Paramedics in Canada

Toronto Paramedic Services ambulance (Formerly Toronto EMS)

Winnipeg Fire Paramedic Service ambulance (Manufactured by Crestline Coach)

In Canada the paramedic or registered paramedic (RPCP, RACP, RCCP)^[1] is a healthcare professional, providing pre-hospital assessment and medical care to people with acute illnesses or injuries. In Canada, the title paramedic generally refers to those who work on land ambulances or air ambulances providing paramedic services. Paramedics are increasingly being utilized in emergency rooms by providing patient care in collaboration with physicians, physician assistants, nurse practitioners, registered nurses, registered practical nurses and registered respiratory therapists. Increasingly in Canada, paramedics are actively pursuing self-regulation. Paramedic suicides are on the rise in Canada. Between April 2014 to April 2015 there have been 35 suicides, and since the beginning of 2015 there have been seven reported suicides.^[2] Paramedics see their patients at their worst, which can have long-lasting effects and may result in PTSD and depression. Because paramedics are front line health care providers, there is stigma that paramedics should not show emotion or even react to traumatic situations.

Training

Paramedic education or the study of paramedicine in Canada is an intensive academic program of theory and clinical experience which varies from province to province across Canada. Paramedics perform various controlled medical acts that can be provided by paramedic services. In Ontario paramedics perform more controlled medical acts than all other health care professions, besides a physician or physician assistant. However, the authorization to perform these controlled medical acts vary province to province. Paramedic education varies regionally, for example, the primary care paramedic program may be six months (British Columbia),^[3] eleven months in Manitoba^[4] and two years to four years in Ontario.^[5]

Training as an advanced care paramedic (ACP) requires that the student be first registered as a primary care paramedic. Eligibility for ACP training varies from immediate entry following PCP registration to a mandatory period of experience working as a PCP for usually one to three years. The length of time required to complete ACP training also varies between provinces, and it is generally inversely related to the length of time required to have completed the prerequisite PCP training. Shorter (around one year) programs build upon the education already learned in a two-year PCP training program, while longer (typically up to two years) college programs typically cater to PCP who graduated from shorter PCP programs.

Thus, while there is continual debate on the merits of longer or shorter PCP programs (often centered around teaching philosophy), in common, ACPs across Canada will generally have completed approximately 3 years of intensive formal education, inclusive of didactic study and clinical placements. There are two Bachelor of Health Science in paramedicine degrees currently available in Canada and becoming the standard of paramedic education. This would be comparable to when nursing moved from the college based program to the collaborative or university based program in Canada. These programs are often offered through partnerships between Canadian universities and community colleges, blending vocational training with higher education.^[6]

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.^[7] Their accreditation model is an independent body, and draws from The "National Occupational Competency Profile" as the benchmark document that details the knowledge, skills and abilities outcomes that must be possessed by practitioners of each respective level of paramedic practice.

Scope of practice

In Canada the scope of practice of paramedics is described by the National Occupational Competency Profile (NOCP) for Paramedics^[8] document developed by the Paramedic Association of Canada with financial support from the Government of Canada. The NOCP outlines four provider levels: Emergency Medical Responder (EMR), Primary Care Paramedic (PCP), Advanced Care Paramedic (ACP), and Critical Care Paramedic (CCP)

Provincial variations on the National Occupational Competency Profile

Of considerable relevance to understanding the nature of Canadian paramedic practice, the reader must appreciate the considerable degree of inter-provincial variation. Although a national consensus (by way of the National Occupational Competency Profile) identifies certain knowledge, skills, and abilities as being most synonymous with a given level of paramedic practice, each province retains ultimate authority in legislating the actual administration and delivery of emergency medical services within its own borders. For this reason, any discussion of paramedic practice in Canada is necessarily broad, and general. Specific regulatory frameworks and questions related to paramedic practice can only definitively be answered by consulting relevant provincial legislation, although provincial paramedic associations may often offer a simpler overview of this topic when it is restricted to a province-by-province basis.

Regulatory frameworks vary from province to province, and include direct government regulation (such as Ontario's method of credentialing its practitioners with the title of A-EMCA, or Advanced Emergency Medical Care Attendant)^[9] to professional self-regulating bodies, such as the Alberta College of Paramedics. Though the title of paramedic is a generic description of a category of practitioners, provincial variability in regulatory methods accounts for ongoing differences in actual titles that are ascribed to different levels of practitioners. For example, the province of Alberta uses the title "emergency medical technician", or 'EMT' for the PCPs and 'paramedic' only for those qualified as ACPs, meaning Advanced Life Support (ALS) providers.^[10] Almost all provinces, however, are gradually moving to adopting the new titles, or have at least recognized the NOCP document as a benchmarking document to permit inter-provincial labour mobility of practitioners, regardless of how titles are specifically regulated within their own provincial systems. In this manner, the confusing myriad of titles and occupational descriptions can at least be discussed using a common language for the sake of comparison.

Emergency Medical Responder

Under the new NOCP most providers that work in ambulances will be identified as 'paramedics'. However, in some cases, the most prevalent level of emergency prehospital care is that which is provided by the emergency medical responder (EMR). This is a level of practice recognized under the National Occupational Competency Profile. As a group, EMRs staff rural ambulance stations, community volunteer ambulance services,^[11] industrial ambulances or mobile treatment centers, and for many small communities, without this level of certification, the operation of a much-needed small community ambulance system might not be possible. EMRs working as first responders in Fire Departments and Police Departments across Canada contribute an important role in the chain of survival. It is a level of practice that is least comprehensive (clinically speaking), and is also generally not consistent with any medical acts beyond advanced first-aid and oxygen administration, with the possible exception of automated external defibrillation, which is still a regulated medical act in Canada, although one which is increasingly delegated to the general public.

Primary Care Paramedics

Primary Care Paramedics (PCPs) are the entry-level of paramedic practice in some Canadian provinces. The scope of practice includes performing semi-automated external defibrillation. Oxygen administration. Establishing an IV. Cardiac monitoring such as Lead 2 and 12 Lead interpretation. Administration of Symptom Relief Medications for a variety of emergency medical conditions (these include epinephrine, salbutamol, ipratropium bromide, aspirin, nitroglycerine, naloxone, dextrose, thiamine, glucagon, gravol, benadryl and nitrous oxide). In addition, some services have started implementing non-opiate medications so that Primary Care Paramedics can treat patients that require pain management. These medications include ketorolac, aceotominophen and ibuprofen. As of 2015, PCP's can now administer Naxolone for suspected opiate overdose. ^[12] performing trauma immobilization, including cervical immobilization, and other basic medical care. PCPs may also receive additional training in order to perform certain skills that are normally in the scope of practice of ACPs, such as interpretation or transmission of a 12 lead EKG. This is regulated both provincially (by statute) and locally (by the medical director), and ordinarily entails an aspect of medical oversight by a specific body or group of physicians. This is often referred to as medical control, and is the role played by a base hospital.

Advanced Care Paramedics

The Advanced Care Paramedic is a level of practitioner that is in high demand by many services across Canada. However, still not all provinces and jurisdictions have ACPs (Quebec, New Brunswick). The ACP typically carries approximately 20 different medications, although the number and type of medications may vary substantially from region to region. ACPs perform advanced airway management including intubation, surgical airways, intravenous therapy, place external jugular IV lines, perform needle thoracostomy, perform and interpret 12-lead ECGs, perform synchronized and chemical cardioversion, transcutaneous pacing, perform obstetrical assessments, and provide pharmacological pain relief for various conditions. Several sites in Canada have adopted pre-hospital fibrinolytics and rapid sequence induction, and prehospital medical research has permitted a great number of variations in the scope of practice for ACPs. Current programs include providing ACPs with discretionary direct 24-hour access to PCI labs, bypassing the emergency department, and representing a fundamental change in both the way that patients with S-T segment elevation myocardial infarctions (STEMI) are treated, but also profoundly affecting survival rates.^[13] as well as bypassing a closer hospitals to get an identified stroke patient to a stroke centre.

Critical Care Paramedics

Critical Care Paramedics (CCPs) are paramedics who are generally significantly experienced advanced care paramedics formerly working land ambulance and servicing years of 9-1-1 emergency calls, a small portion of their call volume remains with helicopter "scene" calls. CCP's expertise focus on critical and ICU level care stabilizing and transporting patients from smaller hospitals with less available resources to tertiary care and regional medical programs in to other hospitals that can provide a higher level of care. CCPs work in pairs of Critical Care Paramedics in the largest systems providing care that would normally be delivered in hospital by a physician, nurse, RRT team. Providing this care to the patient allows the sending hospital to avoid losing highly trained staff on hospital transfers.

CCPs are able to provide all of the care that PCPs and ACPs provide. In addition to this they are trained for other skills such as medication infusion pumps, mechanical ventilation and arterial line monitoring.^[14]

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

Across the prairies, S.T.A.R.S. Shock Trauma Air Rescue Service uses rotary wing aircraft to reach many in isolated communities and traumatic situations for faster response time than by ground ambulance.^[15] In Saskatchewan they also use fixed wing air ambulances. The service, called LIFEGUARD, can respond a greater distance and to more northern communities than S.T.A.R.S.. Sask air ambulance service was the first non-military air ambulance service in the world.^[16] These air ambulances are crewed by Flight Nurses and CCPs.

• Canadian critical care transport
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Image:https://c2.staticflickr.com/2/1366/1177733825_60378e52e8_b.jpg

Medical direction and oversight

In some of Canada, paramedics do not work under their own medical license. Some exceptions are in British Columbia, New Brunswick, Saskatchewan and in the upcoming future Alberta where each paramedic regardless of level, has their own license to practice.^[17] In Ontario, paramedics are permitted to perform regulated medical acts by the process of 'delegation'. This means that one medical doctor (the medical director ) has become familiar with the individual paramedic and then has delegated authority to that paramedic which allows them to perform specific regulated medical act under defined situations. The scope of practice for the paramedic is defined in paramedic protocols (also referred to as advanced medical directives). These protocols specify which skill and the conditions required for the paramedic to act. Each protocol is signed by the medical director. Medical directors are generally ER physicians who work in a hospital associated with the paramedic service. The relationship between this hospital ('Base Hospital') is formalized through legal agreements. Other physicians in the base hospital who are allowed to give direct orders to paramedics that exceed their protocols (often via telephone) are referred to as delegating physicians. These physicians are usually ER physicians. The British Columbia Ambulance Service is moving away from protocols and towards a process called treatment guidelines allowing much more flexibility at all levels when a patient's condition warrants.

Some Canadian paramedics are moving towards the status of self-regulated health professionals with paramedics forming their own professional Colleges in much the same manner as nurses and other health professions. These organizations are responsible to the government for the examination and licensing of practitioners, the establishment of standards of practice, the investigation of public complaints against members, and the disciplining of members. They are also required to advise the government on all issues and legislation related to the practice of their members. Following the example of their British colleagues,^[18] Colleges or Associations have been established in Alberta,^[19] Saskatchewan,^[20] New Brunswick,^[21] and Nova Scotia,^[22] with Ontario^[23] actively moving towards this type of legislation.

Professional environment

Paramedics have a close relationship with the physicians who (in most systems) grant paramedics the legal right to practice their profession with a regulated paramedic service. Some systems in Canada are transitioning to a self regulated organization, where medical authority dervies directly from legislation and self-regulation rather than the approval of a medical doctor. Also, because physician assistants in Canada exist primarily in the Canadian Forces, the role of clinical paramedic practitioners is under serious study.^[24] 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.

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

Paramedics often work long hours; with a variety of 8-, 10-, 12- and 14-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. This incongruity is often argued as being unfair, especially in light of the relative level of responsibility a paramedic may have for acting decisively and without having direct supervision. However, many paramedics consider their career to offer intangible benefits and reported job satisfaction is generally high. Due to the challenging working conditions, paramedics, similarly to other first responders, are at a greatly increased risk to develop Post-Traumatic Stress Disorder as compared to the general population.^[25] Paramedics in Canada generally work only as paramedics, but occasionally are cross-trained as firefighters or police officers, and most are paid full or part-time professionals. In the first quarter of 2005, paramedics were granted status federally as a "Public Safety Occupation" which means that paramedics are now eligible for early retirement, as are police officers and fire fighters.^[26] Many EMS agencies run a full range of paramedic specialty squads including: Marine medics, Bike medics, First Response medics, Tactical ERT & CCU medics, CBRNe medics (Chemical, Biological, Radiological, Nuclear and Explosive) and USAR medics (Urban Search And Rescue - specializing in urban disaster rescue recovery) and finally NOHERT medics (members of Provincial or regional Health Emergency Response Teams)

Salary and employment

Paramedic wages in Canada vary depending on province and experience. Paramedics in Ontario in such regions or cities as Ottawa, Toronto, Peel Region, or Durham, will have an annual salary starting from $70,000 to $100,000 as a Primary Care Paramedic, an Advanced Care Paramedic salary can on average range from $75,000 to $110,000, and Critical Care Paramedics range from $100,000 to $150,000. ^[27] Education background, experience, and level of practice all are contributing factors to which salary is established. ^[28] Many of the paramedics in Alberta are employed by Albert Health Services EMS, and unionized under HSAA. Typical starting annual salaries for an Alberta paramedic working for AHSEMS is $70,000. Oilfield operations also employs a large portion of paramedic practitioners, with a typical daily wage of $750. Paramedics in BC however must accumulate between 5-8 years seniority in rural communities before being able to apply for a full time position. While working in rural communities paramedics are on an "on call" or "stand by" basis. "On call" means they must stay within 10 mins of the station and are 2$/hr to carry a pager. "Stand by" mean they must stay at the station and are payed minimum wage (10.25$). Once a call comes in both on standby and on call basis a new paramedic will earn 22.50/hr.

See also

• Paramedic
• Ambulance
• Emergency Medical Services in Canada
• List of EMS Services in Ontario
• Ottawa Paramedic Service
• Shock Trauma Air Rescue Society
• Saskatchewan Air Ambulance

References

External links

• Paramedic Association of Canada
• Paramedic Association of Manitoba
• Peel Paramedic Association (Ontario)
• Paramedic Association of New Brunswick
• Emergency Medical Care Inc. (Nova Scotia)
• Paramedic Association of Newfoundland and Labrador
• Alberta College of Paramedics
• National Registry of Emergency Medical Technicians
• National Association of Emergency Medical Technicians
• NHTSA Emergency Medical Services National Page
• Association Professionnelle des Paramédics du Québec
• Nova Scotia Paramedic Society