Advanced Practice Paramedic (APP)

Advanced Practice Paramedic (APP)

Occupational Statement

A GEMR certified Advanced Practice Paramedic is physician extender, capable of extensive, advanced patient care interventions in critical and emergent patients. This individual possesses the complex knowledge and advanced interventional skills necessary to provide physician extension to the patient’s side, allowing their physician medical program director (MPD) the ability to have physician level care extended to the scene of any emergency, through the hand, eyes, and ears of the Physician.

Advanced Practice Paramedics are the apex of a comprehensive EMS response, under medical oversight. Advanced Practice Paramedics perform interventions and patient care management with the advanced and diagnostic equipment typically found in an advanced response vehicle, on an advanced practice ALS ambulance, or in an emergency department. The Advanced Practice Paramedic is a tertiary link from the scene into the tertiary health care system, serving as advanced responders, critical care transport providers, aeromedical providers, emergency department providers, hospital rapid response, and atypical care provision.

The Advanced Practice Paramedic functions as part of a comprehensive EMS response, under medical oversight and typically as part of an advanced care EMS system or remote care system.

Advanced Practice Paramedics are also known as Extended Scope of Practice Providers (ESPP), Critical Care Paramedic (CCP), Flight Paramedic (FP), Intensive Care Paramedic (ICP), Assistant Medical Officer (AMO), Mobile Intensive Care Ambulance (MICA) Paramedic, and many other titles in countries around the world.

A GEMR certified Advanced Practice Paramedic (APP) may, under the direction of a Physician Medical Director:

  1. Conduct patient physical examinations.
  2. Obtain patient history.
  3. Obtain and record vital signs.
  4. Utilize noninvasive diagnostic devices in accordance with manufacturer’s recommendation.
  5. Open and maintain an airway by positioning the patient’s head.
  6. Provide external cardiopulmonary resuscitation and obstructed airway care for infants, children, and adults.
  7. Provide immobilization, reduction, manipulation, and temporary splinting care for musculoskeletal injuries.
  8. Complete a clear and accurate patient care report form on all patient contacts.
  9. Administer medical oxygen.
  10. Maintain an open airway through the use of:
    1. A nasopharyngeal airway device.
    2. A non-cuffed oropharyngeal airway device.
    3. A cuffed or uncuffed Supraglottic Airway device.
    4. A single lumen airway device designed for blind insertion into the esophagus providing airway protection where the device prevents gastric contents from entering the trachea space.
    5. Endotracheal intubation, via oral route, nasal route or retrograde technique, with or without the use of sedative and paralytic agents.
    6. Video laryngoscopy or bronchoscopy.
    7. Surgical Cricothyrotomy.
    8. Other airway management techniques as identified by the Medical Program Director
  11. Operate, Utilize, and Manage airway and tracheal/bronchial suctioning devices.
  12. Perform tracheobronchial tube suctioning on the endotracheal intubated patient.
  13. Operate a bag mask ventilation device with/or without reservoir.
  14. Ventilate with a non-invasive positive pressure delivery device.
  15. Initiate, Utilize, Manage mechanical ventilators.
  16. Obtain a capillary blood specimen for blood glucose monitoring.
  17. Initiate, Utilize, Manage peripheral intravenous (IV) lines.
  18. Initiate, Utilize, Manage central venous lines.
  19. Initiate, Utilize, Manage intraosseous needle placement and maintain an intraosseous infusion.
  20. Initiate, Utilize, Manage saline or similar IV locks.
  21. Perform central venous and/or arterial cannulation for Extracorporeal Membrane Oxygenation or Resuscitative Endovascular Balloon Occlusion of the Aorta.
  22. Draw peripheral and central blood specimens.
  23. Draw peripheral or central arterial specimens.
  24. Perform tracheobronchial suctioning of an already intubated patient; and
  25. Perform cardiac defibrillation with a manual defibrillator.
  26. Perform emergency cardioversion.
  27. Perform external transcutaneous pacing.
  28. Perform electrocardiographic interpretation of limb lead ECG, 12 lead ECG, or 24 Lead ECG.
  29. Initiate, Utilize, Maintain needle thoracostomy.
  30. Initiate, Utilize, Manage surgical simple thoracostomy.
  31. Initiate, Utilize, Manage surgical chest tube thoracostomy.
  32. Initiate, manage, and utilize chest drains.
  33. Perform Pulmonary Hilar Twist in circumstances when the patient is in traumatic cardiac arrest and other thoracotomy methods have failed.
  34. Access indwelling catheters and implanted central IV ports for fluid and medication administration.
  35. Initiate, manage, and utilize an orogastric or nasogastric tube.
  36. Initiate, manage, or utilize all forms of vascular access.
  37. With ultrasound guidance, place central vascular access or deep vein cannulation.
  38. With ultrasound guidance, perform needle pericardiocentesis.
  39. With ultrasound guidance, perform Resuscitative Endovascular Balloon Occlusion of the Aorta.
  40. Perform normal and high-risk childbirth.
  41. Perform bimanual massage in life threatening postpartum hemorrhage.
  42. Perform ultrasound guided nerve block.
  43. Perform needle or surgical incision and drainage of fluid filled oral or subcutaneous masses.
  44. Initiate placement of, and maintain, a urinary catheter.
  45. Initiate, Utilize, Manage moderate and deep sedation of a patient for orthopedic, airway, respiratory, cardiac, and emergency surgical procedures outside the operative environment.
  46. Prepare, initiate, and/or administer any medications or blood products by any means, under specific written protocols authorized by the Medical Director, or direct orders from a licensed transferring physician.
  47. Prepare, initiate, perform, and/or interpret any diagnostic test or utilize any diagnostic device under specific written guidelines authorized by the Medical Director, or direct orders from a licensed transferring physician.
  48. May carry out other tasks and procedures as authorized by the Medical Director or direct orders from a licensed transferring physician.
  49. Prepare and administer routine or emergency immunizations and tuberculosis skin testing, as part of an EMS Agency’s occupational health program, to the EMS agency personnel, under the Medical Director’s standing order.
  50. Prepare and initiate or administer any medications under specific written protocols or guidelines authorized by the Medical Director, or direct orders from a licensed transferring physician.
  51. Be unrestricted as to the environment of practice or function, may serve as a physician extender for an authorized Physician Medical Director in EMS, aeromedical, rescue, hospital emergency departments, anesthesia departments, and hospital critical care areas.

The Global Emergency Medical Registry (GEMR) is honored to serve this healthcare workforce with an international standard certification following education, competency evaluation, and testing.

The GEMR Advanced Practice Paramedic Certification is designed to provide industry, governments, regulators, and administrations with a third-party certification for this level of healthcare provider around the globe which is referenceable and can be checked via the gemr.org “Verify Certification or Endorsement” box on the GEMR Home Page.

Click here for the PDF of the 2025 APP Educational Objectives

Responsibilities of Registry Certified Personnel:

Certified personnel must notify the Registry within 30 days regarding the following matters:

  1. Change in mailing address (the best way to update a mailing address is by editing your account profile)
  2. Any criminal conviction.
  3. Disciplinary action taken by any agency having jurisdiction (or government body) that has resulted in suspension, revocation, or expiration of registration/licensure; termination of right to practice; voluntary surrender of registration/licensure while under investigation.

The Registry considers the individual to be solely responsible for their certification and reporting, any failure to follow process or report as required is solely the failure of the certified person and may result in immediate dismissal of their certification, as well as, immediate notification to any pertinent regulatory agency of their dismissal.

Disciplinary Policy and Rights of Appeal for The Registry can be found on The Registry website.

GEMR Required Skills Attestation for Initial Certification:

Educational Program Prerequisites:

Upon completion of a program of education, the candidate will:

  1. Be a minimum of 21 years old.
  2. Be prepared for and eligible to take the GEMR Written Examination and skills process to obtain certification from The Global Emergency Medical Registry (GEMR).
  3. Be prepared to upload all Advanced Practice Paramedic skills sheets with physician or instructor signature, indicating compliance to the standard during examination of that skill.
  4. Have completed an Advanced Practice Paramedic curriculum that meets or exceeds the objectives and components of the Global Emergency Medical Registry (GEMR) guidelines, and the program provides attestation of meeting the objectives and requirements outlined for the certification level and be prepared to upload all educational records to GEMR.
  5. Hold a current GEMR (or equivalent) Paramedic certification or government license, General or Registered Nurse License (with all paramedic scope skills included in education and documented skills log per the Global Emergency Medical Registry Paramedic certification), Physician’s Assistant license, or Physician licensed at the General Practice Physician level may attend the Advanced Practice Paramedic program.
  6. Hold a current Healthcare Provider level CPR certification, which meets all International Liaison Committee on Resuscitation (ILCOR) standards and upload the certification to GEMR.
  7. Hold a current Advanced Cardiac Life Support certification, which meets all International Liaison Committee on Resuscitation (ILCOR) standards and upload the certification to GEMR.
  8. Hold a current Pediatric Advanced Life Support certification, which meets all International Liaison Committee on Resuscitation (ILCOR) standards and upload the certification to GEMR.

Educational Program Expectations:

Educational programs, to meet the GEMR Advanced Practice Paramedic objectives, must have a minimum of 800 hours of training in the following sections during the educational program the candidate attended:

Didactic 300 hours
Practical/Skills: 300 hours under the supervision of an Advanced Practice Paramedic instructor with a minimum of the following skills performed and logged in their student skills log (minimum of skill, date, time, patient type, instructor, and instructor signature):
10 hours Supraglottic Airway Placements with Bag/valve ventilation with EtCO2 per GEMR skills documentation form.
25 hours Endotracheal Intubations utilizing a systematic approach to intubation per GEMR skills documentation form.
25 hours Successful Central Venous Access placements.
10 hours Successful Intravenous access placements (16g or 14g IV catheter) with IV line or saline lock placed on a live human patient (may be a fellow student) per GEMR skills documentation form.
20 hours Successful cardiac arrest simulations at the Advanced Life Support Level per GEMR skills documentation form.
20 hours Successful defibrillations per GEMR skills documentation form in a cardiac arrest simulation.
10 hours Successful synchronized cardioversion per GEMR skills documentation form in a tachycardia simulation.
10 hours Successful transcutaneous pacing per GEMR skills documentation form in a bradycardia simulation.
10 hours Surgical cricothyrotomy on an appropriate manikin or simulator per the GEMR skills documentation form.
100 hours Medication administrations per the GEMR skills documentation forms during simulation.
20 hours Successful trauma simulations at the Advanced Life Support Level per GEMR skills documentation form.
20 hours Successful chest tube thoracotomy.
5 hours Successfully perform Pulmonary Hilar Twist with resuscitative thoracotomy on appropriate manikin system (i.e.: https://pmc.ncbi.nlm.nih.gov/articles/PMC10656785/).
5 hours Successfully perform abnormal delivery and obstetrical emergency skills using an appropriate manikin system (i.e., NOELLE®).
10 hours Successfully performed and interpreted Rapid Ultrasound in Shock (RUSH) exams on a live human medical model.
10 hours Successfully performed and interpreted Bedside Lung Ultrasound Exam (BLUE) exams on a live human medical model.
10 hours Successfully performed and interpreted Focus cardiac ultrasound (FoCUS) exams on a live human medical model.
Clinical Internship: 200 hours under the supervision of an Advanced Practice Paramedic Field Training Officer (or GEMR Resuscitation Officer) and/or Physician in a prehospital and/or clinical setting, with daily observation reports done at the end of each workday; if prehospital, all hours must be on an emergency medical services advanced life support (ALS) or critical care ambulance. The hours must include a minimum of 50 documented advanced life support patient contacts in which the Advanced Practice Paramedic candidate provided care within the Advanced Practice Paramedic scope.

Note: this clinical internship must be in addition to the candidate’s 600 hour Paramedic internship.

GEMR Required Skills Attestation for Initial Certification:

All initial Certification Candidates must upload the following skills sheet documentation forms (located at https://www.gemr.org/library/), signed by the medical director or Course Director, to their transcript page of their profile by creating a “Skills Documentation” course in their transcript and uploading all the following:

  1. Bag Valve Mask Ventilation
  2. Bleeding Control (BLS)
  3. Bleeding Control Combat Application Tourniquet
  4. Blood Glucose Assessment
  5. Bradycardia (Block)
  6. Bradycardia (Sinus Brady)
  7. Cardiac Arrest Ventricular Fibrillation (ALS)
  8. Cardiac Arrest Pulseless Electrical Activity (ALS)
  9. Cardiac STEMI (ALS)
  10. Cardiac Tachyarrhythmia stable (ALS)
  11. Cardiac Tachyarrhythmia unstable (ALS)
  12. Continuous Positive Airway Pressure (CPAP)
  13. Cricothyrotomy (Percutaneous Cricothyrotomy and Transtracheal Jet Insufflation)
  14. Cricothyrotomy (Surgical with Scissor/Tracheal Tube Inducer)
  15. Defibrillation (manual)
  16. ECG Limb and 12 Lead Acquisition
  17. Emergency Blood Transfusion
  18. Endotracheal Intubation in Cardiac Arrest
  19. Endotracheal Intubation with Medication
  20. Hand Washing
  21. Intravenous Access
  22. Intravenous Access Femoral Cannulation for Extracorporeal Membrane Oxygenation
  23. Medication by Auto Injector
  24. Medication by Intramuscular and Subcutaneous Injection Routes
  25. Medication by Intranasal Route
  26. Medication by Intravenous Route
  27. Medication by Nebulization Route
  28. Medication by Oral Chewable Route
  29. Medication by Oral Gel Route
  30. Medication by Oral Route
  31. Medication by Rectal Route
  32. Nasal Pharyngeal Airway
  33. Obstetrics - Abnormal Delivery Prolapsed Cord
  34. Obstetrics - Abnormal Delivery Post-Partum Hemorrhage
  35. Obstetrics - Abnormal Delivery with Newborn Care
  36. Oral Pharyngeal Airway
  37. PPE Donning and Removing Gloves and Gown
  38. Physical Exam (Adult)
  39. Physical Exam (Pediatric)
  40. Quantitative Waveform Capnography
  41. Shock Case (Hemorrhagic)
  42. Shock Case (Septic)
  43. Spinal Immobilization ALS Case (IMMO Protocol for Spinal Injury #1)
  44. Supraglottic Airway Respiratory Arrest
  45. Sync-cardioversion
  46. Transcutaneous Pacing
  47. Thoracotomy - Simple
  48. Trauma – Extremity trauma with hypotension
  49. Trauma – Polytrauma with hypotension and hypoxia
  50. Trauma – Traumatic Brain Injury

GEMR Written Examination:

At the conclusion of initial training, the candidate must complete their profile on gemr.org, upload all skills sheets, CPR certification, certificate or diploma, and highest level of education completion certificate to their skills and transcript area of their profile.

The candidate will then receive an invitation to test for the GEMR Online Testing System, the candidate must score a minimum of 85% to show compliance with the standard and successfully complete the examination process.

Initial Certification Completion:

Once all the above steps have been completed, and the candidate has been audited and completed the GEMR Exam with a score of 85% or greater, the candidate will be able to complete their registration payment and receive their certification.

Advanced Practice Paramedic (APP) - Renewal Certification:

The GEMR Certification expires two years from the time of initial certification. During that two-year period, the certified individual must complete the following process to renew their certification.

GEMR Required Continuing Medical Education:

The certified individual must complete, document, and upload to their GEMR profile transcript the following continuing medical education (CME), prior to the end of their certification period. All CME must be from an accredited organization and the CME certificate must include the topic, the number of hours, the date, the instructor or course director, the name of the organization and contact information, as well as the CME certificate must bear the accreditation logo(s) and accreditation number for the educational program. A maximum of fifty percent (50%) of the CME may be done online.

The following 72 hours are the required CME for Advanced Practice Paramedic Renewal:

1 hour Current Healthcare Professional CPR certification, including in person instructor led skills portion to ILCOR standards.
1 hour Current Advanced Cardiac Life Support certification, including in person instructor led skills portion to ILCOR standards.
1 hour Current Pediatric Advanced Life Support certification, including in person instructor led skills portion to ILCOR standards.
7 hours Airway, ventilation, capnography, and oxygenation.
7 hours Cardiovascular (Cardiac arrest, post cardiac arrest, ventricular assist devices, cerebrovascular accident, congestive heart failure, acute coronary syndromes).
7 hours Trauma (Trauma triage, hemorrhage, central nervous system, special needs, fluid resuscitation, blood administration, trauma assessment, chest trauma, orthopedic trauma).
7 hours Pediatrics (pediatric cardiac arrest, pediatric respiratory failure, pediatric shock, pediatric toxins, pediatric considerations)
8 hours Medical (Special healthcare needs, OB emergencies, Infectious disease, Pharmacology, Medication delivery, Pain management, Psychiatric and behavioral emergencies, Toxicological emergencies, Neurological emergencies, Endocrine emergencies, Immunological emergencies)
6 hours Operations (At risk populations, ambulance safety, casualty incidents, EMS safety, EMS hygiene, Vaccines, Culture of safety)
15 hours Medical Director required topical training
15 hours Independent study (must relate directly to patient care)

GEMR Required Skills Attestation:

The GEMR Certified Advanced Practice Paramedic must complete their skills documentation on their profile page, and those skills must be attested to by a medical director or designee through their own GEMR profile, all the following skills competencies are required for renewal:

  1. Bradycardia (Block)
  2. Cardiac Arrest Ventricular Fibrillation (ALS)
  3. Cardiac Arrest Pulseless Electrical Activity (ALS)
  4. Cardiac STEMI (ALS)
  5. Cardiac Tachyarrhythmia unstable (ALS)
  6. Continuous Positive Airway Pressure (CPAP)
  7. Cricothyrotomy (Surgical with Scissor/Tracheal Tube Inducer)
  8. Defibrillation (manual)
  9. Emergency Blood Transfusion
  10. Endotracheal Intubation in Cardiac Arrest
  11. Endotracheal Intubation with Medication
  12. Obstetrics - Abnormal Delivery Prolapsed Cord
  13. Obstetrics - Abnormal Delivery Post-Partum Hemorrhage
  14. Shock Case (Hemorrhagic)
  15. Shock Case (Septic)
  16. Supraglottic Airway Respiratory Arrest
  17. Sync-cardioversion
  18. Thoracotomy - Simple
  19. Transcutaneous Pacing
  20. Trauma – Extremity trauma with hypotension
  21. Trauma – Polytrauma with hypotension and hypoxia
  22. Trauma – Traumatic Brain Injury

GEMR Written Examination:

No written exam is required for renewal certification

Renewal Certification Completion:

Once all the above steps have been completed, and the candidate has been audited, the candidate will be able to complete their registration payment and receive their certification.

Reciprocity:

A person with one, or more, of the following, may apply for GEMR Advanced Practice Paramedic certification through reciprocity:

  1. The candidate who holds a current certification with the National Registry of Emergency Medical Technicians (NREMT), at this level or higher, may apply for reciprocity at this level, if their initial or CME training meets the scope of practice listed above.
  2. The candidate who holds a current license with a Province of Canada, at the Advanced Care Advanced Practice Paramedic level or higher, may apply for reciprocity at this level, if their initial or CME training meets the scope of practice listed above.
  3. The candidate who holds a current license with a Freely Associated State of the United States, at this level or higher, may apply for reciprocity at this level, if their initial or CME training meets the scope of practice listed above.
  4. The candidate who holds a current license with a State in the United States, at this level or higher, may apply for reciprocity at this level, if their initial or CME training meets the scope of practice listed above.
  5. The candidate who holds a current registration with the Advanced Practice Paramedicine Board of Australia (PBA) at the MICA level or higher, may apply for reciprocity at this level, if their initial or CME training meets the scope of practice listed above.
  6. The candidate who holds a current certification with the Pre-Hospital Emergency Care Council (PHECC), at the Advanced Practice Paramedic level or higher, may apply for reciprocity at this level, if their documented training meets the scope of practice listed above.
  7. The candidate who holds a current certification with the Health & Care Professionals Council (HCPC), at this level or higher, may apply for reciprocity at this level, if their documented training meets the scope of practice listed above.
  8. The candidate who holds a current certification with the Health Professions Council of South Africa (HPCSA), at this level or higher, may apply for reciprocity at this level, if their documented training meets the scope of practice listed above.
  9. The candidate who holds a current position with the National Fire Agency of Korea (NFA) and has completed the national examination process, at this level or higher, may apply for reciprocity at this level, if their documented training meets the scope of practice listed above.
  10. The candidate who holds a federal or state qualification in Germany (Rettungssanitäter, Notfallsanitäter/Notfallsanitäterin), at this level or higher, may apply for reciprocity at this level, if their documented training meets the scope of practice listed above.

In addition to the above, the candidate must show they have met all requirements for Certification Renewal at the time of application; if they are unable to do so, they must follow the initial application for certification process.