BackgroundThe evaluation and the improvement of the quality of telemedical care become increasingly important in times where this type of care is offered to a broad number of patients more and more. As telemedical care in an offshore setting has already been in use for decades, analyzing the extensive experience of offshore paramedics using telemedical care can help identify determinants of quality. Therefore, the aim of this study was to explore determinants of the quality of telemedical care using the experiences of experienced offshore paramedics.MethodsWe conducted a qualitative analysis of 22 semi-structured interviews with experienced offshore paramedics. The results were categorized in a hierarchical category system using content analysis as described by Mayring.ResultsAll 22 participants were males, having a mean of 3.9 years of experience working with telemedicine support offshore. Generally, participants stated that for them telemedical interaction did not differ much from personal interaction. However, the offshore paramedics personality and way to communicate were mentioned to impact the quality of telemedical care as it influenced the way cases were presented. Furthermore, interviewees described it to be impossible to use telemedicine in cases of an emergency as it was too time-consuming, technically too complex, and lead to cognitive overload as other tasks with higher priority needed their attention. Three determinants of a successful consultation were mentioned: low levels of complexity in the reason for consultation, telemedical guidance training for the teleconsultant physician and for the delegatee.ConclusionAppropriate indications for telemedical consultation, communication training of consultation partners, and the impact of personality need to be addressed to enhance the quality of future telemedical care.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12913-023-09664-5.