Paramedics in Canada

Paramedicine training in the province of Quebec has been standardized and now requires all new paramedics to hold a three-year Diploma of College Studies in Emergency Prehospital Care, or Soins préhospitaliers d'urgence (SPU) in French, from a recognized CEGEP program. Upon completion of this diploma and passation of the provincial examination, one is certified at the level of primary care paramedic (PCP). Since 2015, a formal 2-year advanced care paramedic (ACP) training program was developed at Université de Montréal for experienced PCPs from Urgences-santé.

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)[7] 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 British Columbia is the only province that uses the title "Infant Transport Team Paramedic", or 'ITT Paramedic' for PCPs who have received additional critical care training for paediatric, neonatal, and high risk obstetric emergencies.[8] All provinces, however, have moved to standard titles, or have at least recognized the NOCP document as a benchmark document to permit inter-provincial labour mobility of practitioners, regardless of how titles are specifically regulated within their own provincial systems.

This is a level of practice recognized under the National Occupational Competency Profile and the Paramedic Association of Canada. As a group, EMRs staff rural ambulance stations, patient transfer services, community medical event coverage, industrial ambulances or mobile treatment centres. For many small communities, without this level of certification, the operation of a much-needed community ambulance system might not be possible. EMRs working as first responders in fire departments, police departments and institutions across Canada contribute an important role in the chain of survival. It is a level of practice focused primarily on life saving methods and is generally consistent with fewer acts beyond advanced first-aid and is the entry to practice leading to higher paramedic practice. Their scope of practices include oxygen administration, oropharyngeal and nasopharyngeal airway adjuncts, the use and interpretation of a pulse oximeter, use and interpretation of a glucometer, blood pressure assessment by auscultation and palpation, chest auscultation, oropharyngeal airway suctioning, administration of the following oral, sublingual or inhaled medications: anti-anginal, anti-hypoglycemic agent, analgesia, platelet inhibitors (including nitroglycerin, glucose, nitrous oxide, acetylsalicylic acid, salbutamol, intravenous lines without medications or blood products).[9] EMRs may administer naloxone and epinephrine by injection, and use automated external defibrillation, which are still regulated medical acts in Canada, although they are increasingly delegated to the general public.

Primary care paramedics (PCPs) are the entry level of paramedic practice across Canada. The scope of practice includes performing semi-automated external defibrillation, manual defibrillation, oxygen administration, ETCO2 monitoring, supraglottic airways, vascular access, cardiac monitoring such as Lead 2 interpretation and 12 Lead acquisition and interpretation, and administration of Symptom Relief Medications for a variety of emergency medical conditions (these include epinephrine, salbutamol, aspirin, nitroglycerine, naloxone, dextrose, glucagon, gravol, ketorolac, ibuprofen, acetaminophen, benadryl). PCPs may also receive additional authorization in order to perform certain skills that are normally in the scope of practice of ACPs.

The Advanced Care Paramedic is a level of practitioner that is in high demand by many services across Canada. 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 bypass protocols include providing both PCPs and 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.[10] as well as bypassing a closer hospitals to get an identified stroke patient to a stroke centre.

A Critical Care Paramedic ambulance in Toronto

Critical care paramedics' 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 generally work with an ACP, registered nurse, physician, or another CCP. Sometimes ad hoc teams, with multiple practitioners (RTs, emergency physicians, surgeons, etc.) are assembled for certain patients.

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.[11]

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 several cities for long-distance/high acuity transfers and as regular CCP street crews who may do major trauma calls or, performs medevacs, when necessary.

Across the prairies, STARS Shock Trauma Air Rescue Society uses rotary wing aircraft to reach many in isolated communities and traumatic situations for faster response time than by ground ambulance.[12] In Saskatchewan they also use fixed wing air ambulances. The service, called LIFEGUARD, can respond a greater distance and to more northern communities than STARS. Sask air ambulance service was the first non-military air ambulance service in the world.[13] These air ambulances are crewed by Flight Nurses and CCPs.

Tactical paramedics are specialized paramedics who undergo additional training to allow them to perform their usual task in a high risk and dangerous scenario. Some are trained to handle weapons, rappel from buildings and other skills needed to work alongside tactical police units.[14]

These paramedics are required to wear protective gear but are unarmed.

Occupational paramedics work closely with occupational physicians, physician assistants and nurses to help with pre-employment screening, medical surveillance programs and clinical testing for companies. Occupational paramedics may work in a variety of environments including in a clinical setting or in the field including mining sites or other high risk areas.

The newest level/role for paramedics in Canada, community paramedics work in clinics, hospitals, and in patient's homes. They provide immediate or scheduled primary, urgent and specialized healthcare to vulnerable patient populations by collaborating with other healthcare providers, conducting assessments, treating, and doing/ordering tests.[15]

Diagnostics provided by Community Paramedics: Specimen collection (blood, urine, swabs), 12/15 lead ECGs, vital signs (temperature, blood glucose, SPO2, side stream CO2, BP), and facilitate transports for diagnostic imaging.

Treatments provided by Community Paramedics: CVC & IV rehydration, blood transfusions, urinary catheterization, wound closure & care (tissue adhesive, sutures, dressings), oxygen and nebulizer therapy, IV/SQ/IM/PO/PORT/PICC medication administration (including IV antibiotics), and coordination of community services.[16]

A type of specialisation in Alberta Metro areas, IRPs receive intensive training, including toxicology, hazmat chemistry, National Fire Protection Association hazmat awareness and operations certifications, as well as three weeks of CBRNE training, antidote, medical countermeasures, MCI, and protective equipment training.

For day-to-day operations, IRPs respond to hazmat- and toxicology-related incidents. They carry a wider range of medications than advanced care paramedics and more protective equipment, allowing them to better treat poisonings/overdoses and work closely with firefighters and hazmat technicians.[17]