Dr. Geoff King:

I will take the liberty of leaving the committee with my background paper and will speak briefly off the cuff. Members will be able to tell by my accent that I am from Kildare. I have lived there for 12 years. I am happy to live there and will continue to live there forever. I will only leave if my second wife wants to leave, because my first is not going anywhere.

I was medical director of the flying doctors in Queensland until 2001. We covered a population of 4 million, which is similar to the whole of Ireland. I was happy there and had 50 doctors reporting to me. We had about 100 nurses in the team. It is at the acute sharp end - better than some services in the world and probably could learn from some others. I arrived in Ireland as the inaugural director of a nice piece of secondary legislation to establish pre-hospital services in Ireland, which at the time had a basic life-support service. The ambulances were driven by what were called "drivers", which offends me. They were not regarded by the community or people as clinicians but were regarded as drivers who would transport the nurse out and bring patients back into hospital.

When I arrived I wondered what I would do. I decided I should look at what was happening on the ground.

I decided to go with a newly-appointed deputy and visit every ambulance station in the country. I had read all the reports and reviews. Everything had been written down that needed to happen. I agreed to do the exercise. I had some preconceptions about what I would find and decided to validate what I saw. We went to every ambulance station in the country over 18 months. It was hard work and I got some fright. I suddenly had to shift my outlook. I had worked my whole life in acute sharp-end medicine but I realised the best thing I could do to help to improve sharp-end medicine in Ireland was to improve the care of the dead and dying. Frankly, Ireland was doing it appallingly. I am not talking about the wake, I am talking about the technical aspects of dying. I went back to my office and my brief became where to begin. I will march the committee through several points.

There was no policy or procedure in place or legitimisation to say a person was dead. The person could be cold or stiff but not dead. Some of the drivers were great people who had come out of the boiler rooms but they were throwing in their keys despite the training and orientation for sharp-end ambulance work. I spoke to one man who has recently retired. He went to a major bus crash on day one where children were dead as well as others with multiple injuries and whatever. That was his orientation. I can talk to the committee about his fading or whatever another time, but he ended up at a lower tier professional level and he had a valid role to play. Anyone who ended up subsequently being trained at his station had luck. The station got another man who was sharp-end, one of our new graduates at the higher level. He had old soap and new soap so he could learn from the old and new ways. Let us put that aside.

We had to put a policy in place that recognised the problem because some people were actually trying to resuscitate, do mouth-to-mouth or full bottle, bag and mask, on a cold stiff body. At the time they had nowhere to go but the emergency department. It may have been a long way, perhaps an hour away. I mean no disrespect to them, because I would have done the same, but they sat in the back and folded their arms and did not continue cardiopulmonary resuscitation, CPR, because they knew it was death. They then arrived at an emergency department and the emergency department inherited the patient. The doors opened and the paramedics started back doing CPR. I imagine the emergency department people would have said to forget it and not to waste their time on it.

The Pre-Hospital Emergency Care Council, PHECC, has developed clinical practice guidelines and now it is legitimate that there is a recognition of death. If a person is a professional, either at emergency medical technician, EMT, or paramedic level, he does not do that. Instead, if he arrives and there is a dead body, it is not our business and anyway the ambulance may have three 999 calls and if we do not get to them in 80 minutes, there may be a cardiac arrest because we know that two of them are in their mid 40s. Anyway, whatever the age group, these people can be salvaged and can have a normal life while we are wasting our time in the back of an ambulance. The case is fixed and there is no job because it is done.

The next issue is the case where we cease resuscitation. We train our people now like in North America, Australasia, most importantly, and in the United Kingdom in such a way that if we have done all our tricks and our best people have given every drug and intervention but there is a flat-line trace, then the answer to the question on the chances of survival is: "None". Then we cease resuscitation and agree to stop because it is all over.

PHECC has now legitimised that. A paramedic can do that and stop now, whereas before he used to have to keep going. These people would keep going to the emergency department and the staff in the emergency department would take the view that they have an ongoing resuscitation. The emergency department would then spend a minimum of 20 minutes, but we know that 20 minutes goes into an hour and then there is the family aspect and whatever. Again, people become tied up. Am I running out of time?