maEmergency medical services

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A road ambulance belonging to the South Western Ambulance Service in England

Emergency medical services prepare to airlift the victim of a car accident to hospital

Emergency medical services (abbreviated to the initialism EMS in some countries) are a
type of emergency service dedicated to providing out-of-hospital acute medical care,
transport to definitive care, and other medical transport to patients with illnesses and injuries
which prevent the patient from transporting themselves.[1]

Emergency medical services may also be locally known as a paramedic service, a first aid
squad,[2] emergency squad,[3] rescue squad,[4] ambulance, squad[5] ambulance service,[6]
ambulance corps,[7] or life squad.[8]

The goal of most emergency medical services is to either provide treatment to those in need
of urgent medical care, with the goal of satisfactorily treating the presenting conditions, or
arranging for timely removal of the patient to the next point of definitive care. This is most
likely an emergency department at a hospital. The term emergency medical service evolved to
reflect a change from a simple system of ambulances providing only transportation, to a
system in which actual medical care is given on scene and during transport. In some
developing regions, the term is not used, or may be used inaccurately, since the service in
question does not provide treatment to the patients, but only the provision of transport to the
point of care.[9]

In most places in the world, the EMS is summoned by members of the public (or other
emergency services, businesses, or authorities) via an emergency telephone number which
puts them in contact with a control facility, which will then dispatch a suitable resource to
deal with the situation.[10]
In some parts of the world, the emergency medical service also encompasses the role of
moving patients from one medical facility to an alternative one; usually to facilitate the
provision of a higher level or more specialised field of care but also to transfer patients from
a specialized facility to a local hospital or nursing home when they no longer require the
services of that specialized hospital, such as following successful cardiac catheterization due
to a heart attack. In such services, the EMS is not summoned by members of the public but by
clinical professionals (e.g. physicians or nurses) in the referring facility. Specialized hospitals
that provide higher levels of care may include services such as neonatal intensive care
(NICU),[11] pediatric intensive care (PICU), state regional burn centres,[12] specialized care for
spinal injury and/or neurosurgery,[13] regional stroke centers,[14] specialized cardiac care[15][16]
(Cardiac catheterization),[17] and specialized/regional trauma care.[18]

In some jurisdictions, EMS units may handle technical rescue operations such as extrication,
water rescue, and search and rescue.[19] Training and qualification levels for members and
employees of emergency medical services vary widely throughout the world. In some
systems, members may be present who are qualified only to drive the ambulance, with no
medical training.[9] In contrast, most systems have personnel who retain at least basic first aid
certifications, such as Basic Life Support (BLS). Additionally many EMS systems are staffed
with Advanced Life Support (ALS) personnel, including paramedics, nurses, or, less
commonly, physicians.[citation needed]

Service providers

A volunteer ambulance crew in Modena, Italy

Some countries closely regulate the industry (and may require anyone working on an
ambulance to be qualified to a set level), whereas others allow quite wide differences between
types of operator.

 Government Ambulance Service

Operating separately from (although alongside) the fire and police service of the area,
these ambulances are funded by local, provincial or national government. In some
countries, these only tend to be found in big cities, whereas in countries such as
United Kingdom almost all emergency ambulances are part of a national health
system.[34] In the United States, ambulance service provided by a local government are
often referred to as "third service" EMS (the Fire Department, Police Department, and
separate EMS forming an emergency services trio) by the employees of said service,
as well as other city officials and residents.
 Fire or Police Linked Service
 In countries such as the United States, Japan, France, and parts of India; ambulances
can be operated by the local fire or police service. This is particularly common in
rural areas, where maintaining a separate service is not necessarily cost effective. In
some cases this can lead to an illness or injury being attended by a vehicle other than
an ambulance, such as a fire truck. In other staffing schemes, firefighting protective
gear and basic tools are carried on fire based ambulances and the crews respond to
fires and other non medical emergencies in the ambulance. Also, where no private
ambulance service exists, fire based EMS units may provide inter-facility transports.
 Volunteer Ambulance Service

Charities or non-profit companies operate ambulances, both in an emergency and

patient transport function. This may be along similar lines to volunteer fire
companies, providing the main service for an area, and either community or privately
owned. They may be linked to a voluntary fire service, with volunteers providing both
services. There are charities who focus on providing ambulances for the community,
or for cover at private events (sports etc.). The Red Cross provides this service in
some parts of the world on a volunteer basis[35] (and in others as a Private Ambulance
Service), as do other smaller organisations such as St John Ambulance[36] and the
Order of Malta Ambulance Corps.[37] These volunteer ambulances may be seen
providing support to the full time ambulance crews during times of emergency. In
some cases the volunteer charity may employ paid members of staff alongside
volunteers to operate a full time ambulance service, such in some parts of Australia,
Ireland and most importantly Germany and Austria.

A government ambulance service in Kiev, Ukraine

 Private Ambulance Service

Normal commercial companies with paid employees, but often on contract to the local
or national government. Private companies may provide only the patient transport
elements of ambulance care (i.e. nonurgent), but in some places, they are contracted to
provide emergency care, or to form a 'second tier' response, where they only respond
to emergencies when all of the full-time emergency ambulance crews are busy. This
may mean that a government or other service provide the 'emergency' cover, whilst a
private firm may be charged with 'minor injuries' such as cuts, bruises or even helping
the mobility impaired if they have for example fallen and just need help to get up
again, but do not need treatment. This system has the benefit of keeping emergency
crews available all the time for genuine emergencies. These organisations may also
provide services known as 'Stand-by' cover at industrial sites or at special events.[38]
 Combined Emergency Service
 these are full service emergency service agencies, which may be found in places such
as airports or large colleges and universities. Their key feature is that all personnel are
trained not only in ambulance (EMT) care, but as a firefighter and a peace officer
(police function). They may be found in smaller towns and cities, where size or
budget does not warrant separate services. This multi-functionality allows to make the
most of limited resource or budget, but having a single team respond to any
emergency.
 Hospital Based Service

Hospitals may provide their own ambulance service as a service to the community, or
where ambulance care is unreliable or chargeable. Their use would be dependent on
using the services of the providing hospital. Most Advanced Life Support (Paramedic)
services in the United States are this type of service.
 Charity Ambulance

This special type of ambulance is provided by a charity for the purpose of taking sick
children or adults on trips or vacations away from hospitals, hospices or care homes
where they are in long term care. Examples include the UK's 'Jumbulance' project.[39]
 Company Ambulance

Many large factories and other industrial centres, such as chemical plants, oil
refineries, breweries and distilleries have ambulance services provided by employers
as a means of protecting their interests and the welfare of their staff. These are often
used as first response vehicles in the event of a fire or explosion.

Purpose

Six points on the Star of Life

Emergency medical services exists to fulfill the basic principles of first aid, which are to
Preserve Life, Prevent Further Injury, and Promote Recovery. This common theme in
medicine is demonstrated by the "star of life". The Star of Life shown here, where each of the
'arms' to the star represent one of the six points, which are used to represent the six stages of
high quality pre-hospital care, which are:[40]

1. Early detection – members of the public, or another agency, find the incident and
understand the problem
 2. Early reporting – the first persons on scene make a call to the emergency medical
services and provide details to enable a response to be mounted
3. Early response – the first professional (EMS) rescuers arrive on scene as quickly as
possible, enabling care to begin
4. Good on-scene care – the emergency medical service provides appropriate and timely
interventions to treat the patient at the scene of the incident
5. Care in transit – the emergency medical service load the patient in to suitable
transport and continue to provide appropriate medical care throughout the journey
6. Transfer to definitive care – the patient is handed over to an appropriate care setting,
such as the emergency department at a hospital, in to the care of physicians

Levels of care

EMT staff at an emergency call in New York City

A patient arriving at hospital

Emergency Medical Service is provided by a variety of individuals, using a variety of

methods. To some extent, these will be determined by country and locale, with each
individual country having its own 'approach' to how EMS should be provided, and by whom.
In some parts of Europe, for example, legislation insists that efforts at providing advanced
life support (ALS) Mobile Intensive Care Units (MICU) services must be physician-staffed,
while other permit some elements of that skill set to specially trained nurses, but have no
paramedics. Elsewhere, as in North America, the UK and Australia, ALS services are
performed by paramedics, but rarely with the type of direct "hands-on" physician leadership
seen in Europe. Increasingly, particularly in the UK and in South Africa, the role is being
provided by specially trained paramedics who are independent practitioners in their own
right. Beyond the national model of care, the type Emergency Medical Service will be
determined by local jurisdictions and medical authorities, based upon the needs of the
community, and the economic resources to support it.

A category of emergency medical service which is known as 'medical retrieval' or rendez

vous MICU protocol in some countries (Australia, NZ, Great Britain) refers to critical care
transport of patients between hospitals (as opposed to pre-hospital). Such services are a key
element in regionalised systems of hospital care where intensive care services are centralised
to a few specialist hospitals. An example of this is the Emergency Medical Retrieval Service
in Scotland. In the United States, this is referred to as "Critical Care Transport" and
qualifications for this role vary by state and can include an RN, Paramedic and/or EMT.

Generally speaking, the levels of service available will fall into one of three categories; Basic
Life Support (BLS), Advanced Life Support (ALS), and Critical Care Transport (CCT) by
traditional healthcare professionals, meaning nurses and/or physicians working in the pre-
hospital setting and even on ambulances. In some jurisdictions, a fourth level, Intermediate
Life Support (ILS), which is essentially a BLS provider with a moderately expanded skill set,
may be present, but this level rarely functions independently, and where it is present may
replace BLS in the emergency part of the service. When this occurs, any remaining staff at
the BLS level is usually relegated to the non-emergency transportation function. Job titles
typically include Emergency Medical Technician, Ambulance Technician, or Paramedic.
These ambulance care givers are generally professionals or paraprofessionals and in some
countries their use is controlled through training and registration. While these job titles are
protected by legislation in some countries, this protection is by no means universal, and
anyone might, for example, call themselves an 'EMT' or a 'paramedic', regardless of their
training, or the lack of it.[41] In some jurisdictions, both technicians and paramedics may be
further defined by the environment in which they operate, including such designations as
'Wilderness', 'Tactical', and so on.

Basic life support

(BLS)

First responder

A first responder is a person who arrives first at the scene of an incident, and whose job is to
provide early critical care such as CPR or using an AED.[42] First responders may be
dispatched by the ambulance service, may be passers-by, citizen volunteers, lifeguards, or
may be members of other agencies such as the police, fire department, or search and rescue
who have some medical training—commonly CPR, basic first aid, and AED use.[43]

Ambulance driver

Some jurisdictions separate the 'driver' and 'attendant' functions, employing ambulance
driving staff with no medical qualification (or just a first aid certificate), whose job is to drive
the ambulance. While this approach persists in some countries, such as India, it is generally
becoming increasingly rare. Ambulance drivers may be trained in radio communications,
ambulance operations and emergency response driving skills.[44]

Ambulance care assistant

Ambulance Care Assistants (ACAs) have varying levels of training across the world. In many
countries, such staff are usually only required to perform patient transport duties (which can
include stretcher or wheelchair cases), rather than acute care. However, there remain both
countries and individual jurisdictions in which economics will not support ALS service, and
the efforts of such individuals may represent the only EMS available. Dependent on the
provider (and resources available), they may be trained in first aid or extended skills such as
use of an AED, oxygen therapy, pain relief and other live-saving or palliative skills. In some
services, they may also provide emergency cover when other units are not available, or when
accompanied by a fully qualified technician or paramedic.[45][46]

Emergency medical technician

EMTs loading a patient into an ambulance

Emergency medical technicians, also known as Ambulance Technicians in the UK and EMT
in the United States. In the United States, EMT is usually made up of 3 levels. EMT-B, EMT-
I and EMT-Paramedic. The New Educational Standards for EMS renamed the provider levels
as follows: EMR, emergency medical responder, EMT, emergency medical technician,
AEMT, advanced EMT, and Paramedic. Technicians are usually able to perform a wide range
of emergency care skills, such as Automated defibrillation, care of spinal injuries and oxygen
therapy.[47][48] In few jurisdictions, some EMTs are able to perform duties as IV and IO
cannulation, administration of a limited number of drugs, more advanced airway procedures,
CPAP, and limited cardiac monitoring.[49] Most advanced procedures and skills are not within
the national scope of practice for an EMT-B.[50] As such most states require additional training
and certifications to perform above the national curriculum standards.[51][52]

Emergency medical dispatcher

An emergency medical dispatcher is also called an EMD. An increasingly common addition

to the EMS system is the use of highly trained dispatch personnel who can provide "pre-
arrival" instructions to callers reporting medical emergencies. They use carefully structured
questioning techniques and provide scripted instructions to allow callers or bystanders to
begin definitive care for such critical problems as airway obstructions, bleeding, childbirth,
and cardiac arrest. Even with a fast response time by a first responder measured in minutes,
some medical emergencies evolve in seconds. Such a system provides, in essence, a "zero
response time," and can have an enormous impact on positive patient outcomes.
Paramedic

A girl treated by a paramedic

A paramedic has a high level of prehospital medical training and usually involves key skills
not performed by technicians, often including cannulation (and with it the ability to use a
range of drugs to relieve pain, correct cardiac problems, and perform endotracheal
intubation), cardiac monitoring, tracheal intubation,pericardiocentesis, cardioversion, needle
decompression and other skills such as performing a cricothyrotomy.[53] The most important
function of the paramedic is to identify and treat any life-threatening conditions and then to
assess the patient carefully for other complaints or findings that may require emergency
treatment.[54]In many countries, this is a protected title, and use of it without the relevant
qualification may result in criminal prosecution.[55] In the United States, paramedics represent
the highest licensure level of prehospital emergency care. In addition, several certifications
exist for Paramedics such as Wilderness ALS Care,[56] Flight Paramedic Certification (FP-C),
[57]
and Critical Care Emergency Medical Transport Program certification.[58]

Critical care paramedic

Recently studies have looked at new level of pre-hospital care.[59][60] What has developed is
the critical care paramedic, also called an advanced practice Paramedic in some parts of USA
and Canada. These providers represent a higher level of licensure above that of the DOT or
respective paramedic level curriculum.[58] The training, permitted skills, and certification
requirements vary from one jurisdiction to the next. These providers transport critically ill or
injured patients from one hospital to a receiving hospital with higher level of care (ie.. cardiac
catheterization, trauma services or specialized ICU services) not available at referring facility.

These Paramedics receive additional training beyond normal EMS medicine. The Board for
Critical Care Transport Certification (BCCTPC®) has developed a certification exam for
flight and ground critical care paramedics [61][62] Some educational facilities that provide this
training are UMBC Critical Care Emergency Medical Transport Program[63] or "Cleveland
Clinic CICP program".. Individual services such as "Wake County EMS". and "MedStar
EMS". have developed 'in-house' advanced practice paramedic providers. These providers
have a vast array of and medications to handle complex medical and trauma patients.
Examples of medication are Dopamine, Dobutamine, Propofol, Blood and Blood products to
name just a few. Some examples of skills include, but not limited to, life support systems
normally restricted to the ICU or critical care hospital setting such as mechanical ventilators,
Intra-aortic balloon pump (IABP) and external pacemaker monitoring. Depending on the
service medical direction, these providers are trained on placement and use of UVCs
(Umbilical Venous Catheter), UACs (Umbilical Arterial Catheter), surgical airways, central
lines, arterial lines and chest tubes.

Wilderness Emergency Medical Technician

Some paramedics and EMTs, known as Wilderness Emergency Medical Technicians, utilize
expanded scope of practice protocols that are operationalized when in wilderness (remote,
austere, or resource-deficient) environments. Wilderness EMS Systems (WEMS) have been
developed to deliver a standard and professional medical response to wilderness areas.
Examples include the national-level agencies such as the National Ski Patrol in the United
States as well as local responding agencies. Like traditional EMS providers, all WEMS
providers must still operate under on-line or off-line medical oversight. To assist physicians
in the skills necessary to provide this oversight, the Wilderness Medical Society and the
National Association of EMS Physicians jointly supported the development in 2011 of a
unique "Wilderness EMS Medical Director" certification course,[64] which was cited by the
Journal of EMS as one of the Top 10 EMS Innovations of 2011.[65] Common procedures
utilized by WEMS providers that exceed traditional EMS scope of care include joint
reduction, catheterization, antibiotic administration, selective spinal immobilization, and
different training and protocols involving CPR cessation and wilderness skills. A multitude of
organizations provide WEMS training, including private schools,[66][67][68][69][70] non-profit
organizations such as the Appalachian Center for Wilderness Medicine [71] and the Wilderness
EMS Institute,[72] military branches, community colleges and universities,[73][74] EMS-college-
hospital collaborations,[75] and others.

Paramedic practitioner / Emergency care practitioner

In the United Kingdom and South Africa, some serving paramedics receive additional
university education to become practitioners in their own right, which gives them absolute
responsibility for their clinical judgement, including the ability to autonomously prescribe
medications, including drugs usually reserved for doctors, such as courses of antibiotics. An
emergency care practitioner is a position sometimes referred to as a 'super paramedic' and is
designed to bridge the link between ambulance care and the care of a general practitioner.
ECPs are university graduates in Emergency Medical Care or qualified paramedics who have
undergone further training,[76] and are authorized to perform specialized techniques.
Additionally some may prescribe medicines (from a limited list) for longer term care, such as
antibiotics. With respect to a Primary Health Care setting, they are also educated in a range of
Diagnostic techniques.

Traditional healthcare professions

Registered nurse

The use of registered nurses (RNs) in the pre-hospital setting is more common in countries
that have a limited EMS infrastructure in place. Some European countries such as France or
Italy, which do not use paramedics as they are intended in Anglo-Saxon countries, also use
nurses as a means of providing ALS services. These nurses may work under the direct
supervision of a physician, or, in rarer cases, independently. In some places in Europe,
notably Norway, paramedics do exist, but the role of the 'ambulance nurse' continues to be
developed,[77] as it is felt that nurses may bring unique skills to some situations encountered
by ambulance crews. In North America, and to a lesser extent elsewhere in the English-
speaking world, some jurisdictions use specially trained nurses for medical transport work.
These are mostly air-medical personnel or critical care transport providers, often working in
conjunction with a technician or paramedic or physician on emergency interfacility
transports. In the United States, the most common uses of ambulance-based Registered nurses
is in the Critical Care/Mobile Intensive Care transport, and in Aeromedical EMS. Such nurses
are normally required by their employers (in the US) to seek additional certifications beyond
basic nursing registration. In Estonia 60% of ambulance teams are led by nurse. Ambulance
nurses can do almost all emergency procedures and administer medicines pre-hospital such as
physicians in Estonia. In the Netherlands, all ambulances are staffed by a registered nurse
with additional training in emergency nursing, anaesthesia or critical care, and a driver-EMT.
[78]
In Sweden, since 2005, all emergency ambulances should be staffed by at least one
registered nurse since only nurses are allowed to administer drugs.[79][80] And all Advanced
Life Support Ambulances are staffed at least by a registered nurse in Spain.[81] In France,
since 1986, fire department-based rescue ambulances have had the option of providing
resuscitation service (reanimation) using specially trained nurses, operating on protocols,[82]
while SAMU-SMUR units are staffed by physicians and nurses[83]

Physician

There are many places in Europe, most notably in France, Italy, the German-speaking
countries (Germany, Switzerland, Austria) and Spain where the model of EMS is different,
and physicians take a more direct, 'hands-on' approach to pre-hospital care. In France, Italy
and Spain, response to high-acuity emergency calls is physician-led, as with the French
SMUR teams. Paramedics do not exist within those systems, and most ALS is performed by
physicians. In the German-speaking countries, paramedics do exist, but special physicians
(called Notarzt) respond directly to high-acuity calls, supervising the paramedics ALS
procedures directly. Indeed, in these countries paramedics are not typically legally permitted
to practice their ALS procedures unless the physician is physically present, unless they face
immediate life-threatening emergencies.[84] Some systems - most notably air ambulances in
the UK.[85][86] will employ physicians to take the clinical lead in the ambulance; bringing a full
range of additional skills such as use of medications that are beyond the paramedic skill set.
The response of physicians to emergency calls is routine in many parts of Europe, but is
uncommon in the UK, where physicians are generally tasked to high priority calls on a
voluntary basis. Within the UK a sub-speciality of Pre-Hospital Care is being developed for
Doctors, which would allow training programmes and consultant posts to be developed in this
one area of practice.

This 'hands-on' approach is less common in the United States. While one will occasionally
see a physician with an ambulance crew on an emergency call, this is much more likely to be
the Medical Director or an associate, inducting newly trained paramedics, or performing
routine medical quality assurance. In some jurisdictions adult or pediatric critical care
transports sometimes use physicians, but generally only when it appears likely that the patient
may require surgical or advanced pharmacologic intervention beyond the skills of an EMT,
paramedic or nurse during transport. Physicians are leaders of medical retrieval teams in
many western countries, where they may assist with the transport of a critically ill, injured, or
special needs patient to a tertiary care hospital, particularly when longer transport times are
involved.

Prehospital Delivery of care

Depending on country, area within country, or clinical need, emergency medical services may
be provided by one or more different types of organisation. This variation may lead to large
differences in levels of care and expected scope of practice.

The most basic emergency medical services are provided as a transport operation only,
simply to take patients from their location to the nearest medical treatment. This was often
the case in a historical context, and is still true in the developing world, where operators as
diverse as taxi drivers[9] and undertakers may operate this service.

Most developed countries now provide a government funded emergency medical service,
which can be run on a national level, as is the case in the United Kingdom, where a national
network of ambulance trusts operate an emergency service, paid for through central taxation,
and available to anyone in need,[87] or can be run on a more regional model, as is the case in
the United States, where individual authorities have the responsibility for providing these
services.

Typical scene at a local emergency room

Ambulance services can be stand alone organisations, but in some cases, the emergency
medical service is operated by the local fire[88] or police[89] service. This is particularly
common in rural areas, where maintaining a separate service is not necessarily cost effective.
This can lead, in some instances, to an illness or injury being attended by a vehicle other than
an ambulance, such as fire truck.[90][91][92] In some locales, firefighters are the first responders
to calls for emergency medical aid, with separate ambulance services providing transportation
to hospitals when necessary.[93]

Some charities or non-profit companies also operate emergency medical services, often
alongside a patient transport function.[94] These often focus on providing ambulances for the
community, or for cover at private events, such as sports matches. The Red Cross provides
this service in many countries across the world on a volunteer basis (and in others as a Private
Ambulance Service), as do some other smaller organizations such as St John Ambulance.[36]
and the Order of Malta Ambulance Corps.[95] In some countries, these volunteer ambulances
may be seen providing support to the full-time ambulance crews during times of emergency,
or simply to help cover busy periods.[96]

There are also private ambulance companies, with paid employees, but often on contract to
the local or national government. Many private companies provide only the patient transport
elements of ambulance care (i.e. nonurgent), although in some places these private services
are contracted to provide emergency care, or to form a 'second tier' response, where they only
respond to emergencies when all of the full-time emergency ambulance crews are busy or to
respond to non-emergency home calls.[citation needed] Private companies are often contracted by
private clients to provide event specific cover, as is the case with voluntary EMS crews.

Many colleges and universities, especially in the United States, maintain their own EMS
organizations. These organizations operate at capacities ranging from first response to ALS
transport. Campus EMS in the United States is overseen by the National Collegiate
Emergency Medical Services Foundation.

Strategies for delivering care

Ambulance in the Czech Republic

The essential decision in prehospital care is whether the patient should be immediately taken
to the hospital, or advanced care resources are taken to the patient where they lie. The "scoop
and run" approach is exemplified by the MEDEVAC aeromedical evacuation helicopter,
whereas the "stay and play" is exemplified by the French and Belgian SMUR emergency
mobile resuscitation unit or the German "Notarzt"-System (preclinical emergency physician).

The strategy developed for prehospital trauma care in North America is based on the Golden
Hour theory, i.e., that a trauma victim's best chance for survival is in an operating room, with
the goal of having the patient in surgery within an hour of the traumatic event. This appears
to be true in cases of internal bleeding, especially penetrating trauma such as gunshot or stab
wounds. Thus, minimal time is spent providing prehospital care (spine immobilization;
"ABCs", i.e. ensure airway, breathing and circulation; external bleeding control; endotracheal
intubation) and the victim is transported as fast as possible to a trauma centre.[97]

The aim in "Scoop and Run" treatment is generally to transport the patient within ten minutes
of arrival, hence the birth of the phrase, "the platinum ten minutes" (in addition to the "golden
hour"), now commonly used in EMT training programs. The "Scoop and Run" is a method
developed to deal with trauma, rather than strictly medical situations (e.g. cardiac or
respiratory emergencies), however, this may be changing. Increasingly, research into the
management of S-T segment elevation myocardial infarctions (STEMI) occurring outside of
the hospital, or even inside community hospitals without their own PCI labs, suggests that
time to treatment is a clinically significant factor in heart attacks, and that trauma patients
may not be the only patients for whom 'load and go' is clinically appropriate. In such
conditions, the gold standard is the door to balloon time. The longer the time interval, the
greater the damage to the myocardium, and the poorer the long-term prognosis for the patient.
[98]
Current research in Canada has suggested that door to balloon times are significantly
lower when appropriate patients are identified by paramedics in the field, instead of the
emergency room, and then transported directly to a waiting PCI lab.[99] The STEMI program
has reduced STEMI deaths in the Ottawa region by 50 per cent.[100] In a related program in
Toronto, EMS has begun to use a procedure of 'rescuing' STEMI patients from the
Emergency Rooms of hospitals without PCI labs, and transporting them, on an emergency
basis, to waiting PCI labs in other hospitals.[101]

Models of care

Although a variety of differing philosophical approaches are used in the provision of EMS
care around the world, they can generally be placed into one of two categories; one
physician-led and the other led by pre-hospital specialists such as emergency medical
technicians or paramedics (which may, or may not have accompanying physician oversight).
These models are typically identified by their locations of origin.[102]

The Franco-German model is physician-led, with doctors responding directly to all major
emergencies requiring more than simple first aid. In some cases in this model, such as France,
paramedics, as they exist in the Anglo-American model, are not used, although the term
'paramedic' is sometimes used generically, and those with that designation have training that
is similar to an U.S. EMT-B.[103] The team's physicians and in some cases, nurses, provide all
medical interventions for the patient, and non-medical members of the team simply provide
the driving and heavy lifting services. In other applications of this model, as in Germany, a
paramedic equivalent does exist, but is sharply restricted in terms of scope of practice; often
not permitted to perform Advanced Life Support (ALS) procedures unless the physician is
physically present, or in cases of immediate life-threatening conditions.[84] Ambulances in this
model tend to be better equipped with more advanced medical devices, in essence, bringing
the emergency department to the patient. High-speed transport to hospitals is considered, in
most cases, to be unnecessarily unsafe, and the preference is to remain and provide definitive
care to the patient until they are medically stable, and then accomplish transport. In this
model, the physician and nurse may actually staff an ambulance along with a driver, or may
staff a rapid response vehicle instead of an ambulance, providing medical support to multiple
ambulances.

The second care structure, termed the Anglo-American model, utilizes pre-hospital care
specialists, such as emergency medical technicians and paramedics, to staff ambulances,
which may be classified according to the varying skill levels of the crews. In this model it is
rare to find a physician actually working routinely in the pre-hospital setting, although they
may be utilised on complex or major injuries or illnesses. In this system, a physicians
involvement is most likely to be the provision of medical oversight for the work of the
ambulance crews, which may be accomplished in terms of off-line medical control, with
protocols or 'standing orders' for certain types of medical procedures or care, or on-line
medical control, in which the technician must establish contact with the physician, usually at
the hospital, and receive direct orders for various types of medical interventions. In some
cases, such as in the UK, South Africa and Australia, a paramedic may be an autonomous
health care professional, and does not require the permission of a physician to administer
interventions or medications from an agreed list, and can perform roles such as suturing or
prescribing medication to the patient.[104]

In this model, patients may still be treated at the scene up to the skill level of the attending
crew, and subsequently transported to definitive care, but in many cases the reduced skill set
of the ambulance crew and the needs of the patient indicate a shorter interval for transport of
the patient than is the case in the Franco-German model.

Clinical governance

Paramedics in Anglosaxon countries normally function under the authority (medical

direction) of one or more physicians charged with legally establishing the emergency medical
directives for a particular region. Paramedics are credentialed and authorized by these
physicians to use their own clinical judgment and diagnostic tools to identify medical
emergencies and to administer the appropriate treatment, including drugs that would normally
require a physician order. Credentialing may occur as the result of a State Medical Board
examination (U.S.) or the National Registry of Emergency Medical Technicians (U.S.). In
England, and in some parts of Canada, credentialing may occur by means of a College of
Paramedicine.[105] In these cases, paramedics are regarded as a self-regulating health
profession. The final common method of credentialing is through certification by a Medical
Director and permission to practice as an extension of the Medical Director's license to
practice some medical acts. The authority to practice in this semi-autonomous manner is
granted in the form of standing order protocols (off-line medical control) and in some cases
direct physician consultation via phone or radio (on-line medical control). Under this
paradigm, paramedics effectively assume the role of out-of-hospital field agents to regional
emergency physicians, with clinical decision-making authority using standing orders or
protocols.

In some parts of the world, those in the paramedical professional role are only permitted to
practise many of their advanced skills while assisting a physician who is physically present,
or they face cases of immediately life-threatening emergencies.[84] In many other parts in the
world, most notably in France, Belgium, Luxembourg, Italy, and Spain, but also in Brazil and
Chile. All MICU skills in the pre-hospital setting are performed by physicians and nurses and
an On-line Permanent medical supervision is done by the SAMU. In certain other
jurisdictions, such as the United Kingdom and South Africa, paramedics may be entirely
autonomous practitioners capable of prescribing medications.[106] In other jurisdictions, such
as Australia and Canada, this expanded scope of practice is under active consideration and
discussion.[107]
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