There is considerable degree of inter-provincial variation in the Canadian Paramedic practice. Although a national consensus (by way of the National Occupational Competency Profile) identifies certain knowledge, skills, and abilities as being most synonymous with a given level of Paramedic practice, each province retains ultimate authority in legislating the actual administration and delivery of emergency medical services within its own borders. For this reason, any discussion of Paramedic Practice in Canada is necessarily broad, and general. Specific regulatory frameworks and questions related to Paramedic practice can only definitively be answered by consulting relevant provincial legislation, although provincial Paramedic Associations may often offer a simpler overview of this topic when it is restricted to a province-by-province basis.
In Canada, the levels of paramedic practice as defined by the National Occupational Competency Profile are: Emergency Medical Responder (EMR), Primary Care Paramedic, Advanced Care Paramedic, and Critical Care Paramedic.
Regulatory frameworks vary from province to province, and include direct government regulation (such as Ontario's method of credentialing its practitioners with the title of A-EMCA, or Advanced Emergency Medical Care Assistant) to professional self-regulating bodies, such as the Alberta College of Paramedics. Though the title of Paramedic is a generic description of a category of practitioners, provincial variability in regulatory methods accounts for ongoing differences in actual titles that are ascribed to different levels of practitioners. For example, the province of Alberta has legally adopted the title "Emergency Medical Technician", or 'EMT', for the Primary Care Paramedic; and 'Paramedic' only for those qualified as Advanced Care Paramedics Advanced Life Support (ALS) providers. Only someone registered in Alberta can call themselves an EMT or Paramedic in Alberta, the title is legally protected. Almost all other provinces are gradually moving to adopting the new titles, or have at least recognized the NOCP document as a benchmarking document to permit inter-provincial labour mobility of practitioners, regardless of how titles are specifically regulated within their own provincial systems. In this manner, the confusing myriad of titles and occupational descriptions can at least be discussed using a common language for comparison sake.
Most providers that work in ambulances will be identified as 'Paramedics' by the public. However, in many cases, the most prevalent level of emergency prehospital care is that which is provided by the Emergency Medical Responder (EMR). This is a level of practice recognized under the National Occupational Competency Profile, although unlike the next three successive levels of practice, the EMR is not specifically considered a Paramedic, per se. The high number of EMRs across Canada cannot be ignored as contributing a critical role in the chain of survival, although it is a level of practice that is least comprehensive (clinically speaking), and is also generally not consistent with any medical acts beyond advanced first-aid and oxygen therapy, with the exception of automated external defibrillation (which is still considered a regulated medical act in most provinces in Canada).
Primary care paramedics (PCP) are the entry-level of paramedic practice in Canadian provinces. The scope of practice includes performing semi-automated external defibrillation, interpretation of 4-lead ECGs, administration of Symptom Relief Medications for a variety of emergency medical conditions (these include oxygen, epinephrine, dextrose, glucagon, salbutamol, ASA and nitroglycerine), performing trauma immobilization (including cervical immobilization), and other fundamental basic medical care. Primary Care Paramedics may also receive additional training in order to perform certain skills that are normally in the scope of practice of Advanced Care Paramedics. This is regulated both provincially (by statute) and locally (by the medical director), and ordinarily entails an aspect of medical oversight by a specific body or group of physicians. This is often referred to as Medical Control, or a role played by a base hospital. For example, in the provinces of Ontario and Newfoundland and Labrador, many paramedic services allow Primary Care Paramedics to perform 12-lead ECG interpretation, or initiate intravenous therapy to deliver a few additional medications.
The Advanced Care Paramedic is a level of practitioner that is in high demand by many services across Canada. However, still not all provinces and jurisdictions have ACPs (Quebec, New Brunswick). The ACP typically carries approximately 20 different medications, although the number and type of medications may vary substantially from region to region. ACPs perform advanced airway management including intubation, surgical airways, intravenous therapy, place external jugular IV lines, perform needle thoracotomy, perform and interpret 12-lead ECGs, perform synchronized and chemical cardioversion, transcutaneous pacing, perform obstetrical assessments, and provide pharmacological pain relief for various conditions. Several sites in Canada have adopted pre-hospital fibrinolytics and rapid sequence induction, and prehospital medical research has permitted a great number of variations in the scope of practice for ACPs. Current programs include providing ACPs with discretionary direct 24-hour access to PCI labs, bypassing the emergency department, and representing a fundamental change in both the way that patients with S-T segment elevation myocardial infarctions (STEMI) are treated, but also profoundly affecting survival rates. as well as bypassing a closer hospitals to get an identified stroke patient to a stroke centre.
Critical Care Paramedics (CCPs) are paramedics who generally do not respond to 9-1-1 emergency calls, with the exception of helicopter "scene" calls. Instead they focus on transferring patients from the hospital they are currently in to other hospitals that can provide a higher level of care. CCPs often work in collaboration with registered nurses and respiratory therapists during hospital transfers. This ensures continuity of care. However, when acuity is manageable by a CCP or a registered nurse or respiratory therapist is not available, CCPs will work alone. Providing this care to the patient allows the sending hospital to avoid losing highly trained staff on hospital transfers. CCPs are able to provide all of the care that PCPs and ACPs provide. That being said, CCPs significantly lack practical experience with advanced skills such as IV initiation, peripheral access to cardiovascular system for fluid and drug administration, advanced airway, and many other techniques. Where an PCP and ACP may run 40–50 medical codes per year a CCP may run 1–2 in an entire career. IV/IO starts are nearly non-existent in the field and for this reason CCPs are required to attend nearly double the amount of time in classroom situations or in hospital to keep current. In addition to this they are trained for other skills such as medication infusion pumps, mechanical ventilation and arterial line monitoring. CCPs often work in fixed and rotary wing aircraft when the weather permits and staff are available, but systems such as the Toronto EMS Critical Care Transport Program work in land ambulances. ORNGE Transport operates both land and aircraft in Ontario. In British Columbia, CCPs work primarily in aircraft with a dedicated Critical Care Transport crew in Trail for long-distance transfers and a regular CCP street crew stationed in South Vancouver that often also performs medevacs, when necessary.
Paramedic training in Canada varies regionally; for example, the training may be six months (British Columbia) or two to four years (Ontario, Alberta) in length. The nature of training and how it is regulated, like actual paramedic practice, varies from province to province.
Emergency Medical Technician is a legally defined title in the Republic of Ireland based on the standard set down by the Pre-Hospital Emergency Care Council (PHECC). Emergency Medical Technician is the entry-level standard of practitioner for employment within the ambulance service. Currently, EMTs are authorised to work on non-emergency ambulances only as the standard for emergency (999) calls is a minimum of a two-paramedic crew. EMTs are a vital part of the voluntary and auxiliary services where a practitioner must be on board any ambulance in the process of transporting a patient to hospital.
Emergency Medical Technician is a term that has existed for many years in the United Kingdom. Some National Health Service ambulance services are running EMT conversion courses for staff who were trained by the Institute of Healthcare Development (IHCD) as Ambulance Technicians and Assistant Ambulance Practitioners. Ambulance trusts such as the London Ambulance Service and the North West Ambulance Service are in the process of converting existing Ambulance Technicians into Emergency Medical Technician grades 1, 2, 3 or 4, based on their level of experience; in many cases providing a similar level of care to that of a Paramedic.
Emergency Medical Technicians are still widely deployed in private ambulance companies with IHCD NHS trained Emergency Technicians being particularly sought after. There also many newer EMT training courses available. IHCD Ambulance Technicians and Assistant Ambulance Practitioners still exist within other UK ambulance services with Emergency Care Assistants employed in some areas as support, however, this grade of staff is now being phased out and replaced with a much lower qualified Emergency care assistants. The exception to this is the East of England Ambulance Service, who have actively stopped training Emergency Care Assistants, and is upskill training them to Emergency Medical Technician level. With the intention being to convert EMTs to Paramedics, thus up-skilling the entire workforce.
Examples of skills that may be had by an Emergency Medical Technician in the UK are:Administration of selected drugs (usually not IV Medications)
Intermediate life support, including manual defibrillation and superglottic airway adjuncts
Ability to discharge patient to different care pathways
IV Cannulation (usually hospital EMT skill).
The concept of modern-day Emergency Medical Services (EMS) care is widely noted to begin with the academic paper, "Accidental Death and Disability: The Neglected Disease of Modern Society", (or "White Paper") in 1966, according to EMS textbooks and relevant academia in the field. This paper detailed the statistics of highway accidents resulting in injury and death in the mid-1960s, as well as other causes of injury and death, and used the statistics to confirm that reform was needed in the United States, especially concerning public education and the amount of CPR and BLS/First Aid training received by police officers, firemen, and ambulance services at the time.
The EMT program in the United States began as part of the "Alexandria Plan" in the early 1970s, in addition to a growing issue with injuries associated with car accidents. Emergency medicine (EM) as a medical specialty is relatively young. Prior to the 1960s and 1970s, hospital emergency departments were generally staffed by physicians on staff at the hospital on a rotating basis, among them general surgeons, internists, psychiatrists, and dermatologists. Physicians in training (interns and residents), foreign medical graduates and sometimes nurses also staffed the Emergency Department (ED). EM was born as a specialty in order to fill the time commitment required by physicians on staff to work in the increasingly chaotic emergency departments of the time. During this period, groups of physicians began to emerge who had left their respective practices in order to devote their work completely to the ED. The first of such groups was headed by Dr. James DeWitt Mills who, along with four associate physicians; Dr. Chalmers A. Loughridge, Dr. William Weaver, Dr. John McDade, and Dr. Steven Bednar at Alexandria Hospital, VA established 24/7 year-round emergency care which became known as the "Alexandria Plan". It was not until the establishment of American College of Emergency Physicians (ACEP), the recognition of emergency medicine training programs by the AMA and the AOA, and in 1979 a historical vote by the American Board of Medical Specialties that EM became a recognized medical specialty. The nation's first EMT's were from the Alexandria plan working as Emergency Care Technicians serving in the Alexandria Hospital Emergency Room. The training for these technicians was modeled after the established "Physician Assistant" training program and later restructured to meet the basic needs for emergency pre-hospital care. On June 24, 2011, The Alexandria Hospital Celebrated the 50th Anniversary of the Alexandria Plan. In attendance were three of the nation's first ECTs/EMTs: David Stover, Larry Jackson, and Kenneth Weaver.
In the United States, EMTs are certified according to their level of training. Individual states set their own standards of certification (or licensure, in some cases) and all EMT training must meet the minimum requirements as set by the National Highway Traffic Safety Administration's (NHTSA) standards for curriculum. The National Registry of Emergency Medical Technicians (NREMT) is a private organization which offers certification exams based on NHTSA education guidelines and has been around since the 1970s. Currently, NREMT exams are used by 46 states as the sole basis for certification at one or more EMT certification levels. A NREMT exam consists of skills and patient assessments as well as a written portion.
In order to apply for the NREMT Certification applicants must be 18 years of age or older. A few states allow 16- and 17-year olds. Applicants must also successfully complete a state-approved EMT course that meets or exceeds the NREMT Standards within the past 2 years. Those applying for the NREMT Certification must also complete a state-approved EMT psychomotor exam.
The Veteran Emergency Medical Technician Support Act of 2013, H.R. 235 in the 113th United States Congress, would amend the Public Health Service Act to direct the Secretary of Health and Human Services to establish a demonstration program for states with a shortage of emergency medical technicians to streamline state requirements and procedures to assist veterans who completed military EMT training while serving in the Armed Forces to meet state EMT certification and licensure requirements. The bill passed in the United States House of Representatives, but has not yet been voted on in the United States Senate.
The NHTSA recognizes four levels of Emergency Medical Technician:EMR (Emergency Medical Responder)
EMT (Emergency Medical Technician)
AEMT (Advanced Emergency Medical Technician)
Some states also recognize the Advanced Practice Paramedic or Critical Care Paramedic level as a state-specific licensure above that of the Paramedic. These Critical Care Paramedics generally perform high acuity transports that require skills outside the scope of a standard paramedic. In addition, EMTs can seek out specialty certifications such as Wilderness EMT, Wilderness Paramedic, Tactical EMT, and Flight Paramedic.
In 2009, the NREMT posted information about a transition to a new system of levels for emergency care providers developed by the NHTSA with the National EMS Scope of Practice project. By 2014, these "new" levels will replace the fragmented system found around the United States. The new classification will include Emergency Medical Responder (replacing first responder), Emergency Medical Technician (replacing EMT-Basic), Advanced Emergency Medical Technician (replacing EMT-Intermediate/85), and Paramedic (replacing EMT-Intermediate/99 and EMT-Paramedic). Education requirements in transitioning to the new levels are substantially similar.
EMR (Emergency Medical Responder) is the most basic, entry level of EMS. EMRs, many of whom are volunteers, provide basic, immediate lifesaving care including bleeding control, manual splinting of extremities, eye irrigation, taking vital signs, supplemental oxygen administration, oral suctioning, positive pressure ventilation with a bag valve mask, cardio-pulmonary resuscitation (CPR), automated external defibrillator (AED) usage, assist in a normal childbirth, and administration of basic medications such as epinephrine auto-injectors, rescue inhalers, and oral glucose. Due to the opioid crisis, an increasing number of EMRs are now being trained in and allowed to administer intranasal naloxone. The skills allowed at this level are almost identical to that of the EMT level with some exceptions, but the training is significantly shorter and more condensed. An EMR can assume care for a patient while more advanced resources are on the way, and then can assist EMTs and Paramedics when they arrive. Training requirements and treatment protocols vary from area to area.
EMT is the main entry level of EMS. The procedures and skills allowed at this level are generally non-invasive such as bleeding control, positive pressure ventilation with a bag valve mask, oropharyngeal airway, nasopharyngeal airway, supplemental oxygen administration, taking vital signs, pulse oximetry, glucometry, oral suctioning, eye irrigation, cardio-pulmonary resuscitation (CPR), use of an automated external defibrillator (AED), splinting (including full spinal immobilization), traction splinting, deliver in a normal childbirth, assist with a complicated birth, and medication administration (such as epinephrine auto-injectors, oral glucose gel, aspirin, nitroglycerin, and albuterol). Some areas may add to the scope of practice for EMT's, including intranasal nalaxone administration, use of mechanical CPR devices, insertion of additional airway devices, and CPAP. Training requirements and treatment protocols vary from area to area.
Advanced EMT is the levels of training between EMT and Paramedic. They can provide limited advanced life support (ALS) care including obtaining intravenous/intraosseous access, use of advanced airway devices, limited medication administration, and basic cardiac monitoring.
Paramedics, represents the highest level of EMT, and in general, the highest level of prehospital medical provider, though some areas utilize physicians as providers on air ambulances or as a ground provider. Paramedics perform a variety of medical procedures such as endotracheal intubation, fluid resuscitation, drug administration, obtaining intravenous access, cardiac monitoring (continuous and 12-lead), cardioversion, transcutaneous pacing, cricothyrotomy, manual defibrillation, chest needle decompression, and other advanced procedures and assessments.
An ambulance with only EMT-Bs is considered a Basic Life Support (BLS) unit, an ambulance utilizing AEMTs is dubbed an Intermediate Life Support (ILS), or Limited Advanced Life Support (LALS) unit, and an ambulance with Paramedics is dubbed an Advanced Life Support (ALS) unit. Some states allow ambulance crews to contain a mix of crews levels (e.g. an EMT and a Paramedic or an AEMT and a Paramedic) to staff ambulances and operate at the level of the highest trained provider. There is nothing stopping supplemental crew members to be of a certain certification, though (e.g. if an ALS ambulance is required to have two Paramedics, then it is acceptable to have two Paramedics and an EMT). An emergency vehicle with only EMRs or a combination of both EMRs and EMTs is still dubbed a Basic Life Support (BLS) unit.
EMT training programs for certification vary greatly from course to course, provided that each course at least meets local and national requirements. In the United States, EMR's receive at least 24–60 hours of classroom training, EMTs receive at least 120–180 hours of classroom training. AEMTs generally have 200–500 hours of training, and Paramedics are trained for 1,000–1,800 hours or more. In addition, a minimum number of continuing education (CE) hours are required to maintain certification. For example, to maintain NREMT certification, EMTs must obtain at least 48 hours of additional education and either complete a 24-hour refresher course or complete an additional 24 hours of CEs that would cover, on an hour by hour basis, the same topics as the refresher course would. Recertification for other levels follows a similar pattern.
EMT training programs vary greatly in calendar length (number of days or months). For example, fast track programs are available for EMTs that are completed in two weeks by holding class for 8 to 12 hours a day for at least two weeks. Other training programs are months long, or up to 2 years for Paramedics in an associate degree program. In addition to each level's didactic education, clinical rotations may also be required (especially for levels above EMT). Similar in a sense to medical school clinical rotations, EMT students are required to spend a required amount of time in an ambulance and on a variety of hospital services (e.g. obstetrics, emergency medicine, surgery, psychiatry) in order to complete a course and become eligible for the certification exam. The number of clinical hours for both time in an ambulance and time in the hour vary depending on local requirements, the level the student is obtaining, and the amount of time it takes the student to show competency. EMT training programs take place at numerous locations, such as universities, community colleges, technical schools, hospitals or EMS academies. Every state in the United States has an EMS lead agency or state office of emergency medical services that regulates and accredits EMT training programs. Most of these offices have web sites to provide information to the public and individuals who are interested in becoming an EMT.
In the United States, an EMT's actions in the field are governed by state regulations, local regulations, and by the policies of their EMS organization. The development of these policies are guided by a physician medical director, often with the advice of a medical advisory committee.
In California, for example, each county's Local Emergency Medical Service Agency (LEMSA) issues a list of standard operating procedures or protocols, under the supervision of the California Emergency Medical Services Authority. These procedures often vary from county to county based on local needs, levels of training and clinical experiences. New York State has similar procedures, whereas a regional medical-advisory council ("REMAC") determines protocols for one or more counties in a geographical section of the state.
Treatments and procedures administered by Paramedics fall under one of two categories, off-line medical orders (standing orders) or on-line medical orders. On-line medical orders refers to procedures that must be explicitly approved by a base hospital physician or registered nurse through voice communication (generally by phone or radio) and are generally rare or high risk procedures (e.g. rapid sequence induction or cricothyrotomy). In addition, when multiple levels can perform the same procedure (e.g. AEMT-Critical Care and Paramedics in New York), a procedure can be both an on-line and a standing order depending on the level of the provider. Since no set of protocols can cover every patient situation, many systems work with protocols as guidelines and not "cook book" treatment plans. Finally, systems also have policies in place to handle medical direction when communication failures happen or in disaster situations. The NHTSA curriculum is the foundation Standard of Care for EMS providers in the US.
EMTs and Paramedics are employed in varied settings, mainly the prehospital environment such as in EMS, fire, and police agencies. They can also be found in positions ranging from hospital and health care settings, to industrial and entertainment positions. The prehospital environment is loosely divided into non-emergency (e.g. patient transport) and emergency (9-1-1 calls) services, but many ambulance services and EMS agencies operate both non-emergency and emergency care.
In many places across the United States, it is not uncommon for the primary employer of EMRs, EMTs, and Paramedics to be the fire department, with the fire department providing the primary emergency medical system response including "first responder" fire apparatus, as well as ambulances. In other locations, such as Boston, Massachusetts, emergency medical services are provided by a separate, or “third-party”, municipal government emergency agency (e.g. Boston EMS). In still other locations, emergency medical services are provided by volunteer agencies. College and university campuses may provide emergency medical responses on their own campus using students.
In some states of the US, many EMS agencies are run by Independent Non-Profit Volunteer First Aid Squads that are their own corporations set up as separate entities from fire departments. In this environment, volunteers are hired to fill certain blocks of time to cover emergency calls. These volunteers have the same state certification as their paid counterparts.