Paramedic: What’s in a name anyways?

[As published in EMS Director Magazine 2019Q4, The official magazine of the National EMS Management Association: This was written as an opinion piece as part of a special series debating the varied titles of “EMS” Personnel in the U.S.]

Paramedic: What’s in a name anyways? A lived experience.

In the early- to mid-1990s, I was working for the Metropolitan Toronto Department of Ambulance Services – an upper-tier (regional) municipal government ambulance service. At the time, it was the only one with this model in Ontario, Canada. My official role was ambulance driver-attendant and my official title was Emergency Medical Assistant (EMA-I); suffice to say, my career has evolved to Critical Care Paramedic, Paramedic Leader, and Paramedic Researcher.

The EMA-I was considered as the basic life support position. We also had paramedics – as one of the first and leading services in Canada delivering advanced life support (ALS), they were known as Level-III Paramedics due to their designation at EMA-III within the Canadian Medical Association accreditation structure at the time.

During this particular period, our Paramedic Chief – a particularly astute people-person with vision and perspective – made a declaration: all EMA levels were now to be called Paramedic with their level distinction I for BLS, II for Intermediate, III for ALS. On the precipice of this declaration, the Paramedic Association of Canada (PAC) was developing four distinct levels within the National Occupational Competency Profiles (NOCP) to create a national nomenclature for Paramedics in Canada. These became Emergency Medical Responder (EMR), Primary Care Paramedic (PCP), Advanced Care Paramedic (ACP), and Critical Care Paramedic (CCP).

This was the birth of “paramedicine” as a profession in Canada. It has been a long and winding journey over the past couple of decades, but our services evolved beyond the original adoption of the Emergency Medical Services (EMS) term, they evolved into what many have now adopted as Paramedic Services.

In Canada, we find ourselves distinctly placed with one foot in healthcare and one foot remaining in the public safety realm. And we are better for it.

The initial days of this transition had some rocky moments. The traditional rhetoric and tribalism emerged with paramedics declaring that they would not recognize or call “non-ALS” providers paramedics. The landscape was shifting and the definition of ALS was defined by the provincial Ministry of Health (MOH) to include any delegated medical acts. Thus, defibrillation and basic symptom relief medication such as nitroglycerin and salbutamol (albuterol, as they say in America) essentially made you a paramedic.

The provincial MOH – as a regulator – adjusted the credentialing to include the word “advanced” in the certificate if you graduated with the delegated skill set. The old guard rhetoric was losing the battle and the title of “paramedic” was catching on.

Initially, yes, there was some confusion. As the barriers broke down, so did the identities of the tribes. Paramedics once proudly wore one-piece, flight-style navy blue jumpsuits … while EMAs wore dark pants and pale blue police style shirts. Can you imagine the horror as BLS crews started showing up on scenes wearing navy jumpsuits with title of “paramedic” emblazoned on their uniform?

What was the public to think? What were the hospital staff to think when this crew showed up at the hospital ventilating a patient without an advanced airway placed? This would be the end of any respect for paramedics and a slippery slope to their demise!

But, the identity re-emerged … as one tribe: Paramedics.

Fast forward to the present day and we are mid-way through a transition to a self-regulated profession across all of Canada. Five of the provinces have legislated a College of Paramedics to declare paramedicine a regulated health care profession. Several other provinces are in consultation and consideration of this transition.

The term “Paramedic Service” is becoming the predominant service delivery designation, as it is the professional paramedics who provide services, care for you, make transport & treatment decisions, and offer non-conveyance solutions. Paramedics are no longer restricted to working on an ambulance … paramedics staff entire sections of an urban emergency department and rural emergency & urgent care clinics with nursing colleagues.

I would be remiss not to mention that we earn a living wage on par with, or better than both healthcare professionals and public safety professions. We don’t need a dual role position to aim for a living wage … and the best part, paramedics are widely recognized and respected across the entire country!

A common name has unified the profession and brought everyone together as one team and made public education more direct. Yes, there are different levels of paramedics … but ultimately, the public wants appropriate care and help; they don’t know or care what your level or designation of paramedic is … they trust paramedics and that the right resource has been delivered through their community leaders. What they really remember about interactions with paramedics is how well or how poorly we made them feel in their time of need (but that is an entirely different article!).

Recently, I spoke at the PAC conference in Winnipeg, Manitoba, with a colleague. We conducted an international scoping review of paramedic education, scopes of practice, and designations (submitting for peer reviewed publication in the near future) … and presented our synthesis to a broad audience from Canada & various international locations. Our interactive talk sought input & ideas from the audience to further inform our article on the topic.

What did we learn? While this EMT vs Paramedic debate is underway in the United States, much of the world has moved on and left America behind. “Paramedic” as a title and “paramedicine” as a profession are now internationally synonymous. In fact, a speaker in attendance from the U.S. at the opening of his talk apologized for the EMT terminology and presented a legend to decipher the nomenclature for the rest of the world, noting his recognition that the U.S. EMT terminology was no longer relevant on the international stage. This may seem harsh, but this was a lived experience I am sharing. We also learned that – even in Canada – our model needs to evolve further within the context of global paramedicine.

Globally, “paramedicine” has become a profession and “paramedic” a protected title. “Paramedic,” as we mostly know it in North America, is the entry to practice level and scope with some minor variances in many other countries. This is becoming an undergraduate degree program in concert with other healthcare professions; which puts paramedics internationally on an equal footing with roles such as registered nurses (RN), respiratory therapists, and more.

The next phase that has emerged is the Advanced Practice Paramedic. Just as the RN is the core nursing role and entry to practice degree, “paramedic” is becoming the same with post-graduate degrees and diplomas to define specialty practice.

Do you do critical care inter-facility transport? There is a Master’s Degree in Critical Care Paramedicine. Consider medical consultation in the United Kingdom (U.K.) … the Doctorate-level Consultant Paramedic provides medical advice and direction to paramedics in the field, while also making clinical decisions overseeing operations in the communication center.

Community Paramedicine? Primary care and public health post-graduate diplomas define this specialty paramedic. Nurse Practitioner? Paramedics in the U.K. attend post-graduate advanced practice and prescribing programs to bring this care to the community and medical clinics. Would you like to add ultrasonography to your skill set and role? Paramedics can attend a post-graduate ultrasound fellowship with colleagues from medicine, nursing, and radiography.

What is the commonality? “Paramedicine” is the profession … “paramedic” is the role; they are healthcare professionals in the same right.

I grew up watching Emergency! and Johnny & Roy were a big part of my desire to pursue my career ambitions in this field (ironically, very few newer paramedics get this reference … maybe that tells us something!?).

I have a lot of respect for the history of paramedicine in the U.S. and how it contributed to the advancement of pre-hospital medicine. Dr. Ron Stewart (a Canadian), who played a large role in the southwest U.S. model, brought his experiences to Canada in developing our original programs. This is the history of the profession. It is time for evolution.

The profession has evolved globally and it’s time for the U.S. (as a whole) to come together and define the profession. To some respects, there is a decision to be made on the healthcare versus public safety debate. Clinical practice is clearly healthcare, while the other foot retains the public safety element for both clinician safety in the austere environment and for large scale incidents.

Should paramedicine, out-of-hospital and pre-hospital care be primarily healthcare professionals with capabilities for unique and varied settings? Absolutely.

Can dual-role operational models still exist? Absolutely. The operational models can still embrace the integration to healthcare while significantly improving quality and patient safety overall … considering the ability to embrace, and expertise to lead culture shifts.

So, what’s in a name?  International community … collegiality … branding … marketing … universal recognition … simplicity … uniformity … standardization … professionalism … a profession.

My call to action for our American neighbours: look globally, get on the same page domestically, find the patient-centered care value stream that enhances timely, safe, efficient, effective, and appropriate care for patients with the valuable and unique resources that have become paramedicine as a healthcare profession.

Embrace the evolution. Strive to understand how paramedicine delivers healthcare in public safety environments, not how public safety drives paramedicine.

We are now at a major crossroads in Canada … we are on the verge of a major shift within the international context. We have paramedic researchers with master’s and doctorate degrees conducting research, synthesizing & analyzing evidence, and translating knowledge to drive practice & operations in the context of healthcare. We look forward to having you join this new global paramedic profession and community … with a definitive title for all of your providers that deliver paramedic services to the community and patients.

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