A paramedic is a
healthcare professional trained in the medical model, whose main role has historically been to respond to emergency calls for medical help outside of a hospital. Paramedics work as part of the
emergency medical services (EMS), most often in
ambulances. They also have roles in emergency medicine, primary care, transfer medicine and remote/offshore medicine. The
scope of practice of a paramedic varies between countries, but generally includes autonomous decision making around the emergency care of patients.
Not all ambulance personnel are paramedics, although the term is sometimes used informally to refer to any ambulance personnel. In some English-speaking countries, there is an official distinction between paramedics and
emergency medical technicians (or
emergency care assistants), in which paramedics have additional educational requirements and scope of practice.
Functions and duties
The paramedic role is closely related to other healthcare positions, especially the
emergency medical technician, with paramedics often being at a higher grade with more responsibility and autonomy following substantially greater education and training.
The primary role of a paramedic is to stabilize people with life-threatening injuries and transport these patients to a higher level of care (typically an emergency department). Due to the nature of their job, paramedics work in many environments, including roadways, people's homes, and depending on their qualifications, wilderness environments, hospitals, aircraft, and with SWAT teams during police operations. Paramedics also work in non-emergency situations, such as transporting chronically ill patients to and from treatment centers and in some areas, address social determinants of health and provide in-home care to ill patients at risk of hospitalization (a practice known as community paramedicine).
The role of a paramedic varies widely across the world, as EMS providers operate with many different
models of care. In the Anglo-American model, paramedics are autonomous decision-makers. In some countries such as the United Kingdom and South Africa, the paramedic role has developed into an autonomous health profession. In the Franco-German model, ambulance care is led by physicians. In some versions of this model, such as France, there is no direct equivalent to a paramedic. Ambulance staff have either the more advanced qualifications of a physician or less advanced training in
first aid. In other versions of the Franco-German model, such as Germany, paramedics do exist. Their role is very similar to the role of paramedics in the Anglo-American model with an advanced scope of autonomy and practice, and the added element of
emergency physician backup, either virtually (
Tele-Notarzt) or on scene with a rapid response vehicle / helicopter. The role of paramedics in Germany has evolved from support to physicians in the field to the central role in pre-hospital emergency care.
The development of the profession has been a gradual move from simply transporting patients to hospital, to more advanced treatments in the field. In some countries, the paramedic may take on the role as part of a system to prevent hospitalization entirely and, through practitioners, are able to prescribe certain
medications, or undertaking 'see and refer' visits, where the paramedic directly refers a patient to specialist services without taking them to hospital.
Occupational hazards
Paramedics are exposed to a variety of hazards such as lifting patients and equipment, treating those with infectious disease, handling hazardous substances, and transportation via ground or air vehicles. Employers can prevent occupational illness or injury by providing safe patient handling equipment, implementing a training program to educate paramedics on job hazards, and supplying PPE such as respirators, gloves, and isolation gowns when dealing with biological hazards.
Infectious disease has become a major concern, in light of the
COVID-19 pandemic
The COVID-19 pandemic (also known as the coronavirus pandemic and COVID pandemic), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), began with an disease outbreak, outbreak of COVID-19 in Wuhan, China, in December ...
. In response, the U.S.
Centers for Disease Control and Prevention and other agencies and organizations have issued guidance regarding
workplace hazard controls for COVID-19. Some specific recommendations include modified call queries, symptom screening, universal PPE use, hand hygiene, physical distancing, and stringent disinfection protocols. Research on ambulance ventilation systems found that aerosols often recirculate throughout the compartment, creating a health hazard for paramedics when transporting sick patients capable of airborne transmission.
Unidirectional airflow design can better protect workers.
To further safeguard paramedics, incorporating evidence-based strategies for managing
chemical exposures and
environmental risks is crucial. Agencies such as
OSHA,
WHO and
NIOSH offer comprehensive guidelines that highlight the integration of safety protocols, technological advancements, and procedural innovations to enhance paramedic safety and well-being.
Physical injuries
Paramedics are widely recognized to face high risks of physical injuries in their line of work. More than 22,000 EMS providers visit
the emergency room each year for work-related injuries.
Some physical injuries encountered when providing healthcare services include
lifting injuries,
back strains, and
needlestick incidences. Injuries such as
sprains and
strains mostly occur in the back and neck, and injuries are most prevalent while responding to
911 calls, which include patient care and transport.
These injuries are prevalent but not impossible to overcome; they require preventive measures to minimize the chance of them happening. Safe
lifting techniques and patient-handling equipment are major factors in reducing paramedics’ physical injury risk. Workers with less than 10 years’ experience are most at risk, pointing to the need for targeted prevention strategies for newer employees.
By employing the proposed measures to reduce physical injuries, it will be possible to mitigate the hazards faced by paramedics, to help paramedics stay safe while rendering the most needed services.
Infectious diseases
The risk of contracting
infectious diseases is common in the paramedic profession. The
COVID-19
Coronavirus disease 2019 (COVID-19) is a contagious disease caused by the coronavirus SARS-CoV-2. In January 2020, the disease spread worldwide, resulting in the COVID-19 pandemic.
The symptoms of COVID‑19 can vary but often include fever ...
pandemic strengthens the necessity of following safety protocols.
Preventive measures for healthcare workers from needlestick injuries and
infectious disease is critical. Including, the immediate
disposal of sharps in puncture-resistant containers and wearing appropriate
personal protective equipment (PPE) and strict adherence to post-exposure protocols, enhances safety. Additionally, staying updated with
vaccination
Vaccination is the administration of a vaccine to help the immune system develop immunity from a disease. Vaccines contain a microorganism or virus in a weakened, live or killed state, or proteins or toxins from the organism. In stimulating ...
s, including those for
flu,
COVID-19
Coronavirus disease 2019 (COVID-19) is a contagious disease caused by the coronavirus SARS-CoV-2. In January 2020, the disease spread worldwide, resulting in the COVID-19 pandemic.
The symptoms of COVID‑19 can vary but often include fever ...
,
Hepatitis B. Furthermore, adhering to infection control practices, such as
hand hygiene, environmental cleaning, and specialized control programs, are vital for preventing infections like
MRSA,
TB, and
COVID-19
Coronavirus disease 2019 (COVID-19) is a contagious disease caused by the coronavirus SARS-CoV-2. In January 2020, the disease spread worldwide, resulting in the COVID-19 pandemic.
The symptoms of COVID‑19 can vary but often include fever ...
.
Personal Protective Equipment (PPE) usage in implementation and vaccination compliance are effective transmission reduction measures for
infectious diseases among paramedics. Exposures to blood pathogens and body fluids through incidents, for example,
needlestick injuries which jeopardizes paramedics at risk of infectious diseases such as
Hepatitis B, and
Hepatitis C, and
HIV affecting around 6,000 EMS workers.
This realization strengthens the need for science-based methods in preventing the occupational risks posed by infectious diseases with a foregrounding of the role of preventative measures geared towards protecting the health of paramedic professionals and, at the same time, the community.
Chemical exposures
Paramedics encounter daily risks associated with handling
hazardous chemicals. As a result, they must understand how to deliver care safely to remain protected in the service provision. They need to remain cautious for them to stay safe in the process of providing care. There are numerous associated risks from
chemical exposures in prehospital settings.
The use of
PPE and standard precautions are necessary to prevent harmful exposures for paramedics.
Desirable implementation of the ordered processing of hazardous material and the proper decontamination process are effective strategies in combating hazard risk. Such steps are necessary to ensure fewer cases of health hazards to paramedics.
Environmental and operational hazards
Paramedics are confronted with many challenges exhibited in the form of environmental and
operational risks, primarily during transportation. These transportation-related hazards should be considered and addressed in
prehospital care. Slips, trips, and falls;
motor vehicle incidents; and
violence or
assault
In the terminology of law, an assault is the act of causing physical harm or consent, unwanted physical contact to another person, or, in some legal definitions, the threat or attempt to do so. It is both a crime and a tort and, therefore, may ...
s have huge impact on paramedics'
occupational hazards, resulting to thousands of paramedics impacted annually.
Vehicle safety features need to be known by paramedics, and so must undergo exhaustive emergency driving training, which looks into curbing the provisions that are the peril of transportation. Paramedics are frequently assaulted by patients or bystanders affecting around 2,000 EMS workers annually, which further hammers the need for training on de-escalation.
NIOSH and the
Department of Homeland Security have conducted ambulance crash testing, resulting in the development of 10 test methods published by the
Society of Automotive Engineers (SAE) to reduce and eliminate crash-related injuries to EMS workers.
Through effective training, the threat cases are more likely to be mitigated, and the paramedics will have a better chance to provide services as required.
Protective measures and equipment

One way of ensuring paramedics work at optimal efficiency is to provide them with protective equipment and gear to mitigate the possible risks when executing their duties.
PPE keeps paramedics’ occupational risks low. Examples of PPEs include
gloves,
masks, and
gown or specific clothing; they protect workers from
physical,
biological, and
chemical hazards. The different types of PPE include respiratory, eye, face, and hand protection. Under respiratory protection, paramedics can use
N95 masks to filter
airborne contaminants. Chemical splashes are also a common hazard faced by paramedics, where
safety goggles can be used for eye protection. Underhand protection, paramedics can employ gloves mainly to curb burns. One of the principles of PPE is that choices should be guided by specific risks associated with various emergencies, which warrant different PPE requirements.
Mental health and stress management
Paramedic are involved in challenging professions and can be subject to different kinds of
psychological stress, for instance,
post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) is a mental disorder that develops from experiencing a Psychological trauma, traumatic event, such as sexual assault, domestic violence, child abuse, warfare and its associated traumas, natural disaster ...
,
depression, or severe
burnout. The psychological aspect is intertwined with the nature of the paramedics' work. Exposure to traumatic events such as accidents,
medical emergencies, and
violence are some of the factors undermining the psychological health of paramedics.
Mental health
Mental health is often mistakenly equated with the absence of mental illness. However, mental health refers to a person's overall emotional, psychological, and social well-being. It influences how individuals think, feel, and behave, and how t ...
issues, including
depression,
anxiety, and
substance abuse, are some of the mental health issues paramedics are likely to get exposed to due to their nature of work as compared to the general population. Stable support systems that may include peer counselling and the availability of mental health resources become essential in building the resilience of paramedic professionals. Peer counselling programs appear to be an effective stress management strategy for paramedics.
Taking part in open discussions with other peers who understand what the employee is going through determines the necessary supportive grounds that facilitate managing and processing feelings related to this work.
Health risks and monitoring
The long-term health risks that need to be observed by the paramedics are
Post Traumatic Stress Disorder (PTSD),
cardiovascular diseases (CVDs), and
cancer risk. There are a variety of challenges paramedics encounter, including
PTSD, which should provide a compelling reason to implement preventive mental health measures within this profession.
Moreover, there is an extra risk for CVDs because of the heaviness of emergency response operations. There is a need to emphasize cancer risk and the importance of constant exploration and individualized prevention patterns. Besides, there is the cumulative effect of fatigue, violence, and trauma on the health of paramedics. As a result, there is a need for systematic monitoring and preventive measures in health among paramedics. It is necessary to study long-term health risks for paramedics and apply a prophylactic approach to maintaining the health state of healthcare professionals.
Regulatory guidelines and recommendations
The regulatory guidelines are fundamental in eliminating occupational risk in
paramedicine; authoritative bodies like the
Occupational Safety and Health Administration (OSHA) and the
World Health Organization (WHO) provide specific guidelines. For example, in United States,
physical,
chemical, and
biological hazards are managed by operating under the guidelines and recommendations offered by
NIOSH and
OSHA, targeting the healthcare industry especially. These include properly using
PPE, handling hazardous substances, and adequately managing
workplace violence. Moreover, the
WHO provides global views by laying international standards to protect the well-being of the staff involved in the healthcare provided, irrespective of whether it is an emergency or routine operation. Such regulatory bodies, as the ones promoting national and global safety standards, ensure that evidence-based approaches reinforce adherence to their occupational health being safeguarded.
History
Early history
Throughout the evolution of pre-hospitalization care, there has been an ongoing association with military conflict. One of the first indications of a formal process for managing injured people dates from the
Imperial Legions of Rome, where aging
Centurions, no longer able to fight, were given the task of organizing the removal of the wounded from the
battle
A battle is an occurrence of combat in warfare between opposing military units of any number or size. A war usually consists of multiple battles. In general, a battle is a military engagement that is well defined in duration, area, and force co ...
field and providing some form of care. Such individuals, although not
physicians, were probably among the world's earliest
surgeons by default, being required to
suture wounds and complete
amputations. A similar situation existed in the
Crusades
The Crusades were a series of religious wars initiated, supported, and at times directed by the Papacy during the Middle Ages. The most prominent of these were the campaigns to the Holy Land aimed at reclaiming Jerusalem and its surrounding t ...
, with the
Knights Hospitaller of the
Order of St. John of Jerusalem filling a similar function; this organisation continued, and evolved into what is now known throughout the
Commonwealth of Nations
The Commonwealth of Nations, often referred to as the British Commonwealth or simply the Commonwealth, is an International organization, international association of member states of the Commonwealth of Nations, 56 member states, the vast majo ...
as the
St. John Ambulance and as the
Order of Malta Ambulance Corps in the Republic of Ireland and various countries.
Early ambulance services
While civilian communities had organized ways to deal with prehospitalisation care and transportation of the sick and dying as far back as the
bubonic plague in
London
London is the Capital city, capital and List of urban areas in the United Kingdom, largest city of both England and the United Kingdom, with a population of in . London metropolitan area, Its wider metropolitan area is the largest in Wester ...
between 1598 and 1665, such arrangements were typically ''ad hoc'' and temporary. In time, however, these arrangements began to formalize and become permanent. During the
American Civil War
The American Civil War (April 12, 1861May 26, 1865; also known by Names of the American Civil War, other names) was a civil war in the United States between the Union (American Civil War), Union ("the North") and the Confederate States of A ...
,
Jonathan Letterman devised a system of mobile
field hospitals employing the first uses of the principles of
triage. After returning home, some veterans began to attempt to apply what had they had seen on the battlefield to their own communities, and commenced the creation of volunteer life-saving squads and ambulance corps.
These early developments in formalized ambulance services were decided at local levels, and this led to services being provided by diverse operators such as the local hospital, police, fire brigade, or even
funeral directors who often possessed the only local transport allowing a passenger to lie down. In most cases these ambulances were operated by drivers and attendants with little or no medical training, and it was some time before formal training began to appear in some units. An early example was the members of the
Toronto Police Ambulance Service receiving a mandatory five days of training from St. John as early as 1889.
Prior to
World War I
World War I or the First World War (28 July 1914 – 11 November 1918), also known as the Great War, was a World war, global conflict between two coalitions: the Allies of World War I, Allies (or Entente) and the Central Powers. Fighting to ...
motorized ambulances started to be developed, but once they proved their effectiveness on the battlefield during the war the concept spread rapidly to civilian systems. In terms of advanced skills, once again the military led the way. During
World War II
World War II or the Second World War (1 September 1939 – 2 September 1945) was a World war, global conflict between two coalitions: the Allies of World War II, Allies and the Axis powers. World War II by country, Nearly all of the wo ...
and the
Korean War
The Korean War (25 June 1950 – 27 July 1953) was an armed conflict on the Korean Peninsula fought between North Korea (Democratic People's Republic of Korea; DPRK) and South Korea (Republic of Korea; ROK) and their allies. North Korea was s ...
battlefield medics administered painkilling
narcotics by injection in emergency situations, and pharmacists' mates on warships were permitted to do even more without the guidance of a physician. The Korean War also marked the first widespread use of
helicopter
A helicopter is a type of rotorcraft in which Lift (force), lift and thrust are supplied by horizontally spinning Helicopter rotor, rotors. This allows the helicopter to VTOL, take off and land vertically, to hover (helicopter), hover, and ...
s to evacuate the wounded from forward positions to medical units, leading to the rise of the term "
medevac". These innovations would not find their way into the civilian sphere for nearly twenty more years.
Pre-hospital emergency medical care
By the early 1960s experiments in improving medical care had begun in some civilian centres. One early experiment involved the provision of pre-hospital
cardiac care by physicians in
Belfast
Belfast (, , , ; from ) is the capital city and principal port of Northern Ireland, standing on the banks of the River Lagan and connected to the open sea through Belfast Lough and the North Channel (Great Britain and Ireland), North Channel ...
, Northern Ireland, in 1966. This was repeated in
Toronto
Toronto ( , locally pronounced or ) is the List of the largest municipalities in Canada by population, most populous city in Canada. It is the capital city of the Provinces and territories of Canada, Canadian province of Ontario. With a p ...
, Canada in 1968 using a single ambulance called ''Cardiac One'', which was staffed by a regular ambulance crew, along with a hospital
intern to perform the advanced procedures. While both of these experiments had certain levels of success, the technology had not yet reached a sufficiently advanced level to be fully effective; for example, the Toronto portable
defibrillator and
heart monitor was powered by
lead-acid car batteries, and weighed around .

In 1966, a report called ''Accidental Death and Disability: The Neglected Disease of Modern Society''—commonly known as ''
The White Paper''—was published in the United States. This paper presented data showing that soldiers who were seriously wounded on the battlefields during the
Vietnam War had a better survival rate than people who were seriously injured in motor vehicle accidents on
California
California () is a U.S. state, state in the Western United States that lies on the West Coast of the United States, Pacific Coast. It borders Oregon to the north, Nevada and Arizona to the east, and shares Mexico–United States border, an ...
's
freeways. Key factors contributing to victim survival in transport to definitive care such as a hospital were identified as comprehensive trauma care, rapid transport to designated trauma facilities, and the presence of medical corpsmen who were trained to perform certain critical advanced medical procedures such as
fluid replacement
Fluid replacement or fluid resuscitation is the medical practice of replenishing bodily fluid lost through sweating, bleeding, fluid shifts or other pathologic processes. Fluids can be replaced with oral rehydration therapy (drinking), intravenous ...
and
airway management.
As a result of ''The White Paper'', the US government moved to develop minimum standards for ambulance training, ambulance equipment and vehicle design. These new standards were incorporated into Federal Highway Safety legislation and the states were advised to either adopt these standards into state laws or risk a reduction in Federal highway safety funding. The "White Paper" also prompted the inception of a number of emergency medical service (EMS)
pilot units across the US including paramedic programs. The success of these units led to a rapid transition to make them fully operational.
Founded in 1967,
Freedom House Ambulance Service was the first civilian emergency medical service in the United States to be staffed by
paramedics, most of whom were Black.
New York City's Saint Vincent's Hospital developed the United States' first Mobile Coronary Care Unit (MCCU) under the medical direction of William Grace, MD, and based on Frank Pantridge's MCCU project in Belfast, Northern Ireland. In 1967, Eugene Nagle, MD and Jim Hirschmann, MD helped pioneer the United States' first EKG telemetry transmission to a hospital and then in 1968, a functional paramedic program in conjunction with the City of Miami Fire Department. In 1969, the City of Columbus Fire Department joined with the Ohio State University Medical Center to develop the "HEARTMOBILE" paramedic program under the medical direction of James Warren, MD and Richard Lewis, MD. In 1969, the Haywood County (NC) Volunteer Rescue Squad developed a paramedic program (then called Mobile Intensive Care Technicians) under the medical direction of Ralph Feichter, MD. In 1969, the initial Los Angeles paramedic training program was instituted in conjunction with Harbor General Hospital, now
Harbor–UCLA Medical Center, under the medical direction of
J. Michael Criley, MD and James Lewis, MD. In 1969, the Seattle "Medic 1" paramedic program was developed in conjunction with the
Harborview Medical Center under the medical direction of Leonard Cobb, MD. The Marietta (GA) initial paramedic project was instituted in the Fall of 1970 in conjunction with Kennestone Hospital and Metro Ambulance Service, Inc. under the medical direction of Luther Fortson, MD. The Los Angeles County and City established paramedic programs following the passage of ''The Wedsworth-Townsend Act'' in 1970. Other cities and states passed their own paramedic bills, leading to the formation of services across the US. Many other countries also followed suit, and paramedic units formed around the world.
In the military, however, the required
telemetry and
miniaturization technologies were more advanced, particularly due to initiatives such as the
space program. It would take several more years before these technologies drifted through to civilian applications. In North America, physicians were judged to be too expensive to be used in the pre-hospital setting, although such initiatives were implemented, and sometimes still operate, in
Europe
Europe is a continent located entirely in the Northern Hemisphere and mostly in the Eastern Hemisphere. It is bordered by the Arctic Ocean to the north, the Atlantic Ocean to the west, the Mediterranean Sea to the south, and Asia to the east ...
an countries and
Latin America
Latin America is the cultural region of the Americas where Romance languages are predominantly spoken, primarily Spanish language, Spanish and Portuguese language, Portuguese. Latin America is defined according to cultural identity, not geogr ...
.
Public notability
While doing background research at Los Angeles'
UCLA
The University of California, Los Angeles (UCLA) is a public land-grant research university in Los Angeles, California, United States. Its academic roots were established in 1881 as a normal school then known as the southern branch of the C ...
Harbor Medical Center for a proposed new show about doctors,
television producer Robert A. Cinader, working for
Jack Webb, happened to encounter "firemen who spoke like doctors and worked with them". This concept developed into the television series ''
Emergency!'', which ran from 1972 to 1977, portraying the exploits of this new profession called paramedics. The show gained popularity with emergency services personnel, the medical community, and the general public. When the show first aired in 1972, there were just six paramedic units operating in three pilot programs in the whole of the US, and the term paramedic was essentially unknown. By the time the program ended in 1977, there were paramedics operating in all fifty states. The show's
technical advisor,
James O. Page, was a pioneer of
paramedicine and responsible for the UCLA paramedic program; he would go on to help establish paramedic programs throughout the US, and was the founding publisher of the ''Journal of Emergency Medical Services'' (''JEMS''). The ''JEMS'' magazine creation resulted from Page's previous purchase of the ''PARAMEDICS International'' magazine.
Ron Stewart, the show's
medical director, was instrumental in organizing emergency health services in southern California earlier in his career during the 1970s, in the paramedic program in Pittsburgh, and had a substantial role in the founding of the paramedic programs in Toronto and
Nova Scotia
Nova Scotia is a Provinces and territories of Canada, province of Canada, located on its east coast. It is one of the three Maritime Canada, Maritime provinces and Population of Canada by province and territory, most populous province in Atlan ...
, Canada.
Evolution and growth
Throughout the 1970s and 1980s, the paramedic field continued to evolve, with a shift in emphasis from patient transport to treatment both on scene and en route to hospitals. This led to some services changing their descriptions from "ambulance services" to "
emergency medical services".

The training, knowledge-base, and skill sets of both paramedics and
emergency medical technicians (EMTs) were typically determined by local medical directors based primarily on the perceived needs of the community along with affordability. There were also large differences between localities in the amount and type of training required, and how it would be provided. This ranged from in-service training in local systems, through community colleges, and up to university level education. This emphasis on increasing qualifications has followed the progression of other health professions such as
nursing, which also progressed from on the job training to university level qualifications.
The variations in educational approaches and standards required for paramedics has led to large differences in the required qualifications between locations—both within individual countries and from country to country. Within the UK training is a three-year course equivalent to a
bachelor's degree
A bachelor's degree (from Medieval Latin ''baccalaureus'') or baccalaureate (from Modern Latin ''baccalaureatus'') is an undergraduate degree awarded by colleges and universities upon completion of a course of study lasting three to six years ...
. Comparisons have been made between paramedics and nurses; with nurses now requiring degree entry (BSc) the knowledge deficit is large between the two fields. This has led to many countries passing laws to protect the title of "paramedic" (or its local equivalent) from use by anyone except those qualified and experienced to a defined standard. This usually means that paramedics must be registered with the appropriate body in their country; for example all paramedics in the United Kingdom must by registered with the
Health and Care Professions Council (HCPC) in order to call themselves a paramedic. In the United States, a similar system is operated by the
National Registry of Emergency Medical Technicians (NREMT), although this is only accepted by forty of the fifty states.
As paramedicine has evolved, a great deal of both the
curriculum and skill set has existed in a state of flux. Requirements often originated and evolved at the local level, and were based upon the preferences of physician advisers and medical directors. Recommended treatments would change regularly, often changing more like a fashion than a scientific discipline. Associated technologies also rapidly evolved and changed, with medical equipment manufacturers having to adapt equipment that worked inadequately outside of hospitals, to be able to cope with the less controlled pre-hospital environment.
Physicians began to take more interest in paramedics from a research perspective as well. By about 1990, the fluctuating trends began to diminish, being replaced by outcomes-based research. This research then drove further evolution of the practice of both paramedics and the emergency physicians who oversaw their work, with changes to procedures and
protocols occurring only after significant research demonstrated their need and effectiveness (an example being
ALS). Such changes affected everything from simple procedures such as
CPR, to changes in drug protocols. As the profession grew, some paramedics went on to become not just research participants, but researchers in their own right, with their own projects and journal publications. In 2010, the
American Board of Emergency Medicine created a
medical subspecialty for physicians who work in emergency medical services.
Changes in procedures also included the manner in which the work of paramedics was overseen and managed. In the early days medical control and oversight was direct and immediate, with paramedics calling into a local hospital and receiving orders for every individual procedure or drug. While this still occurs in some jurisdictions, it has become increasingly rare. Day-to-day operations largely moved from direct and immediate medical control to pre-written protocols or standing orders, with the paramedic typically seeking advice after the options in the standing orders had been exhausted.
Canada

While the evolution of paramedicine described above is focused largely on the US, many other countries followed a similar pattern, although often with significant variations. Canada, for example, attempted a pilot paramedic training program at
Queen's University,
Kingston, Ontario, in 1972. The program, which intended to upgrade the then mandatory 160 hours of training for ambulance attendants, was found to be too costly and premature. The program was abandoned after two years, and it was more than a decade before the legislative authority for its graduates to practice was put into place. An alternative program which provided 1,400 hours of training at the
community college level prior to commencing employment was then tried, and made mandatory in 1977, with formal certification examinations being introduced in 1978. Similar programs occurred at roughly the same time in
Alberta
Alberta is a Provinces and territories of Canada, province in Canada. It is a part of Western Canada and is one of the three Canadian Prairies, prairie provinces. Alberta is bordered by British Columbia to its west, Saskatchewan to its east, t ...
and
British Columbia
British Columbia is the westernmost Provinces and territories of Canada, province of Canada. Situated in the Pacific Northwest between the Pacific Ocean and the Rocky Mountains, the province has a diverse geography, with rugged landscapes that ...
, with other Canadian provinces gradually following, but with their own education and certification requirements. Advanced Care Paramedics were not introduced until 1984, when
Toronto
Toronto ( , locally pronounced or ) is the List of the largest municipalities in Canada by population, most populous city in Canada. It is the capital city of the Provinces and territories of Canada, Canadian province of Ontario. With a p ...
trained its first group internally, before the process spread across the country. By 2010 the Ontario system involved a two-year community college based program, including both hospital and field clinical components, prior to designation as a Primary Care Paramedic, although it is starting to head towards a university degree-based program. The province of Ontario announced that by September 2021, the entry level primary care paramedic post-secondary program would be enhanced from a two-year diploma to a three-year advanced diploma in primary care paramedicine. Resultantly, advanced care paramedics in Ontario will require a minimum of four years of post-secondary education and critical care paramedics will require five years of post-secondary education.
Israel
In Israel, paramedics are trained in either of the following ways: a three-year degree in Emergency Medicine (B.EMS), a year and three months
IDF training, or
MADA training. Paramedics manage and provide medical guidelines in
mass casualty incidents. They operate in MED evac and ambulances. They are legalized under the 1976 Doctors Ordinance (Decree). In a 2016 study at the Ben Gurion University of the Negev it was found that 73% of trained paramedics stop working within a five-year period, and 93% stop treating within 10 years.
United Kingdom
In the United Kingdom, ambulances were originally
municipal services after the end of World War II. Training was frequently conducted internally, although national levels of coordination led to more standardization of staff training. Ambulance services were merged into county-level agencies in 1974, and then into regional agencies in 2006. The regional ambulance services, most often trusts, are under the authority of the
National Health Service and there is now a significant standardization of training and skills. The UK model has three levels of ambulance staff. In increasing order of clinical skill these are:
emergency care assistants,
emergency medical technicians, and paramedics.
Today, university qualifications are expected for paramedics, with the current entry level being a
Bachelor of Science degree in Pre-Hospital Care or Paramedic Science. As the title "Paramedic" is legally protected, those utilising must be registered with the
Health and Care Professions Council (HCPC), and in order to qualify for registration you must meet the standards for registration, which include having a degree obtained through an approved course. The change of entry requirements does not affect currently registered Paramedics, some of whom will still only have their entry qualification, but it is common for Paramedics to continue to progress through "top up" courses, for instance, to work towards a Bachelors of Science degree. This has led to Paramedics holding a wide range of qualifications, with some qualifications (such as master's degrees in Advanced or Paramedic Practice) being a pre-requisite for paramedic prescribing.
Paramedics work in various settings including NHS and Independent Ambulance Providers, Air Ambulances, Emergency Departments and other alternative settings. Some paramedics have gone on to become ''Paramedic Practitioners'', a role that practices independently in the pre-hospital environment in a capacity similar to that of a
nurse practitioner. This is a fully autonomous role, and such senior paramedics are now working in hospitals, community teams such as rapid response teams, and also in increasing numbers in general practice, where their role includes acute presentations, complex chronic care and end of life management. They work as part of the
allied health professional team including Doctors, Nurses, physician Associates, Physiotherapists, Associate Physicians, Health Care Assistant and Clinical Pharmacists. Paramedic Practitioners also undertake examinations modelled upon the MRCGP (a combination of applied knowledge exams, clinical skills and work place based assessment) in order to use the title "specialist". There are also now a growing number of these advanced paramedics who are independent and supplementary prescribers. There are also 'Critical Care Paramedics' who specialise in acute emergency incidents. In 2018, the UK government changed legislation allowing Paramedics to independently prescribe, which will open new pathways to Paramedics to progress into. This came into force on 1 April 2018, but did not immediately affect practice as guidance was still being written.
United States
In the United States, the minimum standards for paramedic training is considered
vocational, but many colleges offer paramedic
associate degree or
bachelor's degree
A bachelor's degree (from Medieval Latin ''baccalaureus'') or baccalaureate (from Modern Latin ''baccalaureatus'') is an undergraduate degree awarded by colleges and universities upon completion of a course of study lasting three to six years ...
options. Paramedic education programs typically follow the U.S. NHTSA EMS Curriculum, DOT or National Registry of EMTs. While many regionally accredited
community colleges offer paramedic programs and two-year associate degrees, a handful of universities also offer a four-year bachelor's degree component. The national standard course minimum requires
didactic and clinical hours for a paramedic program of 1,500 or more hours of classroom training and 500+ clinical hours to be accredited and nationally recognized.
Calendar length typically varies from 12 months to upwards of two years, excluding degree options, EMT training, work experience, and prerequisites. It is required to be a certified Emergency Medical Technician prior to starting paramedic training. Entry requirements vary, but many paramedic programs also have prerequisites such as one year required work experience as an
emergency medical technician, or anatomy and physiology courses from an accredited college or university. Paramedics in some states must attend up to 50+ hours of ongoing education, plus maintain Pediatric Advanced Life Support and Advanced Cardiac Life Support. National Registry requires 70 + hours to maintain its certification or one may re-certify through completing the written computer based adaptive testing again (between 90 and 120 questions) every two years.
Paramedicine continues to grow and evolve into a formal profession in its own right, complete with its own standards and body of knowledge, and in many locations paramedics have formed their own
professional bodies.
The early technicians with limited training, performing a small and specific set of procedures, has become a role beginning to require a foundation degree in countries such as
Australia
Australia, officially the Commonwealth of Australia, is a country comprising mainland Australia, the mainland of the Australia (continent), Australian continent, the island of Tasmania and list of islands of Australia, numerous smaller isl ...
,
South Africa
South Africa, officially the Republic of South Africa (RSA), is the Southern Africa, southernmost country in Africa. Its Provinces of South Africa, nine provinces are bounded to the south by of coastline that stretches along the Atlantic O ...
, the
UK, and increasingly in Canada and parts of the U.S. such as
Oregon
Oregon ( , ) is a U.S. state, state in the Pacific Northwest region of the United States. It is a part of the Western U.S., with the Columbia River delineating much of Oregon's northern boundary with Washington (state), Washington, while t ...
, where a degree is required for entry level practice.
Ukraine
As a part of
Emergency Medicine Reform in 2017
Ministry of Healthcare introduced two specialties — "paramedic" and "
emergency medical technician".
Structure of employment
Paramedics are employed by a variety of different organizations, and the services they provide may occur under differing organizational structures, depending on the part of the world. A new and evolving role for paramedics involves the expansion of their practice into the provision of relatively basic primary health care and assessment services.
Some paramedics have begun to specialize their practice, frequently in association with the environment in which they will work. Some early examples of this involved
aviation medicine and the use of
helicopter
A helicopter is a type of rotorcraft in which Lift (force), lift and thrust are supplied by horizontally spinning Helicopter rotor, rotors. This allows the helicopter to VTOL, take off and land vertically, to hover (helicopter), hover, and ...
s, and the transfer of critical care patients between facilities. While some jurisdictions still use physicians, nurses, and technicians for transporting patients, increasingly this role falls to specialized senior and experienced paramedics. Other areas of specialization include such roles as tactical paramedics working in police units, marine paramedics, hazardous materials (
Hazmat) teams,
Heavy Urban Search and Rescue, and paramedics on
offshore oil platforms, oil and mineral exploration teams, and in the
military.
The majority of paramedics are employed by the
emergency medical service for their area, although this employer could itself be working under a number of models, including a specific autonomous public ambulance service, a fire department, a hospital based service, or a private company working under contract. In
Washington, firefighters have been offered free paramedic training. There are also many paramedics who volunteer for backcountry or wilderness rescue teams, and small town rescue squads. In the specific case of an ambulance service being maintained by a fire department, paramedics and EMTs may be required to maintain firefighting and rescue skills as well as medical skills, and vice versa. In some instances, such as
Los Angeles County, a fire department may provide emergency medical services, but as a rapid response or rescue unit rather than a transport ambulance.
The provision of municipal ambulance services and paramedics, can vary by area, even within the same country or state. For instance, in Canada, the province of British Columbia operates a province-wide service (the
British Columbia Ambulance Service) whereas in
Ontario
Ontario is the southernmost Provinces and territories of Canada, province of Canada. Located in Central Canada, Ontario is the Population of Canada by province and territory, country's most populous province. As of the 2021 Canadian census, it ...
, the service is provided by each municipality, either as a distinct service, linked to the
fire service, or contracted out to a third party.
Scope of practice
Common skills
While there are varying degrees of training and expectations around the world, a set of skills practised by paramedics in the pre-hospital setting commonly includes:
*
Advanced cardiac life support, or ACLS, including
cardiopulmonary resuscitation
Cardiopulmonary resuscitation (CPR) is an emergency procedure used during Cardiac arrest, cardiac or Respiratory arrest, respiratory arrest that involves chest compressions, often combined with artificial ventilation, to preserve brain function ...
,
defibrillation,
cardioversion,
transcutaneous pacing, and administration of cardiac drugs
* Patient assessment, including acquisition of
vital signs, physical exam,
chest auscultation, history taking,
electrocardiogram acquisition and interpretation,
capnography,
pulse oximetry, point-of-care
ultrasound and basic
blood chemistry interpretation (glucose, lactate)
*Airway management techniques including
tracheal intubation
Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic catheter, tube into the vertebrate trachea, trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer c ...
,
cricothyrotomy,
rapid sequence induction,
supraglottic airway insertion, manual repositioning, sterile suctioning, use of
oropharyngeal and
nasopharyngeal airway adjuncts, and manual removal of obstructions via direct laryngoscopy and use of
magill forceps
*
Thorocostomy and
pericardiocentesis to relieve pneumothorax and pericardial tamponade
*
Intravenous (IV) and
intraosseous (IO) cannulation
* Oxygen administration and
positive pressure ventilation via
bag-valve-mask,
CPAP device, or
ventilator
*
Fluid resuscitation
* Administration of emergency drugs/medications (see section below)
* Bleeding control and management of
shock
*
Spinal injury management, including immobilization and safe transport
*
Fracture management, including assessment,
splinting, and dislocation reduction
*
Obstetrics, including assessment,
childbirth
Childbirth, also known as labour, parturition and delivery, is the completion of pregnancy, where one or more Fetus, fetuses exits the Womb, internal environment of the mother via vaginal delivery or caesarean section and becomes a newborn to ...
, and recognition of and procedures for obstetrical emergencies such as
breech presentation, cord presentation, and
placental abruption
* Management of
burns, including classification, estimate of surface area, recognition of more serious burns, and treatment
*
Triage of patients in a
mass casualty incident
* Surgical procedures such as field amputation,
escharotomy, or
thorocotomy (if trained and credentialed)
Emergency pharmacology
Paramedics carry and administer a wide array of emergency
medications. The specific medications they are permitted to administer vary widely, based on local standards of care and protocols. For an accurate description of permitted drugs or procedures in a given location, it is necessary to contact that jurisdiction directly. A representative list of medications may commonly include:

*
Analgesic medications such as
aspirin,
ketorolac and
paracetamol (acetaminophen), used to relieve pain or decrease nausea and vomiting
*
Narcotics like
morphine,
pethidine,
fentanyl, and
methoxyflurane, used to treat severe pain.
* Beta and calcium channel blockers such as
diltiazem,
metoprolol and
verapamil used to slow down excessively high
heart rates or severe
hypertension
*
Parasympatholytic drug such as
Atropine, also known as anticholinergic drugs, used to speed up slow
bradycardic heart rates
*
Sympathomimetics such as
dopamine,
dobutamine,
norepinephrine, and
epinephrine used for
cardiac arrest
Cardiac arrest (also known as sudden cardiac arrest CA is when the heart suddenly and unexpectedly stops beating. When the heart stops beating, blood cannot properly Circulatory system, circulate around the body and the blood flow to the ...
, severe
hypotension
Hypotension, also known as low blood pressure, is a cardiovascular condition characterized by abnormally reduced blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood and is ...
(low blood pressure),
shock and
sepsis. These are often known as "vasoactive" agents.
*
Dextrose (often D50W, a solution of 50% dextrose in water), used to treat
hypoglycemia
Hypoglycemia (American English), also spelled hypoglycaemia or hypoglycæmia (British English), sometimes called low blood sugar, is a fall in blood sugar to levels below normal, typically below 70 mg/dL (3.9 mmol/L). Whipple's tria ...
(low blood sugar)
* Sedatives like midazolam, lorazepam, etomidate, and ketamine
used to reduce the irritability or agitation of patients, to relieve symptoms of seizure, or provide procedural sedation
* Paralytics such as succinylcholine, rocuronium, and vecuronium, used when an emergency procedure such as Rapid sequence induction, rapid sequence intubation (RSI) is required
* Antipsychotics like haloperidol or ziprasidone, used to sedate combative patients
* Respiratory medications such as albuterol and ipratropium bromide used to treat conditions such as asthma and acute bronchitis
* Steroids such as hydrocortisone and methylprednisolone used to treat inflammatory respiratory conditions and adrenal crisis
* Cardiac medications such as nitroglycerin and aspirin are used to treat cardiac ailments such as angina and myocardial infarctions
* Diuretic medications such as furosemide to treat congestive heart failure and severe hypertension
* Antiarrhythmics such as amiodarone, adenosine, lidocaine and magnesium sulfate used to treat arrhythmia, abnormal heart rhythms such as ventricular tachycardia and ventricular fibrillation
* Antiemetics such as promethazine or ondansetron used for nausea and vomiting
* Antidotes for a variety of toxins such as naloxone (opioids), pralidoxime (organophosphates), sodium bicarbonate (tricyclic antidepressants), and hydroxocobalamin (cyanide).
*Blood transfusion, Blood products and tranexamic acid in cases of Shock (circulatory), hemorrhagic shock
* Broad spectrum antibiotics such as ceftriaxone or vancomycin for cases of
sepsis
* Hormones like oxytocin to control post-partum bleeding
Skills by certification level
As described above, many jurisdictions have different levels of paramedic training, leading to variations in what procedures different paramedics may perform depending upon their qualifications. Three common general divisions of paramedic training are the basic technician, general paramedic or advanced technician, and advanced paramedic. Common skills that these three certification levels may practice are summarized in the table below. The skills for the higher levels automatically also assume those listed for lower levels.
Medicolegal authority
The medical law, medicolegal framework for paramedics is highly dependent on the overall structure of emergency medical services in the territory where they are working.

In many localities, paramedics operate as a direct extension of a physician medical director and practice as an extension of the medical director's license. In the United States, a physician delegates authority under an individual state's Medical Practice Act. This gives a paramedic the ability to practice within limited scope of practice in law, along with state DOH guidelines and medical control oversight. The authority to practice in this manner is granted in the form of standing orders Guideline (medical), (protocols) (off-line medical control) and 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 independent clinical decision.
In places where paramedics are recognised health care professionals registered with an appropriate body, they can conduct all procedures authorised for their profession, including the administration of prescription medication, and are personally answerable to a regulator. For example, in the United Kingdom, the
Health and Care Professions Council regulates paramedics and can censure or strike a paramedic from the register.
In some cases paramedics may gain further qualifications to extend their status to that of a paramedic practitioner or advanced paramedic, which may allow them to administer a wider range of drugs and use a wider range of clinical skills.
In some areas, paramedics are only permitted to practice many advanced skills while assisting a physician who is physically present, except for immediately life-threatening emergencies.
See also
;Paramedics by country
*Paramedics in Australia
*Paramedics in Canada
*Paramedics in France
*Paramedics in Germany
*PHECC, Paramedics in Ireland
*Emergency medical services in South Africa, Paramedics in South Africa
*Paramedics in the United Kingdom
*Paramedics in the United States
;Related fields
* Biophone
* Field medic
* Flight Paramedic
* Health care providers
* National Association of Emergency Medical Technicians
* National Registry of Emergency Medical Technicians
;Other
*Feldsher
*List of EMS provider credentials
References
Further reading
* Conaghan, Joseph. ''Coach and horses: my history in the ambulance dispute 1989/90''. Glantaff House, 2010.
*
*
*
External links
National EMS MuseumNational Registry of Emergency Medical TechniciansNational Association of Emergency Medical TechniciansNHTSA Emergency Medical Services National PageCollege of Paramedics (UK)
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Emergency medical responders
Health care occupations
Protective service occupations
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