Paramedics in Canada

In Canada the paramedic is a health professional, providing pre-hospital assessment and medical care to the victims of illnesses or injuries. The term is generally limited to include only those who work on emergency ambulances; those who work in a non-emergency patient transport service environment are not regarded as paramedics. In Canada, the term 'paramedic' is typically used generically, to refer to anyone who works on a land or air ambulance. This may not be unreasonable, since the entry level in many jurisdictions involves substantially more mandatory education and training than those called paramedics in other environments, and the skill set is beyond that of the typical EMT. Increasingly in Canada, paramedics are becoming self-regulated health professionals, operating and regulated in the same manner as nurses, physiotherapists, etc.

Training

Paramedic training in Canada is intense, as paramedics are seen as health professionals, equal in importance to nurses, respiratory therapists, cardiac perfusionists and others. Nevertheless, the nature of training and how it is regulated, like actual paramedic practice, varies from province to province. Training varies regionally, for example, the primary care paramedic training may be three months (British Columbia) to three years (Quebec) in length.

Training as an advanced care paramedic (ACP) requires that the student be first qualified as a primary care paramedic. Eligibility for ACP training varies from immediate entry following PCP qualification (typically self-funded) to a mandatory period of experience working as a PCP for usually one to three years (which typically results in employer-sponsored training). The length of time required to complete ACP training also varies between provinces, and it is generally inversely related to the length of time required to have completed the prerequisite PCP training. Shorter (around one year) programs build upon the education already learned in a 2 year PCP training program, while longer (typically up to two years) college programs typically cater to PCP who graduated from shorter PCP programs.

Thus, while there is continual debate on the merits of longer or shorter PCP programs (often centered around teaching philosophy), in common, ACPs across Canada will generally have completed approximately 3 years of formal education, inclusive of didactic study and clinical placements. There is an emerging interest toward further development of applied degrees for paramedics. These programs are often offered through partnerships between Canadian universities and community colleges, blending vocational training with higher education.

The accreditation of paramedic educational programs in Canada also varies from province to province. The Canadian Medical Association's Committee on Conjoint Accreditation offers the most comprehensive and best known system of national accreditation. Their accreditation model is an independent body, and draws from The "National Occupational Competency Profile" as the benchmark document that details the knowledge, skills and abilities outcomes that must be possessed by practitioners of each respective level of paramedic practice. Some provinces require that only graduates from accredited programs may be employed as paramedics, while in others (such as Ontario), it is not required, but may be seen as a value-added benefit to graduates. For example, in Ontario, the province has its own system of approving paramedic programs, and it is not necessary for these programs to seek or obtain CMA Accreditation, although many programs have done so voluntarily.

Scope of practice

In Canada the scope of practice of paramedics is described by the National Occupational Competency Profile (NOCP) for Paramedics document developed by the Paramedic Association of Canada with financial support from the Government of Canada. The NOCP outlines four provider levels: Emergency Medical Responder (EMR), Primary Care Paramedic (PCP), Advanced Care Provider (ACP), and Critical Care Provider (CCP)

Provincial variation on the NOCP

Under the new NOCP most providers that work in ambulances will be identified as 'paramedics'. However, in some 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 3 successive levels of practice, the EMR is not specifically considered a paramedic, per se. As a group, EMRs staff primarily community volunteer ambulance services, and for many small communities, without this level of certification, the operation of a much-needed community ambulance might not be possible. EMRs across Canada should not be ignored, as they contribute a critical role in the chain of survival. 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, with the possible exception of automated external defibrillation, which is still a regulated medical act in Canada, although one which is increasingly delegated to the general public.

Of considerable relevance to understanding the nature of Canadian paramedic practice, the reader must appreciate the considerable degree of inter-provincial variation. 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.

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 uses the title "emergency medical technician", or 'EMT' for the PCPs and 'paramedic' only for those qualified as ACPs, meaning Advanced Life Support (ALS) providers. Almost all provinces, however, 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 the sake of comparison.

Skills by certification level

Although there is a great deal of variation in what paramedics in Canada are trained and permitted to do from region to region, some skills performed by paramedics include:

Treatment issue	PCP skills	ACP skills	Advanced ACP skills
Airway management	Manual and repositioning, Oro- and nasopharyngeal airway adjuncts, manual removal of obstructions, suctioning	endotracheal intubation (in some cases, naso as well), advanced airway management, deep suctioning, use of Magill forceps	Rapid sequence induction, surgical airways (including needle cricothyrotomy and others)
Breathing	Initial assessment (rate, effort, symmetry, skin color), obstructed airway maneuver, passive oxygen administration by nasal canula, rebreathing and non-rebreathing mask, active oxygen administration by Bag-Valve-Mask (BVM) device.	pulse oximetry, active oxygen administration by endotracheal tube or other device using BVM	Use of mechanical transport ventilators, active oxygen administration by surgical airway, decompression of chest cavity using needle/valve device (needle thoracotomy)
Circulation	Assessment of pulse (rate, rhythm, volume), blood pressure and capillary refill, patient positioning to enhance circulation, recognition and control of hemorrhage of all types using direct and indirect pressure and tourniquets	Ability to interpret assessment findings in terms of levels of perfusion, intravenous fluid replacement, vasoconstricting drugs	intravenous plasma volume expanders, blood transfusion, intraosseous (IO) cannulation (placement of needle into marrow space of a large bone), central venous access (central venous catheter by way of external jugular or subclavian)
Cardiac arrest	Cardiopulmonary resuscitation, airway management, manual ventilation with BVM, automatic external defibrillator	Dynamic resuscitation including intubation, drug administration (includes anti-arrhythmics), ECG interpretation (may be limited to Lead II) Semi-automatic or manual defibrillator	Expanded drug therapy options, ECG interpretation (12 Lead), manual defibrillator, synchronized mechanical or chemical cardioversion, external pacing of the heart
Cardiac Monitoring	Cardiac monitoring and interpretation of ECGs	12-lead ECG monitoring and interpretation	18-lead ECG monitoring and interpretation
Drug administration	Limited oral, limited aerosol, limited injection (usually IM)	Intramuscular, subcutaneous, intravenous injection (bolus), IV drip	per ETT, per rectal tube, per infusion pump
Drug types permitted	Low-risk/immediate requirements (e.g. ASA (chest pain), nitroglycerin (chest pain), oral glucose (diabetes), glucagon (diabetes), epinephrine (Allergic Reaction), ventolin (Asthma)). Note: Some jurisdictions also permit naloxone (Narcotic Overdose), nitrous oxide (for pain); considerable variation by jurisdiction	Considerable expansion of permitted drugs, but still typically limited to about 20, including analgesics (narcotic or otherwise) (for pain), antiarrhythmics (irregularities in heartbeat), major cardiac resuscitation drugs, bronchodilators (for breathing), vasoconstrictors (to improve circulation), sedatives	Dramatically expanded (up to 60) drug list, Note: In some jurisdictions advanced levels of paramedics are permitted to administer any drug, as long as they are familiar with it.
Patient assessment	Basic physical assessment, 'vital' signs, history of general and current condition	More detailed physical assessment and history, auscultation, interpretation of assessment findings, ECG interpretation, glucometry, capnography, pulse oximetry	Interpretation of lab results, interpretation of chest x-rays, interpretation of cranial CT scan, limited diagnosis (e.g. rule out fracture using Ottawa Ankle Rules)
Wound management	Assessment, control of bleeding, application of pressure dressings and other types of dressings		Wound cleansing, wound closure with Steri-strips, suturing

Primary care paramedics

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 3-lead or 12 lead ECG's depending on the area, administration of Symptom Relief Medications for a variety of emergency medical conditions (these include [[oxygen#Medical|]], epinephrine, glucagon, salbutamol, aspirin, nitroglycerine, naloxone, and nitrous oxide), performing trauma immobilization, including cervical immobilization, and other basic medical care. PCPs may also receive additional training in order to perform certain skills that are normally in the scope of practice of ACPs. 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, and is the role played by a base hospital. For example, in the province of Ontario many paramedic services allow PCPs to perform 12-lead ECG interpretation, or initiate intravenous therapy, or to deliver a few additional medications, such as 50% Dextrose, ASA, Nitroglycerin, Epinephrine, Ventolin, and Glucagon.

Advanced care paramedics

The ACP is a level of practitioner that is in high demand by many ambulance services across Canada. However, still not all provinces and jurisdictions have ACPs. 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, provide pharmacological chemical pain relief for various conditions, and reverse hypoglycemic states. Several sites in Canada have experimented with pre-hospital fibrinolytics and rapid sequence intubation, 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.

Critical care paramedics

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 very sick patients from the hospital they are currently in to other hospitals that can provide a higher level of care. When CCPs are not available, it is usually necessary to have some combination of nurse, doctor and/or respiratory therapist accompany acute patients on inter-facility transfers. Having CCPs provide care to the patient allows the sending hospital to avoid 'losing' their (often limited) staff on long medevacs.

CCPs are able to provide all of the care that PCPs and ACPs are able to provide. In addition to this they are trained to perform other skills such as: rapid sequence induction, the initiation, maintenance and monitoring of prolonged chemical paralysis, the maintenance and monitoring of arterial catheters and central venous catheters, oro- and naso-gastric tubes and suction, the initiation and adjustment of basic transport mechanical ventilators, interpretation of numerous lab values, the management of chest tubes and chest drainage systems, chest x-ray interpretation, cranial CT scan interpretation, urinary catheter insertion, maintenance and monitoring of intracranial pressure monitoring devices, intravenous blood product administration, doppler flow monitor use, use of infusion pumps, other advanced airway techniques such as surgical airways, maintenance and monitoring of intra-aortic balloon pumps. CCPs usually carry more medications than ACPs do. CCPs in Ontario carry approximately 60 different medications.

CCPs often work in fixed and rotary wing aircraft, but systems such as the Toronto EMS Critical Care Transport Program (which services a large number of hospitals in close proximity) work only in specialized land ambulances. In British Columbia, CCP's work primarily in aircraft with a few ground teams on an as-needed basis, drawing from the air-ambulance staff. As is the case with ACPs, the scope of practice of CCPs in flux, although the trend is to increasing their scope of practice, as opposed to decreasing it. Because the scope of practice is defined by the Medical Director (see below) and not rigid legislation, there is a great deal of rapid flexibility in the scope of CCPs.

Medical direction and oversight

In most jurisdictions in Canada paramedics do not work under their own medical license. One exception is in British Columbia where each paramedic regardless of level, has their own license to practice. Even so, they, (as most paramedics in Canada) are permitted to perform legally restricted medical acts by the process of 'delegation'. This means that one medical doctor (the medical director) has become familiar with the individual paramedic and then has delegated authority to that paramedic which allows them to perform very specific medical acts under carefully defined situations. The scope of practice for the paramedic is defined in paramedic protocols (also referred to as advanced medical directives), which are often dozens and dozens of pages long. These protocols specificy what the paramedic may or may not do, and the conditions under which the paramedics may or may not do them. Each protocol is signed by the medical director and is considered a legal document. Medical directors are generally ER physicians who work in a hospital that is associated with the paramedic service. The relationship between this hospital (referred to as a 'Base Hospital') is formalized through legal agreements. Other physicians in the base hospital who are allowed to give direct orders to paramedics that exceed their protocols (often via telephone) are referred to as delegating physicians. This physicians are usually ER physicians who are also familiar with the individual paramedics. Paramedics cannot accept delegation from physicians other than the medical director or delegating physicians. The British Columbia Ambulance Service is moving away from protocols and towards a process called treatment guidelines, allowing much more flexibility at all levels when a patient's condition warrants.

Increasingly, however, Canadian paramedics are towards the status of self-regulated health professions. What this means is that, as a result of provincial legislation, paramedics are forming their own professional Colleges in much the same manner as nurses and other health professions. These organizations are responsible to the government for the examination and licensing of practitioners, the establishment of standards of practice, the investigation of public complaints against members, and the disciplining of members. They are also required to advise the government on all issues and legislation related to the practice of their members. Following the example of their British colleagues, Colleges have been established in Alberta, Saskatchewan, and Nova Scotia, with Ontario actively moving towards this type of legislation.

Professional Environment

Because paramedics are seen as 'physician extenders', they enjoy a close relationship with the physicians who ultimately grant paramedics the legal right to practice their profession. Also, because physician assistants in Canada exist primarily only in the Canadian Armed Forces, the role of clinical paramedic practitioners is under serious study. Increasingly, both urban and rural centres have begun utilizing paramedics working in-hospital on cardiac arrest teams, patient transfer teams, emergency department triage/treatment and to facilitate faster "off-load" times. Some small hospitals in Alberta and Saskatchewan have engaged paramedics to supervise Emergency Rooms at night in the place of Medical Doctors because of their ability to independently diagnose and direct the rest of the healthcare team in patient care. Similarly, community outreach programs led by paramedics, such as providing tuberculosis screening and influenza vaccinations to the homeless, are becoming more common.

Paramedics often work long hours, most commonly with 12 hour shifts. In some areas, however, 24 and even 96 hour shifts are not unusual. Salary and benefits are generally commensurate with the level of education and certification, though often less than the salary expectations of police officers and firefighters, as well as nurses. This incongruity is often argued as being unfair, especially in light of the relative level of responsibility a paramedic may have for acting decisively and without having direct supervision. However, many paramedics consider their career to offer intangible benefits and reported job satisfaction is generally high. Paramedics in Canada generally work only as paramedics, and only rarely as cross-trained firefighters or police officers, and most are paid full or part-time professionals. In the first quarter of 2005, paramedics were granted status federally as a "Public Safety Occupation" which means that paramedics are now eligible for early retirement, as are police officers and fire fighters. Many EMS agencies run a full range of paramedic speciality squads including: Marine medics, Bike medics, First Response medics, Tactical ERT & CCU medics, CBRNe medics (Chemical, Biological, Radiological, Nuclear and Explosive) and USAR medics (Urban Search And Rescue - specializing in urban disaster rescue recovery) and finally NOHERT medics (members of Provincial or regional Health Emergency Response Teams)

See also

• Ambulance
• Emergency Medical Services
• Ontario Paramedic Association
• Peel Paramedic Association

External links

National

• National Occupation Competency Profile for Paramedics
• Paramedic Association of Canada
• The Canadian Paramedic Web Forum

Provincial

• British Columbia Ambulance Service

• Alberta Health and Wellness

• Paramedic Association of Manitoba
• Professional Paramedic Association of Winnipeg (Manitoba)
• Ontario:
  • Ontario Ministry of Health and Long Term Care
  • Toronto Paramedics Association (Ontario)*
  • Toronto EMS (Ontario)
  • Peel Paramedic Association (Ontario)
• Greater Sudbury Paramedic Association (Ontario)
• Paramedic Association of New Brunswick

• Emergency Medical Care Inc. (Nova Scotia)
• Paramedic Association of Newfoundland and Labrador