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Prehospital emergency medical care by EMS providers can be defined as physician-directed medical care in the prehospital setting with or without ambulance transport. A wealth of details clarifies this definition within specific jurisdictions and for particular circumstances. The care provided by prehospital providers as a part of the EMS system is a practice of medicine with standards of care established by the training and experience of practitioners and system leaders. Therefore, a key component of the EMS system is physician oversight and medical direction. A well-developed and well-designed EMS system usually incorporates four opportunities for physician input:

  • System design

  • Operational policies and guidelines

  • Patient care protocols

  • Medical direction

In an excellent EMS system, all four opportunities are coordinated by EMS physicians collaborating with EMS professionals to produce excellent and efficient care for patients while improving all aspects of the system and the providers working within it. System design, at a national and state level, provides guidance regarding curriculum, scope of practice, regulatory & licensing structure, and other overall aspects of the EMS system. Medical direction, provided at the time of care (online) and all other activities of the medical director (off-line), is discussed in Chapter 4. This chapter focuses on the development of protocols, policies, procedures, and guidelines and defining important concepts relative to these activities.


  • Define the terms guidelines, policies, procedures, protocols.

  • Define the terms scope of practice and standard of care.

  • Discuss how the above concepts relate to the medical care provided in the field.

  • Describe the processes involved in development of guidelines, policies, procedures, and protocols.

In order to fully appreciate the importance of clear and definitive documents defining prehospital medical operations, it is essential to know the purpose of the different document types and understand how they serve to define the parameters by which prehospital care is delivered. If the medical director confuses these components, and their purpose, there is potential for inappropriate development of these documents that could lead to operational, regulatory, legal, and medical complications.


Guidelines: provide broad parameters for management of a particular problem. They should be the result of expert consensus, based on evidence, and typically apply at a national or international level. An example would be recommending early 12-lead ECG acquisition for EMS patients with possible cardiac ischemia as a method to triage STEMI patients to the best treatment option.

Scope of practice: is the range of care expected and allowed for a particular type of care provider, such as an EMT or paramedic, but the term applies to all types of providers. It typically is described in laws, regulations, and protocols and includes allowed procedures, medications, and requirements for each type of provider in a system. Scope-of-practice documents define the bounds of practice ...

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