emergency medical services in new zealand emergency medical services in new zealand emergency medical services in new zealand (more commonly known as ambulance) are provided by the order of st john, except in the greater wellington region where wellington free ambulance provides these services. both have a history of long service to their communities, st john since 1885 and free beginning in 1927, traditionally having a volunteer base, however the vast majority of response work is undertaken by paid career paramedics. strategic leadership of the sector is provided by naso (the national ambulance sector office) which is a unit within the ministry of health responsible for coordinating the purchasing and funding of services on behalf of the ministry and the accident compensation corporation. funding occurs by means of billing part-charges for medical callouts (except wellington free) and charitable funding such as donations, bequests and corporate sponsorship to supplement government funding. in recent years, the government has begun to examine more sustainable funding for ambulance services. however there is still significant exertion within the sector that the level of funding provided falls far below what is required to cover the actual cost of service delivery organisation since the age of the motor vehicle many hospital boards ran their own services. from 1957 to 1990 the hospital act stipulated that hospital boards had to provide an ambulance service. many contracted that out to st john or had ad hoc arrangements with them, often for after hours staffing. when the hospital act was replaced by health boards, many of these boards saw this as a chance to avoid being responsible and subsequently st john took over from many boards (e.g. thames, bay of plenty, wanganui, palmerston north, waipawa, dannevirke, nelson, west coast, ashburton, southland). marlborough stayed a hospital-based service until 2007 and taranaki until 2011. wairarapa was the last region with a hospital-based service, ceasing in march 2012 and being taken over by wellington free ambulance. while both land ambulance service providers do have paid staff, they also rely very heavily on volunteer members. in most cases, paid staff tend to be concentrated in urban areas and in the management of rural areas, with rural response staff being largely volunteer-based. st. john ambulance reports a total of 2,211 paid staff in new zealand, supplemented by 7,647 volunteers. by contrast, wellington free ambulance currently staffs 108 paid paramedics and 35 volunteers, not including the 21 paid staff and 21 auxiliary (volunteer) staff previously from the wairarapa dhb service. land ambulance st. john provides service to approximately 88 percent of the population of new zealand and 17 district health boards (dhbs), through a network of 553 ambulances and 183 ambulance stations. st. john ambulance reports the completion of approximately 274,108 emergency responses for the year ending 1 july 2008. by contrast, wellington free ambulance provides service to 12 percent of the population of new zealand and three district health boards (capital & coast, hutt valley and wairarapa), providing service to more than 500,000 residents. they respond to an estimated 40,000 calls per year. land ambulances in new zealand ambulance station in auckland st john ambulance 274 wellington free ambulance at lower hutt ambulance station wellington free ambulance patient transfer 429 air ambulance westpac rescue helicopter during a demonstration in 2009 otago rescue helicopter at dunedin hospital life flight trust air ambulance – zk-lfw – jetstream air ambulance and helicopter rescue services are vital given the low population density of new zealand and the significant distances between tertiary hospitals. there are a large number of operators with all being sponsored by a commercial entity and bearing its name for marketing purposes; for example auckland, waikato and wellington helicopters are sponsored by the westpac banking corporation and branded as "westpac rescue" while others include the taranaki energy rescue helicopter, square trust rescue helicopter, bay trust rescue helicopter etc. clinical crew (typically intensive care paramedics) for the helicopters are full time employed intensive care paramedics. domestic fixed wing air ambulance services are typically use pressurised and converted fairchild metro aircraft, equipped as flying intensive care units. and it has been estimated that after corporate sponsorship and government subsidy, it is necessary to raise approximately nz$2,500 (around us$1,400 in 2009) in donations for each mission. fire and emergency new zealand fire and emergency new zealand (fenz) provides a medical 'first response' in smaller communities where there is no local ambulance service. these fire personnel are trained to a higher standard than regular firefighters and are equipped with basic ambulance equipment. as of christmas 2013, fenz 'co- responds' to all "code purple" (typically cardiac or respiratory arrest) emergencies st john ambulance and wellington free ambulance attends nationwide. the standard fenz response to a medical emergency is one fire appliance equipped with an automated external defibrillator and oxygen therapy kit. military the new zealand defence force has personnel and equipment available at short notice to assist in civilian matters including medical emergencies. models of care the new zealand system functions on the anglo-american model of care, with most care in the pre-hospital setting being conducted by paramedics. other practitioners, including local physicians and midwives, do appear at calls from time to time, but spend much less time responding to emergency calls than the franco-german model. clinical education the clinical education of ambulance staff in new zealand historically draws parallels to the anglo-american development of the paramedic profession generally but has undergone radical transformation in the past decade closely mirroring developments pursued by nations such as australia, south africa, canada and the united kingdom historical (pre-1977) prior to 1977 the "training" of ambulance officers was arranged in an ad-hoc fashion to a varying degree of first aid preparation to enable passage of a national examination administered on behalf of the department of health by an examination board of the order of st john; a requirement established by the ambulance transport advisory board in 1963. despite the content of this examination being described as "very basic" the requirement for some degree of formal ambulance officer education and training is one of the earliest in the world; in contrast the ambulance service of new south wales established the ambulance education centre at rozelle (sydney) in 1961 – although the first graduates were not until 1966, geelong & districts ambulance in victoria (australia) began a training school in 1962 and the province of ontario (canada) implemented a requirement for a five-week, 160-hour "fundamentals of casualty care" course for ambulance attendants in 1967. into the 1970s there was considerable development of local training amongst ambulance services over-and-above the basic doh/atab requirement; this training particularly focussed on defibrillation to treat cardiac arrest and was most notable in christchurch, wellington and auckland; with auckland introducing the first mobile intensive care (life support unit) on the north shore in 1970 however other subjects covered included the administration of entonox (nitrous oxide) for pain relief and the taking of a patients blood pressure. the introduction of out-of-hospital defibrillation by civilian paramedics to new zealand (1970) is again among the earliest examples in the world; predated only by the original 1966 pantridge experiment in belfast (northern ireland) and its earliest direct replication projects by the miami fire department ("rescue 1" in march 1967 under dr. eugene nagel) and new york city with the mobile coronary care unit established by dr. william grace of st. vincents hospital) also introduced in 1967. national ambulance officers training school (1977–1999) the national ambulance officers training school (naots) was established in 1977 using funds raised from the earlier 1975 telethon and was administered by the auckland centre trust board of the st john ambulance association to fulfill its requirement to the government (through the ambulance transport advisory board) to establish a national system of training for ambulance officers. naots formalised training into three distinct levels of "ambulance aid" with each was a certificate issued jointly by the department of health (through the atab) and the national training school under the auspices of the order of st john. basic grade certification as either six weeks full-time for paid officers or taught in two three-week blocks for volunteers over two years (three weeks each year) provided they had completed at least 400 hours of service in the year prior to commencing and in the year between blocks. intermediate aid consisted of six pre-course correspondence assignments, a two-week block course and two weeks of in-hospital experience. the initial provisions of the intermediate aid course were nebulised salbutamol, mast and intravenous fluid administration. advanced aid built upon intermediate aid and required a minimum of three years' service. the fourteen-week course was spread over a five-week block course, four weeks each of in-hospital and on-road and then a one-week examining period. once qualified in advanced aid (as a "paramedic") an officer could perform defibrillation, intubation, chest decompression and administer a number of drugs. walton and offenberger compiled a review of the naots (and ambulance officer training generally) for the department of health in 1984 which led to the following reforms: the school became affiliated with the (then) auckland institute of technology (now aut) and relocating out of the old central ambulance station in pitt st to the akoranga campus in 1990. elementary ambulance aid was introduced to provide a national first step for volunteers the "basic grade certificate in ambulance aid" was renamed "proficiency ambulance aid" intermediate aid was changed to form two "post-proficiency modules" one in monitoring/defibrillation and the other intravenous therapy. medical treatment protocols for intermediate and advanced aid became the responsibility of the ambulance transport advisory board (later the new zealand ambulance board) as they had initially been developed by the naots however this was seen to be unsatisfactory as it was deemed a responsibility of the medical profession whereas naots was an educational body. the review also consideration the necessity of using qualified ambulance officers when undertaking non-emergency transfer duties; this can be seen today as the patient transport service whereby transfers of nonemergency patients between hospitals, clinics and home are provided by staff who have only minimal clinical training (first responder) as this is the need dictated by their duties. it was recommended that the ambulance qualifications offered through naots be recognised by the authority for advanced vocational awards (aava). with the bolger led national government reforms of the 1990s; the new zealand qualifications authority was established to replace the aava and by 1996 the naots certifications were shifted onto the newly established nationals qualifications framework thus became formal vocational qualifications of higher learning. proficiency ambulance aid was replaced by the national certificate in ambulance (patient care and transport) while the national diploma in ambulance (paramedic) replaced both post-proficiency modules (intermediate aid) as well as advanced aid however in practice the intermediate aid qualification was still offered as two unit standards from the diploma. the national training school closed in 1999 as it had "become dysfunctional" and the recently introduced ambulance education council considered that a drive towards regional service-led training was best thus began a decade of inconsistency within clinical education, although not as great as to return to the pre-naots era of splintification. post naots (1999–2008) following closure of the national training school and disbanding of the new zealand ambulance board which had previously published the national authorised patient care procedures each service took on responsibility for its own clinical education and standing orders (patient care procedures) which would further aggravate regional differences and ultimately, help lead a return to nationalised clinical education. in 1999 a program of "intermediate care upskilling" was introduced by st john (initially in the auckland district ) to equip selected icos with adrenaline, morphine, naloxone and (at the time) metoclopramide. this distinct training package was not part of any formal qualification. st john also merged the two post-proficiency modules back into one education program at some point during this time so that an officer became qualified in both portions of intermediate aid concurrently. wellington free ambulance chose to adhere to the original post-proficiency module design thus retaining two distinct practice levels (cardiac and iv/cardiac). they also developed their own upskilling program known as "advanced life support" consisting of two modules, a and b; module a contained cardiac arrest drugs (at the time adrenaline, atropine and lignocaine) while module b provided intravenous pain relief along with naloxone and