national level, the national highway traffic safety administration (nhtsa), which is the federal organization with authority to administer the ems system, defines the various titles given to prehospital medical workers based on the level of care they provide. they are emt-p (paramedic), emt-i (intermediate), emt-b (basic), and first responders. while providers at all levels are considered emergency medical technicians, the term "paramedic" is most properly used in the united states to refer only to those providers who are emt-p's. apart from this distinction, the only truly common trend that would evolve was the relatively universal acceptance of the term 'emergency medical technician' being used to denote a lower level of training and skill than a 'paramedic'. changes in procedures also included the manner in which the work of paramedics was overseen and managed. in the earliest days of the field, medical control and oversight was direct and immediate, with paramedics calling into a local hospital and receiving orders for every individual procedure or drug. this still occurs in some jurisdictions, but is becoming very rare. as physicians began to build a bond of trust with paramedics, and experience in working with them, their confidence levels also rose. increasingly, in many jurisdictions day-to-day operations moved from direct and immediate medical control to pre-written protocols or 'standing orders', with the paramedic typically only calling in for direction after the options in the standing orders had been exhausted. medical oversight became driven more by chart review or rounds, than by step by step control during each call. scope of practice in the united states there are no federal guidelines for the scope of practice for any level of ems provider. in the field, paramedics follow a set of pre-approved procedures and interventions for particular scenarios. for example, all fifty states allow for the administration of some form of anti-convulsive. in the state of massachusetts a paramedic may administer the anti-convulsant, midazolam, up to a maximum of 6 mg . while in maine paramedics are allowed to administer midazolam in upwards of 10 mg boluses. these pre-approved procedures are known as standing orders. standing orders cannot surpass a provider's scope of practice. scopes of practice represent the degree to which providers are trained. the following is derived nhtsa's "national ems scope of practice model". without federal mandate, each state's office of emergency medical services may alter their respective standing orders. the purpose of the model is to provide a guide toward standardization in patient care that both improves patient outcomes but allows for reciprocity between states. prior to certification as a paramedic, candidates must be a certified emt. traditionally, a paramedic is allowed to perform all skills an emt may perform. below are some of the key skills and procedures expected of a paramedic in the united states. key skills and procedures assessment and evaluation of general incident scene safety. triage of patients in a mass casualty incident. patient primary and secondary assessments. effective verbal and written reporting skills (documentation). carrying/lifting/extrication of patients. peripheral intravenous cannulation. cardiac monitoring and manual defibrillation. ecg acquisition and interpretation. orotracheal intubation. medications one of the primary differences between emergency medical technicians and paramedics includes the breadth and number of medications paramedic ambulances typically carry. due to the variation between each state ems office it would be cumbersome and unrealistic to list each and every single medication paramedics carry across the united states. instead, different medications are carried to serve similar patient-care scenarios. most services carry medications like albuterol or ipratropium to alleviate bronchospasm during an acute asthma attack. they carry cardiac medications to reverse deadly heart rhythms like amiodarone and lidocaine. they can also use medications like atropine, adenosine and different types of beta-blockers as heart rate controls. paramedics may also utilize a number of other medications for analgesia, such as antiemetics and anti-convulsants. in the setting of inter-facility transfers providers may continue the administration of other medications that are not typically carried in the field (heparin, blood products, potassium). variations in scope the aforementioned skills and medications are often standing orders in state protocols. the expectations and responsibilities of providers varies across state lines. there are instances where special waivers granted by states allowing paramedic services to go beyond their protocols. for example, some paramedics in new hampshire may be allowed to perform a surgical cricothyrotomy, medics in virginia are allowed to use ultrasound as a diagnostic technique and paramedics in arizona are allowed to perform rapid-sequence intubation utilizing paralytic and sedating medication to completely control a patient's airway. employment paramedics are employed by various public and private emergency service providers. these include private ambulance services, fire departments, public safety or police departments, hospitals, law enforcement agencies, the military, and municipal ems agencies in addition to and independent from police or fire departments, also known as a 'third service'. paramedics may respond to medical incidents in an ambulance, rescue vehicle, helicopter, fixed-wing aircraft, motorcycle, or fire suppression apparatus. paramedics may also be employed in medical fields that do not involve transportation of patients. such positions include offshore drilling platforms, phlebotomy, blood banks, research labs, educational fields, law enforcement and hospitals. aside from their traditional roles, paramedics may also participate in one of many specialty arenas: critical care transporters move patients by ground ambulance or aircraft between medical treatment facilities. this may be done to allow a patient to receive a higher level of care in a more specialized facility. registered nurses with training in emergency nursing may work with paramedics in these settings. paramedics participating in this role generally also provide care not traditionally administered by paramedics who respond to 911 calls. examples of this are blood transfusions, intra-aortic balloon pumps, and mechanical ventilators. tactical paramedics work on law enforcement teams (swat). these medics, usually from the ems agency in the area, are commissioned and trained to be tactical operators in law enforcement, in addition to paramedic duties. advanced medical personnel perform dual roles as operator and medic on the teams. such an officer is immediately available to deliver advanced emergency care to other injured officers, suspects, innocent victims and bystanders. the advantage to having dual role paramedics is that medical care is provided almost immediately. hospital paramedics are sometimes employed in either of the outpatient and inpatient areas. emergency departments employ the largest number of paramedics working inside of hospitals. considered ambulatory care, emergency departments are classified as an outpatient area of a hospital. depending on their scope of practice and job description within the emergency department, paramedics are allowed to triage and assess incoming patients, provide analysis and interpretation of both labs and ekgs, intravenous therapy, drug administration, transportation of emergency department patients to diagnostic testing or their inpatient rooms. paramedics are also employed indirectly in the inpatient areas of hospitals as well. paramedics are utilized in intensive care units assisting other licensed staff with icu patients and they are utilized on high risk transport teams by providing transportation, continuation of care and assisting in sedation of patients during minimally invasive and invasive procedures at the bedside and in diagnostic areas. because of the nature and purpose of these teams, paramedics work closely with radiology, interventional radiology, nuclear medicine and anesthesiology. salary the salary of a paramedic in the us varies. the mean average is $30,000, with the lowest 10% earning under $20,000 and the top 10% earning over $50,000, considerably less than the salaries of paramedics in canada. factors such as education and location of the paramedic's practice influence the salary. paramedic supervisors and managers may make between $60,000- $80,000, depending on location.