# Who does what in Canada?



## harold1981 (Nov 19, 2014)

This question to try to understand how the system works in Canada:

Here in the Netherlands, we have an RN and an ambulance driver on each ambulance. The system is nurse-based, therefore every nurse has the same skill set and autorization to make decisions and act according to the national ambulance protocol indepentantly at ALS-level.
The ambulance driver is trained to assist the RN, and has secondary tasks when it comes to traffic, safety, access issues and communication. 

If two ambulance crews work together, for example at the scene of a resuscitation or an unstable patient, each crew member knows what his tasks are. This is the same in the whole country, and everyone has been trained at the same national ambulance academy.
The first RN coordinates and takes the lead and is ussually occupied with the A and the B. The second RN will take charge of the C and D, and will be busy with IV's and meds. Each driver assists his own partner, and at some point the drivers will start arranging transport and evacuation. The first ambulance brings along certain equipment, the second ambulance brings other items. For example the resus-protocol has ''blocks'' in which procedures are initiated or repeated, untill you reach a certain outcome and proceed in the "return of spontaneous circulation"-protocol, or you come to the point of transportation or the decision to stop resuscitation. Everyone in the team knows what the next step will be. Even if other non-EMS agencies are on scene, like police or fire crews, resus calls are very controlled and peaceful scenarios.  

If more ambulances are on scene, the first crew will be the coordinator, taking care of triage and assigning the following crews to their patients. Driver and RN of this ambulance will each have specific tasks.
If a helicopter is called in, the HEMS-physician will take charge and will have specific tasks as well.
The system works like an oiled machine.

My question is: how does this work in Canada? I saw that there are ACP's and PCP's, who each are trained to act indepentantly. There seem to be paramedics on fire engines and on rapid responders. There are first responders. There are ambulances with two ACP's onboard, and others with a dual crew of an ACP with a PCP. Plus, ambulances may be on scene from different agencies, but with similar skill levels. I saw that HEMS crews are a mix of ACP's, CCP's and flight nurses. 
So, as an outsider I am bit confused: who takes the lead at a scene with different responders? How do you know who is what? Who is responsible for decisions in a crew with two paramedics of the same level? Who does what at a resus? Do you wait for instructions from the lead paramedic, or do you already know who does what?


----------



## cprted (Nov 19, 2014)

Each province has their own regional take on things, so it is hard to encapsulate what is done "in Canada" in one post.  But I'll paint with some broad brush strokes ...

There are three Paramedic levels in Canada.  Primary Care Paramedic (PCP), Advanced Care Paramedic (ACP), and Critical Care Paramedic (CCP).  You can read about their scopes of practice here http://en.wikipedia.org/wiki/Paramedics_in_Canada

CCP is generally a Critical Care Transport position and they don't generally do scene response.  Either by air or ground, CCPs are doing the high acuity hospital to hospital transfers.  At the moment, only British Columbia and Ontario have accredited CCP programs, so Critical transfer operations are paramedic based and don't usually have Nurses or Respiratory Therapists along for the ride.  In other provinces, HEMS and ground CCT with be an ACP and RN pairing.  Other than BC Ambulance's "Infant Transport Team" who will occasionally bring a neonatal intensivist along, I don't know of any EMS system in Canada (air or otherwise) that routinely uses Physicians.

We really don't have a lot of Fire-based EMS in Canada.  There are a few around, but they're rare.  I've never worked in one of those systems so I really can't say with any authority how it works if a Firefighter-Paramedic has started treatment if they ride in or hand off care to the ambulance crew.  More commonly, firefighters are trained in some form of Advanced First Aid.  In some cities, the fire department is layered in on potentially high acuity calls to be an extra resource or to perform a critical intervention prior to Paramedics arriving (bleeding control, CPR, etc).  Medical training of Canadian firefighters is measured in days, not months and years that Paramedics spend in school.

Staffing of ambulances also varies from region to region.  Some regions have a "Targeted ALS System" where the majority of ambulances are staffed PCP-PCP and Advanced Life Support ambulances are staffed ACP-ACP that get layered in on potentially high acuity calls.  Other areas have an "All ALS System" where every ambulance is staffed ACP-PCP.

On a paired-car, where both Paramedics are of the same license level, we take turns driving and attending.  Whoever is in the attendant's seat is the person making the decisions.  That being said, we do work as a partnership.  For example, if I'm driving, I don't need to be told to gather up the patient's medications, or break down the cot, etc, I know when it is appropriate to get those tasks done.


----------



## Reviresco (Nov 19, 2014)

Like cprted said, Canada's EMS system varies from province to province, which is one of the biggest set backs EMS has in this country and makes transferring from province to province a bit of a pain sometimes. As for your questions...that's a lot. Lol. I'll try and describe it for you as best I can though.

It really comes down to where you took your schooling. Each province has it's own levels of training or terminology for that level and it's own standards of training, including scope of practice. I can't speak for all of the provinces because I really don't know them all but I can speak for some. 

For example, I work in Alberta. Here there are three levels of training, EMR, EMT-A and EMT-P (Paramedic). EMR stands for Emergency Medical Responder and is basically just advanced first aid. Depending on protocols you can assist patients with their own medications however cannot actively given an medications and your treatments are very basic first aid. That program is roughly 2 weeks to 1 month and you cannot work on ambulance in Alberta with it (for the most part, some non-emerge inter-hospital transfer services will accept them however they have to work with someone of higher skill level and they can also work as medical standby for private companies i.e. oil field rigs, concerts etc). The second level of training is EMT-A which stands for Emergency Medical Technician - Ambulance. This course runs anywhere from 6 months to 1 year depending on where you take it. With this training you learn a higher level of skills such as IV therapy, basic airway management and the ability to administer a select few medications (Nitro, ASA, Salbutamol, Ipratropium Bromide, Epinephrine). The third and final level is EMT-P which stands for Emergency Medical Technician - Paramedic. This is a two year full-time program where you learn in the depth materials. Anatomy and physiology, pathophysiology, etc. This gives you a much higher level of skill and knowledge. From this you can administer upwards of 100 medications, and then skills of advanced airway management (RSI, intubation, cricoidthyrotomy) and then other skills such as ventilators, blood transfusions, chest tubes and even pericardial centisis...haha..yep we still learn that. Anyways, you'll find that this system of terminology is common in the US as well as parts of Canada. I believe Ontario follows somewhat of a similar role but not sure. So to those who work in the field there are EMR's EMT's and Paramedics. 

British Columbia follows the terminology cprted stated. With PCP's (primary care paramedics) and ACP's (advanced care paramedics). PCP's are roughly the equivalent to EMT's and ACP's are roughly the equivalent to Paramedics. CCP's (critical care paramedics) are pretty much only found in Ontario. But again, because the schooling is different from province to province, Paramedics in Alberta are trained to nearly the same standards as CCP's in Ontario. 

To try and answer your questions. 

All EMS providers are trained to act independently. We have protocols in place to follow which are drawn up by one or a few physicians, and we actually work under their license essentially. That being said, we run the calls that we go on and choose which treatments to do or not to do. We have the option of contacting a physician through online medical control during a call, but it is not a requirement, our protocols are set out to give us that direction with the assumption that we can form differential diagnosis's. 

As for who takes the lead on scene, it's the person with the highest level of training on that ambulance. If they have equal level of training, then the person attending versus driving, will take that lead, but we all work together anyways. If it really comes down to it, the person with the most seniority or experience will make the final call, but that kind of disagreement is rare. If multiple ambulances are called to a scene, the first one in is the lead and acts as triage, directing which patient needs to be treated or transported first and going from there.  

How do we know who is what? Well we all have flashes on the shoulders of our uniforms and stitching on our uniforms stating what your position or level of training is. 

Ambulances can be staffed with different levels of training depending on where you are within a province or which province you're in. In Alberta, the urban centres pretty much always have a Paramedic (ACP) and an EMT (PCP). Though in Calgary for instance, you'll find a lot of ambulances with two Paramedics. When you get into rural Alberta, you'll start to see to EMT's working together with no Paramedic. This is very common in British Columbia as they have less than 100 Paramedics (ACP) in the entire province, whereas in Alberta, Calgary alone as a few hundred. 

As for who does what at a resus, well we all work together. There is no battle for controlling a call, and there is no one person ALWAYS in charge of the call. We work as a team of 2 or more if more are present. As said, the first ambulance in controls the call, if a second is needed for a major call then they act as the support role and help out or drive. In a resus specifically, the Paramedic (ACP) is in charge of capturing an advanced airway if needed, administering medications and "running" the call. The partner, regardless of level of training, assists, whether that is starting an IV, doing CPR or ventilating the patient. Generally firefighters respond to such calls with us as well and if so, they will do the CPR and keep our hands free from it to do the other tasks. As for waiting for instructions from the lead, well it depends on the call. More often than not, everyone knows what needs to be done on a call and they fill a role. The lead on the call may say they need an IV or pads applied or a certain medication and someone will respond, but everyone just knows what needs to be done, and if that skill can be done by them they will do it. We basically run it the same as you do in the Netherlands, just instead of RN's we have Paramedics. Same skills, same abilities, different titles.

As confusing as our training systems here may be and our terminology differing throughout the country, it still all flows as you said, a well oiled machine. I think the easiest way to put it is that our system is very much like yours only we have Paramedics in the position of your RN's.

Hope that helps, sorry for the long winded response!


----------



## fortsmithman (Nov 23, 2014)

Reviresco said:


> airway management and the ability to administer a select few medications (Nitro, ASA, Salbutamol, Ipratropium Bromide, Epinephrine). The third and final level is EMT-P which stands for Emergency Medical Technician - Paramedic.


Its Emergency Medical Technologist Paramedic.  As well ACoP dropped the A in EMTA it's now just EMT.  They dropped the A around 2008 or so.

http://www.collegeofparamedics.org/home/serving-the-public.aspx


----------



## fortsmithman (Nov 23, 2014)

As well Alberta as one of the highest registration fees in Canada 425.00/year.  Saskatchewan has a higher annual registration fee 470.00/year


----------



## fortsmithman (Nov 23, 2014)

Here in the Northwest Territories we have no ground ALS just BLS and most services are either EMR or AMFR.  As well in the NWT we have no legislation covering EMS.  The only legal requirement to run an ambulance service is a class 4 DL only because the Motor Vehicles Act requires it. Out of the 20 or so communities in the NWT only 8 have EMS in the other communities if you are injured you have to go to the nursing station on your own. The communities that have EMS are run like this
1 is private contract (contractor also owns the local taxi company)
1 is with the health and social services board and they are 1 driver and RN.
2 are third service
4 are fire based
and of those only 2 are paid full time one of the fire based services and the private contractor. The latest community to get EMS is a fly in community and they are all AMFR. As well only 4 communities have accredited hospitals the rest are nursing stations staffed RNs and LPNs.  As well with no legislation it is up each services medical director to decide what each servine can do.  The next town over from me is a fire based EMR service, their medical director allows EMRs to initiate IVs and do other stuff that is EMT/PCP only in other parts of Canada.  The only ALS we have is a private company that has the contract to do air medevacs.


----------



## harold1981 (Jul 24, 2015)

Reviresco, thank you very much for clarifying.


----------

