Survey of paramedic skills in the United Kingdom and Channel Islands

BMJ 1996; 313 doi: (Published 26 October 1996) Cite this as: BMJ 1996;313:1052
  1. Howard K Simpson, specialist registrar in accident and emergencya,
  2. Gary B Smith, chairman, paramedic steering committee, Hampshire Ambulance NHS Trusta
  1. a Department of Intensive Care Medicine, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth PO6 3LY
  1. Correspondence to: Mr Simpson.
  • Accepted 20 August 1996

A national training programme for paramedics was adopted in 1984 on government recommendation.1 Regional training programmes were established under the auspices of local steering committees, and paramedics throughout Britain were trained in endotracheal intubation, intravenous cannulation, cardiac monitoring and defibrillation, and the use of selected parenteral drugs. Further skills could be introduced on the basis of local need.

We believed that regional variation could not be explained by demographic and infrastructural differences alone. We therefore undertook a national survey of the extended skills currently practised by ambulance paramedics.

Subjects, methods, and results

In April 1995 we sent questionnaires to the chief executives of the 47 ambulance trusts in the United Kingdom and Channel Islands and followed up by telephone calls. The respondents were asked to identify which of 108 extended skills were currently being taught and which were expected to be taught by the end of 1995.

We obtained a 100% response rate after telephone follow up. The average number of skills adopted by paramedic services was 12 (range 9 to 16) for adults and 8 (3 to 11) for children. The box shows the skills supported by all ambulance services, representing the national minimum standard.

All 47 trusts supported adult orotracheal intubation; 41 services permitted its use in children, but only 35 in children under 7 years. One service claimed not to allow bag and mask ventilation of children. Nebulised salbutamol could be given to adults and children by all services, but only 36 measured peak flow rate first.

All services had adopted defibrillation of adults, and 32 also used it for children. Of these 32, two services did not train paramedics to intubate children and in five paramedics could not give fluids or drugs intravenously.

All 47 regions cannulated adults and 44 children, but the age of child and the size of cannulae available varied. Only two regions trained paramedics to use intraosseous needles, and one supported scalp vein cannulation. For volume replacement in adults one region used crystalloid exclusively, three only colloid, and 43 both.

All paramedics were taught to measure blood pressure and the Glasgow coma scale. Thirty three regions also taught trauma scoring and 40 pulse oximetry. Only nine services trained paramedics to interpret 12 lead electrocardiographs.

The mean number of drugs permitted for use was 10 (7 to 13) in adults and 6 (2 to 10) in children. In addition to the drugs listed in the box the most commonly used were adrenaline 1:1000 for anaphylaxis (29), rectal or intravenous diazepam (40), glycerine trinitrate (43), nalbuphine (31), and naloxone (29).

Obstetric and neonatal skills have recently been added to paramedic training. Only 11 services taught the obstetric module, but 12 more expected to include this by 1996. Ergometrine was used in five services (11 more by 1996). Neonatal resuscitation was taught in 39 services (6 more by 1996). Fifteen services permitted neonatal intubation.


This study confirms the heterogeneity in paramedic services. The skills taught to all paramedics have changed little since the introduction of national training. Some additional skills have been adopted almost universally, while others have gained favour in only a few regions. The greatest inconsistency is in paediatric life support. Cardiac arrest in children is usually secondary to hypoxia or hypovolaemia2 yet some regions teach paediatric defibrillation in preference to airway, ventilatory, and venous access skills. No national standards exist, and we recommend that achieving national uniformity in airway, ventilation, and fluid resuscitation skills should be a priority.

Skills taught to paramedics in all British ambulance services (April 1995)


  • Oropharyngeal airway

  • Orotracheal intubation

  • Bag and mask ventilation

  • Defibrillation

  • Peripheral vein cannulation

  • Adrenaline 1:10 000

  • Atropine

  • Glucagon

  • Lignocaine

  • Nebulised salbutamol


  • Oropharyngeal airway

  • Nebulised salbutamol


  • Glasgow coma scale

  • Blood pressure

Few prehospital skills have been formally evaluated in the United Kingdom in terms of cost and patient outcome, and debate surrounds even basic skills.3 4 Differences between regions could be used to advantage in future studies by providing control groups. The results of such studies could then be used to decide which skills paramedics should be taught. Formal research is needed to evaluate training costs, retention and use of skills, and patient outcome. More urgently, a national authority is needed to coordinate research and implement the results throughout the paramedic service.


  • Funding None.

  • Conflict of interest None.


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