Ambulance personnel are generally professionals and in some countries their use is controlled through training and registration. While these job titles are protected by legislation in some countries, this protection is by no means universal, and anyone might, for example, call themselves an 'EMT' or a 'paramedic', regardless of their training, or the lack of it. In some jurisdictions, both technicians and paramedics may be further defined by the environment in which they operate, including such designations as 'Wilderness', 'Tactical', and so on. A unique aspect of EMS is that there are two hierarchies of authority, as the
chain of command is separate to medical authority.
Basic life support (BLS) Emergency medical dispatcher An emergency medical dispatcher is also called an EMD. An increasingly common addition to the EMS system is the use of highly trained dispatch personnel who can provide "pre-arrival" instructions to callers reporting medical emergencies. They use carefully structured questioning techniques and provide scripted instructions to allow callers or bystanders to begin definitive care for such critical problems as airway obstructions, bleeding, childbirth, and cardiac arrest. Even with a fast
response time by a first responder measured in minutes, some medical emergencies evolve in seconds. Such a system provides, in essence, a "zero response time", and can have an enormous impact on positive patient outcomes.
First responder Certified first responders may be sent to provide first aid, sometimes to an advanced level. Their duties include the provision of immediate life-saving care in the event of a medical emergency; commonly advanced first aid, oxygen administration,
cardio-pulmonary resuscitation (CPR), and
automated external defibrillator (AED) usage. The first responder training is considered a bare minimum for emergency service workers who may be sent out in response to an
emergency call. First responders are commonly dispatched by the ambulance service to arrive quickly and stabilize the patient before the ambulance arrives, and to then assist the ambulance crew. Some EMS agencies have set up volunteer schemes, who can be dispatched to a medical emergency before the ambulance arrives. Examples of this include
Community First Responder schemes run by ambulance services the UK and
similar volunteer schemes operated by the fire services in France. In some countries such as the US, there may be autonomous groups of volunteer responders such as
rescue squads.
Police officers and
firefighters who are on duty for another emergency service may also be deployed in this role, though some firefighters are trained to a more advanced medical level. Some volunteer-based EMS agencies or rescue squads may sponsor the training of volunteers or offer subsidized costs for EMT training courses. Besides first responders who are deployed to an emergency, there are others who may be stationed at public events. The
International Red Cross and Red Crescent Movement and
St John Ambulance both provide first aiders in these roles.
Ambulance driver Some agencies separate the 'driver' and 'attendant' functions, employing ambulance driving staff with no medical qualification (or just a first aid and CPR certificates), whose job is to drive ambulances. While this approach persists in some countries, such as India, it is generally becoming increasingly rare. Ambulance drivers may be trained in radio communications, ambulance operations and emergency response driving skills.
Non-emergency attendant Many countries employ ambulance staff who only carry out non-emergency patient transport duties (which can include stretcher or wheelchair cases). Dependent on the provider (and resources available), they may be trained in first aid or extended skills such as use of an
AED, oxygen therapy, pain relief and other live-saving or
palliative skills. In some services, they may also provide emergency cover when other units are not available, or when accompanied by a fully qualified technician or paramedic. The role is known as an Ambulance Care Assistant in the United Kingdom.
Emergency care assistant Emergency care assistants are of a frontline under both emergency and non-emergency conditions to incidents. Their role is to assist the clinician that they are working with, either a Technician or Paramedic, in their duties, whether that be drawing up drugs, setting up fluids (but not attaching), doing basic observations or performing 12 lead ECG assessments.
Emergency medical technician Emergency medical technicians are usually able to perform a wide range of emergency care skills, such as automated
defibrillation, care of spinal injuries and
oxygen therapy. In few jurisdictions, some EMTs are able to perform duties as IV and IO cannulation, administration of a limited number of drugs (including but not limited to Epinephrine, Narcan, Oxygen, Aspirin, Nitroglycerin – dependent on country, state, and medical direction), more advanced airway procedures, CPAP, and limited cardiac monitoring. Most advanced procedures and skills are not within the national scope of practice for an EMT. As such most states require additional training and certifications to perform above the national curriculum standards. In the United States, an EMT certification requires intense courses and training in field skills. Certifications are state-specific and last varying durations, though
National Registry certification simplifies the reciprocity process in many states. The National Registry of Emergency Medical Technicians renamed the certification levels for EMS professionals as follows: Emergency Medical Responder (NREMR), Emergency Medical Technician (NREMT), Advanced EMT (NRAEMT), and Paramedic (NRP).
Advanced life support (ALS) Paramedic A
paramedic has a high level of pre-hospital medical training and usually involves key skills not performed by technicians, often including
cannulation (and with it the ability to use a range of drugs to relieve pain, correct cardiac problems, and perform
endotracheal intubation),
cardiac monitoring, 12-lead ECG interpretation,
ultrasound,
intubation, pericardiocentesis, cardioversion,
thoracostomy, and other skills such as performing a surgical
cricothyrotomy. The most important function of the paramedic is to identify and treat any life-threatening conditions and then to assess the patient carefully for other complaints or findings that may require emergency treatment. In many countries, this is a protected title, and use of it without the relevant qualification may result in criminal prosecution. In the United States, paramedics represent the highest licensure level of prehospital emergency care. In addition, several certifications exist for Paramedics such as Wilderness ALS Care, Flight Paramedic Certification (
FP-C), and Critical Care Emergency Medical Transport Program certification.
Critical care paramedic Critical Care ambulance A critical care paramedic, also known as an advanced practice paramedic or specialist paramedic, is a paramedic with additional training to deal with critically ill patients. Critical care paramedics often work on
air ambulances, which are more likely to be dispatched to emergencies requiring advanced care skills. They may also work on land ambulances. or 'in house' by their EMS agency. These providers have a vast array of and medications to handle complex medical and trauma patients. Examples of medication are
dobutamine,
dopamine,
Propofol,
blood and
blood products to name just a few. Some examples of skills include, but not limited to, life support systems normally restricted to the ICU or critical care hospital setting such as
mechanical ventilators,
Intra-aortic balloon pump (IABP) and external
pacemaker monitoring. Depending on the service medical direction, these providers are trained on placement and use of UVCs (
Umbilical Venous Catheter), UACs (
Umbilical Arterial Catheter),
surgical airways,
central lines,
arterial lines and
chest tubes.
Emergency care practitioner In the United Kingdom and South Africa, some serving
paramedics receive additional university education to become practitioners in their own right, which gives them absolute responsibility for their clinical judgement, including the ability to autonomously prescribe medications. An
emergency care practitioner or paramedic practitioner is a position that is designed to bridge the link between ambulance care and the care of a
general practitioner. ECPs are university graduates in Emergency Medical Care or qualified paramedics who have undergone further training, and are authorized to perform specialized techniques. Additionally some may prescribe medicines for longer-term care, such as antibiotics and in the United Kingdom they can prescribe a broad range of medicines. With respect to a Primary Health Care setting, they are also educated in a range of Diagnostic techniques.
Traditional healthcare professionals in EMS Registered nurses The use of
registered nurses (RNs) in the pre-hospital setting is common in many countries in absence of paramedics. In some regions of the world nurses are the primary healthcare worker that provides emergency medical services. In European countries such as France or Italy, also use nurses as a means of providing ALS services. These nurses may work under the direct supervision of a physician, or, in rarer cases, independently. In some places in Europe, notably Norway, paramedics do exist, but the role of the 'ambulance nurse' continues to be developed, as it is felt that nurses may bring unique skills to some situations encountered by ambulance crews. In North America, and to a lesser extent elsewhere in the English-speaking world, some jurisdictions use specially trained nurses for medical transport work. These are mostly air-medical personnel or critical care transport providers, often working in conjunction with a technician, paramedic or physician on emergency interfacility transports. In the United States, the most common uses of ambulance-based registered nurses is in the Critical Care/Mobile Intensive Care transport, and in Aeromedical EMS. Such nurses are normally required by their employers (in the US) to seek additional certifications beyond the primary nursing licensure. Four individual states have an Intensive Care or Prehospital Nurse licensure. Many states allow registered nurses to also become registered paramedics according to their role in the emergency medical services team. In
Estonia 60% of ambulance teams are led by nurse. Ambulance nurses can do almost all emergency procedures and administer medicines pre-hospital such as physicians in Estonia. In the
Netherlands, all ambulances are staffed by a registered nurse with additional training in emergency nursing, anesthesia or critical care, and a driver-EMT. In
Sweden, since 2005, all emergency ambulances should be staffed by at least one registered nurse since only nurses are allowed to administer drugs. And all Advanced Life Support Ambulances are staffed at least by a registered nurse in Spain. In France, since 1986, fire department-based rescue ambulances have had the option of providing resuscitation service (reanimation) using specially trained nurses, operating on protocols, while SAMU-SMUR units are staffed by physicians and nurses
Physician In countries with a
physician-led EMS model, such as France, Italy, the German-speaking countries (Germany, Switzerland, Austria), and Spain, physicians respond to all cases that require more than basic first aid. In some versions of this model (such as France, Italy, and Spain), there is no direct equivalent to a
paramedic, as ALS is performed by physicians. In the German-speaking countries, paramedics are assistants to ambulance physicians (called Notarzt). In these countries, if a physician is present, paramedics require permission from the physician to administer treatments such as defibrillation and drugs. If there is no physician on scene and a life-threatening condition is present, they may administer treatments that follow the physician's instructions. In countries where EMS is led by paramedics, the ambulance service may still employ physicians. They may serve on specialist response vehicles, such as the
air ambulances in the UK. They may also provide advice and devise protocols for treatment, with a
medical director acting as the most senior medical adviser to the ambulance service. In the United States, EMS became an officially recognized subspecialty by the American Board of Emergency Medicine in 2010, and the first examinations were held in 2013. Many states now recommend EMS board certification for newly hired medical directors of EMS agencies. ==Specialist EMS==