metoclopramide. to coincide with introduction of the various upskilling packages in the early 2000s there was a move away from the once nationally consistent qualification titles (ambulance officer, intermediate care officer, advanced care officer (paramedic)) that existed under the national training school to the introduction of new titles into each of the services. st john renamed intermediate care officer to "paramedic" and paramedic (aco) to "advanced paramedic" in 2001 along with a new national uniform. wellington free ambulance chose to rename all staff qualified at national certificate (proficiency) or intermediate aid to "paramedic" and their paramedics (acos) to "intensive care paramedic". there is anecdotal suggestion that the renaming of staff who did not hold the full national diploma/advanced aid to "paramedic" was due in part to the high media profile of programs such as third watch and rescue 911 which glorified and glamorised the role of "paramedic" thus giving the public an expectation that they, as on tv, should be attended to by a "paramedic". it has also been recorded that the move to rename intermediate care officer to "paramedic" on the part of st john was somewhat motivated by their desire to expedite contract negotiations with the ministry of health and acc which required a certain number of "paramedics" however it can be logically assumed that the contract did not actually define what a "paramedic" was, as the original definition of a paramedic in new zealand was somebody qualified to national diploma/advanced care level. with the demise of naots; auckland institute of technology, having been awarded university status and renamed auckland university of technology, developed the bachelor of health science (paramedic) degree while victoria university (melbourne) partnered with wellington free ambulance to create a tertiary paramedic degree administered through whitireia community polytechnic. in 2003 st john began to require completion of the bachelor of health science (paramedic) for those staff who wished to move to the advanced life support (advanced aid) qualification level. wellington free introduced an "intern paramedic" position in 2004 to accommodate staff who would completing the degree while also working on the road at the same time. by the late 2000s there was a need to once again bring reform to clinical education; and although not as marked as those introduced during the time of the national training school the following issues needed urgent attention introduction of tertiary degrees and the apparent double standard this created compared to more technically focussed vocational qualifications centred around a narrow scope of knowledge; coupled to this the ongoing viability of nzqa unit standards as a realistic platform to deliver comprehensive paramedic education (many felt they had outlived their useful life for higher practice levels) moves by comparative jurisdictions in australia totally towards tertiary education only the lack of a distinct qualification for the intermediate tier practitioner; originally the certificate in intermediate aid was awarded upon completion of the ico course however with the introduction of the national certificate and diploma in 1995 there was no longer a distinct external qualification for this level and this was even more true for the "upskilled" provider as this was an internally run course the need for structured ongoing clinical education once a qualification had been gained the very low completion rate of the national certificate by volunteers (19%) when considering the goal of naots had been to qualify all ambulance officers to the "basic" level (originally proficiency but later national certificate) increasing complexity of ambulance practice beyond "scoop and run" and early paramedic practice focussing mainly on early defibrillation/cardiac arrest and trauma care increasing chronic disease, impracticality of delivering all patients to a hospital emergency department, particularly in the face of increasing chronic disease or mental health problems which are not ideally handled in an acute presentation to ed. increasing public expectation (see above) inconsistency between service providers' levels of practice and the requirements of a newly introduced ambulance sector standard which defined three levels of practice (discussed below) the long-held view (since 1993) that paramedics should be registered health practitioners in their own right. the 2007 health select committee report into the provision of ambulance services and the resulting national ambulance service strategy included requirements to "achieve national consistency" in ambulance education and scope of practice (clinical competency). st john had during this time developed a draft "operations competency framework" which would become the foundation of more recent developments; specifically the replacement of the national certificate, the requirement for all the various intermediate level officers to transition to a new "paramedic" level which would approximate the "upskilled paramedic (als-a/als-b)" levels and become a degree course, the development <refof a post-graduate program for advanced life support (advanced aid) and the introduction of a mandatory program of continuing clinical education. national diploma in 2008 the national diploma in ambulance practice (level 5) replaced the national certificate in ambulance patient care and transport (level 4) as the qualification for the basic life support level. the national diploma is required to be referred to as an emt (emergency medical technician). the diploma is a "blended" learning program comprising approximately 1,300 hours of online and in-class learning plus on-road clinical experiences. there are three modules (core skills, medical and trauma) which each have an online component prior to classroom education and this theoretical component is run concurrently while a student is practicing in the operation environment thus building the requisite base of experience to become a qualified ambulance officer. core skills (four weeks online and 2 days in-class) covering scene assessment, primary/secondary survey and vital signs, resuscitation, defibrillation trauma (six weeks online and 6 days in-class) covering trauma and anatomy, shock and anaphylaxis, chest injuries, soft tissue injuries, environmental, head and spine medical (six weeks online and 6 days in-class) covering cardiac and respiratory, children's health, pregnancy, childbirth and newborns, older persons health, abdominal, diabetes, stroke, seizures, altered levels of consciousness, scene management, mental health while the format of the qualification has changed significantly in the move to predominantly online learning that the actual content of has not been reduced; if anything it has increased considering the national certificate had twenty-eight credits at level 5 whereas the diploma has one hundred and eleven. the number (and focus) of classroom days have been changed due to the majority of theoretical learning taking place online and classroom days heavily focussing on the psychomotor aspects of ambulance practice rather than teaching and assessing anatomy, physiology and pathology in great detail. during (and after) the online and class phases of national diploma the student must complete a portfolio of evidence for presentation at the end of course interview and assessment. the portfolio requires the student to demonstrate integrated clinical practice as well as self-reflection/professional development through skill logs, mentor reports and exemplars. degree a bachelor's degree in paramedicine (level 7) is set to be required nationally for the intermediate life support level as of 2014. while it has essentially become the de facto standard for entry to the profession st john still offer an internal ils course for currently practicing paid staff who wish to move to the ils level from either the old paramedic level (intermediate aid) or the bls level (certificate or diploma). the degree was scheduled for introduction by the beginning of 2012 however it is understood that there have been delays in assembling a realistic framework to transition totally away from an in-service education model. the degree is required to be referred to as a paramedic. the degree is a comprehensive education program over three years consisting of 3,600 hours of learning which enables students to build a solid foundation of knowledge, skill, rationale and clinical judgement to the ils level as a mixture of classroom, simulation suite and practical (on-road) experience catering for both school leavers who wish to pursue a paramedic career (in the same way at other health professional degrees) and also for working ambulance officers who wish to upgrade their knowledge and obtain a tertiary qualification. there were previously suggestions by st john that the organisation may follow western australia, the northern territory and the ambulance service of new south wales by offering employment at a defined exit point of the degree allowing the student to essentially become a bls emergency medical technician full-time and complete the rest of the degree over a number of years and qualify as an ils paramedic. this pathway appears to no longer be being considered. postgraduate certificate a postgraduate certificate (level 8) is, as of 2013, the required qualification to reach als level (known as intensive care paramedic) and is offered by aut as the postgraduate certificate in emergency management or whitireia as the postgraduate certificate in specialty care (advanced paramedic practice). the postgraduate certificate is required to be referred to as an icp (intensive care paramedic). the focus of this qualification is to build upon the paramedics' knowledge and skillset to deliver advanced resuscitation interventions such as intubation, rapid sequence induction, chest decompression, thrombolysis and pacing as well as developing more advanced capability in clinical leadership and decision-making. clinical practice the revised new zealand ambulance and paramedical service standard (nzs8156:2008) defines three levels of practice and gives guidance as to their depth and breadth but it does not however define the specific interventions to be included in each (scope of practice). the specific scopes of practice are set every two years as part of the clinical practice guidelines developed by the clinical working group (part of ambulance new zealand) which consists of the medical directors, medical advisors and paramedic representatives from both st john and wellington free ambulance as well as the new zealand defence force. although the standard is more or less correct, there are aspects of practice which have evolved since it was written. ecg interpretation is a good example, where in-depth 12 lead ecg interpretation is now taught at ils level as part of the degree where at the time of writing the standard (2008) this level of skill was generally reserved for als practitioners given the number of practicing graduates was smaller at that time. like other similar systems around the world such as south africa, the uk and australia, and in sharp polar contrast to the united states and (to a lesser degree) canada, the system of practice is entirely based upon the professional discretion of the attending ambulance officers, and there is no need for "online medical direction" to obtain approval for drugs or procedures. there is however a strong system of collegial support via the communications centre clinical desk (and on-call medical advisors) to assist with clinical decision-making when required, this however is not a system of seeking permission. the below delegated scopes of practice are as per the 2013–2015 clinical procedures and guidelines first responder basic pre-hospital emergency care (phec) medication can be used by staff in the entry level of ambulance care (event staff and new volunteers). current scope of practice: paracetamol, ibuprofen, aspirin, oxygen therapy, intermittent positive pressure ventilation (ippv), oropharyngeal airway (opa), nasopharyngeal airway (npa). additionally, certain medications from the emt scope of practice may be given by a first responder with clinical direction from an emt/paramedic/icp at the scene or via the st john/wfa clinical desk. emergency medical technician general pre-hospital emergency care to assess and manage both life-threatening and non-life-threatening situations using knowledge, skills and clinical judgement appropriate to generally non-invasive techniques and non-intravenous drug regimens. current scope of practice: 3/12 lead ecg acquisition, nasopharyngeal airway, nebulised salbutamol, nebulised ipratropium, gtn (sl and transdermal), im glucagon, laryngeal mask airway, ondansetron (intramuscular), loratadine, ibuprofen, methoxyflurane, peep valve, adrenaline (im, in and nebulised), prednisone, prednisolone, tramadol, urinary catheter troubleshooting, laryngoscopy, magill forceps. paramedic knowledge and skill to provide invasive care that significantly builds upon bls capacity in terms of clinical judgement and capability including a wide range of pharmacology. current scope of practice: all of the above plus manual defibrillation, synchronised cardioversion, iv cannulation, iv fluid administration, iv glucose, morphine, fentanyl, naloxone, ondansetron, adrenaline (iv) for cardiac arrest, amiodarone (iv) for cardiac arrest, ceftriaxone, naloxone, midazolam (im) for seizures, oxytocin, ceftriaxone, clopidogrel, lignocaine (sc) for ring blocks intensive care paramedic provides advanced management where knowledge, rationale, judgement, skill and leadership are well developed and utilises the most comprehensive regime of pharmacology, airway support and ecg interpretation. current scope of practice: all of