Paramedical personnel



A paramedic is a medical professional, usually a member of the emergency medical service, who primarily provides pre-hospital advanced medical and trauma care. A paramedic is charged with providing emergency on-scene treatment, crisis intervention, life-saving stabilization and, when appropriate, transport of ill or injured patients to definitive emergency medical and surgical treatment facilities, such as hospitals and trauma centers.

The use of the specific term paramedic varies by jurisdiction, and in some places is used to refer to any member of an ambulance crew. In countries such as Canada and South Africa, the term paramedic is used as the job title for all EMS personnel, who are then distinguished by the terms primary or basic (e.g. Primary Care Paramedic) intermediate, or advanced (e.g. Advanced Care Paramedic). This approach may be completely appropriate in such jurisdictions, where primary care staff receive more than double the classroom and clinical training of an EMT, and in fact more than those in some jurisdictions permitted by law to call themselves paramedics. In countries such as the United States and the United Kingdom, the use of the word paramedic is restricted by law, and the person claiming the title must have passed a specific set of examinations and clinical placements, and hold a valid registration, certification, or license with a governing body. Even in countries where the law restricts the title, lay persons may incorrectly refer to all emergency medical personnel as 'paramedics', even if they officially hold a different qualification, such as emergency medical technician-basic.

The category may also include:
 * Attendants (institutions)
 * Psychiatric aides

The term paramedic comes from para- (auxiliary) +medical, meaning "related to medicine in an auxiliary capacity ," the military term paramedic, meaning a parachuting medical corpsmen, came later.

History of paramedicine
Throughout the evolution of what we now call paramedicine, 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 tasked with organizing the removal of the wounded from the battlefield and providing some form of care. Such individuals, although not physicians, were probably among the world's earliest surgeons, suturing wounds, completing amputations, and not through training, but by default. This trend would continue throughout the Crusades, with the Knights Hospitallers of the Order of St. John of Jerusalem, known throughout the British Commonwealth today as St. John Ambulance, filling a similar function.

The first vehicle that was specifically designed as an ambulance was created during the Napoleonic War, and called the ambulance volante. Created by Napoleon's Chief Surgeon, Baron Dominique Jean Larrey, this new horse-drawn contrivance was intended to rapidly (and jarringly...they had no springs)transport the wounded to surgeons, waiting at the rear. If they survived their wounds and the trip in the ambulance, given the level of surgical skill and sepsis in the early 19th century, their nightmare was just beginning! Such vehicles were seen by the military as a general resource and care of the wounded was not given much priority; it was not uncommon for such vehicles to be tasked with carrying fresh ammunition to the battlefront, before they transported the wounded back. The basic design of such vehicles remained unchanged for nearly 100 years.

While communities had organized to deal with the care and transportation of the sick and dying as far back as the plague in London, England (1598, 1665), such arrangements were typically temporary. In time, however, such arrangements began to formalize and become permanent. During the American Civil War, Jonathan Letterman had devised a system of forward first aid stations at the regimental level, where principles of triage were first instituted. Letterman, with the rank of major, served as the medical director of the Army of the Potomac. He established mobile field hospitals to be located at division and corps headquarters. The United States Army had reeled from inefficient treatment of casualties, in part because of the adoption of new firearm technology such as breech-loadingrifles and Minié ball systems. Letterman established mobile field hospitals to be located at division and corps headquarters. This was all connected by an efficient ambulance corps, established by Letterman in August 1862, under the control of medical staff instead of the Quartermaster Department. Letterman also arranged an efficient system for the distribution of medical supplies. His system was adopted by other Union armies and was eventually officially established as the medical procedure for the entirety of the United States' armies by an Act of Congress in March 1864. Following the American Civil War, some veterans began to attempt to apply what had they had seen on the battlefield to their own communities, through the creation of volunteer life-saving squads and ambulance corps. This translation to civilian use did not occur in the same way everywhere; in Britain, early civilian ambulances were often operated by the local hospital or the police, while in some parts of Canada, it was common for the local undertaker (having the only transport in town in which one could lie down) to operate both the local furniture store (making coffins as a sideline) and the local ambulance service. In larger centers in various countries, such services might fall to the local Health Department, the Police, the Fire Department, or some combination of all of the above. Once again, the civilian model followed the lead of the military; although there were a handful of motorized ambulances just prior to the First World War (1914-1918), the concept of motorized ambulances was proven first on the battlefield, and spread rapidly to civilian systems immediately following the war.

There is some debate as to when the first formal training of "ambulance attendants" began. The generally accepted belief is that this occurred in the United States, at Roanoke, Virginia, with the Roanoke Life Saving and First Aid Crew, under Julian Stanley Wise, in 1928. While this may have been true of the U.S., Canadian records indicate the members of the Toronto Police Ambulance Service received a mandatory five days of training, conducted by St. John, as early as 1889, and well developed printed manuals, clearly beyond the scope of simple first aid, were present in England even earlier. In terms of advanced skills, it is known that, once again, the military led the way. During the Second World War (1939-1945) and the Korean Conflict, battlefield 'medics' were administering painkilling narcotics by injection, as emergency procedures, and 'pharmacists' mates' on warships without physicians were permitted to do even more. Korea also marked the first widespread use of helicopters to evacuate the wounded from forward positions to medical units, coining the phrase 'medevac'. These innovations would not find their way into the civilian sphere for nearly twenty more years.

By the early 1960s experiments in improving care had begun in some civilian centres. The first such experiment involved the provision of pre-hospital cardiac care by physicians in Belfast, Northern Ireland, in 1966. This was repeated in Toronto, Canada in 1968, using a single ambulance called Cardiac One, staffed by a regular ambulance crew, plus a hospital intern, who was tasked with performing the advanced procedures. While both of these experiments had certain levels of success, technology had not yet reached the required level (the Toronto 'portable' defibrillator/heart monitor was powered by lead-acid car batteries and weighed nearly 100 lbs.). The required telemetry and miniaturization technologies already existed in the military, and particularly in the space program, but it would take several more years before they found their way to civilian applications. In North America, physicians were judged to be too expensive to be used in the pre-hospital setting, although such intiatives were implemented, and in some cases still operate, in the United Kingdom, Europe, and Latin America.

Around 1966 in a published report entitled "Accidental Death and Disability: The Neglected Disease of Modern Society", (known in EMS trade as the White Paper) medical researchers began to reveal, to their astonishment, that soldiers who were seriously wounded on the battlefields of Vietnam had a better survival rate than those individuals who were seriously injured in motor vehicle accidents on California freeways. Early research attributed these differences in outcome to a number of factors, including comprehensive trauma care, rapid transport to designated trauma facilities, and a new type of medical corpsman, one who was trained to perform certain critical advanced medical procedures such as fluid replacement and airway management, which allowed the victim to survive the journey to definitive care. As a result, a series of grand experiments began in the United States. Almost simultaneously, and completely independent from one another, experimental programs began in three U.S. centers; Miami, Florida, Seattle, Washington, and Los Angeles, California. Each was aimed at determining the effectiveness of using firefighters to perform many of these same advanced medical skills in the pre-hospital setting in the civilian world. Many in the senior administration of the Fire Departments were initially quite opposed to this concept of 'firemen giving needles', and actively resisted and attempted to cancel pilot programs more than once.

In a curious example of 'life imitating art' a television producer, working for producer Jack Webb, of Dragnet and Adam-12 fame, happened to be in Los Angeles' UCLA Harbor Medical Center, doing background research for a proposed new TV show about doctors, when he happened to encounter these 'firemen who spoke like doctors and worked with them'. This novel idea would eventually evolve into the Emergency! television series, which ran from 1972-1977, portraying the exploits of a new group called 'paramedics'. The show captured the imagination of emergency services personnel, the medical community, and the general public. When the show first aired in 1972, there were exactly 6 paramedic units operating in 3 pilot programs (Miami, Los Angeles, Seattle) in the whole of the United States. No one had ever heard the term 'paramedic'; indeed, it is reported that one of the show's actors was initially concerned that the 'para' part of the term might involve jumping out of airplanes! By the time the program ended production in 1977, there were paramedics operating in every state. The show's technical advisor was a pioneer of paramedicine, James O. Page, then a Battalion Chief responsible for the Los Angeles County Fire Department 'paramedic' program, but who would go on to help establish other paramedic programs in the U.S., and to become the founding publisher of the Journal of Emergency Medical Services (JEMS).

Throughout the 1970s and 80s, the field continued to evolve, although in large measure, on a local level. In the broader scheme of things the term 'ambulance service' was replaced by 'emergency medical service' in order to reflect the change from a transportation system to a system which provided actual medical care. The training, knowledge base, and skill sets of both Paramedics and Emergency Medical Technicians (both competed for the job title, and 'EMT-Paramedic' was a common compromise) were typically determined by what local medical directors were comfortable with, what it was felt that the community needed, and what could actually be afforded. There were also tremendous local differences 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 ultimately even to universities. In the U.S. the community college training model remains the most common, although university-based paramedic education models continue to evolve. These variations in both educational approaches and standards led to tremendous differences from one location to another, and at its worst, created a situation in which a group of people with 120 hours of training, and another group (in another jurisdiction) with university degrees, were both calling themselves 'paramedics'. There were some efforts made to resolve these discrepancies. The National Association of Emergency Medical Technicians (NAEMT) along with National Registry of Emergency Medical Technicians ((NREMT) attempted to create a national standard by means of a common licensing examination, but to this day, this has never been universally accepted by U.S. States, and issues of licensing reciprocity for paramedics continue, although if a EMT obtains certification through NREMT (NREMT-P, NREMT-I, NREMT-B), this is accepted by 40 of the 50 states in the United States. This confusion was further complicated by the introduction of complex systems of gradation of certification, reflecting levels of training and skill, but these too were, for the most part, purely local. The only truly common trend that would evolve was the relatively universal acceptance of the term 'Emergency Medical Technician' being used to denote a lower lever of training and skill than a 'Paramedic'.

During the evolution of paramedicine, a great deal of both curriculum and skill set was in a state of constant flux. Permissible skills evolved in many cases at the local level, and were based upon the preferences of physician advisers and medical directors. Treatments would go in and out of fashion, and sometimes, back in again. The use of certain drugs, Bretyllium for example, illustrate this. In some respects, the development seemed almost faddish. Technologies also evolved and changed, and as medical equipment manufacturers quickly learned, the pre-hospital environment was not the same as the hospital environment; equipment standards which worked fine in hospitals could not cope well with the less controlled pre-hospital environment. Physicians began to take more interest in Paramedics from a research perspective as well. By about 1990, most of the 'trendiness' in pre-hospital emergency care had begun to disappear, and was replaced by outcome-based research; the gold standard for the rest of medicine. This research began to drive the evolution of the practice of both paramedics and the emergency physicians who oversaw their work; changes to procedures and protocols began to occur only after significant outcome-based research demonstrated their need. Such changes affected everything from simple procedures, such as CPR, to changes in drug protocols. As the profession of paramedic grew, some of its members actually went on to become not just research participants, but researchers in their own right, with their own projects and journal publications.

Changes in procedures also included the manner in which the work of paramedics was overseen and managed. In the earliest days of the field, medical control and oversight was direct and immediate, with paramedics calling into a local hospital and receiving orders for every individual procedure or drug. This still occurs in some jurisdictions, but is becoming very rare. As physicians began to build a bond of trust with paramedics, and experience in working with them, their confidence levels also rose. Increasingly, in many jurisdictions day to day operations moved from direct and immediate medical control to pre-written protocols or 'standing orders', with the paramedic typically only calling in for direction after the options in the standing orders had been exhausted. Medical oversight became driven more by chart review or rounds, than by step by step control during each call.

In other places, the evolution of paramedicine occurred somewhat differently. In Canada, for example, there was an early, but unsuccessful attempt to introduce paramedicine. In 1972, a pilot paramedic training program occurred at Queen's University, located in Kingston, Ontario. The program, intended to upgrade the mandatory 160 hours of training then required for 'ambulance attendants', was found to be too costly and premature. While the program operated for two years and produced a number of graduates, it would be more than a decade before the legislative authority for them to practice was put into place. The program then moved in another direction, providing 1,400 hours of training at the community college level, prior to commencing employment. This change was made mandatory in 1977, with formal certification examinations being introduced for the first time in 1978. Similar, but not identical, programs occurred at roughly the same time in the Province of Alberta, and in British Columbia, through its Justice Institute. Other Canadian provinces gradually followed, but with their own education and certification requirements. Advanced Care Paramedics were not introduced until 1984, when Toronto trained its' first group internally, and the process continued to spread across the country. The current model in Ontario calls for a two year community college based program, including both hospital and field clinical components, prior to designation as an Advanced Care Paramedic, although this is gradually evolving in the direction of a university degree-based program. Some services, such as Toronto EMS, continue to train paramedics internally (indeed, Toronto EMS is accredited in its own right by the Canadian Medical Association as an Advance Care Paramedic training academy).

In the United Kingdom, ambulance services became largely municipal services, with some exceptions, shortly after the end of World War Two. Training was frequently conducted internally, although national levels of coordination led to better standardization of staff training. All public ambulance services are currently operated by regional entities, most often 'trusts', under the authority of the National Health Service. Tremendous standardization of training and permitted skills has also occurred. The English model utilizes, two levels of ambulance staff. The first of these is 'Ambulance Technician'. This role is not a paramedic, but more closely corresponds to the EMT role in the United States. Most services train these individuals internally, using a common curriculum. The second role is that of 'Paramedic'. These are practitioners of advanced life support skills, similar to U.S. paramedics. Initially, many of these individuals were trained internally by the services that employed them, with the step to Paramedic being a logical career path progression for an experienced Ambulance Technician. Increasingly, this trend has moved toward training in the University system, with the entry level for Paramedics being an Honours Bachelor of Science degree in Pre-Hospital or Paramedic Care. Some British Paramedics have been further elevated, into the role of Paramedic Practitioner, a role that practices independently in the pre-hospital environment, in a capacity similar to that of a nurse practitioner, but with more of an acute care orientation. Some Paramedic Practitioners in the U.K. hold M.Sc. degrees. Today, the field of paramedicine continues to grow and evolve into a formal profession in its' own right, complete with its own standards and body of knowledge. What began as a concept of simple 'technicians' with a couple of weeks of training, performing procedures that they didn't fully understand, has evolved into a career that in many cases (U.K., Australia, increasingly U.S. and Canada)requires a university education, and which is, in some locations actually evolving into a second tier medical practitioner. In many places, the practice of paramedics began as an extension of the supervising physician's license to practise medicine. As such, they were absolutely subject to every condition that the physician placed on their practice. More recently, however, paramedics in both the U.K. and some Canadian provinces have been granted the legal status of self-regulated health professions. When this occurs, the individual paramedics are certified and licensed by a College of Paramedicine, created by legislation but run by the paramedics themselves. This body sets standards, conducts licensing exams, deals with complaints regarding individual practitioners, and consults the government with respect to legislation, policy, and regulations. Paramedics are governing and regulating themselves; the true measure of a profession. In the U.S., paramedics are subject to regulation by individual states, and the degree and type of regulation, as well as paramedic participation in that process, varies from state to state.

Places of work
Paramedics are employed by a variety of different organizations, and the services provided by paramedics may occur under differing organizational structures, depending on the part of the world. In the United States, a paramedic can be employed by government agencies such as the Parks Service or the Coast Guard. They may also be employed as part of a public hospital system; in some cases working inside the hospital. They are most commonly employed as part of a municipal Emergency Medical Service, which may be free-standing "Third Service" (municipal department operating independently of other emergency services) option, or a part of some other public safety agency, such as a fire, police, or the health department. Paramedics may also be employed by private companies, some of which may have contractual emergency service provision commitments to local municipalities, corporations, mines, air ambulances, or racetracks or entertainment venues. Paramedics may also work on a volunteer basis, receiving no monetary compensation for their services (i.e. Volunteer Rescue Squad / Volunteer Fire Department and community response units).

In England, paramedics are typically employed by ambulance services, as a part of the National Health Service Trust system. An NHS Trust is, in effect, a type of public sector corporation, and most NHS health services, including both primary care and hospitals, are organized in this fashion. Service organization occurs regionally, with Ambulance Service Trusts typically covering several local Counties, and with 12 such Trusts currently providing coverage for the entire country. Ambulance Service in Wales operates on a similar system, while the Scottish Ambulance Service and Northern Ireland Ambulance Service are single entities provided by the Health Departments of their respective federal governments. Additional coverage, particularly for special events, may be provided by Voluntary Ambulance Services, including the British Red Cross and St. John Ambulance, or by private companies, but neither of these typically uses fully qualified paramedics.

In Canada, paramedics are employed almost exclusively by publicly operated EMS systems. The manner in which such systems are organized and funded varies somewhat from province to province. The British Columbia Ambulance Service is organized as a branch of the provincial government, with that government providing services directly through a branch of the Ministry of Health. In Ontario, the provision of EMS has been allocated to Upper-tier municipalities (like U.S. Counties). Each of these provides its own EMS, and is free to operate the service directly as third service or, in rare cases, as a branch of the fire department, or to contract those services to a private business entity or a local hospital. In all of these cases, the provincial government accredits the services, and provides operating standards and some funding. In the Maritime Provinces the provincial governments have entered into long term contractual arrangements with a single private company for the operation of their EMS systems. Other Canadian provinces use still other approaches to the provision of service and the operating environment in which paramedics will work.

In Australia, paramedics work exclusively for the State Ambulance Service, including Ambulance Victoria service (http://www.ambulance.vic.gov.au/), among others. Public ambulance services in Australia are exclusively third-service option. These services are operated directly by each of the states and territories. A separate service is provided for the Australian Capitol Territory. Unlike the U.S., Australian paramedics are not typically employed in hospitals or the fire brigade. While there are a handful of private ambulance companies operating in Australia, these do not typically provide what would normally be described as 'paramedic' levels of service.

In some centers, some paramedics have begun to specialize their practice. This specialization frequently is to some degree tied to the environment in which the paramedic will work. One of the earliest examples of this involved aviation medicine, and the use of helicopters. Another was the transfer of critical care patients between facilities. While some jurisdictions still use physicians, nurses and technicians for this purpose, increasingly, this role falls to specially-trained, very senior and experienced paramedics, who perform this role as their primary job function. Other areas of specialization include such roles as tactical paramedics working in police tactical units, marine paramedics, hazardous materials (Hazmat)teams, and Heavy Urban Search and Rescue. Still others work in physical isolation, on offshore oil platforms, oil and mineral exploration teams, and in the military. In some cases, one can even find paramedics working on cruise ships! A new and evolving role for paramedics involves the expansion of their practice into the provision of relatively simple primary health care and assessment services.

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

Skills common to all EMTs and Paramedics

 * Spinal injury management, including immobilization and safe transport.
 * Fracture management, including assessment, splinting, traction splints where appropriate.
 * Obstetrics, assessment, assisting with uncomplicated childbirth, recognition of and procedures for obstetrical emergencies, such as breech presentation, cord presentation, placental abruption.
 * Management of Burns, including classification, estimate of surface area, recognition of more serious burns, treatment.
 * Assessment and evaluation of general incident scene safety.
 * Effective verbal and written reporting skills (Charting).
 * Routine medical equipment maintenance procedures.
 * Routine radio operating procedures.
 * Triage of patients in a mass casualty incident.
 * Emergency vehicle operation.

Medications administered
Paramedics in most jurisdictions administer a variety of emergency medications; the individual medications vary widely, based on physician medical director preference, local standard of care, and law. These drugs may include Adenocard (Adenosine), which will slow the heart for a short period of time, and Atropine, which will speed a heartbeat that is too slow. The list may include sympathomimetics like dopamine for severe hypotension (low blood pressure) and cardiogenic shock. Diabetics often benefit from the fact that paramedics are able to give D50W (Dextrose 50%) to treat hypoglycemia (low blood sugar). They can treat crisis and anxiety conditions; some may also be permitted to perform rapid sequence inductionRSI, a rapid way of obtaining an advanced airway with the use of paralytics and sedatives, using such medications as Versed, Ativan, or Etomidate, and paralytics such as succinylcholine, rocuronium, or vecuronium. Paramedics in some jurisdictions may also be permitted to sedate combative patients using antipsychotics like Haldol or Geodon. The use of medications for treating respiratory conditions such as, albuterol, atrovent, and methylprednisolone is common. Paramedics may also be permitted to administer medications such as those which relieve pain or decrease nausea and vomiting. Nitroglycerin, baby aspirin, and morphine sulfate may be administered for chest pain. Paramedics may also use other medications and antiarrhythmics like amiodarone to treat cardiac arrhythmias such as ventricular tachycardia and ventricular fibrillation not responding to defibrillation. Paramedics also treat for severe pain, i.e. burns or fractures, with narcotics like morphine sulfate, pethidine, fentanyl and in some jurisdictions, ketorolac. This list is not representative of all jurisdictions, and EMS jurisdictions may vary greatly in what is permitted. Some jurisdictions may not permit administration of certain classes of drugs, or may use drugs other than the ones listed for the same purposes. For an accurate description of permitted drugs or procedures in a given location, it is necessary to contact that jurisdiction directly. The material included here is, however, fairly typical and representative.

United States
In the United States, there are 4 levels of emergency prehospital care defined by the U.S. Department of Transportation, which regulates prehospital emergency care education federally. From the most basic level to the most advanced, they are Medical First Responder, Emergency Medical Technician-Basic (EMT-B), Emergency Medical Technician-Intermediate (EMT-I), and Emergency Medical Technician-Paramedic (EMT-P). The paramedic is the most advanced level of EMT; however, in order to avoid confusion about the level of care, in practice the term "EMT" usually refers to Emergency Medical Technicians below the paramedic level. Official paramedic insignias and laws that designate level of care have codified this custom in many places. In the United States, paramedics working under the direction of emergency medical control physicians, provide the most advanced level of emergency medical care available to the general public outside of a hospital setting. Exceptions to this general statement include those physicians who sometimes operate with air ambulance services, and some jurisdictions with specially trained Critical Care Paramedic for inter-hospital critical care transfers.

Canada


In most of Canada there are 3 levels of Paramedics: the Primary Care Paramedic with limited pharmaceutical protocols, the Advanced Care Paramedic with full ACLS qualification, and the Critical Care Transport Paramedic with very advanced qualifications. Several variations to this system occur in the City of Toronto and the province of Saskatchewan, which uses a four level model with Level I (Primary Care), Level II (Intermediate Care), Level III (Advanced Care) and Critical Care Transport Paramedics. It should also be noted that many Canadian jurisdictions do not use multiple levels of paramedics. There are many smaller and isolated communities which, for reasons of potential skills decay, medical control issues, or costs, operate with Primary Care Paramedics only. In Canada, paramedics provide the most advanced level of emergency medical care available to the general public outside of a hospital setting. Advanced Care and Critical Care Paramedics are able to perform more delegated medical acts than any other health professional besides physicians in the pre-hospital setting.

In a number of Canadian centres, paramedics are currently using a 12-Lead ECG to diagnose ST-Elevated Myocardial Infarction (STEMI), a specific type of heart attack. The experience of paramedics from the City of Ottawa with the use of this procedure was recently a topic of an article in the New England Journal of Medicine. Ottawa paramedics were the first paramedic service in Canada to have this STEMI protocol, which is now being implemented across the world, available to treat their patients.

Europe
In many parts of Europe a different paradigm is used for prehospital care, in which doctors, nurses and occasionally medical students function as pre-hospital providers, either in conjunction with or instead of paramedics. The following are two fairly representative examples illustrating the differing approach to the idea of paramedics in Europe.

France


Paramedics, as we understand the role, do not exist in France. Within France, EMS is provided by means of an organization called a SAMU for each French Departement (county). Emergency response may be through the use of a fire department-based ambulance, such as the Paris Fire Department (www.pompiersparis.fr), or by an ambulance (labeled SAMU)staffed by a physician-led team (SMUR). The French philosophy is to provide more definitive care at the scene during life-threatening emergencies, and a SMUR team, consisting of a physician, a nurse, and an ambulance driver, may elect to conduct the majority of care, even resusctitation attempts, at the scene, prior to transport. SMUR teams are typically hospital-based. Since 1986, fire department-based ambulances have had the option of providing resuscitation service (reanimation) using specially-trained nurses, operating on protocols, in the role that we would normally expect to be performed by the paramedic. In actual practise, however, such units, and nurses, are extremely rare outside of the City of Paris. In France non-emergency and low-priority ambulance services are normally provided by private companies, with no formal requirements for the training of their staff.

Germany


In Germany, the closest role to that of paramedic is called Rettungassistent. Although there are others working in EMS in Germany, this is considered to be the only professional role, and the training of subordinate staff can vary greatly. The Rettungassistent is required to complete two years of training, the first consisting of theory classes at the post-secondary level, and hospital-based clinical experience. The second year consists of a 1,600 hour EMS-based preceptorship. At the conclusion of this training the Rettungassistent will have a skill set which is roughly similar to that of paramedics in many other countries, and will function as the crew chief on an emergency ambulance. One important difference, however, involves the manner in which EMS operates in Germany. In the German system it is much more common for emergency doctors (called Notarzt) to respond directly to high priority emergency calls. A Notarzt is a physician with additional training; although no specific medical specialty is required, the majority are anesthetists. The role of the Rettungassistent is to assist the Notarzt in the treatment of the patient; they may perform all of their advanced life support skills only under the direct supervision of the Notarzt. In exceptional circumstances, when there is an immediate threat to life, and when the Notarzt is not present, the Rettungassistent must be able to unilaterally perform all of their ALS skills. Not doing so places them in violation of federal German legislation (Handeln durch Unterlassen), however, federal law in German will normally provide the Rettungassistent with legal protection, under these extraordinary circumstances. (32,35 StGB)

Hong Kong
Hong Kong is currently progressing toward a system staffed with paramedics. Different from United Kingdom and Australia,ambulance service is run by Fire Services Department, Hong Kong. a long history stretching back over a century and has been serving the community since 1884. In Hong Kong, the St. John Ambulance Association was established in 1884.It provides ambulance service,first aid and caring training course. that trained, committed voluntary medical and health services provider in Hong Kong. Its mission is to supply effectively and efficiently regular services.
 * St. John Ambulance in Hong Kong A charitable organization with
 * Auxiliary Medical Service An independent government department

South Africa
All health practitioners in The Republic of South Africa are regulated by a standards generating body (SGB), the Health Professions Council of South Africa (HPCSA). The Department of Education has initiated the phasing out of short course training. This is to be replaced with a mid-level worker, and a prehospital clinician. The mid-level course is 2 years in duration, and exits on a level just above what many know as Intermediate Life Support (ILS), but below Advanced Life Support (ALS). They are placed on the Emergency Care Technician (ECT) register. The clinician qualification is a four year professional degree in Emergency Medical Care (Bachelor Emergency Medical Care), and is placed on the Emergency Care Practitioner (ECP) register. The only four institutions in the country to obtain the ECP qualification are the:
 * University of Johannesburg
 * Central University of Technology
 * Durban University of Technology
 * Cape Peninsula University of Technology

Australia
In Australia, the paramedic is a health care professional who responds to and treats all types of medical and trauma emergencies outside of a hospital setting before and during transportation to an appropriate medical facility. Paramedics also work in the inter-facility transport environment where a paramedic will continue or upgrade medical care to a higher level while transporting a patient from one healthcare facility to another. Under normal circumstances, paramedics transport patients to a hospital-based emergency department, however, this is not their only option. When it is clinically appropriate to do so, paramedics can also choose to treat patients requiring simple primary care or procedures in the out of the hospital setting, without the need to transport the patient to a hospital (e.g. a paramedic gives a diabetic patient 50% dextrose in water).

In Australia use of the term "paramedic" is not restricted, registered or licensed. Prior to the 1990s most paramedics were known as "ambulance officers". Today student paramedics are referred to as Ambulance Officers.

Paramedics spend a minimum of four years being trained and can attend university. At the end of three years a Bachelor of Science (Paramedical Science) is granted (the name of the degree varies from state to state). The successful officers then complete a further 12 month internship under the guidance of senior paramedics before they become a paramedic. Another method is to apply directly to the ambulance service and undergo a traineship which takes a couple of years to compleate. Following successful completion of internship Australian paramedics can choose to further their education to become certified as a Intencive Care Paramedic after four years of experience in the job.

Medicolegal authority
Paramedics normally function under the authority (medical direction) of one or more physicians charged with legally establishing the emergency medical directives for a particular region. Paramedics are credentialed and authorized by these physicians to use their own clinical judgment and diagnostic tools to identify medical emergencies and to administer the appropriate treatment, including drugs that would normally require a physician order. Credentialing may occur as the result of a State Medical Board examination (U.S.) or the National Registry of Emergency Medical Technicians (U.S.). In England, and in some parts of Canada, credentialing may occur by means of a College of Paramedicine (http://www.britishparamedic.org/). In these cases, paramedics are regarded as a self-regulating health profession. The final common method of credentialing is through certification by a Medical Director and permission to practice as an extension of the Medical Director's license to practice medicine. The authority to practice in this semi-autonomous manner is granted in the form of standing order protocols (off-line medical control) and in some cases direct physician consultation via phone or radio (on-line medical control). Under this paradigm, paramedics effectively assume the role of out-of-hospital field agents to regional emergency physicians, with independent clinical decision-making authority that is typically enjoyed only by expert clinicians within the hospital setting. In some parts of Europe, those in the paramedic role are only permitted to practice many of their advanced skills while assisting a physician who is physically present, except in cases of immediately life-threatening emergencies. In certain other jurisdictions, such as the United Kingdom and South Africa, paramedics may be entirely autonomous practitioners capable of prescribing medications.