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 those who work on emergency and non-emergency patient transport service environment ambulances. 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 some jurisdictions involves substantially more mandatory education and training than paramedics (generally speaking Advanced Care Paramedic equivalent) in other environments, and the skill set is sometimes, but not always, beyond that of an EMT (generally speaking Primary Care Paramedic equivalent). 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. 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 six 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.

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 Paramedic (ACP), and Critical Care Paramedic (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. As a group, EMRs staff rural ambulance stations, 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

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	Critical Care Paramedic skills
Airway management	Manual and repositioning, Oro- and nasopharyngeal airway adjuncts (in some case supraglottic airways like the King LT) 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),pulse oximetry, 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, semi-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 (PCPs) 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, epinephrine, antihistamine, salbutamol, aspirin, nitroglycerine, naloxone, dextrose, thiamine, glucagon 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.

• Paramedics work almost exclusively in ambulances
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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 (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, 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 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.

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 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, 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 staff on long transfers.

CCPs are able to provide all of the care that PCPs and ACPs are able to provide. In addition to this they are trained for other skills such as medication infusion pumps, mechanical ventillation and advanced monitoring hemodynamic monitoring.

CCPs often work in fixed and rotary wing aircraft, but systems such as the Toronto EMS Critical Care Transport Program work in land ambulances. In British Columbia, CCP's work primarily in aircraft with a dedicated CCT crew in Trail for long-distance transfers and a regular CCP street crew stationed in South Vancouver that often also performs medevacs, when necessary.

• Canadian critical care transport
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Medical direction and oversight

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 other paramedics in Canada, are permitted to perform regulated 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 specific regulated medical act under defined situations. The scope of practice for the paramedic is defined in paramedic protocols (also referred to as advanced medical directives). These protocols specify which skill and the conditions required for the paramedic to act. Each protocol is signed by the medical director. Medical directors are generally ER physicians who work in a hospital associated with the paramedic service. The relationship between this hospital ('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. These physicians are usually ER 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.

Some Canadian paramedics are moving towards the status of self-regulated health professionals with paramedics 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 or Associations have been established in Alberta, Saskatchewan, New Brunswick, and Nova Scotia, with Ontario actively moving towards this type of legislation.

Professional Environment

Paramedics have a close relationship with the physicians who ultimately grant paramedics the legal right to practice their profession with a regulated paramedic service. Also, because physician assistants in Canada exist primarily in the Canadian Forces, the role of clinical paramedic practitioners is under serious study. 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 determine a patients immediate health status and assist the rest of the healthcare team in patient care.^{[citation needed]} Similarly, community outreach programs led by paramedics, such as providing tuberculosis screening and influenza vaccinations to the homeless, are becoming more common.

In Halifax, NS, ACPs and CCPs work side by side with physicians in various emergency departments within the Capital District Health Authority. The responsibilities of these department paramedics varies from ER to ER within CDHA but include advanced airway stabilization, suturing, minor treatment as well as other expanded paramedic roles such as procedural sedations. They have also proven a necessary and integral member of the cardiac arrest and trauma teams. PCPs have been employed by CDHA since the early 1990s to perform triage assessments.

Paramedics often work long hours, most 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)

Salary And Employment

Paramedic wages in Canada vary depending on province and experience. Paramedics in Ontario in such regions or cities as Ottawa, Toronto, Peel Region, or Durham, will have an annual salary starting from $60,000 to $75,000 as a Primary Care Paramedic, an Advanced Care Paramedic salary can on average range from $80,000 to $90,000, and Critical Care Paramedics range from $95,000 to $120,000. Education background, experience, and level of practice all are contributing factors to which salary is established.

Many of the paramedics in Alberta are employed by Albert Health Services EMS, and unionized under HSAA. Typical starting annual salaries for an Alberta paramedic working for AHSEMS is $70,000. Oilfield operations also employs a large portion of paramedic practitioners, with a typical daily wage of $650.

See also

• Paramedic
• Ambulance
• Emergency Medical Services in Canada
• List of EMS Services in Ontario

External links

• Paramedic Association of Canada
• Paramedic Association of Manitoba
• 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
• Alberta College of Paramedics
• National Registry of Emergency Medical Technicians
• National Association of Emergency Medical Technicians
• NHTSA Emergency Medical Services National Page
• Association Professionnelle des Paramédics du Québec