Editing Emergency medical services (section)

==<span id="Personnel"></span>Personnel==
[[File:Woman collapses in the East Village of New York.jpg|thumb|EMT staff at an emergency call in [[New York City]]]]
[[File:MS1 on stretcher.jpg|thumb|A patient arriving at a hospital]]

Ambulance personnel are generally professionals and in some countries their use is controlled through training and registration. While these job titles are protected by legislation in some countries, this protection is by no means universal, and anyone might, for example, call themselves an 'EMT' or a 'paramedic', regardless of their training, or the lack of it. In some jurisdictions, both technicians and paramedics may be further defined by the environment in which they operate, including such designations as 'Wilderness', 'Tactical', and so on.<ref>{{Cite web|title=EMTs and Paramedics : Occupational Outlook Handbook: : U.S. Bureau of Labor Statistics|url=https://www.bls.gov/ooh/healthcare/emts-and-paramedics.htm#tab-3|access-date=2023-05-10|website=bls.gov|language=en-us}}</ref>

A unique aspect of EMS is that there are two hierarchies of authority, as the [[command hierarchy|chain of command]] is separate to medical authority.<ref>{{cite magazine|url=https://www.fireengineering.com/1998/09/01/228424/fire-ems-merger-an-examination-of-cultural-differences/#gref|date=1998-09-01|access-date=2019-02-15|title=Fire/EMS Merger: An Examination of Cultural Differences|magazine=[[Fire Engineering (magazine)|Fire Engineering]]|archive-date=29 August 2018|archive-url=https://web.archive.org/web/20180829175240/https://www.fireengineering.com/articles/print/volume-151/issue-9/features/fire-ems-merger-an-examination-of-cultural-differences.html#gref|url-status=dead}}</ref>

===Basic life support (BLS)===

====Emergency medical dispatcher====
An emergency medical dispatcher is also called an EMD. An increasingly common addition to the EMS system is the use of highly trained dispatch personnel who can provide "pre-arrival" instructions to callers reporting medical emergencies. They use carefully structured questioning techniques and provide scripted instructions to allow callers or bystanders to begin definitive care for such critical problems as airway obstructions, bleeding, childbirth, and cardiac arrest. Even with a fast [[Emergency service#Response time|response time]] by a first responder measured in minutes, some medical emergencies evolve in seconds. Such a system provides, in essence, a "zero response time," and can have an enormous impact on positive patient outcomes.

====First responder====
{{See also|Certified first responder}}
Certified first responders may be sent to provide first aid, sometimes to an advanced level. Their duties include the provision of immediate life-saving care in the event of a medical emergency; commonly advanced first aid, oxygen administration, [[cardio-pulmonary resuscitation]] (CPR), and [[automated external defibrillator]] (AED) usage. The first responder training is considered a bare minimum for emergency service workers who may be sent out in response to an [[emergency call]]. First responders are commonly dispatched by the ambulance service to arrive quickly and stabilize the patient before the ambulance arrives, and to then assist the ambulance crew.<ref>{{Cite web|url=http://medical-dictionary.thefreedictionary.com/first+responder|title=Free Dictionary}}</ref>

Some EMS agencies have set up volunteer schemes, who can be dispatched to a medical emergency before the ambulance arrives. Examples of this include [[Community First Responder]] schemes run by ambulance services the UK and [[Certified First Responder in France|similar volunteer schemes]] operated by the fire services in France. In some countries such as the US, there may be autonomous groups of volunteer responders such as [[rescue squad]]s. [[Police officer]]s and [[firefighter]]s who are on duty for another emergency service may also be deployed in this role, though some firefighters are trained to a more advanced medical level.

Besides first responders who are deployed to an emergency, there are others who may be stationed at public events. The [[International Red Cross and Red Crescent Movement]] and [[St John Ambulance]] both provide first aiders in these roles.

====Ambulance driver====
Some agencies separate the 'driver' and 'attendant' functions, employing ambulance driving staff with no medical qualification (or just a first aid and CPR certificates), whose job is to drive ambulances. While this approach persists in some countries, such as India, it is generally becoming increasingly rare. Ambulance drivers may be trained in radio communications, ambulance operations and emergency response driving skills.<ref>{{cite web|url=http://www.unionems.com/categories_vol_membership.htm|title=Union EMS|access-date=2008-08-20|archive-url=https://web.archive.org/web/20080929213547/http://www.unionems.com/categories_vol_membership.htm|archive-date=29 September 2008|url-status=dead}}</ref>

====Non-emergency attendant====
Many countries employ ambulance staff who only carry out non-emergency patient transport duties (which can include stretcher or wheelchair cases). Dependent on the provider (and resources available), they may be trained in first aid or extended skills such as use of an [[Automated external defibrillator|AED]], oxygen therapy, pain relief and other live-saving or [[palliative]] skills. In some services, they may also provide emergency cover when other units are not available, or when accompanied by a fully qualified technician or paramedic. The role is known as an Ambulance Care Assistant in the United Kingdom.<ref>{{cite web|url=http://www.nhscareers.nhs.uk/details/Default.aspx?Id=907/|title=NHS Careers|access-date=2008-08-20|archive-date=21 May 2020|archive-url=https://web.archive.org/web/20200521233658/https://www.healthcareers.nhs.uk/|url-status=dead}}</ref><ref>{{cite web|url=http://www.health-care-jobs.co.uk/index/index.php?item_id=107|title=ACA job description|access-date=2008-08-20|archive-url=https://web.archive.org/web/20090211102913/http://www.health-care-jobs.co.uk/index/index.php?item_id=107|archive-date=11 February 2009|url-status=dead}}</ref>

====Emergency care assistant====
[[Emergency care assistant]]s are of a frontline under both emergency and non-emergency conditions to incidents. Their role is to assist the clinician that they are working with, either a Technician or Paramedic, in their duties, whether that be drawing up drugs, setting up fluids (but not attaching), doing basic observations or performing 12 lead ECG assessments.

====Emergency medical technician====
[[File:EMTs loading a patient.jpg|thumb|right|EMTs loading a patient into an ambulance]]
[[Emergency medical technician]]s are usually able to perform a wide range of emergency care skills, such as automated [[defibrillation]], care of spinal injuries and [[oxygen therapy]].<ref>{{cite web|url=http://stats.bls.gov/oco/oco2001.htm#training|title=Dept. of Labor EMT Job Description|access-date=2008-08-20|archive-url=https://web.archive.org/web/20080725011655/http://www.stats.bls.gov/oco/oco2001.htm#training|archive-date=25 July 2008|url-status=dead}}</ref><ref>{{cite web|url=http://www.health.state.ny.us/nysdoh/ems/pdf/srgemt.pdf|title=NYS EMT-B Job Description|access-date=2008-08-20}}</ref> In few jurisdictions, some EMTs are able to perform duties as IV and IO cannulation, administration of a limited number of drugs (including but not limited to Epinephrine, Narcan, Oxygen, Aspirin, Nitroglycerin – dependent on country, state, and medical direction), more advanced airway procedures, CPAP, and limited cardiac monitoring.<ref>{{cite web|url=http://www.medicalalertsystemsnews.com/EMS%20Scope%20of%20Practice2006.pdf|title=North Dakota EMT-B Scope of Practice|access-date=2008-08-20|archive-url=https://web.archive.org/web/20160303220257/http://www.medicalalertsystemsnews.com/EMS%20Scope%20of%20Practice2006.pdf|archive-date=3 March 2016|url-status=dead}}</ref> Most advanced procedures and skills are not within the national scope of practice for an EMT.<ref>{{cite web|url=http://www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pdf|title=NHTSA EMT-B Scope of Practice|access-date=2008-08-20}}</ref> As such most states require additional training and certifications to perform above the national curriculum standards.<ref>{{cite web|url=http://www.health.state.nd.us/EMS/pdfs/EMS%20Provider%20Skill%20Sets/EMS%20Skills%20for%20providers%202008EMTB.pdf|title=EMT-B additional skills|access-date=2008-08-20}}</ref><ref>{{cite web|url=http://www.healthoneems.com/course_pdf/2008/IV_Student_Application_Packet.pdf|title=Colorado EMT-B IV Certification|access-date=2008-08-20|archive-url=https://web.archive.org/web/20080824013231/http://www.healthoneems.com/course_pdf/2008/IV_Student_Application_Packet.pdf|archive-date=24 August 2008|url-status=dead}}</ref> In the United States, an EMT certification requires intense courses and training in field skills.  A certification expires after two years and holds a requirement of taking 48 CEUs (continuing education credits).  24 of these credits must be in refresher courses while the other 24 can be taken in a variety ways such as emergency driving training, pediatric, geriatric, or bariatric care, specific traumas, etc. Is usually made up of 3 levels in the US. EMT-B, EMT-I (EMT-A in some states) and EMT-Paramedic. The National Registry of EMT New Educational Standards for EMS renamed the provider levels as follows: Emergency Medical Responder (EMR), Emergency Medical Technician (EMT-B), Advanced EMT (AEMT), and Paramedic (EMT-P).

===Advanced life support (ALS)===

====Paramedic====
[[File:Cervical Collar Emergency.jpg|thumb|A girl treated by a paramedic]]
A [[paramedic]] has a high level of pre-hospital medical training and usually involves key skills not performed by technicians, often including [[Intravenous therapy|cannulation]] (and with it the ability to use a range of drugs to relieve pain, correct cardiac problems, and perform [[endotracheal intubation]]), [[cardiac monitoring]], 12-lead ECG interpretation, [[ultrasound]], [[intubation]], pericardiocentesis, cardioversion, [[thoracostomy]], and other skills such as performing a surgical [[cricothyrotomy]].<ref>{{cite web|url=http://www.prospects.ac.uk/cms/ShowPage/Home_page/Explore_types_of_jobs/Types_of_Job/p!eipaL?state=showocc&pageno=1&idno=205|title=Paramedic: Job description|access-date=2008-08-20|archive-url=https://web.archive.org/web/20090202161146/http://www.prospects.ac.uk/cms/ShowPage/Home_page/Explore_types_of_jobs/Types_of_Job/p!eipaL?state=showocc&idno=205&pageno=1|archive-date=2 February 2009|url-status=dead}}</ref> The most important function of the paramedic is to identify and treat any life-threatening conditions and then to assess the patient carefully for other complaints or findings that may require emergency treatment.<ref>Editors of Salem Press (2008). Paramedics. Magill's Medical Guide, 4th Rev. ed.. Salem Press. Retrieved from http://elibrary.bigchalk.com {{Webarchive|url=https://web.archive.org/web/20200527092602/https://explore.proquest.com// |date=27 May 2020 }}</ref> In many countries, this is a protected title, and use of it without the relevant qualification may result in criminal prosecution.<ref>{{cite web|url=http://www.hpc-uk.org/aboutregistration/protectedtitles/|title=HPC – Health Professions Council – Protected titles|access-date=2008-08-20|archive-url=https://web.archive.org/web/20181107140106/http://www.hpc-uk.org/aboutregistration/protectedtitles/|archive-date=7 November 2018|url-status=dead}}</ref> In the United States, paramedics represent the highest licensure level of prehospital emergency care. In addition, several certifications exist for Paramedics such as Wilderness ALS Care,<ref>{{cite journal|vauthors=Schmidt TA, Federiuk CS, Zechnich A, Forsythe M, Christie M, Andrews C|title=Advanced life support in the wilderness: 5-year experience of the Reach and Treat team|journal=Wilderness & Environmental Medicine|volume=7|issue=3|pages=208–15|date=August 1996|pmid=11990115|doi=10.1580/1080-6032(1996)007[0208:ALSITW]2.3.CO;2|doi-access=free}}</ref> Flight Paramedic Certification ([[FP-C]]),<ref>{{cite web|url=http://www.flightparamedic.org/|title=Flight Paramedic Certification|access-date=2008-08-20|archive-date=19 July 2012|archive-url=https://web.archive.org/web/20120719110810/http://www.flightparamedic.org/|url-status=dead}}</ref> and Critical Care Emergency Medical Transport Program certification.<ref name=CCEMTP>{{cite web|url=http://ehs.umbc.edu/CE/CCEMT-P/|title=CCEMTP|access-date=2008-08-20|url-status=dead|archive-url=https://web.archive.org/web/20080621174320/http://ehs.umbc.edu/CE/CCEMT-P/|archive-date=21 June 2008}}</ref>

====Critical care paramedic====
[[File:Toronto Paramedic Services Critical Care Transport ambulance.jpg|thumb|A [[Toronto Paramedic Services]] Critical Care ambulance]]
A critical care paramedic, also known as an advanced practice paramedic or specialist paramedic, is a paramedic with additional training to deal with critically ill patients.<ref name=CCEMTP/><ref>{{Cite thesis|last1=Paquette|first1=Anthony John|title=The Feasibility of the Advanced Practice Paramedic|type=MPH thesis|publisher=University of Connecticut|year=2005|url=https://opencommons.uconn.edu/uchcgs_masters/78}}</ref><ref>{{cite web|title=Critical Care Paramedic Position Paper|url=http://www.flightparamedic.org/documents/CriticalCareParamedicPositionPaper.pdf|publisher=International Association of Flight Paramedics|access-date=29 September 2011|archive-url=https://web.archive.org/web/20120111064235/http://www.flightparamedic.org/documents/CriticalCareParamedicPositionPaper.pdf|archive-date=11 January 2012|url-status=dead}}</ref> Critical care paramedics often work on [[Air medical services|air ambulances]], which are more likely to be dispatched to emergencies requiring advanced care skills. They may also work on land ambulances.<ref name="bcctpc"/> The training, permitted skills, and certification requirements vary from one jurisdiction to the next. It also varies to whether they are trained externally by a university or professional body<ref name="bcctpc">{{cite web|title=Report of a National Study of the Certified Critical Care Paramedic|url=http://www.bcctpc.org/Documents/Ground%20Critical%20Care%20Summary%20Blueprint.pdf|publisher=The Board for Critical Care Transport Certification|access-date=29 September 2011|archive-url=https://web.archive.org/web/20120119104656/http://www.bcctpc.org/Documents/Ground%20Critical%20Care%20Summary%20Blueprint.pdf|archive-date=19 January 2012|url-status=dead}}</ref><ref>{{cite web|title=Board of Critical Care Transport Paramedic|url=http://www.bcctpc.org/|publisher=The Board for Critical Care Transport Certification|access-date=29 September 2011}}</ref><ref>{{cite web|title=CCEMTP Course|url=http://ehs.umbc.edu/CE/CCEMT-P/|publisher=University of Maryland Baltimore County|access-date=11 August 2011|url-status=dead|archive-url=https://web.archive.org/web/20110811164911/http://ehs.umbc.edu/CE/CCEMT-P/|archive-date=11 August 2011}}</ref><ref>{{cite web|url=http://www.emsacademy.us/Education/CriticalCareEducation/CertifiedIntensiveCareProvider/tabid/1962/Default.aspx|title=Cleveland Clinic CICP program|access-date=29 September 2011|archive-url=https://web.archive.org/web/20110822013843/http://www.emsacademy.us/Education/CriticalCareEducation/CertifiedIntensiveCareProvider/tabid/1962/Default.aspx|archive-date=22 August 2011|url-status=dead}}</ref> or 'in house' by their EMS agency.<ref>{{cite web|url=http://www.wakegov.com/ems/staff/app|title=Wake County EMS|access-date=29 September 2011|archive-date=8 August 2019|archive-url=https://web.archive.org/web/20190808140756/http://www.wakegov.com/ems/staff/app|url-status=dead}}</ref><ref>{{cite web|url=http://www.medstar911.org/critical-care-transport|title=MedStar EMS|access-date=29 September 2011|archive-url=https://web.archive.org/web/20131020163723/http://www.medstar911.org/critical-care-transport|archive-date=20 October 2013|url-status=dead}}</ref>

These providers have a vast array of and medications to handle complex medical and trauma patients. Examples of medication are [[dobutamine]], [[dopamine]], [[Propofol]], [[blood]] and [[blood products]] to name just a few. Some examples of skills include, but not limited to, life support systems normally restricted to the ICU or critical care hospital setting such as [[Mechanical ventilation|mechanical ventilators]], [[Intra-aortic balloon pump]] (IABP) and external [[pacemaker]] monitoring. Depending on the service medical direction, these providers are trained on placement and use of UVCs ([[Umbilical vein catheter|Umbilical Venous Catheter]]), UACs ([[Umbilical artery catheter|Umbilical Arterial Catheter]]), [[Cricothyrotomy|surgical airways]], [[Central venous catheter|central lines]], [[Arterial catheter|arterial lines]] and [[chest tube]]s.

====Emergency care practitioner====
In the United Kingdom and South Africa, some serving [[paramedic]]s receive additional university education to become practitioners in their own right, which gives them absolute responsibility for their clinical judgement, including the ability to autonomously prescribe medications. An [[emergency care practitioner]] or paramedic practitioner is a position that is designed to bridge the link between ambulance care and the care of a [[general practitioner]]. ECPs are university graduates in Emergency Medical Care or qualified paramedics who have undergone further training,<ref>{{cite web|url=http://www.swast.nhs.uk/careersandvac/careers.htm#ECP|title=South Western Ambulance Service NHS Trust|access-date=2008-08-20|archive-url=https://web.archive.org/web/20070517154015/http://www.swast.nhs.uk/careersandvac/careers.htm#ECP|archive-date=17 May 2007|url-status=dead}}</ref> and are authorized to perform specialized techniques. Additionally some may prescribe medicines for longer-term care, such as antibiotics and in the United Kingdom they can prescribe a broad range of medicines. With respect to a Primary Health Care setting, they are also educated in a range of Diagnostic techniques.

===Traditional healthcare professionals in EMS===

====Registered nurses====
The use of [[registered nurses]] (RNs) in the pre-hospital setting is common in many countries in absence of paramedics. In some regions of the world nurses are the primary healthcare worker that provides emergency medical services. In European countries such as France or Italy, also use nurses as a means of providing ALS services. These nurses may work under the direct supervision of a physician, or, in rarer cases, independently. In some places in Europe, notably Norway, paramedics do exist, but the role of the 'ambulance nurse' continues to be developed,<ref>{{cite journal|vauthors=Melby V, Ryan A|title=Caring for older people in prehospital emergency care: can nurses make a difference?|journal=Journal of Clinical Nursing|volume=14|issue=9|pages=1141–50|date=October 2005|pmid=16164532|doi=10.1111/j.1365-2702.2005.01222.x}}</ref> as it is felt that nurses may bring unique skills to some situations encountered by ambulance crews.

In North America, and to a lesser extent elsewhere in the English-speaking world, some jurisdictions use specially trained nurses for medical transport work. These are mostly air-medical personnel or critical care transport providers, often working in conjunction with a technician, paramedic or physician on emergency interfacility transports. In the United States, the most common uses of ambulance-based registered nurses is in the Critical Care/Mobile Intensive Care transport, and in Aeromedical EMS. Such nurses are normally required by their employers (in the US) to seek additional certifications beyond the primary nursing licensure. Four individual states have an Intensive Care or Prehospital Nurse licensure. Many states allow registered nurses to also become registered paramedics according to their role in the emergency medical services team. In [[Estonia]] 60% of ambulance teams are led by nurse. Ambulance nurses can do almost all emergency procedures and administer medicines pre-hospital such as physicians in Estonia. In the [[Netherlands]], all ambulances are staffed by a registered nurse with additional training in emergency nursing, anesthesia or critical care, and a driver-EMT.<ref>{{cite journal|author=Wulterkens D|title=EMS in the Netherlands: A Dutch Treat?|journal=Journal of Emergency Medical Services|date=6 December 2005|url=http://m.jems.com/article/operations-protcols/ems-netherlands-dutch-treat|access-date=15 May 2012|archive-url=https://web.archive.org/web/20150217201958/http://m.jems.com/article/operations-protcols/ems-netherlands-dutch-treat|archive-date=17 February 2015|url-status=dead}}</ref> In [[Sweden]], since 2005, all emergency ambulances should be staffed by at least one registered nurse since only nurses are allowed to administer drugs.<ref>{{cite journal|author=Suserud B|title=A new profession in the pre-hospital care field: the ambulance nurse|journal=Nursing in Critical Care|volume=10|issue=6|pages=269–71|year=2005|pmid=16255333|doi=10.1111/j.1362-1017.2005.00129.x|doi-access=free}}</ref><ref>{{cite journal|author=Bom A|title=International EMS system Design: Sweden|journal=Emsnews|date=Feb 2012|url=http://www.emsnews.com/read/featured-articles/international-ems-system-design-sweden|access-date=2012-08-29|archive-date=30 March 2014|archive-url=https://web.archive.org/web/20140330055643/http://www.emsnews.com/read/featured-articles/international-ems-system-design-sweden|url-status=dead}}</ref> And all Advanced Life Support Ambulances are staffed at least by a registered nurse in Spain.<ref>{{cite journal|url=https://www.boe.es/buscar/doc.php?id=BOE-A-2012-7655|title=Real Decreto 836/2012, de 25 de mayo, por el que se establecen las características técnicas, el equipamiento sanitario y la dotación de personal de los vehículos de transporte sanitario por carretera|trans-title=Royal Decree 836/2012, of 25 May, which establishes the technical characteristics, the sanitary equipment and the staffing of the vehicles of sanitary transport by road|language=es|journal=Boletín Oficial del Estado|volume=137|date=8 June 2012|pages=41589–41595}}</ref> In France, since 1986, fire department-based rescue ambulances have had the option of providing resuscitation service (reanimation) using specially trained nurses, operating on protocols,<ref>{{cite web|url=http://www.interieur.gouv.fr/sections/a_l_interieur/defense_et_securite_civiles/sapeurs-pompiers/sdis/sssm/downloadFile/attachedFile_2/Protocoles.pdf?nocache=1143132331.45|title=Infermier Sapeur-Pompiers (French govt website)|language=fr|access-date=2012-08-29|archive-url=https://web.archive.org/web/20120306002244/http://www.interieur.gouv.fr/sections/a_l_interieur/defense_et_securite_civiles/sapeurs-pompiers/sdis/sssm/downloadFile/attachedFile_2/Protocoles.pdf?nocache=1143132331.45|archive-date=6 March 2012|url-status=dead}}</ref> while SAMU-SMUR units are staffed by physicians and nurses<ref>{{cite web|url=http://www.samu06.org/en/smur.php?PHPSESSID=800aadc6593ea9bb266fac13beb29793|archive-url=https://archive.today/20130415211141/http://www.samu06.org/en/smur.php?PHPSESSID=800aadc6593ea9bb266fac13beb29793|url-status=dead|archive-date=2013-04-15|title=The SMUR of Nice|access-date=2012-08-29}}</ref>
[[File:Prehospital RSI training.jpg|thumb|364x364px|Prehospital anaesthesia training]]

====Physician====
In countries with a [[physician]]-led EMS model, such as France, Italy, the German-speaking countries (Germany, Switzerland, Austria), and Spain, physicians respond to all cases that require more than basic first aid. In some versions of this model (such as France, Italy, and Spain), there is no direct equivalent to a [[paramedic]], as ALS is performed by physicians. In the German-speaking countries, paramedics are assistants to ambulance physicians (called Notarzt). In these countries, if a physician is present, paramedics require permission from the physician to administer treatments such as defibrillation and drugs. If there is no physician on scene and a life-threatening condition is present, they may administer treatments that follow the physician's instructions.<ref name=g1>{{cite web|url=http://www.bundesaerztekammer.de/page.asp?his=0.7.47.3222|title=Bundesärztekammer – Notfall: Notkompetenz I (German Federal Board of Physicians: Directives regarding emergency powers for Paramedics)|publisher=Bundesaerztekammer.de|access-date=2010-07-29|language=de|archive-url=https://web.archive.org/web/20101120171646/http://bundesaerztekammer.de/page.asp?his=0.7.47.3222|archive-date=20 November 2010|url-status=dead}}</ref>

In countries where EMS is led by paramedics, the ambulance service may still employ physicians. They may serve on specialist response vehicles, such as the [[air ambulance]]s in the UK.<ref>{{cite web|url=http://www.londonsairambulance.com/|title=Londons Air Ambulance|access-date=2007-06-18|archive-url=https://web.archive.org/web/20080723121904/http://www.londonsairambulance.com/|archive-date=23 July 2008|url-status=dead}}</ref><ref>{{cite web|url=http://www.surreyairambulance.co.uk/crew.asp/|title=Surrey Air Ambulance|access-date=2007-06-18|archive-url=https://web.archive.org/web/20171010101142/http://surreyairambulance.co.uk/crew.asp|archive-date=10 October 2017|url-status=dead}}</ref> They may also provide advice and devise protocols for treatment, with a [[medical director]] acting as the most senior medical adviser to the ambulance service. In the United States, EMS became an officially recognized subspecialty by the American Board of Emergency Medicine in 2010, and the first examinations were held in 2013.<ref>{{Cite web|last=PA-C|first=Fred Wu, MHS|date=2010-10-05|title=EMS officially recognized as an EM subspecialty|url=https://www.aliem.com/ems-officially-recognized-as-em/|access-date=2022-08-14|website=ALiEM|language=en-US}}</ref> Many states now recommend EMS board certification for newly hired medical directors of EMS agencies.