Scope of Practice
Primary Care Paramedic - PCP (Level 1)
The Primary Care Paramedic (PCP) is a college graduate of a program dedicated to the Paramedic profession. The diploma in "Paramedic Studies" is generally two years in duration and emphasizes anatomy, physiology, pharmacology, and mechanisms involved in acute injury and illness. The program involves classroom learning and clinical hours working directly in the field. Once the college program is successfully completed, a Paramedic must complete a provincial examination. This certification, known as the Paramedic exam or Advanced Emergency Medical Care Assistant (A-EMCA) exam, must be successfully completed to practice as a Primary Care Paramedic in Ontario. In addition, each PCP must complete many continuing medical education courses on an annual basis to maintain their qualifications. The PCP is also certified by a physician to perform a number of controlled medical acts for individuals experiencing acute injury or illness. PCP's can be recognized by the one stripe above the word "Paramedic" on their shoulder epaulettes.
PCP skill set:
- emergency patient care
- cardiopulmonary resuscitation (CPR)
- patient immobilization
- oxygen therapy
- basic trauma life support
- blood glucose testing
- SpO2 Monitoring
- Side stream ETCO2 monitoring (capnography and capnometry)
- Lead 2 ECG interpretation
- 12-Lead ECG application, interpretation and STEMI diagnosis
- 15-Lead ECG (modified 12 Lead) application, interpretation and STEMI diagnosis
- manual defibrillation
- monitor intravenous line (IV) with normal saline, Thiamine, multivitamin preparations and potassium chloride (KCL)
- Taser probe removal
- emergency disconnect of home dialysis
- Code STEMI bypass to ER of PCI hospital
- Code STROKE bypass to regional or secondary stroke centre dependent on assessment findings
- FTT trauma bypass to Trauma Centre
- Burn centre bypass
- Isolated Amputation bypass
The PCP skill set includes these medications:
- acetaminophen (Tylenol)
- acetylsalicylic acid (ASA)
- dimenhydrinate (Gravol)
- diphenhydramine (Benadryl)
- ibuprofen (Advil)
- ketorolac (Torodol)
- naloxone (Narcan)
- nitroglycerine spray
- salbutamol (Ventolin)
- *currently involved in PITSTOP study using Ceftriaxone vs placebo IM
Primary Care Paramedic Enhanced (Level 2 - Toronto)
The Level 2 Paramedic is a community college graduate of an Ambulance and Emergency Care Program, has obtained EMCA certification with two years of practical experience, and is employed in an ambulance service.
The function of a Level 2 Paramedic includes all the responsibilities of the PCP (level 1) Paramedic and is further enhanced with additional training and skills.
Additional training includes 120 hours didactic training, 40 hours of clinical training, and 120 hours of preceptorship (supervised service delivery).
Level 2's can be recognized by the two stripes above the word "Paramedic" on their shoulder epaulettes.
The level II Paramedic is additionally certified by a physician to:
- Initiate an Intravenous Line (autonomous IV start)
- Initiate fluid bolus (Gravity and Pressure Infuser)
- Administer Dextrose IV
- Administer Gravol IV
- Administer Ketorolac IV
- Administer Naloxone IV
When working with an ACP (Level 3) Paramedic
- Perform endotracheal tube (ETT) care and maintenance
- Intraosseous access (IO)
- Draw up additional ALS medications
Advanced Care Paramedic - ACP (Level 3)
The ACP program is an additional 1 year in length and is considered a post-diploma program (1200 hours). Some institutions require previous "road" experience as a PCP prior to entering the program. The ACP will have had 2 years of training to become a PCP before he/she spends the addition year to progress to the advanced care level. The ACP course is highly intensive and requires weeks of in class didactic training, weeks of in hospital clinical training where the ACP learner works directly with physicians and months of preceptorship practicum where the ACP must demonstrate competence to multiple preceptors. In addition, each ACP must successfully complete many mandatory and elective continuing medical education courses on an annual basis to maintain their qualifications and certifications. ACP's can be recognized by the three stripes above the word "Paramedic" on their shoulder epaulettes.
In addition to the PCP skill set, ACP providers are qualified to perform and/or use:
- advanced airway management equipment
- orotracheal and nasotracheal intubation equipment
- lighted stylet intubation equipment
- orogastric and nasogastric tubes
- mechanical ventilation
- laryngoscopy and removal of foreign body obstruction using MacGill forceps
- initiate an Intravenous Line (autonomous IV start)
- initiate intraosseous and external jugular sites
- initiate fluid bolus (Gravity and Pressure Infuser)
- pharmaceutical therapy
- needle thoracostomy
- chest tube monitoring
- synchronized cardioversion and external transcutaneous cardiac pacing
- treatment of cardiac emergencies according to Heart & Stroke Foundation Advanced Cardiac Life Support (ACLS) guidelines
In addition to PCP medications ACP providers are certified to use:
- Calcium Gluconate
- Sodium Bicarbonate
- *currently involved in TXA (Tranexamic acid) for trauma brain injury
The Critical Care Paramedic
(CCP) functions with the broadest scope of Paramedic practice. Their
knowledge and skill sets are based on the foundations of the PCP and the ACP
paramedic scopes of practice. The CCP
specific training is an additional 2 years. This is inclusive of Didactic,
Clinical, preceptorship, and multiple evaluations leading to certification.
The Critical Care Paramedic is specialized in the care of
Critically ill or injured Adults and Paediatrics as well as High Risk
Obstetrics. Intra Aortic Balloon Pump, and shared care ECMO/ECLS are also part
of their scope. Their primary responsibility is servicing Critical Care Calls.
Functioning as a mobile ICU CCP's respond to the needs/requests of various
hospital units that require Critical Care and transport of patients. The CCP is
capable of assessing, initiating care, resuscitation, and continuity of care in
the management of virtually any clinical condition.
CCP's can be recognized by the three stripes above the words
“Critical Care" on their shoulder epaulettes.
In addition to the skills that ACP's perform, the Critical Care Paramedic practice includes:
- Transvenous pacing
- Management of PA Lines
- Art Line Monitoring
- An extensive pharmacology scope
- Administration of blood and blood
- UVC Line insertion
- Foley catheter insertion
- NG tube insertion
- CT-head scan
- Chest X-ray interpretation
- Multiple Difficult Airway maneuvers
Ventilation, multiple modes
- Chest Tube management
- Blakemore Tube management
- Blood gas analysis
- Various medications with physician's orders
For a more detail scope of practice explanation please see our
Paramedic Scope of Practice under the Regulated Health Professions Act (1991)
The Regulated Health Professions Act details the controlled acts that a physician or his delegate can perform with respect to an individual. The list is comprised of 13 main acts. Of these 13 acts, it is within the Paramedic Scope of Practice to perform 8 procedures* on the list when the Paramedic is certified under a Base Hospital Physician who is licensed to practice in the Province of Ontario. This means that aside from Physicians, Paramedics are able to perform more controlled acts under a standing order from their own Base Hospital Physician than any other medical discipline including Nurses, Respiratory Therapists and Midwives.
A "controlled act" is any one of the following done with respect to an individual:
- * Communicating to the individual or his or her personal representative a diagnosis identifying a disease or disorder as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual or his or her personal representative will rely on the diagnosis.
- * Performing a procedure on tissue below the dermis, below the surface of a mucous membrane, in or below the surface of the cornea, or in or below the surfaces of the teeth, including the scaling of teeth.
- * Setting or casting a fracture of a bone or a dislocation of a joint.
- Moving the joints of the spine beyond the individual's usual physiological range of motion using a fast, low amplitude thrust.
- * Administering a substance by injection or inhalation.
- * Putting an instrument, hand or finger,
- beyond the external ear canal,
- beyond the point in the nasal passages where they normally narrow,
- beyond the larynx,
- beyond the opening of the urethra,
- beyond the labia majora,
- beyond the anal verge, or
- into an artificial opening into the body.
- * Applying or ordering the application of a form of energy prescribed by the regulations under this Act.
- * Prescribing, dispensing, selling or compounding a drug as defined in subsection 117 (1) of the Drug and Pharmacies Regulation Act, or supervising the part of a pharmacy where such drugs are kept.
- Prescribing or dispensing, for vision or eye problems, subnormal vision devices, contact lenses or eye glasses other than simple magnifiers.
- Prescribing a hearing aid for a hearing-impaired person.
- Fitting or dispensing a dental prosthesis, orthodontic or periodontal appliance or a device used inside the mouth to protect teeth from abnormal functioning.
- * Managing labour or conducting the delivery of a baby.
- Allergy challenge testing of a kind in which a positive result of the test is a significant allergic response.