new local knowledge. “… [there is a] lack of formal 
information sharing structure like symposiums and gatherings of this 
professional body” (P19). Emergency care training at post-graduate level will 
not only enhance the standard of pre-hospital care in South Africa but provide a 
locally based research foundation upon which the profession will stand 
(MacFarlane, van Loggerenberg and Kloeck, 2005:148). 
The challenges that would need to be overcome before the ALS practitioner is 
regarded as a „true‟ professional would include a clear definition of their 
independent practitioner status; earning the trust of other health professionals; 
the use of reflection and consultation in their clinical practice, and the 
production of research and new knowledge by the practitioners that will evolve 
their practice. Registration with the PBECP ensures autonomy, self regulation 
and self determination of the ALS practitioner. (Figure 7.)  
 
Figure 7. Factors influencing the evolution of ALS practice. 
EMS Research 
Evolving professional 
status 
Reflection & 
consultation  
 
Trust of ALS 
practitioner 
Self regulation 
 
Self determination Autonomy  
 Independent 
practice 
PBECP 
 
4.6. Summary  
 
The health system focus on delivering health care to the community as part of 
the Primary Health Care focus has created new challenges for the ALS 
practitioner. The PBECP guidelines and protocols do not accommodate the 
unique circumstances of rural ALS practice and this disjuncture between the 
guidelines and protocols and the realities of rural health care contribute to the 
eventual non-compliance.  
 
EMS as an organisation has responsibilities include creating an enabling 
environment for the ALS practitioner. The inability of EMS to provide clinical 
support consistent with the prescripts of the PBECP guidelines and protocols is 
cited as a concern. ALS practitioners are issued with a limited range of drugs by 
EMS employers and inadequate clinical support is provided by EMS to rural 
ALS practitioners. These factors contribute to the ALS practitioner‟s non-
compliance. 
 
The PBECP guidelines are not clear as to the definitions of guidelines and 
protocols and what these definitions mean for ALS practice. The process 
followed to develop and implement the guidelines and protocols has been 
flawed. There is a lack of consultation and the guidelines and protocols conflict 
with other universally accepted guidelines. These factors, together with the 
delayed implementation of CPD, contribute to the non-compliance of the ALS 
practitioner with the PBECP guidelines and protocols. 
 
The ALS training achieved by means of the CCA short course is inconsistent 
with that of the education of the National Diploma: Emergency Medical Care. 
The CCA course curriculum is outdated, does not include sufficient 
pharmacology and is presented by unqualified instructors that utilise outdated 
teaching methods to deliver the content. The current training does not support 
CPD. The way in which ALS practitioners are taught contributes to non-
compliance.  
 
The ALS profession is immature in comparison with other health professionals. 
To attain professional status, the ALS practitioner must produce local research 
and include inward reflection and consultancy in clinical practice. In so doing 
the ALS practitioner may earn the trust of fellow professionals and begin to view 
themselves as more than just ambulance drivers with drugs. The lack of these 
professional attributes leads to non-compliance.  
Although five major categories have emerged as reasons for non-compliance, 
they are also interrelated. The roles and responsibilities of Emergency Medical 
Services as an organisation, emergency care education and training and the 
PBECP overlap and operate within the context of the South African health 
system. These form the environment in which the ALS practitioner practices. 
The investigation into non-compliance with the PBECP guidelines and protocols 
revealed the interrelatedness between the major categories as is illustrated in 
Figure 8. 
 
Figure 8. The Context of the Emergency Care Profession  
4.6.1. Interrelated Categories 
Figure 9 illustrates the interrelatedness that exists as similar categories, such 
as CPD, link across major categories. The categories that overlap across major 
categories and the linkages are explained in below. 
CPD (See in the Figure 9:a) is a category that emerges in each major category. 
The lack of access to CPD activities in rural areas, the delayed implementation 
of a compulsory CPD requirement by the PBECP, the education and training 
Health System 
EMS Education 
PBECP  
 
ALS 
Profession 
system that does not encourage voluntary participation in CPD and the 
individual‟s lack of self motivation to engage voluntarily in CPD, are linked. 
Essentially, CPD activity is minimal amongst practitioners and this is seen as a 
reason for non-compliance.    
The PBECP has a legislative role as the regulator of emergency care education 
and training (See in the Figure 9:b). This role includes generating learning 
outcomes for emergency medical care qualifications. Formal qualifications 
enhance the professional development of the ALS practitioner.  
The development of new guidelines and protocols must be followed by an 
update on the changes. The teaching method influences the degree of 
consultation that occurs in practice.    
The differences that exist between the hospital guidelines and the PBECP 
guidelines and protocols (See in the Figure 9: d) causes the hospital staff not to 
trust what the ALS practitioner has done. 
There is a linkage between the health system and EMS. Inadequate clinical and 
resource support, communications, distance to hospitals (See in the Figure 9: e, 
f, g) and inadequate medical practitioner support are common to both the health 
system and EMS.  
 
ALS
 Pr
ac
tit
ion
er 
 
(a)
  C
on
tin
uo
us 
Pro
fess
ion
al 
Dev
elo
pm
en
t 
Pro
fess
ion
al 
dev
elo
pm
en
t 
Tr
ust o
f AL
S 
Pra
ctitio
ner
 
Co
nsu
ltatio
n 
Healt
h S
yste
m 
EM
S 
PBE
CP 
Gu
ide
lin
es & 
Pr
otoc
ols
 
Ed
uc
ation
 & 
Tr
ain
ing
 
 
 
 
 
Chapter 5 
 
5.0. Findings as to How to Improve Compliance 
 (b
) L
eg
islatio
n 
(c)
 Dev
elo
pm
en
t o
f 
gu
idelin
es 
 
EMC E
du
catio
n &
 
Tr
ain
ing
 
(d)
 C
on
flict w
ith
 
ho
spital p
rac
tice
 
(g)
 Dis
tan
ce 
to 
Hea
lth
 Facility
 
Fo
rm
al 
ed
uca
tio
n 
(e)
 In
ad
eq
uate 
Clin
ical 
Su
pp
ort
 
(f)
 C
om
mu
nicatio
ns
 
Figure 9. Categories that interrelate across the major categories 
 
5.1 Introduction 
 
This chapter represents the major categories and their categories and 
subcategories which emerged from the data analysis in response to the 
research question: "How can compliance with the PBECP guidelines and 
protocols be improved?" They will be explained separately, followed by a 
discussion of the linkages between them.  
 
As in  chapter four, the findings as to how to improve compliance in so far as 
the views of rural versus urban practitioners, private versus public sector 
practitioners, the qualifications and experience of practitioners are similar and 
discussed collectively.  
 
Five categories were identified in seeking solutions as to how compliance by 
ALS practitioners with the PBECP guidelines and protocols could be achieved. 
As can be expected, they reflect the categories of the reasons for non-
compliance, namely the health system as a whole, the EMS, the PBECP, the 
ALS education and training system and the ALS practitioner. Essentially, the 
influences, roles and responsibilities and improvements in the health system, 
the legislative framework of the HPCSA, the formulation of EMS health policies, 
and a review of the education and training framework of ALS practitioners will 
form the basis for improved compliance. However, the evolution of the EMC 
profession and the professional status of the ALS practitioner will ultimately be 
required to ensure sustainable compliance. 
 
5.2. Health System Improvements to Increase Compliance  
 
The NCEMS is a committee that has as its members the Directors from the nine 
Provincial EMS‟s, representatives from the South African Military Health 
Services, organised labour, private ambulance association and representation 
from the PBECP. The committee is chaired by the National Department of 
Health, Emergency Services Directorate. The committee is mandated to advise 
the National Minister of Health on matters related to emergency medical 
services. Consultation with the National Committee on EMS (NCEMS) is 
necessary to ensure national health policies and priorities with regard to 
emergency medical services are embodied in the PBECP guidelines and 
protocols. NECMS performs an important role with regards to determining 
indicators against which EMS service delivery in the nine provinces can be 
monitored and evaluated. These indicators include nationally agreed to 
response time targets for urban and rural areas and a 20%:50%:30% ratio of 
personnel with Basic, Intermediate and Advanced Life Support qualifications 
employed in EMS. Items under discussion by NCEMS include models of service 
delivery, medical equipment tenders, preparation for national events such as 
the 2010 Soccer World Cup, EMS training and the EMS strategic framework. 
Resolutions taken by NCEMS influence provincial EMS policy and therefore 
ALS practice (Fuhri, 2006). Quality improvement of emergency care practice is 
a prominent issue on the NCEMS agenda. The committee is represented in the 
review of emergency care qualifications and has a representation on the 
PBECP. Any measure to improve compliance of ALS practitioners with the 
PBECP guidelines and protocols should be implemented in consultation with 
NCEMS, as it has a broad EMS representation.   
 
Providing internet access to ambulance stations will allow for practitioners in 
rural areas to have access to participate in changes to the guidelines and 
protocols and engage in online CPD programmes. “The HPCSA website should 
be more interactive…other websites…have continuing medical education 
facilities” (P2).   
 
Figure 10 below illustrates the mechanism that exists to address health system 
problems that impact on EMS service provision. Resources shortages in the 
Department of Health that impact on non-compliance can be raised at NCEMS 
by the PBECP. Decisions reached at NCEMS are fed back to the Department of 
Health, and influence EMS policy development and decisions taken by the 
PBECP.  
 
Figure 10. The Health System mechanism to resolve resource provision  
 
5.3. The Role of EMS to Improve Compliance  
 
The EMS organization creates the immediate environment for ALS practice. In 
this regard, the responsibilities of EMS includes the equitable distribution of 
resources to rural areas where distances to hospitals are vast and clinics and 
district hospitals may not be adequately equipped to treat the critically ill or 
injured. These responsibilities must be fulfilled, in order to provide an 
environment that will facilitate compliance with the guidelines and protocols. 
Specific aspects which require attention are identified hereafter. 
 
Firstly, the improvement of the communications network coverage will ensure 
access that ALS practitioners are able to obtain clinical advice at any stage of 
their journey to hospital. As a consequence, they will be able to obtain direction 
from a medical practitioner in instances where they need to deviate from a 
guideline or protocol.  
 
Secondly, clinical support that is provided must be consistent and aligned with 
the PBECP guidelines and protocols. Local EMS policies may be required to 
PBECP 
Constitution 
Health Act 
NCEMS  
Dept. 
Health  
Inadequate 
resources 
EMS policy 
Provide internet 
to support CPD 
ensure that those providing medical direction to ALS practitioners are 
themselves following accepted practice guidelines.  
  
Expanding the scope of practice for practitioners working in rural EMS systems 
may need to be considered. However one could argue that rural EMS 
practitioner‟s treat fewer patients and therefore there would a deterioration of 
clinical skills over time. A randomised controlled trail to assess decay in 
acquired knowledge among paramedics in the USA completing a paediatric 
resuscitation course found that knowledge decays rapidly with time (Eustacia, 
et al. 2000:779).  
 
Thirdly, clinical quality assurance programmes should be implemented by EMS 
in order to introduce effective monitoring and evaluation of the ALS practitioner 
and check compliance with the PBECP guidelines and protocols. The data 
gathered from the clinical quality system may be used to identify the CPD topics 
for the further development of the ALS practitioner. The employer has an 
obligation to support and encourage employees to engage in life-long learning 
to improve their education and training. “…the Diploma course that has been 
out of reach for some of us…” (P16).   
 
In so far as which drugs are issued by EMS, the implementation of the 
guidelines and protocols is currently at the discretion of the EMS organization 
as was confirmed by a senior paramedic in an interview: “…people that are 
working in services that don‟t have access to the things that they should have 
access to, so even though they want to comply they can‟t because they 
employer doesn‟t provide with what they require”. EMS organizations have a 
choice to issue and allow the use of drugs, such as Morphine, Adenosine, 
Flumazenil and Amiodarone, within their services. Cost and clinical control are 
cited most often as the reasons for non-issue of drugs by EMS organisations. 
The argument of cost is non-scientific as it can be argued that the unavailability 
of PBECP approved medications to paramedics may increase morbidity and 
therefore increase the overall financial burden on the health system. As an 
example, EMS does not issue ALS practitioners with Adenosine and 
Amiodarone due to cost. These drugs are indicated for the treatment of the peri-
arrest arrhythmia, paroxysmal supra ventricular tachycardia. The ineffective 
management of this arrhythmia may lead to increasing myocardial ischemia or 
cardiac arrest which effectively creates an additional burden on the health 
system (American Heart Association, 2005).  The lack of trust is mentioned in 
Chapter 4 as another reason why employers do not issue ALS practitioners with 
drugs such as Morphine. If quality is at the core of any EMS organisation then it 
will rationally follow that best practice standards should be universally accepted 
and adopted.  
 
Good radio communications are vital to ensure that the ALS practitioner can 
access clinical advice at the scene of the incident or en route to hospital. 
Communication with the supervising medical practitioner is a medico-legal 
requirement  before any treatment that is outside the PBECP guidelines and 
protocols is undertaken The establishment of a communications centre in the 
Overberg area of the Western Cape in 2006 will improve rural access to 
communications (Uys, 2006).  
 
The distribution of resources to areas of need will reduce the effect of long 
travel distances to hospital. The establishment of an ambulance station at Leeu-
Gamka along the so called "road of death" between Laingsburg and Beaufort 
West in the Western Cape in 2005 is an example of how resources should be 
distributed. The town in situated on a national route on which more then a 
million vehicles travel every year and where there is a high number of serious 
and fatal vehicle accidents. The location of an ambulance station in this town 
will reduce the time taken to reach hospital as previously access to health 
services in emergencies on this specific road and in the surrounding remote 
rural communities, was a challenge and was dependent on the availability of 
ambulances from other areas. "With this new service we will improve our 
response time significantly and lighten the pressure on ambulance staff 
operating currently within the Central Karoo communities" Minister Pierre Uys 
(2006) said.  A benefit of the new service is that it increases availability of 
existing ambulances for emergency responses to local communities in the 
district thus reducing the overall mission time. The incidence of non-
compliance, as a result of shorter travel time to hospital, may be reduced by the 
strategic positioning of ambulance stations. 
 
A further measure that may overcome the travel distance to hospitals is the 
introduction of an air ambulance service. The advanced life support services in 
the Southern Cape area received a substantial boost with the introduction of a 
medical emergency helicopter service in Oudtshoorn. At the opening of the 
base, Minister Uys said that the emergency helicopter service will provide 
advanced life support for critically ill or injured patients, effectively cutting the 
time of patient transport by road by about two-thirds and providing the very best 
chance for patient recovery. This will be especially useful in providing access to 
inaccessible areas and serving rural communities (Uys, 2006). 
 
Figure 11 illustrates how introducing quality control will identify the gaps that 
could be filled by CPD. Improving the communication network will ensure 
adequate access to clinical support for rural ALS practitioners and how the 
strategic positioning of ambulance bases and helicopter services will reduce 
travel time to hospitals.  
 
 
Figure 11. EMS organisational role in improving compliance 
 
5.4. The PBECP Role in Improving Compliance 
 
The PBECP is, through its mandate from the HPCSA, mainly responsible for 
the registration of emergency care practitioners; the regulation of education and 
training; and determining the scope of practice of emergency care practitioners 
and in so doing guides the profession and protects the public (Health 
Professions Council of South Africa, 2004). The guidelines and protocols that it 
produces and enforces are fundamental to fulfilling this responsibility. 
 
An important finding of the research is that there is confusion about these 
guidelines and protocols as it relates to the status of independent practitioner.  
As one informant puts it: “I think you must know that the protocol is a guideline 
that‟s the key thing” (P16). The guidelines and protocols that are published 
must provide clear unambiguous direction to ALS practitioners with regard to 
the terms of reference of their use. Specific questions need to be answered, 
namely when is deviation permissible, how does contacting a medical 
Provide 
resources  
ALS CPD  Improve access to 
clinical 
supervision 
EMS 
ORGANISATION 
Location of 
ambulance 
station & air 
ambulance 
Improvement of 
clinical quality 
control 
Improve 
communication 
network 
Improved patient 
outcomes  
Issue of 
ALS drugs 
practitioner affect the ALS practitioner‟s status as an independent practitioner, 
is clinical judgement more important that compliance and what are the possible 
medico-legal implications of non-compliance?  
 
To date, neither the PBECP nor other regulatory Departments of Health have 
policy documents on “guidelines for the creation of guidelines” for ALS 
practitioners. Schwartz, et al. (1999: 1155) suggests several key attributes of 
good guidelines which should be considered by the Professional Board when 
developing and reviewing the guidelines and protocols. Firstly, they must 
consider face credibility that is the credibility accorded to the guidelines by the 
ALS practitioners who will use them. The team whose responsibility it is to 
generate these must be respected for their expertise and be representative of 
the ALS population (e.g. rural/urban). Validity of the guidelines can only be 
evaluated by determining whether they lead to the better management and 
outcome of patients. Even though South Africa is represented at ILCOR, there 
is no pre-hospital research contribution to ILCOR from South Africa. A study to 
determine if the guidelines lead to improvements in the practice may result in 
further improvements in the drafting of guidelines. This is also suggested by 
Participant 6: “Do studies, if it does not work, then increase the dose”.  
Reproducibility is integral to decreasing inconsistency between the different 
guidelines as this creates confusion and renders the guidelines less credible. A 
review of guidelines from other authorities is necessary before starting any 
review. Representativeness ensures the guidelines are free from bias. The 
guidelines should take into account the views and experiences of those ALS 
practitioners that practice in unique environments where health resources are 
not readily accessible. In addition, clinical applicability is necessary to ensure 
that significant health problems and specific patient cohorts are defined in 
accordance with scientific, medical and health economic criteria. This will 
enable the practitioner to easily link the clinical presentation of the patient with 
the appropriate guideline. Flexibility to the above is important in identifying valid 
exceptions to recommendations and suggestions on how patient preference 
can be incorporated into the decisions made by the ALS practitioner. Due to the 
nature of emergency medicine, flexibility based on patient preference may be 
uncommon. Clarity obviates ambiguity and imprecision without necessarily 
limiting clinical freedom. If a guideline is too specific, clinical decision making 
may be compromised. Guidelines must be reliable, meaning that they are 
interpreted by different practitioners in different environments in the same way. 
This will avoid regional differences in interpretation. Transparency establishes 
authority of the guidelines by making public the process in which they were 
generated. The HPCSA website and the PBECP newsletter can be effectively 
used to communicate changes to the PBECP guidelines and protocols. Finally 
the authority of guidelines must be maintained if they are at all to be adhered to. 
This may be achieved by continuous scheduled review of between three to five 
years. This links well with the ILCOR five year review policy. 
 
The above guidelines for developing these documents are supported by 
different respondents as indicated by Participant 18 and others: “Experts 
…must come together in a forum and give input”. The guidelines and protocols 
should be reviewed frequently and each review should be accompanied by a 
national CPD programme on the new changes as is suggested by Participants 
15 and 19: “…the people that write the protocol don‟t update the change…” 
(P15). “The way the protocols can be introduced is through updates, case 
reviews and forums” (P19).   
 
“They [the protocols] need to be updated often” (P15). This recommendation 
may not be practical because the PBECP guidelines and protocols set a 
standard. If this standard is in a constant state of flux, it would be difficult to hold 
practitioners accountable for non-compliance. The PBECP schedules the 
revision of the guidelines and protocols to coincide with the ILCOR 
recommendations. 
 
“We need to get it right in terms of integrity” (P22). Consultation with other 
health professional bodies and organisations such as the Medical and Dental 
Professional Board, the Emergency Care Society of South Africa, and the South 
African Resuscitation Council would be prudent to ensure universal acceptance 
of the standard and approval by the HPCSA (Moody-Williams, et al. 2002:409).  
 
The guidelines and protocols must align closely with international best practices 
and other nationally accepted guidelines such as the SAMF as is suggested by 
Participant 15: “…there are slight differences with the protocol and the SAMF”. 
They must also consider local circumstances unique to South Africa‟s health 
systems, such as those found in rural areas: “In the past a lot of the information 
came from the [United] States [of America]” (P4).  
 
The PBECP roles and responsibilities include the regulation the emergency 
care practitioner scope of practice, the regulation of education and training, 
taking disciplinary action against practitioners that transgress the rules of the 
PBECP and HPCSA and administering the emergency care practitioner 
registers. The PBECP has the legal authority to develop and publish guidelines 
and protocols for emergency care practitioners in terms of the HPCSA Act, 
1974 (Act No.56 of 1974) and the subsequent regulations (No. R.1379 of 1994). 
Guidelines and protocols development must follow an accepted scientific 
process, as illustrated in Figure 12, to ensure acceptance and compliance. Note 
the division in the figure. 
 
 
Figure 12. Roles and responsibilities of PBECP and the criteria for the 
development of guidelines and protocols 
 
5.5. The Role of ALS Education in Improving Compliance 
 
The PBECP has communicated the move away from short course training to 
formal education in the October edition of E.C. News (2006:2). This decision is 
supported by the findings on how the move to formal education can be used to 
improve compliance. Education can be used as an effective tool for change. 
The outcomes and curriculum of the ALS practitioner education and training 
must align with the role that the practitioner has to perform as part of a broader 
health care system. ALS practitioner education must be holistic and meet the 
academic, psychological and social needs to achieve transformational change 
in the learner.   
Continuous  
scheduled 
review 
Transparency 
Validity 
Reproducibility  
Reliability 
Scope of practice 
Regulation of 
education & 
training  
Practitioner 
registration & 
discipline 
Authority of 
PBECP 
guidelines & protocols 
Face credibility 
Representativeness 
Clinical 
applicability & 
flexibility 
Clarity 
Development of guidelines & protocols 
Role & responsibility of PBECP 
 
As an independent practitioner, the ALS practitioner must be equipped with the 
knowledge, skills and behaviours that inculcate problem solving abilities, critical 
thought, scientific enquiry and reflection as is supported by Participant 12 
“…you should have lateral thinking and ….an open mind”. These attributes will 
lay a foundation for the professional development and growth of the practitioner.  
 
The educators engaged in ALS practitioner training and education must 
complete formal training such as the Post Graduate Certificate in Education.  
Employing operationally experienced ALS practitioners without the necessary 
educational background to teach is unlikely to result in the practice of 
outcomes-based education principles (Mekwa, 2000:278). 
 
“Every college has its own way of training” (P18). To ensure that there is 
uniformity in the teaching, interpretation and classroom application of   the 
PBECP guidelines and protocols, collaboration and external moderation 
between educational institutions is necessary. 
 
The pharmacology curriculum content must explore to a greater depth the 
knowledge that an independent ALS practitioner requires to effectively 
administer drugs that may have significant side effects as is supported by 
Participant 21: “A solution is to adapt the training in such a way that if we are 
allowed a drug we allowed its full use, must be taught and be able to use it to 
the full extent”. 
  
A senior paramedic confirmed in an interview that opportunities for life long 
learning and access to continuous professional development are required to 
facilitate the acquisition of new knowledge “…I would like to see …mandato ry 
continuing medical education”.  
 
Figure 13 illustrates how formal education and training using the outcomes 
based education approach would provide the practitioner with the skills, 
knowledge and behaviour required for independent, professional practice. 
Formal education must address the discrepancies in lecturer education 
qualifications and the inadequate pharmacology content taught to ALS 
practitioners.  Collaboration between institutions with external moderation of 
examination will reduce discrepancies that may exist in the teaching of 
guidelines and protocols between institutions. CPD provides an opportunity for 
the practitioner to engage in life long learning. Critical and reflective review by 
the individual practitioner will help to identify gaps in knowledge and skills that 
can be addressed by participating in CPD activities. These gaps in knowledge 
should filter through and be included in the mainstream education of ALS 
practitioners. 
 
 
Figure 13. The role of ALS education in improving compliance 
 
5.6. The Role of the ALS Practitioner in Improving Compliance   
 
Inputs: 
Behaviour, 
knowledge & 
skills 
Education  
CPD Reflective practice Scientific inquiry Problem solving & 
critical thinking 
 
OBE Methodology/Process 
Improved quality 
of care  
Implement formal 
educator 
qualifications 
Improve 
pharmacology 
knowledge 
Increase 
institutional 
collaboration  
Any interventions to improve compliance must address the professional 
development of the ALS practitioner. “We need to get to the stage that we are 
actually a profession” (P16).  
 
The apparent lack of intrinsic motivation to seek self improvement is raised by 
Participant 3: “…with doctor‟ s it‟s their individual responsibility to update 
themselves, why can‟t we paramedics be the same”? Reflective practice is 
supported by Participant 22 “Reflective practice will find out how we are doing”. 
“It‟s a never ending task to expect people to police the system it has to be self 
motivated and self sustained”. The intrinsic need to improve ones knowledge 
and skill coupled with a critical appraisal of ones clinical performance may 
contribute not only to the professional development of the practitioner but also 
may improve compliance with guidelines and protocols.  
 
“We need to start respecting each other and what we do” (P13). Professional 
respect between ALS practitioner and ALS practitioner and other health workers 
will improve once ALS practitioners are given the opportunity to work closely 
with other health professionals. “Once we work side by side there is going to be 
a whole new view on what paramedics are doing” (P1). Professional respect by 
other health professionals may encourage confidence in ALS practice and 
support compliance with the PBECP guidelines and protocols.  
 
Self regulation, autonomy, independent practice and self determination of the 
profession are in place largely as a result of the formation of the Professional 
Board for Emergency Care Practitioners. The full implication of these 
professional responsibilities has not been realised by the profession as 
Participant 10 states: “You are an independent practitioner and you are 
responsible for your actions…”.  The South African Medical Association 
represents medical practitioners and has as its objectives the promotion of the 
integrity and image of the medical profession, to provide medical practitioners 
with knowledge relevant to the demands of medical practice, the promotion of 
education, research and academic excellence, to encourage involvement in 
health promotion and education, to develop medical leadership and skills and to 
influence  the health care environment to meet the needs and expectations of 
the community by promoting improvements to health reform, policy and 
legislation  (South African Medical Association, 2006). The formation of an ALS 
practitioner association to further the professional interests of the ALS 
practitioner is needed to address similar professional issues. Compliance with 
guidelines and protocols are in keeping with the objectives of the medical 
association. 
 
The move to higher education is welcomed by Participant 16 who is an ALS 
practitioner that holds the Critical Care Assistant short course qualification. 
“I…think that all short courses should be done away with”. “To reach that level 
[of professionalism] we need to sort out the training”. 
 
The ALS practitioner is on a continuum of development towards earning the title 
of a professional. The individual ALS practitioner does not guide and influence 
the realisation of the guidelines and protocols to the degree to which it is 
intended because the immaturity the profession has resulted in few 
opportunities for life long learning and formal education, current ALS clinical 
practice does not routinely include reflective practice, there is no ALS 
association to further the professionalism of the practitioner and there is a lack 
of professional respect from fellow health workers (See Figure 14). 
 
Self regulation 
PBECP 
Formation 
ALS 
association 
ALS 
Professionalism  
Move to 
formal 
education 
Self 
determination Autonomy 
Earn trust & 
respect of other 
health workers 
CPD Reflective practice 
 
 
 
5.7. Summary  
 
The multi-system view that looks at each major category is necessary to 
understand the multifaceted pattern of non-compliance. While this is true, it is 
also ethically necessary that recommendations from this study have some 
immediate relevance that may decrease any potential risk to health care users 
and practitioners alike. To this end, the discussion on improvements to the EMS 
systems, ALS practitioner education and training are for medium to long term 
implementation. In the short term the recommendations with regards to the 
PBECP, as the quality assuror, are for immediate implementation and are 
discussed in the next chapter.   
 
There are two important linkages that emerge from the findings as to how 
compliance can be improved. The key linkage that is evident in each major 
category is the lack of consultation with other stakeholders. There is a need for 
dialogue to take place between the NCEMS, the PBECP, institutions that offer 
ALS education and an association that would represent the ALS practitioners.   
 
Another important category that is common is that of CPD. The ongoing 
professional development is seen as key to improving the overall compliance of 
the ALS practitioner with the PBECP guidelines and protocols. Internet access 
will allow for CPD to take place in rural areas, EMS can use clinical quality 
control information to identify CPD topics, CPD should be used to bring ALS 
practitioners up to date with the latest guideline and protocol review, students 
should attend CPD sessions to keep abreast of new developments and ongoing 
review is necessary for professional development. 
  
Chapter 6 
 
6.0. Conclusion and Recommendations 
Figure 14. Factors that influence the professional development of ALS 
practitioner 
At the time when non-compliance was initially discussed with colleagues at the 
PBECP, it was readily ascribed to an isolated group of deviant practitioners that 
had not bothered to keep themselves updated. The extent and reasons for non-
compliance were poorly understood.       
 
As the findings of the study began to unfold, my perceptions as to the reasons 
for non-compliance began to change. The practitioner was no longer the only 
reason for non-compliance, other equally important categories started to 
emerge. Understanding the reasons for non-compliance is crucial to answering 
the second and more important question, that is, how can compliance be 
improved. Chapter 6 presents the conclusion and the recommendations on 
what can be done to improve compliance. 
                                                                 
6.1. Conclusion 
 
Practitioners that participated in the focus group discussions and interviews 
unanimously acknowledged that non-compliance with the guidelines and 
protocols is a common practice amongst ALS practitioners. The participants 
represented the spectrum of ALS practitioners in terms of years of experience, 
qualifications, private and public sector employment, gender, race, and urban 
and rural practice. It was evident that the participants identified with the purpose 
of the study and viewed their contribution as an opportunity to reflect on their 
own practices without risk of punitive action. The spontaneity of their responses, 
understanding and empathy with the study topic suggests some previous self-
reflection after either witnessing non-compliance by other practitioners or 
themselves being non-compliant.  
 
Agreement as to the reasons for non-compliance was evidenced by the 
repetition of the reasons for non-compliance given by different participants 
during different focus group discussions. At the conclusion of the third focus 
group discussion, it became evident to both the researcher and research 
assistant that little new information was emerging.  This however, did serve as 
an endorsement of the findings of the previous discussion groups.  
 
What is evident from the investigation is that there is a pattern of interrelated 
and complex factors that contribute towards the eventual non-compliance of 
ALS practitioners with the PBECP guidelines and protocols. The findings fall 
into five major categories, namely: the influences of the health system; the role 
of the EMS organization; the role of education and training; the role of the 
Professional Board and the professional status of the individual ALS 
practitioner. The combination of the factors ultimately leads to non-compliance. 
 
A core category did not emerge immediately. At a point in the study, the 
research assistant pointed out that the researcher bias as the Chairperson of 
the PBECP was obstructing the view that the PBECP was at the core of non-
compliance. However, after reorganising the major categories and 
subcategories, the core category that emerged was the ALS practitioner. The 
health system, EMS as the employer, the education and training that the 
practitioner receives and the role of the PBECP cannot individually be held 
accountable for non-compliance. Furthermore, non-compliance is not a 
universal amongst all ALS practitioners. The other categories help to create an 
environment that influences non-compliance to differing extents; however, the 
decision to be non-compliant is taken solely by the individual practitioner. What 
is important is that there is communication between all the role-players in order 
to seek solutions that will improve compliance. The interrelated role of the major 
categories and categories in influencing compliance is illustrated in Figure 15. 
 
 
 
 
 
 
 
6.2. Recommendations 
 
NCEMS  
ALS 
practitioner  
EMS 
PBECP Education 
Health 
system 
Inadequate 
resources 
Provide internet 
to support CPD 
Improvement of 
clinical quality 
control 
Improve 
communication 
network 
Provide resources  
Practitioner 
registration & 
discipline 
Regulation 
education & 
training  
Scope of practice Increase 
institutional 
collaboration  
Implement formal 
educator 
qualifications 
Improve 
pharmacology 
knowledge 
co
mm
un
icat
ion
 co
mm
un
icat
ion
 
Figure 15. The interrelated role of the major categories to improve compliance, 
showing the ALS practitioner as central to the process 
It is recommended the PBECP refrain from using the term protocol as protocols 
do not allow the practitioner to exercise clinical judgement based on individual 
patient requirements and would conflict with the independent status of the ALS 
practitioner. 
 
This study has led to an understanding of the reasons that ALS practitioners are 
non-compliant with the PBECP guidelines. It would be prudent for the PBECP, 
as the custodian for the development, revision and implementation of guidelines 
for ALS practitioners, to consider the recommendations to decrease the 
incidence of non-compliance. 
 
However, the onus to comply with any guidelines still rests with the individual, 
„independent‟, „professional‟ ALS practitioner. Any deviation from the PBECP 
guidelines must be clinically, ethically, legally and socio-economically justifiable. 
 
EMS must create an enabling environment that supports ALS practice and the 
independence thereof.  
 
6.2.1. Recommendations for PBECP interventions 
 
The PBECP must provide clear specifications on the definition of independent 
practitioner in relation to the limitations to the scope of practice as published in 
the PBECP guidelines. It must also clearly specify when, how and what 
deviations from the guidelines may be exercised. The Board must provide 
medico-legal clarity on the general advice from medical practitioners. It is 
recommended that the Board develops a policy that will guide EMS 
organisations and limit their discretionary and selective implementation of 
aspects of the guidelines as well as provisioning of resources.  
 
6.2.2. Education, Training and CPD 
 
The PBECP must ensure that the learning outcomes and curriculum approved 
by the PBECP provides the ALS practitioner with the knowledge, attitudes and 
behavioural attributes that support the ALS practitioner‟s status as an 
independent practitioner. Education institutions must ensure that any teaching 
practice that promotes memorisation of guidelines is not condoned. Revision of 
guidelines must be supported by a national awareness programme where 
practitioners will have an opportunity to engage with the changes. A CPD 
programme may be needed for practitioners that are ill equipped to implement 
the new changes due to past inadequacies in their education and training. 
 
6.2.3. Role of the PBECP in Guideline Development 
 
The PBECP must ensure future guidelines are developed in accordance with 
the attributes suggested by Schwatz et al. (1999)  
 
 In the development of guidelines and protocols the Professional Board 
must consider face credibility. Due consideration must be given to the 
credibility of those who generate guidelines and for whom they are 
generated. To this end there is a need for ongoing consultation and 
review with all stakeholders,  
 Validity of the guidelines can only be evaluated by determining whether 
they lead to the better management and outcome of patients, 
 Reproducibility is integral to decrease inconsistency between the 
different guidelines as this creates confusion and renders the guidelines 
less credible,   
 Representativeness, to ensure the guidelines are free from bias. In 
addition clinical applicability is necessary to ensure that significant health 
problems and specific patient cohorts are defined in accordance with 
scientific, medical and health economic criteria,  
 Flexibility to the above is important in identifying valid exception to 
recommendations and suggestions for how patient preference can be 
incorporated into decision making, 
 Clarity obviates ambiguity and imprecision without necessarily limiting 
clinical freedom,  
 Guidelines must be reliable in that they are interpreted by different 
practitioner in different environments in the same way,  
 Transparency establishes authority of the guidelines by making public 
the process in which they were generated,  
 Finally the authority of guidelines must be maintained is they are at all to 
be adhered to. This may be achieved by continuous scheduled review of 
between three to five years.  
 
6.3. Area for Future Study 
 
This study investigated the non-compliance with PBECP guidelines and 
protocols by the ALS practitioners and not by the Basic and Intermediate Life 
Support practitioners. It is possible that the reasons for non-compliance and 
consequently the approaches to improving compliance might have been 
different to those for ALS practitioners. The Basic and Intermediate Life Support 
guidelines are significantly different and including these findings would have 
made an in-depth study difficult. This may be an area for any future study. 
 
6.4. Closing Statement 
 
The study was successful. The findings as to the reasons why ALS practitioner 
are non-compliant and how compliance can be improved are evident. The 
researcher and the research assistant, despite their significant combined 
experience, have gained new insights into rural ALS practice, the overall views 
of ALS practitioners to education, the shortcomings of the PBECP and the 
interpretation of the guidelines. The confusion as to what is a protocol and what 
is a guideline has been resolved. The direction that the PBECP has embarked 
upon with regards to replacing short course training with two year mid-level 
qualification and a four year professional qualification in emergency care is 
supported in the findings. The agreement on the importance of continuing 
professional development was unanimous. This project forms the beginning of 
knowledge that will help emergency medical care to evolve as a profession in 
South Africa. 
 
 
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APPENDIX 01: DISUSSION GUIDE FOR FOCUS GROUP DISCUSSION 
 
 
 
 
Focus Group Discussion Guide 
 
Preamble: Welcome to this focus group discussion. There is evidence that 
some ALS practitioners do not follow the PBECP 2003 guidelines and 
protocols. The purpose of this discussion is to explore the reasons for this and 
identify what can be done about it.   
  
1. What has been your experience of working with the PBECP 2003 
guidelines and protocols?  
 
2. What are the reasons that ALS practitioners are non compliant with the 
PBECP 2003 guidelines and protocols? 
a. Are they too complex? 
b. Are they suited for the pre-hospital environment? 
c. Are the recommended drug dosages appropriate? 
 
3. Are there any specific protocols or guidelines that are problematic?   
a. Why or in what way? 
b. Are there any protocols or guidelines that conflict with other 
guidelines that you are aware of? 
 
4. What can be done to improve compliance?  
a. Suggestions on how compliance can be improved? 
b. How should new protocols and guidelines be introduced? 
 
 
 
APPENDIX 02: INFORMATION GIVEN TO PARTICIPANTS 
 
 
 
 
 
22 February 2006 
 
Letter of Information 
 
Title of research project: An investigation into the non-compliance of 
advanced life support practitioners with the guidelines and protocols of 
the Professional Board for Emergency Care Practitioners  
 
 
Name of Investigator: Lloyd Christopher  (083 3269428) 
Name of Assistant:     Navin Naidoo (082 337 2647) 
 
Dear ALS Practitioner 
 
I am a student registered with the Department of Emergency Medical Care and 
Rescue, Durban University of Technology. You are requested to take part in my 
research study. The purpose of the study is to investigate why some advanced 
life support practitioners in the Western Cape do not comply with the PBECP 
2003 guidelines and protocols and how compliance with PBECP protocol 
guidelines can be improved.   
 
I am conducting this research for the purpose of my Masters in Technology: 
Emergency Medical Care qualification. This study does not have anything to do 
with my role as Chairperson of the PBECP or Principal of the Academy of 
Emergency Care. Your participation in this study will in no way prejudice you as 
a registered advanced life support emergency care practitioner. 
 
I have selected you for participation as you are an ALS practitioner practicing in 
the Western Cape. As such you have valuable perceptions and views and 
would be regarded as a participant in the research.  This research is intended to 
benefit our profession not find fault with practitioners.  
 
If you agree to participate, you will be required to be a one of six participants in 
a focus group discussion. The discussion will last no more than one hour. The 
preliminary venue for the discussion will be the board room at the Academy of 
Emergency Care. The actual date, time and place will be arranged to 
accommodate all invited participants.  Proceedings will be voice tape recorded 
(if you agree) and notes will be taken by a research assistant. This person is 
also an ALS practitioner, who is a lecturer in the Academy of Emergency Care 
at Cape Peninsula University of Technology. A copy of the transcript of the 
proceedings will be made available to you on request and you will be given an 
opportunity to correct any statements that you feel do not reflect your opinion.  
 
Participation is entirely voluntary and you will have the right to withdraw consent 
and discontinue participation in the study at any time without prejudice. You will 
not be made to answer any question that you do not wish to answer. You will 
not be asked about your own practice. It is your perceptions of reasons for non-
compliance by other ALS practitioners that are being sought.   
  
Information from the study will be coded and not contain any identifying details 
to ensure confidentiality. You will not be personally identified in any publication 
containing the results of the study. All participants in the discussion group as 
well as the researcher and his assistant will be required to sign a written 
undertaking to keep all information shared in the discussion confidential.  
 
The audio tapes and written material from the study will be kept in a locked 
cabinet and destroyed after three years. This material will be used solely by the 
investigator, his supervisor and research assistant.  
 
The findings of the study will be made available to you on request.  
 
No discomfort or risks are anticipated. It is hoped that you will enjoy the sharing 
your knowledge and experience with fellow colleagues.  
 
The research supervisor, Dr Linda Grainger (Tel.: 031 3085402) will be 
available to answer any questions you may have concerning the study, the 
procedures, and any risks or benefits that may arise from you participation in 
the study. 
 
 
Thanking you 
 
 
 
 
 
 
L. Christopher 
 
 
 
 
 
APPENDIX 03: INFORMED CONSENT DOCUMENT 
 
 
 
 
 
INFORMED CONSENT  
(To be completed in duplicate by the participant) 
 
TITLE OF RESEARCH PROJECT: An investigation into the non-compliance 
of advanced life support practitioners with the guidelines and protocols of 
the Professional Board for Emergency Care Practitioners  
  
 
NAME OF SUPERVISOR: Dr L Grainger (PhD) (Durban Institute of 
Technology, Tel.: 031 30854020 
 
Date:      
 
PLEASE CIRCLE THE APPROPRIATE ANSWER 
 
1.   Have you read the information sheet?             YES/NO 
 
2.   Have you had the opportunity to ask questions regarding the study?          YES/NO 
 
3.   Have you received satisfactory answers to your questions?           YES/NO 
 
4.   Have you had the opportunity to discuss this study?            YES/NO 
 
5.   Have you received enough information about this study?           YES/NO 
 
6.   Who have you spoken to?        
 
7.   Do you understand the implications of your involvement in the study?          YES/NO 
 
8.   Do you understand that you are free to withdraw from this study?          YES/NO 
a) at any time, and 
b) without having to give reasons for withdrawing 
 
9.   Do you agree to voluntarily participate in this study?            YES/NO 
 
 
 
 
 
 
 
If you have answered “NO” to any of the above questions please obtain 
the information before signing. 
 
PARTICIPANT NAME:    SIGNATURE:     
 
 
WITNESS NAME:    SIGNATURE:     
 
 
RESEARCH STUDENT:   SIGNATURE:     
 
 
 
APPENDIX 04: PAGE EXTRACTS FROM 2003 PBECP GUIDELINES & 
PROTOCOLS 
 
          PAGE   
 
INTRODUCTORY LETTER FROM CHAIRPERSON   02 
 
TABLE OF CONTENTS & NOTE     03 
 
LIST OF MEDICATIONS       05 
 
ASPIRIN         06 
 
ADRENALINE        12 
 
AMIODARONE         17 
 
ATROPINE SULPHATE       19 
 
DIAZEPAM         33 
 
FUROSEMIDE        38 
 
LIGNOCAINE HYDROCHLORIDE     44 
 
MIDAZOLAM        54 
 
MORPHINE SULPHATE       57 
 
SODIUM BICARBONATE       66 
 
REFERENCES         92 
 
CAPABILITIES        93 
 
PROTOCOL LEGISLATION      115 
 
 
 
 
HEALTH PROFESSIONS COUNCIL  
 
 
OF SOUTH AFRICA 
 
 
PROFESSIONAL BOARD FOR  
EMERGENCY CARE PERSONNEL 
 
 
 
ADVANCED LIFE SUPPORT  
PRACTITIONER 
PROTOCOLS 
JANUARY 2003 
 
 
 
ALS PRACTITIONER PROTOCOLS 
 
 
PROFESSIONAL BOARD FOR 
EMERGENCY CARE PERSONNEL 
 
 
HEALTH PROFESSIONS COUNCIL 
OF SOUTH AFRICA 
 
 
 
P O Box 205 553 Vermeulen Street  
Pretoria Arcadia  
0001 Pretoria  
 
. (012) 338-9300 FAX (012) 328-4862  
e-mail: EmmanuelC@hpcsa.co.za Website: http://www.hpcsa.co.za  
 
DEPT: PROFESSIONAL BOARDS: GROUP B  
SENIOR MANAGER: J H COETZER  
 
 
IMPORTANT NOTICE TO ALL REGISTERED PARAMEDICS  
 
Herewith the booklet containing the most recently approved Medications,  
Protocols, Capabilities, Regulations and Ethical Rules for Registered  
Paramedics as approved by the Professional Board for Emergency Care  
Personnel (PBECP).  
 
It is imperative that you familiarise yourself with the entire content thereof,  
as this document and the inherent recommendations and guidelines  
replace all previous versions and publications issued under the authority of  
the Professional Board for Emergency Care Personnel.  
 
Any comment or enquiries in this regard can be directed in writing to Mr E.  
Chanza, the Secretary of the Professional Board for Emergency Care  
Personnel, at the above address or via email on EmmanuelC@hpcsa.co.za  
 
Yours sincerely  
T. Justus  
Chairperson  
PBECP  
 
2 January 2003  
 
ALS PRACTITIONER PROTOCOLS 
 
 
TABLE OF CONTENTS 
 
 
No. TOPIC PAGE  
1. Medications 4  
2. Protocols 70  
3. Commonly Encountered Abbreviations 91  
4. References and Acknowledgements 92  
5. Capabilities 93  
6. Regulations 96  
7. Rules 101  
8. Patients Rights Charter 117  
 
PLEASE TAKE CAREFUL NOTE  
 
These documents are intended to serve as guidelines for the treatment of  
patients by registered paramedics and do not replace sound clinical judgement.  
 
Consultation with fellow paramedics or colleagues in challenging or difficult  
situations is strongly advocated.  
 
It is your medico-legal responsibility to ensure that all the necessary and  
appropriate documentation is duly completed and processed.  
 
All doses, unless otherwise specified, must be calculated according to  
each patient‟s individual requirements.  
 
It is implied, that where applicable, that intraosseous injection / infusion  
doses are as for intravenous doses.  
 
The general principal of drug administration is that of titrating the minimum  
dose against the desired effect / response.  
 
The onus rests upon the paramedic to ensure that he/ she is adhering to  
the correct and most recently approved standards and guidelines.  
 
 
ALS PRACTITIONER PROTOCOLS 
 
 
MEDICATIONS 
 
 
ALS PRACTITIONER PROTOCOLS 
 
 
NO. MEDICATION PAGE  
Acetyl Salicylic Acid 6  
Activated Charcoal 8  
Adenosine 9  
Adrenaline 12  
Amiodarone Hydrochloride 17  
Atropine Sulphate 19  
ß2 Stimulants 22  
Calcium Chloride 10% 25  
Corticosteroids 27  
Dextrose 50% 29  
Oral Glucose Powder/ Gel 32  
Diazepam 33  
Flumazenil 36  
Furosemide 38  
Glyceryl Trinitrate 40  
Ipratropium Bromide 42  
Lignocaine Hydrochloride (systemic) 44  
Lidocaine Hydrochloride (local anaesthetic) 48  
Medical Oxygen 50  
Metoclopramide Monohydrochloride 52  
Midazolam 54  
Morphine Sulphate 57  
Nalbuphine Hydrochloride 59  
Naloxone Hydrochloride 61  
Nitrous Oxide 63  
Sodium Bicarbonate 8.5% 66  
Tramadol Hydrochloride 68  
 
 
ALS PRACTITIONER PROTOCOLS 
 
 
ACETYL SALICYLIC ACID - ASPIRIN  
 
DESCRIPTION:  
 
• Classification  
: Non-steroidal anti-inflammatory / platelet  
aggregation inhibitor  
• Schedule : 1  
PHARMACOLOGICAL ACTION:  
 
• Prostaglandins are responsible for:  
- Somatic pain  
- Inflammatory reaction  
- Hyperthermia  
- Bronchodilation  
- Gastric mucosa protection  
- Platelet aggregation  
- Uterine contractions  
- Patency of foetal ductus arteriosus  
• Aspirin inhibits the production of prostaglandins and thereby leads to the  
opposite effects as noted above, as well as inhibiting the production of  
SRS-A, which can cause acute anaphylaxis  
 
ADVERSE EFFECTS:  
 
• Anaphylactic reaction (some patients, especially asthmatics exhibit  
notable sensitivity to aspirin, which may provoke various hypersensitivity  
/ allergic reactions)  
• Bronchoconstriction in asthmatics  
• Gastric mucosa irritation (dyspepsia; peptic ulceration; peptic bleeding)  
• Bleeding tendency  
• Foetal distress due to obliteration of foetal ductus arteriosus  
• Suppression of uterine contractions  
INDICATIONS:  
 
• Suspected myocardial infarction  
• Decompression sickness  
 
CONTRA-INDICATIONS:  
 
• Known hypersensitivity / allergy to aspirin  
•Bronchial asthma  
• Peptic ulceration  
• Bleeding tendency  
• Patients already receiving Platelet Aggregation Inhibitors or  
Anticoagulants  
•Pregnancy  
• Children <12  
• Severe renal impairment/ renal transplant  
RECAUTIONS:  
 
• Patient must be conscious  
 
PACKAGING:  
 
• Junior aspirin : 150mg tablet  
• Regular aspirin : 300mg tablet  
• Double strength : 500mg tablet  
• Disprin CV : 100mg tablet (purpose-produced for  
anti-coagulation)  
 
DOSAGE AND ADMINISTRATION:  
 
• Administer 150mg - 300mg orally, chewed, crushed, or dissolved  
 
 
ACTIVATED CHARCOAL  
 
DESCRIPTION:  
 
• Classification : Carbon  
• Schedule: : 1  
 
PHARMACOLOGICAL ACTION:  
 
• Activated charcoal adsorbs many poisonous compounds to its surface,  
thereby reducing their absorption by the GIT  
 
 
ADVERSE EFFECTS:  
 
• The patient may experience mild constipation  
 
INDICATIONS:  
 
•To assist in the treatment of certain cases of overdoses and poisonings  
where the agent/s was/were orally ingested  
 
CONTRA-INDICATIONS:  
 
• There are no absolute contra-indications, but there are a number of  
poisonings where it is ineffective and may cause further problems:  
-Of no value in poisonings due to methanol, caustic acids and alkalis,  
iron tablets or lithium  
-Cyanide poisoning  
-Unprotected airway in a patient with decreased level of consciousness  
 
• Do not use if the container was not properly sealed (de-activation due to  
moisture exposure)  
 
PRECAUTIONS:  
 
• It should not be administered simultaneously with Ipecac in order to  
avoid vomiting and thus possible aspiration of activated charcoal  
• Patients with a decreased level of consciousness need to be intubated  
before activated charcoal can be administered via a nasogastric tube  
 
PACKAGING:  
 
• Fine black powder in bottles of 25g and 50g  
 
DOSAGE AND ADMINISTRATION:  
 
• Adult and Paediatric: 0.5g/kg - 1g/kg mixed with water, given orally or  
administered via the nasogastric tube  
ADENOSINE  
 
DESCRIPTION:  
 
• Classification : Endogenous purine nucleoside  
• Schedule : 4  
 
PHARMACOLOGICAL ACTION:  
 
• Conduction in SA and AV node: slows inward Ca2+ flow and therefore  
decreases automaticity and rate of discharge in SA and AV node cells  
• Adenosine is produced from the breakdown (de-phosphorylation) of ATP  
• It blocks the influx of Ca2+ by inhibiting cAMP formation  
• The above therefore terminates supraventricular arrhythmias due to  
re-entry pathways involving the AV node (i.e. most PSVTs)  
• SVT‟s that do not involve the AV node (eg. Wolf-Parkinson-White  
syndrome) are sometimes also terminated by Adenosine, however, this  
is not true for atrial flutter, atrial fibrillation or ventricular tachycardia  
• Adenosine does not adversely affect conduction through accessory  
pathways (e.g. Bundle of Kent)  
 
PHARMACO-KINETICS:  
 
• Half life : 10 seconds  
• Onset of action : immediate  
• Duration of action : 1-2 minutes  
 
INDICATIONS:  
 
• Stable patients with symptomatic Paroxysmal Supra-Ventricular  
(narrow-complex) Tachycardia  
 
CONTRA-INDICATIONS:  
 
• Known hypersensitivity  
• Sick sinus syndrome  
• Underlying second or third degree AV heart block  
•Avoid in patients taking Dipyridamole  
• Atrial flutter  
• Atrial fibrillation  
• Poisoning / drug induced tachycardia  
 
  
 
 
ADVERSE EFFECTS:  
 
•Transient in effects  
• CVS:  
•Vasodilation 
-Flushing 
-Light-headedness 
-Headache 
-Hypotension 
• Arrhythmias  
-Chest pain  
-Palpitations  
- Transient sinus bradycardia / asystole  
- Ventricular ectopics  
• Other:  
• Paresthaesia  
• Diaphoresis  
• Dyspnoea  
•Bronchoconstriction  
• Nausea  
• Metallic taste in mouth  
• Chest tightness  
 
PRECAUTIONS:  
 
• Brief arrhythmia and asystole (up to 30 seconds) may be present after  
conversion  
• Constant ECG monitoring during administration  
• Less effective in patients taking Theophyllin  
• Patient must be supine during administration  
 
PACKAGING:  
 
• 6mg/2ml glass vial  
 
  
DOSAGE AND ADMINISTRATION:  
 
Adults:  
 
• 6mg IVI slam* (followed immediately by 20ml NaCl IVI push)  
• 12mg IVI slam* (after 2 minutes) if no response  
• 12mg IVI slam* (after 2 minutes) may be considered  
 
Children:  
 
• 0.1mg/kg IVI slam* (followed immediately by 5ml NaCl IVI push)  
• 0.2mg/kg IVI slam* (after 2 minutes) if no response  
• 0.2mg/kg IVI slam* (after 2 minutes) may be considered  
• Max. : First dose : 6mg  
: Subsequent doses : 12mg  
 
NOTE:  
 
• An IVI slam is an extremely rapid IVI push using the “two syringe”  
technique  
 
  
ADRENALINE/ EPINEPHRINE  
 
DESCRIPTION:  
 
• Classification : Sympathomimetic  
• Schedule : 4  
 
PHARMACOLOGICAL ACTION:  
 
• Both  
a and ß adrenergic activity  
• The primary beneficial effect of epinephrine in cardiac arrest is due to its  
potent a effects:  
- Increased peripheral vasoconstriction  
- Improved coronary and cerebral blood flow  
- Renders ventricular fibrillation more susceptible to defibrillation  
 
a-EFFECTS  
 
•Vasoconstriction (smooth muscle contraction):  
- Increased peripheral resistance  
- Increased systolic and diastolic blood pressure  
- Decreased skin, GIT and renal blood flow  
• Mydriasis  
• Diaphoresis, erection of hair (piloerection)  
• Intestinal and urinary bladder sphincter constriction  
• Increased breakdown of glycogen to glucose  
 
ß1 -EFFECTS  
 
• Myocardium:  
- Positive inotrope  
- Positive chronotrope  
- Positive dromotrope  
- Increased myocardial oxygen consumption  
 
ß2 -EFFECTS  
 
• Skeletal muscle : contraction  
•Bronchial smooth muscle : relaxation  
•Vascular smooth muscle : vasodilation  
• Bladder smooth muscle : relaxation  
• Intestinal smooth muscle : decreased peristalsis  
• Uterine smooth muscle : relaxation  
• Glycogen stores : breakdown of glycogen to glucose  
  
PHARMACO-KINETICS:  
 
• Onset of action: immediately  
 
ADVERSE EFFECTS:  
 
a- EFFECTS  
 
• Acute hypertension (risk of cerebral haemorrhage or acute pulmonary  
oedema)  
• Nausea and vomiting  
• Cold, clammy skin  
• Acute renal failure  
• Urinary retention  
• Diplopia  
• Hyperglycaemia  
•Vasoconstriction:  
-Gangrene of fingers, toes, nose or ear if administered locally  
-Tissue necrosis from extravasation  
 
ß1 -EFFECTS  
 
•Tachycardia / palpitations  
• Arrhythmias / cardiac arrest  
• Myocardial ischaemia  
 
ß2 -EFFECTS  
 
•Tremors, cramps  
• Restlessness, anxiety, confusion, headache  
 
INDICATIONS:  
 
• Cardiac arrest  
-Ventricular fibrillation, Pulseless ventricular tachycardia, Pulseless  
Electrical Activity, Asystole  
 
• Resistant symptomatic bradycardia unresponsive to oxygenation  
•  
Anaphylaxis  
•  
Upper airway obstruction due to inflammation e.g:  
-Upper airway infection  
-Burns  
• Catastrophic / severe asthma (last resort)  
• Severe hypotension not due to hypovolaemia  
• Beta-blocker / calcium channel blocker toxicity  
 
 
CONTRA-INDICATIONS:  
 
• There are no absolute contra-indications in an emergency setting  
 
PRECAUTIONS:  
 
• Do not mix with alkaline solutions (e.g. sodium bicarbonate)  
• Hypertension  
• Myocardial ischaemia, congestive cardiac failure  
• Diabetes Mellitus  
• Hyperthyroidism  
•Pregnancy  
• Stimulant abuse (e.g. cocaine)  
 
PACKAGING:  
 
• Ampoules: 1mg/1ml (1:1000)/ 0.1%  
•Various pre-filled syringes designed to deliver predetermined doses  
 
DOSAGE AND ADMINISTRATION:  
 
A. CARDIAC ARREST  
Adults:  
 
• Intravenous  
: 1mg IVI push  
• Endotracheal  
: 2x IVI dose, diluted to 10ml with NaCl  
• Repeat  
: every 3 minutes  
• Constant infusion : post-cardiac arrest hypotension  
(SBP<70 mmHg) 2-10µg/min - titrating  
against effect  
 
Children:  
 
• Intravenous  
: 0.01mg/kg IVI push  
• Endotracheal  
- Newborn (at birth) : 0.01mg/kg, diluted to 3ml with NaCl  
- All other children : 0.1mg/kg, diluted to 3-5ml with NaCl  
• Repeat  
: every 3 minutes  
• Constant infusion : post-cardiac arrest hypotension  
0.1-1µg/kg/min - titrating against effect  
 
B. SYMPTOMATIC BRADYCARDIA  
Adult infusion:  
 
• 2-10µg/min  
• Titrate against effect  
 
Children:  
 
• Intravenous bolus : 0.01mg/kg IVI push every 3 minutes  
• Endotracheal bolus : 0.1mg/kg every 3 minutes  
• Infusion : 0.1-1µg/kg/min - titrating against effect  
 
C. ANAPHYLACTIC SHOCK/ CATASTROPHIC OR SEVERE ASTHMA  
Adults:  
 
Intramuscular:  
 
• Initial : 0.5mg  
• Repeat : every 5 minutes  
• Titrate against effect  
• Undiluted  
 
Intravenous (only if decreased cerebral perfusion):  
 
• Caution - extremely dangerous  
• Initial : 0.1-0.2mg IVI slowly  
• Repeat : every 5 minutes  
• Titrate against effect  
• Diluted  
-Dilute 1mg to 10ml with NaCl (i.e. 1:10 000)  
-Further dilute 1 ml of 1:10 000 solution to 10ml with NaCl (1:100 000)  
• Only administer IVI epinephrine to an unconscious patient  
• Continuous ECG monitoring is important  
 
Nebulization (stridor or bronchoconstriction):  
 
• Mild : 1mg Epinephrine + 4ml NaCl  
• Moderate : 2mg Epinephrine + 3ml NaCl  
• Severe : 3mg Epinephrine + 2ml NaCl  
Children:  
 
 
Intramuscular:  
 
• Initial : 0.01mg/kg  
• Repeat : every 5 minutes  
• Titrate against effect  
• Undiluted  
 
Intravenous (only if decreased cerebral perfusion):  
 
• Caution - extremely dangerous  
• Initial : 0.01mg/kg IVI slowly  
• Repeat : every 5 minutes  
• Titrate against effect  
• Diluted  
-Dilute 1mg to 10ml with NaCl (1:10 000)  
-Further dilute 1 ml of 1:10 000 solution to 10ml with NaCl (1:100 000)  
• Only adminster IVI epinephrine to an unconscious child  
• Continuous ECG monitoring is important  
 
Nebulization (stridor or bronchoconstriction):  
 
• Mild : 0.5mg Epinephrine + 4.5ml NaCl  
• Moderate : 1mg Epinephrine + 4ml NaCl  
• Severe : 2mg Epinephrine + 3ml NaCl  
  
AMIODARONE HYDROCHLORIDE  
 
DESCRIPTION:  
 
• Classification : Anti-arrhythmic  
• Schedule : 4  
 
PHARMACOLOGICAL ACTION:  
 
• Amiodarone (an iodine-containing agent) is a very effective anti-arrhythmic 
medication that has a profound effect on the sodium, potassium and  
calcium channels of the cardiac cells whilst simultaneously blocking  
both a and ß adrenergic receptors  
 
PHARMACO-KINETICS:  
 
• Elimination half-life : 40 days  
 
ADVERSE EFFECTS:  
 
•Vasodilation / hypotension  
• Negative inotropic effects  
• Negative chronotropic effects  
•Prolongation of QT interval  
 
INDICATIONS:  
 
• Refractory pulseless ventricular tachycardia or ventricular fibrillation  
• Stable ventricular tachycardia  
• Polymorphic ventricular tachycardia  
•Wide complex tachycardia of uncertain origin  
• As an adjunct to electrical cardioversion of refractory PSVTs, atrial  
tachycardias and for drug induced cardioversion of atrial fibrillation  
(particularly when associated with a rapid ventricular rate)  
 
CONTRA-INDICATIONS:  
 
• Atrioventricular block  
• Sinus bradycardia  
• Sino-atrial block  
• Allergy to Iodine  
• Severe hypokalaemia  
• Porphyria  
• Prior use of Lignocaine hydrochloride  
 
  
PRECAUTIONS:  
 
• MUST be diluted with 5% Dextrose  
• Not recommended for paediatrics  
 
PACKAGING:  
 
• 150mg/3ml ampoule  
 
DOSAGE AND ADMINISTRATION:  
 
A. REFRACTORY PULSELESS VENTRICULAR TACHYCARDIA OR 
VENTRICULAR FIBRILLATION  
• Administer 300mg IVI as a rapid bolus  
• If ventricular fibrillation or pulseless ventricular tachycardia do not  
respond to defibrillation 1 minute post administration (or recurs after  
successful defibrillation), consider the administration of additional  
dosages of 150 mg every 3-5 minutes  
• Infusion: following successful defibrillation with Amiodarone, a slow  
intravenous infusion of 1mg/minute (360mg IV over 6 hours) may be  
administered  
• Maximum cumulative dose of 2.2g IV/24 hours  
 
B. VENTRICULAR TACHYCARDIA /  
SUPRAVENTRICULAR TACHYCARDIA  
• 150mg IVI over 10 minutes (15mg/min)  
• This may be repeated every 10 minutes, titrating against the effect  
• Infusion: a slow IVI of 1mg/minute (360mg over 6 hours)  
• Maximum cumulative dose of 2.2g IV/24 hours  
 
  
ATROPINE SULPHATE  
 
DESCRIPTION:  
 
• Classification : Anti-cholinergic  
• Schedule : 2  
 
PHARMACOLOGICAL ACTION:  
 
• Atropine acts as a competitive antagonist at muscarinic (cholinergic)  
receptor sites, blocking the stimulation of parasympathetic nerve fibres  
• Atropine (anti-cholinergic) effects:  
• Heart: supraventricular conductive tissue  
- Positive inotrope  
- Positive chronotrope  
- Positive dromotrope  
• Eyes : mydriasis  
• Exocrine glands : decreased sweat, tears, salivary and pancreatic  
secretions  
• Lungs : bronchodilation  
• Digestive system : decreased peristalsis, sphincter constriction  
• Urinary : bladder relaxation, sphincter constriction  
 
PHARMACO-KINETICS:  
 
• Half-life : 2 - 4 hours  
• Onset of action : Immediate  
 
ADVERSE EFFECTS:  
 
• Confusion, restlessness  
• Mydriasis (72hrs), diplopia, photophobia, blurred vision  
• Dry mucous membranes: mouth, eyes, respiratory and digestive tract  
•Tachycardia, palpitations, arrhythmias, paradoxical bradycardia  
• Dry, hot, flushed skin  
• Acute urinary retention  
• Constipation, nausea, vomiting  
 
  
INDICATIONS:  
 
• Symptomatic bradycardia, associated with signs or symptoms of shock:  
(chest pain, dyspnoea, decreased level of consciousness, hypotension,  
pulmonary oedema, congestive cardiac failure, AMI)  
• Bradycardia (< 60) associated with:  
- Multiple (> 6/minute) Ventricular Extra Systoles  
• Repeated intubation attempts in paediatric patients  
• Asystolic cardiac arrest in adults  
• Pulseless electrical activity with bradycardia  
•Organophosphate poisoning  
 
CONTRA-INDICATIONS:  
 
• Not indicated for use in neonates  
• There are no absolute contra-indications in an emergency setting  
 
PRECAUTIONS:  
 
• First rule out other causes of bradycardia:  
- e.g. hypoxia, hypothermia, head injuries (raised intra-cranial pressure),  
and healthy, asymptomatic athletes)  
• Second degree type II and third degree AV heart blocks with wide QRS  
complexes (indicating a possible point of origin below the supraventricular 
conductive tissue) as atropine may induce a paradoxical slowing of  
the heart rate  
• Children are more prone to a paradoxical bradycardia in reaction to  
small dosages due to an active parasympathetic nervous system  
• Ischaemic heart disease, hypertension  
 
PACKAGING:  
 
0.5mg/1ml glass / plastic ampoule  
0.6mg/1ml glass / plastic ampoule  
1.0mg/1ml glass / plastic ampoule  
1.2mg/1ml glass / plastic ampoule  
 
 
  
DOSAGE AND ADMINISTRATION:  
 
Treat all reversible causes of bradycardia  
 
A. ASYSTOLE/ P.E.A. - BRADYCARDIA  
 
Adults:  
 
• Intravenous : 1mg IVI push  
• Endotracheal : 2 x IVI dose  
• Repeat : every 3 minutes  
• Maximum : 0.04mg/kg (3mg) IVI or 0.08mg/kg (6mg) ET  
= total vagolytic dose  
 
Children:  
 
• Not recommended  
 
B. SYMPTOMATIC BRADYCARDIA  
Adults:  
 
• Intravenous : 0.5mg IVI push  
• Repeat : 0.5-1mg every 3 minutes  
• Maximum : 0.04mg/kg (3mg) = total vagolytic dose  
 
Children:  
 
• Intravenous : 0.02mg/kg IVI push  
• Repeat : once, after 3 minutes  
• Max single dose : 0.5mg (child); 1mg (adolescent)  
• Min single dose : 0.1mg  
• Maximum total : 0.04mg/kg = total vagolytic dose  
 
C. ORGANOPHOSPHATE POISONING  
Adults:  
 
• Intravenous : 0.5 - 2mg IVI  
• Repeat : every 3 minutes until atropinization occurs  
• Titrate against effect  
• No absolute maximum dosage  
 
Children:  
 
• Intravenous : 0.02mg/kg  
• Repeat : every 3 minutes until atropinization occurs  
• Titrate against effect  
• Min single dose : 0.1mg  
• No absolute maximum dosage  
 
 
ß2 STIMULANTS  
 
DESCRIPTION:  
 
• Classification  
: Bronchodilators  
• Schedule : 2 - Aerosol  
: 3 - Inhalant solutions and unit dose vials  
: 4 - Ampoules  
 
PHARMACOLOGICAL ACTION:  
 
• Hexoprenaline, Fenoterol and Salbutamol are selective ß2 stimulants  
acting on the ß2 receptors in the lungs:  
- Bronchial smooth muscle : bronchodilation  
• At higher/repeated dosages, the systemic absorption progressively  
increases, thus acting on other organs with ß2 receptors e.g.  
-Skeletal muscle : contraction  
- Vascular smooth muscle : vasodilation  
-Bladder smooth muscle : relaxation  
-Intestinal smooth muscle : decreased peristalsis  
-Uterine smooth muscle : tocolysis  
- Glycogen stores : break down of glycogen to glucose  
• At higher/repeated dosages, the selectivity is also progressively lost and  
ß1 effects (myocardium) are experienced:  
- Positive inotrope  
- Positive chronotrope  
- Positive dromotrope  
- Increased myocardial oxygen consumption  
 
PHARMACO-KINETICS:  
 
• Onset of action : 5-15 minutes  
• Duration of action : 3-6 hours  
 
ADVERSE EFFECTS:  
 
•Tremors, restlessness, anxiety, confusion, headache  
• Hypotension  
•Tachycardia, palpitations  
• Cramps  
• Nausea, vomiting  
• Urinary retention  
•Tocolysis  
• Hyperglycaemia  
 
INDICATIONS:  
 
• Acute bronchospasm  
•Premature or obstructed labour  
 
CONTRA-INDICATIONS:  
 
• Known hypersensitivity / allergy to ß2 stimulants  
• Neonates  
 
PRECAUTIONS:  
 
• Special caution must be used when a patient presents with a pulse rate  
greater than 120 beats / minute  
• Intravenous ß2 stimulants should be used with caution in patients with:  
- Ischaemic heart disease, cardiac arrhythmias, cardiac failure  
- Occlusive vascular disorders, hypertension, hypotension  
- Hyperthyroidism, diabetes mellitus  
- Prostate hypertrophy  
 
PACKAGING:  
 
• Fenoterol : Berotec aerosol : 100µg  
: Resp. solution : 1mg/ml  
: UDV : 1.25mg/2ml or 0.5mg/2ml  
: IV solution :  
• Hexoprenaline : Ipradol aerosol : 100µg  
Sulphate  
: Resp. solution : 0.25mg/ml  
: UDV :  
: IV solution : 5µg/2ml or 25µg/10ml  
 
• Salbutamol : Ventolin aerosol : 100µg  
: Resp. solution : 5mg/ml  
: UDV : 2.5mg/2.5ml or 5mg/2.5ml  
: IV solution : 0.5mg/ml or 1mg/ml  
 
  
DOSAGE AND ADMINISTRATION:  
 
A. ACUTE BRONCHOSPASM  
Aerosol:  
 
•2 puffs may be administered by the patient or paramedic during an  
episode, which may then be repeated every 2 minutes  
Inhalant solution: (use half the dosage for paediatrics)  
 
• 2ml Fenoterol (1.25mg/2ml)(UDV) + 3ml NaCl  
• 2ml Fenoterol (0.5mg/2ml) (UDV) + 3ml NaCl (paediatric solution)  
• 1ml Fenoterol solution (1mg/ml) + 4ml NaCl  
• 2ml Hexoprenaline (0.25mg/ml) + 3ml NaCl  
• 1ml Salbutamol (5mg/ml) + 4ml NaCl  
• Repeat if necessary  
Ampoules:  
 
Adults:  
 
• Dilute 5µg IV Hexoprenaline with 8ml NaCl = 5µg/10ml  
• Administer 1ml/min (total of 5µg/10 min)  
• Repeat once if necessary  
Paediatrics:  
• 3-6 months : 1µg Hexoprenaline diluted to 10ml IVI over 10 minutes  
• 6-12 months : 2µg Hexoprenaline diluted to 10ml IVI over 10 minutes  
• 1-3 years : 3µg Hexoprenaline diluted to 10ml IVI over 10 minutes  
• 3-10 years : 4µg Hexoprenaline diluted to 10ml IVI over 10 minutes  
 
B. PREMATURE / OBSTRUCTED LABOUR  
Hexoprenaline:  
 
Bolus:  
 
• Dilute 5µg IV Hexoprenaline with 8ml NaCl = 5µg/10ml  
• Administer 1ml/min until:  
- Total of 5µg/10 min  
-Mothers‟ heart rate > 120bpm  
-Contractions cease  
Maintenance Infusion:  
 
• 0.3µg – 0.45µg/min  
 
  
CALCIUM CHLORIDE 10%  
 
DESCRIPTION:  
 
• Classification : Electrolyte/ mineral  
• Schedule : 1  
PHARMACOLOGICAL ACTION:  
 
• Calcium is essential for the initiation and maintenance of normal  
muscular contractions  
• Calcium has a positive inotrope effect on the cardiac muscle  
• In addition, calcium aids general vasoconstriction (vascular smooth  
muscle)  
 
ADVERSE EFFECTS:  
 
• Tissue necrosis (if extravasation occurs)  
• Thrombophlebitis  
•Vasospasm (coronary and cerebral vessels)  
 
INDICATIONS:  
 
Any of the following suspected cardiac arrest/ pre-arrest conditions:  
 
• Hyperkalaemia (indicated by flattened p-waves, broadened QRS complexes, 
tall peaked t-waves e.g. renal failure, severe tissue damage  
crush syndrome)  
• Calcium channel blocker toxicity (e.g. verapamil)  
• ß blocker toxicity (e.g. propanolol)  
• Hypocalcaemia (e.g. massive blood transfusion)  
• Hypermagnesaemia  
 
CONTRA-INDICATIONS:  
 
• Not for routine use in cardiac arrest unless the above indications are present  
• There are no absolute contra-indications in cardiac arrest  
• Not indicated for use in neonates  
 
  
 
PRECAUTIONS:  
 
• Rapid administration may cause bradycardia/ asystole  
• Use cautiously in patients receiving Digitalis  
- May induce increased cardiac irritability  
• Never combine with sodium bicarbonate in the same infusion  
- May cause precipitations  
• Never administer via the endotracheal route  
•Well placed and free flowing IVI line is mandatory  
 
PACKAGING:  
 
• 1g/10ml (10%) glass/plastic ampoule  
DOSAGE AND ADMINISTRATION:  
 
Adults:  
 
• 10ml of calcium chloride 10% solution, slowly IVI  
• If being administered pre-arrest, administer at 1ml/min  
Children:  
 
• 0.2ml/kg of calcium chloride 10% solution, slowly IVI  
• If being administered pre-arrest, administer at 1ml/min  
 
CORTICOSTEROIDS  
 
DESCRIPTION:  
 
• Classification : Corticosteroids  
• Schedule : 4  
 
PHARMACOLOGICAL ACTION:  
 
• Corticosteroid hormones are produced by the adrenal cortex that acts  
via messages to the cell nucleus (slow onset of action)  
• Physiological release follows a circadian rhythm, being maximal at 08h00  
and minimal at 24h00 (high incidence of nocturnal asthma attacks in children)  
• Inhibition of inflammatory/ allergic reactions  
• Suppression of antibody production  
• Stabilization of mast cell membranes  
• Restoration of ß2 receptor responsiveness (up-regulation) of receptors  
 
PHARMACO-KINETICS:  
 
Hydrocortisone Methylprednisolone  
 
• Half-life 8-12 hours 18-36 hours  
• Approximate equivalent IV dose 5 mg 1 mg  
 
ADVERSE EFFECTS:  
 
•Side effects occur following prolonged use and are of little consequence  
in an emergency setting  
 
INDICATIONS:  
 
• Acute hypersensitivity / allergic reactions  
• Management of bronchospasm due to allergic and inflammatory disorders/ 
anaphylaxis  
 
CONTRA-INDICATIONS:  
 
• There are no absolute contra-indications in the emergency setting  
 
PRECAUTIONS:  
 
• There are no applicable precautions in the emergency setting  
 
 
PACKAGING:  
 
• Hydrocortisone:  
100mg/2ml or 500mg/4ml  
• Methylprednisolone:  
40mg/ml or 125mg/2ml or 500mg/8ml or 1000mg/16ml  
 
DOSAGE AND ADMINISTRATION:  
 
Adults:  
 
• Hydrocortisone:  
200mg - 500mg IVI slowly  
• Methylprednisolone:  
62.5mg - 125mg IVI slowly  
 
Children:  
• Hydrocortisone:  
5mg/kg IVI slowly  
• Methylprednisolone:  
1mg/kg IVI slowly (maximum dose 30mg)  
  
DEXTROSE 50%  
 
DESCRIPTION:  
 
Classification : Carbohydrate  
Schedule : 1  
 
PHARMACOLOGICAL ACTION:  
 
• Monosaccharides (basic units/ building blocks of carbohydrates)  
• Because monosaccharides are the most basic units to which all carbohydrates 
are broken down, glucose is therefore immediately available as  
a source of energy  
 
ADVERSE EFFECTS:  
 
• Local irritation of vein  
• Thrombophlebitis  
• Extravasation  
• Local tissue necrosis  
• Hyperosmolarity  
• Diuresis  
• Hyperglycaemia  
 
INDICATIONS:  
 
• Acute management of symptomatic hypoglycaemia  
• HGT < 4.4mmol/l  
 
CONTRA-INDICATIONS:  
 
• There are no absolute contra-indications in the presence of true symptomatic 
hypoglycaemia  
• Do not administer dextrose routinely during resuscitation unless there is  
confirmed hypoglycaemia  
 
PRECAUTIONS:  
 
• Dehydration and hypovolaemia  
- High concentrations of IVI dextrose cause an increase in osmolarity  
that draws H2O from the cells and causes diuresis, aggravating  
dehydration  
- Dehydration / hypovolaemia and hypoglycaemia must be corrected  
simultaneously  
• Intracranial haemorrhage  
- Glucose leaking into the cerebral tissue will aggravate the injury and  
result in cerebral oedema  
- Careful titration in all head injured patients is vital  
• Renal failure  
- Excessive glucose is excreted through the kidneys  
All complications and adverse effects can be prevented by:  
 
• Limiting the use of dextrose to symptomatic hypoglycaemic patients  
• Administering dextrose slowly through a free-flowing IV line  
• Re-assessing the HGT 5 minutes post administration  
•Avoiding hyperglycaemia  
• Never combine dextrose and sodium bicarbonate in the same infusion  
(i.e. hyperosmolarity)  
 
PACKAGING:  
 
• 20/ 50ml ampoules of a 50% solution (0.5g/ml)  
• 50ml vacolitre containing a 50% solution  
DOSAGE AND ADMINISTRATION:  
 
Adults:  
• 10g (20ml of a 50%) slowly IVI  
• Repeat every 5 minutes should blood glucose remain low  
 
Children:  
 
• 1ml/kg of a 50% solution which is then diluted to a 25% solution  
• Repeat every 5 minutes should blood glucose remain low  
Neonates:  
• 1ml/kg of a 50% solution which is then diluted to a 12.5% solution with  
sterile water*  
• Repeat every 5 minutes should blood glucose remain low  
 
  
NOTE:  
 
• If blood glucose remains low after 3 doses, reassess patient, equipment  
and administration technique  
•Treat the patient and not the test result  
•* Sterile water is indicated in neonates due to the risk of hypernatraemia  
with NaCl boluses  
 
  
ORAL GLUCOSE POWDER/ GEL  
 
DESCRIPTION:  
 
• Classification : Carbohydrate  
• Schedule : 1  
 
PHARMACOLOGICAL ACTION:  
 
• Administration of an oral glucose solution / preparation provides a  
source of soluble carbohydrates to the tissues in order to raise the blood  
glucose levels  
 
ADVERSE EFFECTS:  
 
• Hyperglycaemia  
 
INDICATIONS:  
 
• Acute management of hypoglycaemia in a conscious patient  
• HGT < 4,4mmol/l  
 
CONTRA-INDICATIONS:  
 
• Decreased level of consciousness  
 
PRECAUTIONS:  
 
• Patient must be lateral if unconscious  
•Avoid aspiration  
 
PACKAGING:  
 
• 25g and 50g powder sachet  
• 25g and 50g gel  
 
DOSAGE AND ADMINISTRATION:  
 
• 25g of gel applied to the oral mucosa of the patient with a gloved finger  
•Preferably dilute powder in glass of water if patient is conscious  
• Repeat after 5 minutes should blood glucose remain low  
 
  
ALS PRACTITIONER PROTOCOLS 
 
 
DIAZEPAM  
 
DESCRIPTION:  
 
• Classification : Sedative/ hypnotic/ anti-convulsant  
• Schedule : 5  
• Antidote : Flumazenil  
 
PHARMACOLOGICAL ACTION:  
 
• Diazepam is a benzodiazepine acting on the central nervous system  
• These actions result from the potentiation of the neural inhibition that is  
mediated by GABA  
• It has anxiolytic, sedative, sleep-inducing, anticonvulsant and muscle  
relaxant properties  
• It can also cause anterograde amnesia  
 
PHARMACO-KINETICS:  
 
• Elimination half-life : 20-70 hours  
• Onset of action : 1-5 minutes  
• Duration of action : 15-120 minutes  
 
ADVERSE EFFECTS:  
 
• CNS : Depression  
• Resp : Depression (rapid administration)  
•CVS : Hypotension (large dosages)  
• Nausea, vomiting  
• Diplopia  
• Thrombophlebitis  
• Paradoxical excitation  
• Physical and psychological dependence  
 
INDICATIONS:  
 
• Anti-convulsive therapy  
• Sedation  
• Muscle relaxant  
 
  
CONTRA-INDICATIONS:  
 
• Known hypersensitivity/ allergy to benzodiazepines  
•  
In a patient with persistent convulsions, there are no other absolute contra-
indications, but due to its ability to cause respiratory depression, it  
must not be used if the patient cannot be artificially ventilated should the  
need arise  
 
PRECAUTIONS:  
 
• Respiratory disorders:  
-COPD / asthma / hypoventilation  
• Cardiovascular disorders:  
- Hypotension / hypovolaemia / congestive cardiac failure  
• Psychosis:  
- No anti-psychotic effects  
- May increase agitation  
• Active Labour:  
- Neonatal suppression  
• Rule out all reversible causes of convulsions e.g. hypoglycaemia  
• In IM injections absorption is erratic and unreliable  
•Elderly, debilitated and paediatric patients are more sensitive to the  
adverse effects  
• Alcohol, barbiturates, narcotics and other depressants acting on the  
central nervous system may enhance / alter the effects of diazepam  
• Do not mix diazepam with any other drug or solution unless advised  
otherwise by the manufacturers instruction brochure  
 
PACKAGING:  
 
• 10mg/2ml amber coloured ampoule  
 
DOSAGE AND ADMINISTRATION:  
 
• Only administer during active convulsions  
• Do not dilute, unless advised otherwise by the manufacturers instruction  
brochure  
 
Adults:  
 
• Sedation/ convulsions 5 mg/min slowly IVI (0.15mg/kg)  
• Repeat every 2 - 5 minutes  
• Titrate against effect (use the lowest effective dosage)  
•Maximum 20mg  
• Rectally 10mg (maximum 20mg)  
 
Children:  
 
• Sedation / convulsions 0.2 mg/kg slowly IVI  
• Repeat every 2 - 5 minutes  
• Titrate against effect (use the lowest effective dosage)  
• Maximum : children > 5 years : 10mg  
: children < 5 years : 5mg  
• Rectally : 0.5 mg/kg (maximum 1mg/kg)  
 
  
FLUMAZENIL  
 
DESCRIPTION:  
 
• Classification : Benzodiazepine antagonist  
• Schedule : 5  
 
PHARMACOLOGICAL ACTION:  
 
• Binds to GABA receptors (competing with benzodiazepines)  
• Flumazenil is a benzodiazepine antagonist that specifically blocks the  
central effects of agents acting through the receptor-receptor complex  
by competitive inhibition  
 
PHARMACO-KINETICS:  
 
• Half-life : 60 minutes  
• Onset of action : 1-2 minutes  
• Duration of action : 45 minutes  
 
ADVERSE EFFECTS:  
 
• CVS:  
-Flushed skin  
- Thrombophlebitis  
-Arrhythmias  
-Hypertension  
-Chest pain  
• CNS:  
-Excitation  
-Convulsions  
• General:  
-Acute benzodiazepine withdrawal in dependant patients  
- Tremors and involuntary movements  
 
INDICATIONS:  
 
• Reversal of central nervous system sedative effects and respiratory  
depression due to benzodiazepines alone  
• Coma (non-traumatic)  
 
CONTRA-INDICATIONS:  
 
• Known hypersensitivity  
• Suspected Tricyclic Anti-depressant overdose  
• Unknown mixed-drug overdose  
• Patients with a high risk of convulsions  
• Neonates  
 
PRECAUTIONS:  
 
• Suspected benzodiazepine addiction  
• The half-life is shorter than that of most benzodiazepines (therefore  
monitor for recurrent respiratory depression)  
 
PACKAGING:  
 
• 0.1mg/1ml 10ml ampoule = 1.0mg  
• 0.1mg/1ml 5ml ampoule = 0.5mg  
 
DOSAGE AND ADMINISTRATION:  
 
Adults:  
 
• Initial bolus : 0.2mg slowly IVI  
• Repeat : 0.1mg at 1 minute intervals  
• Max dose : 1mg  
 
Children:  
 
• Safety has not been established  
 
 
 
FUROSEMIDE  
 
DESCRIPTION:  
 
• Classification : Diuretic  
• Schedule : 3  
 
PHARMACOLOGICAL ACTION:  
 
• Furosemide is a loop diuretic acting primarily by inhibiting electrolyte  
(Na+) and fluid re-absorption in the ascending limb of the loop of Henlé  
• Loop diuretics increase the excretion of sodium, chloride, potassium,  
calcium and magnesium. Water follows passively  
• In patients with pulmonary oedema, furosemide increases systemic  
venous capacitance, thereby decreasing left ventricular filling pressure  
(pre-load)  
 
PHARMACO-KINETICS:  
 
• Half-life : 30-90 minutes  
• Diuretic action : within 5 minutes  
• Duration of action : 120 minutes  
 
ADVERSE EFFECTS:  
 
• Hyponatraemia  
• Hypokalaemia  
• Hypotension  
• Hypovolaemia  
• Hyperuricaemia / gout  
• Tinnitus and deafness (following rapid IVI administration)  
 
INDICATIONS:  
 
• Acute pulmonary oedema of cardiac, hepatic or renal origin  
• Hypertensive emergencies  
 
CONTRA-INDICATIONS:  
 
• Known hypersensitivity / allergy to furosemide or sulphonamides  
• Systolic blood pressure < 90 mmHg  
• Hypovolaemia / dehydration  
 
PRECAUTIONS:  
 
• Urinary obstruction or retention  
• Patients with hypokalaemia  
• Elderly patients are particularly susceptible to dehydration and hypotension  
 
PACKAGING:  
 
• 20mg in 2ml ampoule  
• 50mg in 5ml ampoule  
• 250mg in 25ml ampoule  
 
DOSAGE AND ADMINISTRATION:  
 
Adults and Children:  
 
• 0.5mg - 1mg/kg IVI slowly over 1-2 minutes  
 
  
GLYCERYL TRINITRATE  
 
DESCRIPTION:  
 
• Classification : Vasodilator  
• Schedule : 3  
 
PHARMACOLOGICAL ACTION:  
 
• Nitrates cause dilation of the venous system, which decreases venous  
return (pre-load) and decreases myocardial wall tension  
• This improves sub-endocardial perfusion  
•Nitroglycerin dilates the coronary arteries, antagonises coronary  
vasospasm and increases coronary collateral blood flow to the  
ischaemic myocardium  
 
PHARMACO-KINETICS:  
 
• Half-life : 1-4 minutes  
• Onset of action : 1-3 minutes  
• Duration of action : 30-60 minutes  
 
ADVERSE EFFECTS:  
 
• Headache  
• Hypotension  
•Tachycardia  
• Flushed skin  
 
INDICATIONS:  
 
• Angina pectoris  
• Acute myocardial infarction  
• Acute pulmonary edema  
• Hypertensive emergency  
 
CONTRA-INDICATIONS:  
 
• Known hypersensitivity / allergy to nitrates  
• Children  
• Hypotension (SBP < 90 mmHg)  
• Decrease in blood pressure > 10%  
• Sildenafil (Viagra) taken during the preceding 24 hours  
• Bradycardia / severe tachycardia  
• Right inferior ventricular infarction  
PRECAUTIONS:  
 
•Patient must be positioned in semi-fowlers or supine position prior to  
drug administration  
•Do not administer simultaneously with other vasodilators  
•Do not shake the aerosol prior to administration  
 
PACKAGING:  
 
•Nitrolingual spray container containing 200 x 0.4mg atomized sprays  
•Tablets, 0.5mg in amber coloured container  
 
DOSAGE AND ADMINISTRATION:  
 
•One spray / tablet onto the oral mucosa (preferably sub-lingual)  
• Repeat every 5 minutes if no improvement noted  
• Maximum of 3 sprays/ tablets  
•Terminate administration if systolic blood pressure (SBP):  
- Decreases by more than 10% in a normotensive patient  
- Decreases by more than 30% in a hypertensive patient  
- Measures lower than 90 mmHg  
 
 
  
IPRATROPIUM BROMIDE  
 
DESCRIPTION:  
 
•Classification : Bronchodilators - inhalants  
•Schedule : 2  
PHARMACOLOGICAL ACTION:  
 
•Ipratropium bromide causes relaxation of bronchial muscles due to its  
anti-cholinergic effects (blocks parasympathetic system)  
•Its bronchodilation action is particularly effective in conjunction with  
ß2-stimulants  
 
PHARMACO-KINETICS:  
 
•Onset of action : 30 minutes  
•Duration of action : 4-6 hours  
 
ADVERSE EFFECTS:  
 
•With larger / repeated dosages, it is absorbed from the lungs into the  
systemic circulation resulting in systemic anti-cholinergic effects  
- Tachycardia  
- Dry, hot skin  
-Mydriasis  
- Urinary retention  
 
INDICATIONS:  
 
•To be used in conjunction with ß2-stimulants for acute bronchospasm  
 
CONTRA-INDICATIONS:  
 
•Known hypersensitivity to ipratropium bromide or other anti-cholinergic  
drugs  
• Children up to the age of 4 years  
 
PRECAUTIONS:  
 
•The onset of action is only after 30 minutes, which is much longer than  
the ß2-stimulants  
 
 
  
•The duration of action is 4 - 6 hours, which is also longer than the ß2-
stimulants  
 
PACKAGING:  
 
•Unit dose vial (UDV) containing 0.25 mg or 0.5 mg/2ml  
•Aerosol spray (home medication) 0.04mg  
•Nebulizer solution (bottle) 0.25mg/ml  
 
DOSAGE AND ADMINISTRATION:  
 
Adults:  
UDV:  
•Ipratropium bromide 0.5mg + appropriate ß2 stimulant + balance of NaCl  
to a total of 5ml solution  
•Nebulised over 10 minutes  
•May be repeated  
 
Aerosol:  
•The patient or paramedic may administer this during an episode. Two  
puffs of ipratropium bromide are administered if no improvement occurs  
following ß2 stimulant administration  
•May be repeated  
 
Children 5 years and older:  
 
•Use half the adult dose  
•Ipratropium bromide 0.25mg + appropriate ß2 stimulant + balance of  
NaCl to a total of 5ml solution  
•Nebulised over 10 minutes  
• May be repeated  
 
NOTE:  
 
•Ipratropium bromide + ß2 stimulant have a synergistic effect  
•May be particularly useful in patients with bronchospasm who have  
taken beta-blockers  
 
 
  
LIGNOCAINE HYDROCHLORIDE/  
LIDOCAINE (Systemic)  
 
DESCRIPTION:  
 
• Classification : Ventricular anti-arrhythmic  
• Schedule : 4  
 
PHARMACOLOGICAL ACTION:  
 
• Conduction in SA and AV node has a slow inward Ca 2+ flow (adenosine  
and Ca 2+ antagonists blocks the flow of Ca 2+ and therefore mainly  
affects supra-ventricular conduction)  
• All other myocardial tissues (including His-Purkinje system) have a fast  
inward Na+ flow. Lidocaine blocks the flow of Na+ and K+ ions in  
ischaemic cells and therefore mainly affects the ventricular conduction  
• Lidocaine acts as a membrane stabilizer resulting in the following  
effects:  
-Inhibition of fast sodium channels  
- Termination of ectopic beats  
-Shortened action potential duration  
- Decreased myocardial excitability  
- Protection of myocardium against arrhythmias  
- In toxic doses though, lignocaine will cause generalised myocardial  
suppression  
 
PHARMACO-KINETICS:  
 
• Half-life : 1-2 hours  
• Onset of action : Immediate  
• Duration of action : 10-20 minutes  
 
ADVERSE EFFECTS:  
 
• Early signs of systemic toxicity include, numbness of the tongue and  
peri-orbital region  
• The main systemic toxic effects are central nervous system excitation  
evidenced by:  
-Restlessness  
-Muscle twitching  
-Convulsions  
• This is followed by central nervous system depression evidenced by:  
- Drowsiness  
- Respiratory failure  
-Coma  
• There is a simultaneous cardiovascular system depression:  
-Hypotension  
- Bradycardia  
- Cardiac arrest  
 
INDICATIONS:  
 
•Ventricular fibrillation  
•Ventricular tachycardia  
• Symptomatic / unstable ventricular ectopic beats:  
-Runs  
-Frequent (> 6/min)  
-Ventricular bigeminal / trigeminal rhythm  
-Coupled beats (salvos / triplets)  
-Multi-focal ectopics  
-R on T phenomenon  
-Associated with AMI  
• Wide-complex tachycardia of unknown origin  
 
CONTRA-INDICATIONS:  
 
• Known hypersensitivity / allergy to lignocaine  
• Heart blocks (second or third degree AV blocks)  
• Bradycardia  
• Hypotension not due to ventricular arrhythmia  
• Severe sinus node dysfunction  
• Accelerated idioventricular rhythm  
• Prior use of Amiodarone Hydrochloride  
 
PRECAUTIONS:  
 
• Caution must be exercised in the presence of:  
-Geriatrics  
- Impaired liver function  
- Left ventricular failure  
• Discontinue immediately if signs of toxicity occur  
 
PACKAGING:  
 
• 50mg/5ml (1%) ampoule  
• 100mg/5ml (2%) ampoule  
• 500mg/5ml (10%) ampoule  
• 1000mg/5ml (20%) ampoule  
 
  
DOSAGE AND ADMINISTRATION:  
 
ADULTS:  
 
A. STABLE VENTRICULAR TACHYCARDIA/ SYMPTOMATIC VENTRICULAR 
ECTOPICS/ WIDE COMPLEX TACHYCARDIA  
• Loading dose : 1mg/kg slow IVI  
• Repeat loading dose : 0.5mg/kg every 5 minutes  
• Maximum (for loading dose) : 3mg/kg  
• Note: administration of bolus doses must be terminated when:  
- A maximum of 3mg/kg has been administered  
- The blood pressure drops by >10 mmHg  
- Ventricular arrhythmias cease  
-Signs of toxicity develop  
• Then establish a maintenance infusion of 1-4mg/min  
• Repeat the loading dose (0.5-1mg/kg) if the maintenance infusion was  
started >15 minutes after the last loading dose  
• Geriatrics (> 65 years) should receive half the adult dose for the bolus  
and infusion  
 
B. UNSTABLE VENTRICULAR TACHYCARDIA (i.e. decreased level of 
consciousness, hypotension, pulmonary oedema, congestive cardiac failure  
or acute myocardial infarction)  
• Synchronised cardioversion according to protocol  
• Follow with a loading dose and maintenance infusion once successful  
(see A)  
• If the ventricular tachycardia recurs after successful cardioversion,  
cardiovert again using the last successful joules. Once successful,  
administer another bolus dose (0.5-1mg/kg) of lignocaine and continue  
the infusion. Should this reoccur, continue repeating this process,  
administering up to a maximum bolus dose of 3mg/kg in total. Consider  
increasing the infusion‟s administration rate up to a maximum of  
4mg/min.  
• Should the monitor not discharge on synchronous mode, asynchronous  
cardioversion must be performed in order to avert any further delays in  
an already seriously compromised patient  
  
C. VENTRICULAR FIBRILLATION  
• Cardiac arrest protocol  
• Administer a bolus dose of 1mg/kg IVI push (or 2mg/kg ET) followed by  
0.5mg/kg IVI (or 1mg/kg ET) every 5 minutes  
• Maximum total dose of 3mg/kg IVI or 6mg/kg ET  
• Defibrillate one minute after each dose of lignocaine if cardiac arrest persists  
 
D. POST DEFIBRILLATION/ SYNCHRONISED CARDIOVERSION  
• Follow with loading dose and maintenance infusion (see A)  
 
CHILDREN:  
 
• As for adults, except maintenance infusion is 20-50 µg/kg/min  
  
LIGNOCAINE HYDROCHLORIDE/ LIDOCAINE  
(Local anaesthetic)  
 
DESCRIPTION:  
 
• Classification : Local anaesthetic  
• Schedule : 4  
 
PHARMACOLOGICAL ACTION:  
 
• Lidocaine spray has a local anaesthetic action when applied to mucous  
membranes  
• The direct administration of a local anaesthetic agent into tissues  
induces the absence of sensation to a localized area of the body. Brief  
surgical (suturing) or dental procedures are the most common indications for 
local anaesthesia  
• The anaesthetic may be applied topically to the surface of the mucous  
membrane or injected subcutaneously  
• Lidocaine spray is ineffective when applied to intact skin  
 
PHARMACO-KINETICS:  
 
• Onset of action : 2-5 minutes  
• Duration of action : 10-15 minutes  
•Effects may, however, last for up to 3 hours with the addition of a 
vasoconstrictor (e.g. epinephrine)  
 
ADVERSE EFFECTS:  
 
• Signs of toxicity are the same as for systemic lidocaine administration  
• Early signs of systemic toxicity include numbness of the tongue and  
peri-orbital region  
• The main systemic toxic effect is central nervous system excitation  
evidenced by:  
-Restlessness  
-Muscle twitching  
-Convulsions  
• This is followed by central nervous system depression evidenced by:  
- Drowsiness  
- Respiratory failure  
-Coma  
• There is a simultaneous cardiovascular system depression:  
-Hypotension  
- Bradycardia  
- Cardiac arrest  
  
INDICATIONS:  
 
• Local anaesthesia  
-Endotracheal intubation  
-Suturing  
-Intraosseous infusion placement (conscious patients)  
-Femoral vein cannulation placement (conscious patients)  
CONTRA-INDICATIONS:  
 
• Known hypersensitivity / allergy to lidocaine  
•Pre-hospital personnel should not use lignocaine anaesthetic injection  
for suturing purposes unless advise is sought from a suitable practitioner  
• Lidocaine (with epinephrine as a vasoconstrictor) must not be used in  
areas supplied by end arteries e.g. fingers, toes, nose and ears  
• Gunshot wounds, dog bites, human bites, or wounds where the tendons  
have been separated should not be sutured pre-hospital  
• An aseptic technique must otherwise be adhered to  
 
PACKAGING:  
 
• Aerosol : 10 mg/spray discharge  
• Injection cartridge : 20mg/ml (1.8 ml)  
• Multi-dose vial : 100mg/10ml (1%), 200mg/10ml (2%)  
 
DOSAGE AND ADMINISTRATION:  
 
TOPICAL SPRAY:  
 
• Administer 2 sprays onto identified area  
• Use the minimum effective dose  
 
INJECTION FOR LOCAL ANAESTHESIA:  
 
• Infiltrate the skin with lidocaine, sufficient to produce local anaesthesia  
or as discussed with a suitably qualified practitioner  
• Dose/kg  
- 1-3mg/kg (maximum dose) without adrenaline  
- 1-6mg/kg (maximum dose) with adrenaline  
  
MEDICAL OXYGEN  
 
DESCRIPTION:  
 
• Classification : Naturally occurring atmospheric gas  
 
PHARMACOLOGICAL ACTION:  
 
• Oxygen is an odourless, tasteless, colourless gas present in the atmosphere 
at a concentration of approximately 21%  
• It reverses the deleterious effects of hypoxaemia on the brain, heart and  
other vital organs  
• Expired air contains 16-17% oxygen  
• During optimal active CPR only 25-30% of the normal cardiac output is  
maintained and for these reasons supplemental oxygen should be  
administered  
 
INDICATIONS:  
 
• Glasgow Coma Scale of less than 15/15  
• Any patient with abnormal vital signs  
• Any respiratory insufficiency or arrest  
• Acute decompensation of COPD  
• Confirmed or suspected hypoxia  
• Chest pain of medical or trauma origin  
• Multiple or severe trauma  
• Cardiac arrest  
•Toxic inhalations  
•Prophylactically during air transportation  
• Scuba diving accidents  
 
CONTRA-INDICATIONS:  
 
• There are no absolute contra-indications for the use of oxygen in the  
emergency setting  
 
PRECAUTIONS:  
 
• High concentrations of oxygen may reduce the respiratory drive of a  
COPD patient; therefore, careful monitoring of the patient is required. Do  
not withhold oxygen from these patients if their prevailing condition is  
such that oxygen is required  
 
  
• Long exposures to high concentrations of oxygen may result in  
retrolental fibroplasia in neonates and pulmonary fibrosis  
• Neonates with a patent ductus arteriosus (PDA - a rare condition  
characterised by a significant heart murmur). Signs of hypoxia may  
occur after oxygen administration. Remove oxygen if PDA is confirmed  
• Oxygen supports combustion - do not use in the presence of fire, smoke  
or cigarette smoking  
•High pressure oxygen should not be used with oil or grease based substances 
as it causes an exothermic reaction with the risk of explosion  
•Production of oxygen super radicals in the presence of Paraquat  
 
PACKAGING:  
 
•Pressurised cylinder containing 100% medical oxygen  
 
DOSAGE AND ADMINISTRATION:  
 
• Administered via:  
-Oxygen masks  
-Nasal cannulae  
- Bag-valve-mask / tube-reservoir device  
-Nebulizer device  
- Jet insufflation  
• At the correct flow rate the following devices will deliver approximately  
the following percentages of oxygen:  
- Sampson‟s neonatal = 2 - 4 litres/minute  
-Simple face mask = 35 - 60% at 6 - 10 litres/minute  
-24% and 28% face masks  
= 4 litres/minute or as / manufacturer‟s  
instructions  
-35% and 40% face masks  
= 8 litres/minute or as / manufacturer‟s  
instructions  
-Nasal cannulae  
= 24 - 40% at 1 - 5 litres/minute( 20% + (l/min X 4) = %) 
- Partial re-breather mask = 60% at 10 - 15 litres/minute  
- Non-re-breather mask = 95% at 10 - 15 litres/minute  
-Bag-valve-mask/tube = 50% at 12 - 15 litres/minute  
-Bag-valve- mask/ tube-  
= 100% at 12 - 15 litres/minute 
reservoir device 
-Adequate flow rate = Reservoir bag inflated > 2/3 at all times  
NOTE:  
 
• Oxygen is a non-explosive gas  
  
METOCLOPRAMIDE MONOHYDROCHLORIDE  
 
DESCRIPTION:  
 
• Classification : Anti-emetic  
• Schedule : 4  
 
PHARMACOLOGICAL ACTION:  
 
• Metoclopramide acts on the chemo-emetic trigger zone (CETZ) to produce a 
central anti-emetic effect  
• With regard to the gastrointestinal tract, metoclopramide enhances the  
motility of smooth muscle from the oesophagus through the proximal  
small bowel and accelerates gastric emptying and the transit of intestinal 
contents from the duodenum to the ileo-caecal valve  
 
PHARMACO-KINETICS:  
 
• Half-life : 4-6 hours  
 
ADVERSE EFFECTS:  
 
• CNS  
- Extra-pyramidal effects  
- Depression  
• GIT  
-Diarrhoea  
-Abdominal cramps  
 
INDICATIONS:  
 
• Nausea and vomiting due to:  
-Stimulation of CETZ by medication (e.g. morphine)  
- Motility disorders of the GIT (e.g. gastro-enteritis)  
 
CONTRA-INDICATIONS:  
 
• Known hypersensitivity / allergy to metoclopramide  
• CNS : Epilepsy  
• GIT : Haemorrhage, obstruction, perforation, or post-  
operative  
• Children : Increased incidence of extra-pyramidal effects  
  
PRECAUTIONS:  
 
•Pregnancy and lactation  
•Elderly  
• Not effective against direct stimulation of Vomiting Centre (e.g. emotional, 
visual, olfactory or labyrinthine disorders or motion sickness)  
• In Parkinson‟s disease, metoclopramide increases extra-pyramidal effects  
 
PACKAGING:  
 
• 10mg/2ml ampoule  
 
DOSAGE AND ADMINISTRATION:  
 
• Adults > 60 kg : 10 mg slowly IVI/ IMI  
• Adults < 60 kg : 5 mg slowly IVI/ IMI  
 
  
MIDAZOLAM  
 
DESCRIPTION:  
 
• Classification : Sedative / hypnotic  
• Schedule : 5  
• Antidote : Flumazenil  
 
PHARMACOLOGICAL ACTION:  
 
• Midazolam is a benzodiazepine, acting on the central nervous system  
• These actions result from the potentiation of the neural inhibition that is  
mediated by GABA  
• It has anxiolytic, sedative, sleep-inducing, anticonvulsant and muscle  
relaxant properties  
• It causes anterograde and retrograde amnesia  
 
PHARMACO-KINETICS:  
 
• Half-life : 1.5-2.5 hours  
• Onset of action : 1-3 minutes  
• Duration of action : 30 minutes  
• 2-3 times more potent than diazepam  
• Rapidly absorbed after IMI injection  
 
ADVERSE EFFECTS:  
 
• CNS : Depression  
• Resp : Depression (rapid administration)  
•CVS : Hypotension (large dosages)  
• Nausea and vomiting  
• Diplopia  
• Thrombophlebitis  
• Paradoxical excitation  
• Physical and psychological dependence  
 
INDICATIONS:  
• Sedation  
• Induction of anaesthesia  
• Anticonvulsive therapy  
• Muscle relaxant  
 
  
CONTRA-INDICATIONS:  
 
• Known hypersensitivity / allergy to benzodiazepines  
• In a patient with persistent convulsions, there are no other absolute  
contra-indications, but due to its ability to cause respiratory depression,  
it must not be used if the patient cannot be artificially ventilated should  
the need arise  
 
PRECAUTIONS:  
 
• Respiratory disorders:  
-COPD / asthma / hypoventilation  
• Cardiovascular disorders:  
- Hypotension / hypovolaemia / congestive cardiac failure  
• Psychosis:  
- No anti-psychotic effects  
- May increase agitation  
• Active Labour:  
- Neonatal suppression  
• Rule out all reversible causes of convulsions e.g. hypoglycaemia  
• Elderly, debilitated and paediatric patients are more sensitive to the side  
effects  
• Alcohol, barbiturates, narcotics and other depressants acting on the  
central nervous system may enhance/ alter the effects of midazolam  
 
PACKAGING:  
 
• 5mg/5ml ampoule  
• 15mg/3ml ampoule  
• 50mg/10ml ampoule  
 
  
DOSAGE AND ADMINISTRATION:  
 
Adults:  
 
• Sedation  
: 1mg/min slowly IVI  
• Induction  
: 5mg/min slowly IVI  
• Repeat every 5 minutes  
• Maximum  
: 0.3mg/kg  
• Titrate against effect  
: use the minimum effective dosage  
• Maintenance infusion : 0.03mg/kg/hr - 0.1mg/kg/hr when used in  
combination with narcotic analgesics  
• Convulsions : 0.15mg/kg slowly IVI  
(maximum 0.3mg/kg)  
• Rectally  
: 0.3mg/kg (maximum 0.6mg/kg)  
• Buccally  
: 0.3mg/kg  
• IMI  
: 0.15mg/kg (maximum 0.3mg/kg)  
 
Children:  
• Sedation  
: 0.05mg/kg slowly IVI  
• Induction  
: 0.15mg/kg slowly IVI  
• Repeat every 5 minutes  
• Maximum  
: 0.15mg/kg  
• Titrate against effect  
: use the minimum effective dosage  
• Maintenance infusion : 0.03mg/kg/hr - 0.1mg/kg/hr when  
used in combination with narcotic  
analgesics  
• Convulsions  
: 0.15mg/kg slowly IVI  
• Rectally  
: 0.3mg/kg  
• Nasally/ buccally  
: 0.3mg/kg  
• IMI  
: 0.15mg/kg  
 
MORPHINE SULPHATE  
 
DESCRIPTION:  
 
• Classification : Narcotic analgesic  
• Schedule : 7  
• Antidote : Naloxone hydrochloride  
•To be kept behind two locks  
• Strict register to be maintained by individual paramedics  
• Administration to be witnessed by at least one medically qualified person  
 
PHARMACOLOGICAL ACTION:  
 
• Morphine is a centrally acting analgesic that binds to specific opioid  
receptors in the brain and spinal cord, resulting in an increase of the  
pain threshold  
• Reduced myocardial oxygen consumption and workload  
 
PHARMACO-KINETICS:  
 
• Half-life : 2 hours  
• Onset of action : 2-3 minutes  
• Peak effect : 20 minutes  
• Duration of action : 4-6 hours  
 
ADVERSE EFFECTS:  
 
• Resp:  
- Depression  
- Bronchoconstriction  
• CVS:  
-Flushing, sweating  
-Hypotension  
- Bradycardia  
• CNS:  
-Convulsions  
- Depression  
• GIT:  
-Nausea, vomiting  
-Dry mouth  
-Biliary spasm  
• Other:  
- Miosis, blurred vision  
- Tolerance  
-Dependence  
- Urinary retention  
- Histamine release  
 
INDICATIONS:  
 
• Acute severe pain  
• Cardiogenic pulmonary oedema  
• Concomitant use with benzodiazepines for synergism in sedation  
 
CONTRA-INDICATIONS:  
 
• Known hypersensitivity/ allergies  
 
PRECAUTIONS:  
 
• CNS disorders:  
- Head injury, raised ICP  
• CVS disorders:  
-Hypotension, hypovolaemia  
• Resp disorders:  
-COPD, asthma  
•GIT disorders:  
-Undiagnosed abdominal pain  
• Children under the age of 1 year  
•Elderly, debilitated patients  
• The effects of opiates may be enhanced by alcohol, barbiturates, 
benzodiazepines, narcotics and other depressants acting on the central  
nervous system  
 
PACKAGING:  
 
• 10mg/1ml amber coloured ampoule  
•15mg/1ml amber coloured ampoule  
• 20mg/1ml amber coloured ampoule  
 
DOSAGE AND ADMINISTRATION:  
 
Adults:  
 
• Administer in increments of 1-3mg slowly IVI  
• Repeat every 2 - 5 minutes  
• Titrate against effect (use minimum effective dosage)  
•Maximum 15mg  
 
Children:  
• 0.1mg/kg slowly IVI  
•Repeat once, 5 minutes after initial administration  
• Titrate against effect (use the minimum effective dosage)  
•Maximum 0.2mg/kg  
 
 
NALBUPHINE HYDROCHLORIDE  
 
DESCRIPTION:  
 
• Classification : Opioid analgesic  
• Schedule : 5  
• Antidote : Naloxone hydrochloride  
 
PHARMACOLOGICAL ACTION:  
 
• 50% analgesic effect of morphine  
• Nalbuphine is a centrally acting analgesic that binds to specific opioid  
receptors in the brain, resulting in an increase of the pain threshold  
• Opioid dualist (at higher dosages it has an additional antagonistic effect,  
limiting its agonistic action)  
• Nalbuphine decreases the myocardial workload and oxygen consumption  
• Nalbuphine has a low abuse potential  
 
PHARMACO-KINETICS:  
 
• Half-life : 5 hours  
• Onset of action : 2-3 minutes  
• Peak effect : 15-20 minutes  
• Duration of action : 3-6 hours  
 
ADVERSE EFFECTS:  
 
• CNS : Depression  
•CVS : Hypotension  
• Resp : Depression  
• Nausea and vomiting  
• Dry mouth  
• Sweating  
 
INDICATIONS:  
 
• Moderate to severe pain  
• Acute myocardial infarction  
• Obstetrical analgesic during labour  
• Concomitant use with benzodiazepines for sedation purposes  
 
  
CONTRA-INDICATIONS:  
 
• Known hypersensitivity / allergy  
 
PRECAUTIONS:  
 
• CNS disorders:  
- Head injury, raised ICP  
• Cardiovascular disorders:  
-Hypotension, hypovolaemia  
• Respiratory disorders:  
-COPD, asthma  
• Gastro-intestinal disorders:  
-Intestinal obstruction  
• Concomitant administration with alcohol, hypnotics and other CNS  
medication may exhibit an additive effect  
 
PACKAGING:  
 
• 20mg/2ml ampoule  
• 20mg/1ml ampoule  
 
DOSAGE AND ADMINISTRATION:  
 
Adults:  
 
• 2mg/min slowly IVI/IMI/SCI  
• Titrate against effect (use the minimum effective dosage)  
• Maximum 20mg (ceiling effect)  
 
Children:  
 
• 0.1 - 0.2mg/kg slowly (1mg/min) IVI/IMI/SCI  
• Titrate against effect (use the minimum effective dosage)  
•Maximum 0.2mg/kg  
  
NALOXONE HYDROCHLORIDE  
 
DESCRIPTION:  
 
• Classification : Narcotic antagonist  
• Schedule : 4  
 
PHARMACOLOGICAL ACTION:  
 
• Naloxone competes with narcotic drug‟s opiate receptors in the central  
nervous system to displace the narcotic analgesics from their receptor  
sites. It will thus reverse the effects of narcotic analgesics such as respiratory 
depression, stupor, etc., but it also has the ability, because of  
its action, to cause acute withdrawal in a patient who is dependent on  
narcotics  
 
PHARMACO-KINETICS:  
 
• Half-life : 60 minutes  
• Onset of action : 2 minutes  
• Duration of action : 1-4 hours  
 
ADVERSE EFFECTS:  
 
• Acute withdrawal symptoms in opioid dependent patients  
- Sweating, piloerection, tremors  
-Agitation and convulsions  
• Mydriasis  
• Excessive lacrimation  
• Nausea and vomiting  
• CVS:  
- Ventricular tachycardia or fibrillation, hypotension or hypertension  
 
INDICATIONS:  
 
• Reversal of sedative effects and respiratory depression due to opiates  
• Neonatal respiratory depression secondary to the administration of  
opioids to the mother  
• Coma (non-traumatic)  
 
  
CONTRA-INDICATIONS:  
 
• Known hypersensitivity / allergy  
 
PRECAUTIONS:  
 
• Suspected narcotic dependence (may precipitate an acute withdrawal  
syndrome)  
• The effect of naloxone is usually shorter than that of long acting narcotics and 
therefore repeated doses may have to be given in order to  
maintain the desired effect  
•Provide adequate ventilation until respiratory depression has been adequately 
reversed  
 
PACKAGING:  
 
•0.4mg/ml ampoule  
• 0.02mg/ml (neonatal) ampoule  
 
DOSAGE AND ADMINISTRATION:  
 
Adults:  
 
• 0.4mg slowly IVI/IMI/SCI  
• 0.8mg ET  
• Repeat every 2 - 5 minutes  
•Maximum 10mg  
• Should 2mg fail to elicit the desired response, then overdose with  
agents other than opioids should be considered  
 
Children:  
 
• 0.01-0.1mg/kg slowly IVI/IMI/SCI  
• 0.02-0.2mg/kg ET  
• Repeat every 2 - 5 minutes  
• Maximum 2mg  
 
NOTE:  
 
• The therapeutic goal is to reverse any respiratory depression in a suspected 
narcotic overdose or coma of unknown origin, and not to fully  
awaken such patients, who may become violent should acute withdrawal occur  
 
  
NITROUS OXIDE - ENTONOX  
 
DESCRIPTION:  
 
• Classification : Analgesic gas  
• Schedule : 4  
 
PHARMACOLOGICAL ACTION:  
 
• Colourless, sweet-smelling, non-irritant gas  
• Heavier than room air / oxygen  
•Nitrous oxide has mild analgesic and anaesthetic effects depending on  
the dose inhaled  
• When inhaled it depresses the central nervous system causing anaesthesia  
• In addition, the high concentration of oxygen delivered along with the  
nitrous oxide increases oxygen tension in the blood, thereby reducing  
hypoxia  
• It provides rapid, easily reversible relief of mild to moderate pain  
 
PHARMACO-KINETICS:  
 
• Extremely blood-insoluble  
• Not metabolised by the body  
• Eliminated via lungs (small amounts are eliminated through the skin)  
• Onset of action: 30-60 seconds (maximum 3-4 minutes)  
 
ADVERSE EFFECTS:  
 
• Light-headedness  
•Drowsiness  
• Nausea and vomiting  
 
INDICATIONS:  
 
• Relief of pain from:  
- Acute myocardial infarction  
-Musculo-skeletal trauma  
- Burns - not including burns of the respiratory tract  
-Active labour  
- Any other condition requiring pain relief provided there are no contra- 
indications present  
 
  
CONTRA-INDICATIONS:  
 
• Neurological impairment:  
- Any altered level of consciousness  
-Inability to comply with instructions or unable to comply with  
instructions 
-Head injuries  
•Air entrapment:  
-COPD/asthma patient during an acute episode  
-Acute pulmonary oedema  
-Chest injuries  
-Abdominal trauma  
- Diving accidents (specifically Acute Decompression Illness)  
- Burns to the respiratory tract  
• Other limitations:  
-Hypotension (SBP < 90 mmHg)  
-Major facial trauma (anatomic)  
 
PRECAUTIONS:  
 
• The constituent gases nitrous oxide and oxygen disassociate at < 4°C.  
It is imperative that the cylinder is inverted a few times and then placed  
horizontal when used in cold conditions as the patient will otherwise  
inhale pure nitrous oxide  
•Nitrogen has decreased solubility in blood. Once in a gas-containing  
space the gas dissociates and nitrogen diffuses out slower than nitrous  
oxide diffuses in, and there is a net increase in gas volume  
• When the mask is removed after prolonged use, the gas will come out  
of solution in the lungs and displace the oxygen in the alveoli, causing  
hypoxia  
• In order to prevent this, the mask must not be strapped to the patient‟s  
face, and the patient must receive oxygen for ± 5-10 minutes, especially after 
prolonged use  
•Nitrous oxide is a non-explosive gas  
 
PACKAGING:  
 
•Pressurised cylinders containing a mixture of 50% nitrous oxide and  
50% Oxygen (N2O+O2: 50/50%)  
  
DOSAGE AND ADMINISTRATION:  
 
• Entonox is predominantly a self-administered gas  
• The administration procedure is to be explained to the patient carefully  
before hand to prevent unnecessary complications  
• Once the patient has inhaled enough entonox to control his / her pain  
they will remove the mask thereby preventing any chances of overdosing  
• Registered paramedics are entitled to administer entonox to a patient,  
but this requires careful monitoring of the patient in order to prevent  
complications arising  
• If the patient becomes drowsy, remove the Entonox and replace immediately 
with oxygen  
• If in doubt as to the use of Entonox, call for assistance  
 
  
SODIUM BICARBONATE 8.5%  
 
DESCRIPTION:  
 
• Classification : Electrolyte/ mineral  
• Schedule : 1  
 
PHARMACOLOGICAL ACTION:  
 
• Sodium bicarbonate is an electrolyte solution intended for intravenous  
use for restoring the balance of the bicarbonate-carbonic acid systems  
 
ADVERSE EFFECTS:  
 
• Hypernatraemia  
• Metabolic alkalosis  
• Tissue necrosis and thrombophlebitis (if extravasation occurs)  
• Hyperosmolarity  
• Hypokalaemia  
• Hypocalcaemia  
• Intracranial haemorrhage (children)  
 
INDICATIONS:  
 
CLASS I : Definitely helpful  
 
•Pre-existing hyperkalaemia  
CLASS IIa : Acceptable and probably helpful  
•Pre-existing metabolic acidosis e.g. Diabetic Keto-Acidosis, renal failure  
•Tricyclic anti-depressant, aspirin overdose, stimulant abuse (e.g.  
cocaine)  
CLASS IIb : Acceptable and possibly helpful  
 
•Protracted cardiac arrest (where effective artificial ventilation and circulation 
have been established)  
• Post-cardiac arrest (where spontaneous circulation has been estab 
lished)  
CLASS III : Not indicated and possibly harmful  
 
• Respiratory acidosis  
•Prolonged cardiopulmonary arrest without effective ventilatory and circulatory 
support  
 
  
CONTRA-INDICATIONS:  
 
• Respiratory acidosis  
• Absence of effective ventilation and circulation  
 
PRECAUTIONS:  
 
• Never combine with calcium chloride in the same infusion and never  
administer via an infusion line containing calcium containing solutions  
(e.g. Ringers Lactate or Haemaccell), unless the IV line is flushed with  
NaCl before and after administration (it may otherwise lead to precipitation)  
• Never combine with catecholamines (e.g. epinephrine) in the same infusion 
(this may lead to inactivation)  
• Never administer via the ET route  
•A well-placed and free flowing IVI line is mandatory  
 
PACKAGING:  
 
• 20 ml ampoule of 8.5% solution (1.7g/ 20ml)  
• 50 ml ampoule of 8.5% solution (4.25g/50ml)  
• 100 ml vacolitre containing 50ml of an 8.5% solution  
 
DOSAGE AND ADMINISTRATION:  
 
• Initial : 1ml/kg (8.5%) slowly IVI with free flowing line  
• Repeat : 0.5ml/kg (8.5%) slowly IVI every 10 minutes if  
required  
  
TRAMADOL HYDROCHLORIDE  
 
DESCRIPTION:  
 
• Classification : Opioid analgesic  
• Schedule : 5  
• Antidote : Naloxone hydrochloride  
 
PHARMACOLOGICAL ACTION:  
 
•Tramadol is a centrally acting analgesic that binds to specific receptors:  
- Opioid receptors in the brain  
- Norepinephrine and Serotonin receptors  
- Synergism of above two receptors  
• Resulting in an increase of the pain threshold  
 
PHARMACO-KINETICS:  
 
• Half-life : 5-7 hours  
• Duration of action : 6-9 hours  
 
ADVERSE EFFECTS:  
 
• GIT  
-Nausea  
- Vomiting  
-Dry mouth  
• CNS  
- Depression  
-Convulsions  
•CVS  
- Bradycardia  
- Tachycardia  
-Hypotension  
-Flushing  
-Sweating  
• Resp  
- Depression  
 
  
INDICATIONS:  
 
• Moderate to severe pain  
• Concomitant use with benzodiazepines for sedation purposes  
 
CONTRA-INDICATIONS:  
 
• Known hypersensitivity to tramadol or other opioids  
 
PRECAUTIONS:  
 
• Rapid intravenous administration may be associated with a higher incidence 
of adverse effects and should therefore be avoided  
• CNS disorders:  
- Head injury, raised ICP  
-Epileptic patients  
• CVS disorders:  
-Hypotension, hypovolaemia  
• Resp disorders:  
-COPD, asthma  
•GIT disorders:  
-Intestinal obstruction  
 
PACKAGING:  
 
• 100mg/2ml ampoule  
 
DOSAGE AND ADMINISTRATION:  
 
Adults:  
• Administer 100mg slowly IVI/IMI/SCI (1-2mg/kg)  
• Repeat every 5 minutes  
• Titrate against effect (use the minimum effective dose)  
•Maximum 400mg  
• The dosage should be adjusted to the intensity of pain and the individual‟s 
response  
 
Children:  
 
• Safety not established  
 
  
 
ALS PRACTITIONER PROTOCOLS 
 
 
No. Protocols PAGE  
1. Anaphylaxis - Adult 72  
2. Anaphylaxis - Paediatric 73  
3. Asthma - Adult 74  
4. Asthma - Paediatric 75  
5. Cardiac Arrest - Adult 76  
6. Cardiac Arrest - Paediatric 77  
7. Coma - Non Trauma - Adult 78  
8. Coma - Non Trauma - Paediatric 79  
9. Convulsions - Adult 80  
10. Convulsions - Paediatric 81  
11. Non-Traumatic Cardiac Chest Pain - Adult 82  
12. Pulmonary Oedema of Cardiac Origin - Adult 83  
13. Supraventricular Tachycardia - Adult 84  
14. Supraventricular Tachycardia - Paediatric 85  
15. Symptomatic Bradycardia - Adult 86  
16. Symptomatic Bradycardia - Paediatric 87  
17. Ventricular Tachycardia - Adult 88  
18. Ventricular Tachycardia - Paediatric 89  
19. Declaration of Death 90  
 
  
 
  
 
ALS PRACTITIONER PROTOCOLS 
 
 
DECLARATION OF DEATH  
 
Death may be declared to have occurred by a registered paramedic if:  
 
A. The person is obviously dead due to / or evidenced by:  
1. Decapitation or mortal disfigurement  
2. Generalised charring due to extensive burns  
3. Putrefaction  
4. Post mortem lividity  
OR  
 
B.  
1. There is no evidence of cardiac electrical activity on the  
Electrocardiogram in all 3 leads and 
2. There are no palpable pulses and  
3. There are no audible heart sounds and  
4. Bilateral fixed and dilated pupils are present and  
5. There has been no spontaneous breathing for the past 5 minutes and  
6. There are no dolls eye movements present  
Provided that:  
 
The signs B 1 - 6 have been considered in terms of hypothermia, or  
possible drug effects.  
 
If the above guidelines are adhered to, paramedics may declare death  
and hence further declaration by a medical practitioner would not be  
necessary before removing the patient from the scene.  
 
  
COMMONLY ENCOUNTERED ABBREVIATIONS 
 
 
No. ABBREVIATION MEANING  
1. a Alpha  
2. ß Beta  
3. µg/ mcg Microgram  
4. AMI Acute myocardial infarction  
5. AV Atrio-ventricular  
6. bpm Beats per minute  
7. Ca2+ Calcium  
8. CETZ Chemo-emetic triggerzone  
9. CNS Central nervous system  
10. COPD Chronic obstructive pulmonary disease  
11. CPR Cardiopulmonary resuscitation  
12. CVS Cardiovascular system  
13. d Drops  
14. ECG Electrocardiogram  
15. ET Endotracheal administration  
16. g Gram  
17. GABA Gamma-aminobutyric acid  
18. GIT Gastrointestinal tract  
19. H20 Water  
20. HGT Haemo-glucose test  
21. hr/s Hour/s  
22. ICP Intracranial pressure  
23. IMI Intramuscular injection  
24. IOI Intraosseous injection  
25. IOI =IVI Equivalent doses  
26. IVI Intravenous injection  
27. K+ Potassium  
28. kg Kilogram  
29. max Maximum  
30. mg Milligram  
31. min Minimum  
32. min Minute  
33. ml Millilitre  
34. Na+ Sodium  
35. NaCl Sodium chloride 0.9%  
36. p.o. Per os  
37. Resp Respiratory  
38. SBP Systolic blood pressure  
39. SCI Subcutaneous injection  
40. UDV Unit dose vial  
 
ALS PRACTITIONER PROTOCOLS 
 
 
REFERENCES  
 
1. South African Medicines Formulary  
2. American Heart Association. 2000 Handbook of Emergency  
Cardiovascular Care 
3. International Liaison Committee on Resuscitation Advisory Statements  
4. The Merck Manual. 16th ed.  
5. Countless scientific, peer reviewed and published journal articles  
6. Manufacturer‟s Medication Package Inserts  
ACKNOWLEDGEMENTS  
 
1. Barrie de Villiers  
2. Carin Loedolff  
3. Danie van der Merwe  
4. Trevor Justus  
5. Walter Kloeck  
6. And countless other dedicated individuals who gave so freely and  
willingly of their time and expertise  
January 2003  
 
  
CAPABILITIES  
 
These paramedic capabilities are as per the BLS and ILS Protocols and, in  
addition to the following, but not limited to, however, within the confines  
and constraints of the PBECP approved Critical Care Assistant and National  
Diploma EMC Curricula.  
 
These capabilities are with reference to all emergencies falling within the  
scope of the profession of emergency care, and are applicable to patients  
of all ages.  
 
No. CAPABILITY  
1 ALS patient assessment, treatment, management and  
tranportation  
2 Oral endotracheal intubation  
3 Nasal intubation  
4 Blind nasal intubation  
5 Double lumen airway  
6 Retrograde intubation  
7 Tactile intubation  
8 Needle cricothyrotomy  
9 Surgical cricothyrotomy  
10 Bag-valve-tube- reservoir nebulization  
11 Use of ventilators  
12 Nasogastric intubation  
13 Orogastric intubation  
14 CPAP  
15 PEEP  
16 Defibrillation  
17 Cardioversion  
18 External pacing  
19 Vagal manoeuvres  
20 Crystalloids and colloids  
21 Peripheral vein cannulation  
22 External jugular vein cannulation  
23 Femoral vein cannulation  
24 Intraosseous cannulation  
25 Umbilical vein cannulation  
26 Pressure infusion devices  
27 Infusion pumps  
28 Syringe pumps  
29 Blood pressure monitors  
30 Capnographs  
31 Pulse oximeters  
32 Care of CVP lines  
33 Tourniquets  
34 PASG - entire garment  
35 Thoracentesis  
36 Normal vaginal delivery  
37 Mal-presentation management  
38 Premature labour management  
39 Obstructed labour management  
40 Prolapsed cord management  
41 Urinary catheterisation  
42 Incubator transport and management  
43 Drug administration as per medication schedules /  
standards / guidelines  
44 Intravenous, intra-muscular, subcutaneous, endotracheal,  
intra-osseous routes of administration as per the standards  
and guidelines