<P> There are many places in Europe, most notably in France, Italy, the German - speaking countries (Germany, Switzerland, Austria), and Spain where the model of EMS is different, and physicians take a more direct,' hands - on' approach to pre-hospital care . In France, Italy, and Spain, response to high - acuity emergency calls is physician - led, as with the French SMUR teams . Paramedics do not exist within those systems, and most ALS is performed by physicians . In the German - speaking countries, paramedics do exist, but special physicians (called Notarzt) respond directly to high - acuity calls, supervising the paramedics ALS procedures directly . In these countries, paramedics may perform many procedures under their "Notfallkompetenz" ("emergency competence"), meaning that they may autonomously perform treatments, such as defibrillation or administering drugs, if there is no physician on scene, and a life - threatening condition is present, otherwise they may only act on the physician's instructions . Some systems - most notably air ambulances in the UK. will employ physicians to take the clinical lead in the ambulance; bringing a full range of additional skills such as use of medications that are beyond the paramedic skill set . The response of physicians to emergency calls is routine in many parts of Europe, but is uncommon in the UK, where physicians are generally tasked to high priority calls on a voluntary basis . Within the UK a sub-speciality of Pre-Hospital Care is being developed for Doctors, which would allow training programs and consultant posts to be developed in this one area of practice . </P> <P> This' hands - on' approach is less common in the United States . While one will occasionally see a physician with an ambulance crew on an emergency call, this is much more likely to be the Medical Director or an associate, inducting newly trained paramedics, or performing routine medical quality assurance . In some jurisdictions adult or pediatric critical care transports sometimes use physicians, but generally only when it appears likely that the patient may require surgical or advanced pharmacologic intervention beyond the skills of an EMT, paramedic or nurse during transport . </P> <P> Physicians are leaders of medical retrieval teams in many western countries, where they may assist with the transport of a critically ill, injured, or special needs patient to a tertiary care hospital, particularly when longer transport times are involved . In these cases the physician's role is extended to ensure the highest level of care is provided throughout the transport and diagnosis of serious medical conditions . </P> <P> Depending on country, area within country, or clinical need, emergency medical services may be provided by one or more different types of organization . This variation may lead to large differences in levels of care and expected scope of practice . </P>

Who are the most highly trained individuals in the ems system