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BackgroundThe rate of Israeli paramedics leaving the profession has been increasing in recent years: 50% leave the profession in three years, for the most part before retirement. While approximately 2500 paramedics have been trained, only about a third of them are still active.The number of paramedics per 100,000 in Israel is only 8, compared to around 66 in the US, and in light of the shortage of paramedics it is important to enhance retention rates. The purpose of the study was to examine the factors related to paramedics leaving the profession in Israel.Methods1. An online survey was sent to 1000 paramedics via Email. 533 were recruited of whom 200 have left the profession. Questions included demographics, job satisfaction, and reasons for leaving or remaining in the profession.2. In-depth interviews with 15 paramedics who left the profession.ResultsOut of 1000 emails sent, 533 Paramedics responded, of which 200 paramedics who left the profession responded (73% left five years after completing training and 93% after 10 years). Among these former paramedics, choosing the paramedic profession was based mainly on an idealistic sense of mission and eagerness to help others, yet leaving the paramedic profession was related to extrinsic factors: lack of career options, extensive and strenuous physical demands accompanied by unrewarding salaries, unusually long work hours, and shift work that negatively affected family and personal life.ConclusionsIt seems that work conditions, including the lack of opportunities for promotion, lack of professional prospects, and inappropriate compensation for hard work are crucial factors in the decision to leave.RecommendationsA joint committee of the Ministries of Health, Justice, and Finance and MDA (Magen David Adom, the national EMS in Israel) should be established for the purpose of improving the conditions and modalities of employment of paramedics and providing appropriate emotional support for paramedics who are exposed daily to work under extreme conditions of stress and human suffering. A joint effort could greatly reduce rates of leaving, training costs, and costs incidental to turnover, as well as increase job satisfaction. Moreover, regulating the profession and expanding the scope of practice to new fields like community paramedicine as part of the EMS service and expanding the scope of physician assistants as an academic profession can create opportunities for advancement and diversity at work that will help retain paramedics in the profession.

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Dinoflagellates associated with coral reefs produce ciguatoxin which is concentrated in the marine food chain and subsequently ingested by humans resulting in ciguatera poisoning.' It is an endemic and underreported* problem in Queensland. We present two cases of cardiac dysfunction temporally related to ciguatera poisoning.A 65-year-old Vietnamese male (Case 1) presented to the Princess Alexandra Hospital with findings consistent with ciguatera poisoning. He described paraesthesia of the tongue, abdominal skin, distal extremities and perioral region. Temperature sensation reversal, nausea, vomiting and mild diarrhoea were noted. These symptoms began within 24 hours of eating portions of a large reef fish, including the head and liver. Others who shared the meal had the same typical but milder symptoms of ciguatera poisoning.On examination the patient was shocked, without fever or signs of dehydration. Blood pressure (BP) was 75 mmHg systolic with a relative bradycardia of 60 beatshinute. The ECG showed only non-specific minor ST shift. Serial serum creatine phosphokinase levels were normal.The patient responded to fluid loading. The cardiac findings resolved over three days and the non-cardiac symptoms cleared over the subsequent 14 days.A 54-year-old Caucasian male (Case 2) was admitted to Townsville General Hospital with progressive dyspnoea, dizziness and peripheral oedema dating from his ingestion of several large portions from a large coral trout two weeks previously. He also complained of perioral paraesthesia, myalgia, arthralgia, and limb hyperaesthesia. Diarrhoea, abdominal pain and temperature sensation reversal were not described. Others from the group who had eaten the same fish had typical symptoms of ciguatera poisoning. Pulse rate was 110 beatdminute, BP 165/95 mmHg, third and fourth heart sounds were evident, the JVP was raised and the apex beat displaced. Diminution of light touch, pin prick and vibration sense was noted below the level of the knees with ankle and knee jerks being absent. Proprioception was impaired and the gait ataxic.

The paramedic profession in Israel was established in 1979 by Dr Nancy Caroline, medical director of the national emergency medical services (EMS) system, Magen David Adom. Since its establishment the profession has developed considerably and paramedics are currently at the frontier of pre-hospital emergency care in Israel. This article looks at the evolution of the paramedic profession in Israel, considering the introduction of mobile intensive care units and the paramedic's ever changing role in the provision of pre-hospital care.