Paramedics in Canada

A paramedic in Canada is a highly educated medical professional that brings emergency medicine to the patient in their time of need in their home, in the street or in the vast wilderness of the country. Frequently these patients will be treated in their homes and released under their own care or transported to hospital for further assessment and treatment. In the cases of patients requiring emergent surgical intervention a paramedic's role is to provide rapid stabilization and rapid transport to the surgical suite for definitive treatment. In Canada the scope of practise 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 Federal Government. Under the new NOCP most providers that work in Ambulances will be identified as 'Paramedics'. However, in many cases, the most prevalent level of emergency prehospital care is that which is provided by the Emergency Medical Responder (EMR). This is a level of practice recognized under the National Occupational Competency Profile, although unlike the next 3 successive levels of practice, the EMR is not specifically considered a Paramedic, per se. The high number of EMRs across Canada cannot be ignored as contributing a critical role in the chain of survival, although it is a level of practice that is least comprehensive (clinically speaking), and is also generally not consistent with any medical acts beyond advanced first-aid, with the exception of automated external defibrillation.

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.

A Primary Care Paramedic (PCP) is the entry-level paramedic. An Advanced Care Paramedic (ACP) is a higher level of practitioner, and typically has an additional year of formal education. Finally, there are Critical Care Paramedics (CCP). This level of practitioner generally has between nine months and one year of additional training beyond the ACP. CCPs are relatively few in number, and do not exist in all provinces. However, where CCPs are employed, they typically provide comprehensive out-of-hospital care consistent with the needs of an ICU patient, though typically in an inter-facility context, while Primary and Advanced Care Paramedics are far more numerous and dominate the pre-hospital role.

Actual credentialling, licensure or certification to practice is still a provincial sphere of responsibility. Regulatory frameworks vary from province to province, and include direct government regulation (such as Ontario's method of credentialling 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 provinces of Alberta and Saskatchewan use the title "Emergency Medical Technician", or 'EMT' for the Primary Care Paramedic and 'Paramedic' only for those qualified as Advanced Care Paramedics Advanced Life Support (ALS) providers - but almost all provinces are gradually moving to adopting the new titles, or have at least recognized the NOCP document as a benchmarking document to permit inter-provincial labour mobility of practitioners, regardless of how titles are specifically regulated within their own provincial systems. In this manner, the confusing myriad of titles and occupational descriptions can at least be discussed using a common language for comparison sake.

Primary Care Paramedics
Primary Care Paramedics (PCP) are the entry-level of paramedic practice in Canadian provinces. They perform semi-automated external defibrillation, interpret 3-lead ECG's and administer Symptom Relief Medications for a variety of emergency medical conditions (these include Oxygen, Epinephrine, Glucagon, Ventolin, ASA, Nitroglycerine, etc.) and perform spinal immobilization and other fundamental basic medical care. Primary Care Paramedics may also receive some additional training in order to perform certain skills that are normally in the scope of practice of Advanced Care Paramedics. This is both provincially (by statute) and locally (by the medical director) regulated, and ordinarily entails an aspect of medical oversight by a specific body or group of physicians tasked with providing such medical oversight. This is often referred to as Medical Control, or a role played by a Base Hospital. For example, in the province of Ontario many paramedic services allow Primary Care Paramedics to perform 12-lead ECG interpretation, or initiate intravenous therapy to deliver a few additional medications, such as 50% Dextrose.

Advanced Care Paramedics
Advanced Care Paramedics (ACP) are often thought of as the most desirable level of practice, as it most closely resemebles a level of practice that is conjured up by the lay-public as defining what Paramedics do, or ought to be able to do. The ACP a level of practitioner that is in high demand by many ambulance services across Canada. However, still not all provinces and jurisdictions have Advanced Care Paramedics, The Advanced Care Paramedic typically carries approximately 20 different medications, although the number and type of medications may also vary from substantially from region to region. Advanced Care Paramedics perform advanced airway management including intubation, surgical airways, intravenous therapy, place external jugular IV lines, perform needle thoracic decompression, perform and interpret 12-lead ECGs, perform synchronized and chemical cardioversion, transcutaneous pacing, perform limited obstetrical assessments, provide pharmacological chemical pain relief for various conditions, and reverse hypoglycemic states. Several sites in Canada have experimented with pre-hospital fibrinolytics and rapid sequence intubation, and prehospital medical research has permitted a great number of variations in the scope of practice for Advanced Care Paramedics. In fact, the standard of care provided by Advanced Care Paramedics tends to be highly evolutionary and, arguably, more dynamic than the pace of change affecting Primary Care Paramedics.

Critical Care Paramedics
Critical Care Paramedics (CCP) carry an extensive range of medications; well in excess of that used by Advanced Care Paramedics. They are also generally trained and able to use a number of additional drugs that they do not ordinarily carry, but may access and obtain from medical facilities when the need arises. They also perform cursory interpretation of basic chest, neck and skeletal x-rays, CT-scans and 12-18 lead ECG's, can perform rapid sequence intubation and surgical airway management, place or maintain external jugular lines, program medication pumps, use ICU-quality transport ventilators and isolettes, run intra-aortic balloon pumps, use transvenous pacers, administer blood and blood products, perform obstetrical assessments, and perform invasive pressure monitoring while maintaining central lines, as well as maintain chest drainage devices and and chest tubes. Essentially, they run a mobile intensive care unit. CCPs work in close communication with their controlling physicians and often do not require additional medical staff to accompany their patients. This level of paramedic usually works on an aircraft, or in a Critical Care Transfer ambulance. Their primary function is usually to transfer critical patients between medical facilities, although in some cases, they may also perform scene responses to the most critical emergencies in some jurisdictions. Often upon arriving at a peripheral or rural hospital, the CCPs will cooperatively assume care of critically ill and injured patients from the ER staff in order to prepare them for transport to a more specialized facility. Critical Care Paramedics do not exist in many jurisdictions; most Paramedics with CCP training are employed in Ontario, Nova Scotia and Alberta.

A medical doctor who certifies the paramedics under his license to perform delegated controlled medical acts is generally part of the medical oversight system governing Paramedics of all levels. These physicians typically work as part of a system that is defined Provincially (by statute) and locally (by the medical director).

Training
Paramedic training in Canada is intense, as paramedics are seen as health professionals, equal in importance to nurses, respiratory therapists, cardiac perfusionists and others. Nevertheless, the nature of training and how it is regulated, like actual paramedic practice, varies from province to province. Training varies regionally with Primary Care Paramedicine being a 3 month (British Columbia) to two year (Ontario) program.

Training as an Advanced Care Paramedic requires that the student be qualified as a Primary Care Paramedic. Eligibility for ACP training varies from immediate entry following Primary Care Paramedic qualification (self funded) to a mandatory period of experience working as a Primary Care Paramedic - usually one to three years (employer sponsored training). The length of time required to complete Advanced Care Paramedic training also varies between provinces, and it is generally related to the length of time required to have completed the prerequisite Primary Care Training. Shorter (around one year) programs build upon the education already learned in a 2 year Primary Care Paramedic training program, while longer (typically up to two years) college programs typically cater to Primary Care Paramedics 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, Advanced Care Paramedics across Canada will generally have completed approximately 3 years of formal education, inclusive of didactic study and clinical placements.

Training as a Critical Care Paramedic follows a similar logic, usually requiring mandatory field experience as an Advanced Care Paramedic beforehand. This level of education tends to be highly variable and flexible in its design and delivery. The length of time required for completion may take as little as a few months, or up to one year. Almost all CCP programs have extensive field-training requirements with an experienced Critical Care Paramedic mentor or preceptor, in addition to supervised, intensive classroom, lab, clinical and field experience.

There is an emerging interest towards 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, and a list of accredited programs can be found on their site at [http://www.cma.ca/index.cfm/ci_id/19316/la_id/1.htm 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. The nature of these competency expectations can be found on the Paramedic Association of Canada website at www.paramedic.ca

Some provinces require that only graduates from accredited programs may be employed as Paramedics, while in others (such as Ontario), it is not required, but may be seen as a value-added benefit to graduates. For example, in Ontario, the province has its own system of approving Paramedic Programs, and it is not necessary for these programs to seek or obtain CMA Accreditation, although many programs have done so voluntarily.

Paramedic Training in the province of Quebec is anomalous to the rest of Canada. Until very recently, Quebec was alone in following the European model of staffing ambulances or special response vehicles in some jurisdictions with physicians. For various reasons, this model is being abandoned, and Quebec is slowly beginning to follow the general standards of EMS in the rest of the country.

Professional Environment
Because paramedics are seen as 'physician extenders', they enjoy a close relationship with the physicians who ultimately grant paramedics the legal right to practise their profession. Also, because physician assistants in Canada exist primarily only in the Canadian Forces, the role of Clinical Paramedic Practitioners may gradually be expanding. Increasingly, both urban and rural centres have begun utilizing paramedics working in-hospital on cardiac arrest teams, patient transfer teams, emergency department triage/treatment and to facilitate faster "off-load" times. Some small hospitals in Alberta and Saskatchewan have engaged paramedics to supervise ER's at night in the place of M.D.'s because of their ability to independently diagnose and direct the rest of the healthcare team in patient care. Similarly, community outreach programs led by Paramedics, such as providing TB screening and influenza vaccinations to the homeless, are becoming more common.

Paramedics often work long hours, most commonly with 12 hour shifts. In some areas, however, 24 and even 96 hour shifts are not unusual. Salary and benefits are generally commensurate with the level of education and certification, though often less than the salary expectations of police officers and firefighters, as well as nurses. This incongruity is often argued as being unfair, especially in light of the relative level of responsibility a Paramedic may have for acting decisively and without having direct supervision. However, paramedicine as a career offers intangible benefits and job satisfaction is generally high. Paramedics in Canada generally work only as paramedics, not as cross-trained firefighters or police officers, and most are paid full or part-time professionals, as opposed volunteers. 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 specialty squads including Marine medics, Bike medics, First Response medics, Tactical medics, CBRN medics (Chemical, Biological, Radiological and Nuclear) and HUSAR medics (Heavy Urban Search And Rescue - specializing in urban disaster recovery).

British Columbia Ambulance Service
The British Columbia Ambulance Service, is the sole provider of pre-hospital emergency care, in the province of British Columbia, at the paramedic level of care. Some stats:

Coverage
 * 4.2 Million Population
 * 926,492 km². coverage area
 * 551,290 Total Responses (Fiscal 2004/2005)

Paramedics and Equipment
 * 3,177 Total field paramedics/EMA's
 * 450 Total ambulances and support units
 * 190 Total paramedic stations

Alberta College of Paramedics
The Alberta College of Paramedics, a regulatory college in the name of public safety towards the code of conduct towards the profession of paramedic within the province of Alberta.

Alberta Health & Wellness
Alberta Health & Wellness provides ambulance services (both Air and Ground) to the province of Alberta. Total population served is 3 million and they have about 3,000 ambulance attendants in their ground ambulance service.

Toronto EMS
Toronto EMS is also the largest municipal paramedic service in Canada with 920 active paramedics in 146 ambulance transport units and a 2002 call volume of:


 * 425,000 Phone Calls via the 9-1-1 system
 * 247,000 Requests for service
 * 187,000 Responses
 * 140,000 Emergency patient transports

On December 7, 2004 TEMS was awarded "Queen's Colours" (a royal heraldic emblem, approved by the Queen) in recognition of services rendered to the community. The only other non-military organization to receive this honour is the Royal Canadian Mounted Police. More information is available on the Ontario Paramedic Association website here

The Association representing close to 300 of Toronto's Paramedics is known as the Toronto Paramedic Association, and can be reached at their website.

Saskatchewan College of Paramedics
In May 2007 Saskatchewan's professional association received Royal Assent for the Paramedic Act which will enable self-regulation and licensure of EMS for the province. The Paramedic Act will eventually replace the outdated Ambulance Act currently governing provincial EMS.