Qualitative evaluation of ambulance paramedic staff’s medication practices and awareness in cardiovascular emergency care

Abstract

Background

Ambulance paramedics are essential in the early management of cardiovascular emergencies, where timely and accurate medication administration can significantly influence patient outcomes. Despite their frontline role, limited research has explored paramedics’ medication practices and awareness in these high-pressure, prehospital settings. This study investigates the lived experiences and decision-making processes of paramedic staff in the UAE to identify challenges and opportunities for improving practice.

Methods

A qualitative research design was employed using semi-structured, open-ended interviews with paramedics of varying scopes of practice across multiple ambulance coverage points in the UAE. Purposive sampling was used to recruit participants during their duty shifts, partly adopting convenience sampling. Interviews were audio-recorded using smartphone applications, and thematic analysis was conducted using ATLAS.ti Version 24.1.1. Of the fifteen paramedics interviewed, six met the inclusion criteria and were included in the final analysis.

Results

Data saturation was achieved with six participants, yielding 265 unique quotations and 25 recurring codes. Six core themes emerged and were grouped into two categories: Challenges in Cardiovascular Medication Use (Highly Demanding, High-Stake – High-Risk Medication, Tight Scope of Practice) and Strengths and Opportunities for Improvement in Practice (Value-Laden, Medicines Stewardship, Enhanced Scope of Practice). These themes formed a conceptual framework—the “Value-based Care Ladder”—illustrating a progressive path for improving paramedic medication practice.

Conclusion

The findings underscore the need for continuous education, hands-on training, and expanded clinical exposure to emergency medications, alongside the development of interpersonal and ethical competencies. These efforts are vital for cultivating a confident, competent, and well-prepared paramedical workforce in prehospital cardiovascular care.

Introduction

Paramedic practice is guided by defined scopes, clinical guidelines, and regulatory frameworks to ensure safe pharmacological interventions in dynamic environments. Recognized as a health profession with a broad scope, paramedics may operate under medical direction or independently, depending on regulatory authorities [1–3]. Often first-line responders, paramedics are increasingly expected to assess, diagnose, prescribe, and treat patients independently in prehospital settings. However, it remains uncertain whether their education, training, and experience adequately prepare them for such critical decision-making. A retrospective study in northeastern U.S. reviewed 183 cases of Adenosine use for stable supraventricular tachycardia (SVT) from 2019 to 2021, showing 87% conversion success but highlighting diagnostic variability and the need for improved training [4].

Critical judgment is essential in prehospital medication practice, where decisions must be made rapidly with limited patient history. Effective clinical judgment relies on evidence-based prescribing, experience, medication knowledge, accountability, and patient-centered care—pillars emphasized in clinical practice guidelines worldwide [5, 6]. Prehospital medications are chosen for rapid onset and life-saving potential, especially cardiovascular drugs like diuretics (Furosemide), beta blockers (Labetalol), antiarrhythmics (Amiodarone, Adenosine), antiplatelets (Aspirin), and vasodilators (Nitroglycerin). High-alert medications such as Morphine, Magnesium Sulfate 50%, Insulin, and Glucose 50% are also used, alongside other classes including Acetaminophen, Ipratropium, Diclofenac Sodium, Glucocorticoids, Metoclopramide, Tranexamic Acid, and Methoxyflurane [7–10].

Prehospital emergency cases often involve varying degrees of cardiovascular impact, directly or indirectly affecting the heart and vessels [11]. High-alert and cardiovascular medications carry risks of worsening clinical cases, prolonged hospital stays, or fatalities when handled with inadequate training. A narrative review of 75 studies, including 7 systematic reviews and 3 meta-analyses, showed cardiovascular drugs account for ~ 20% of medication-related harm, increasing by 50% in older adults due to poor monitoring and system failures [12].

Medications not primarily intended for cardiovascular use, such as Epinephrine for anaphylaxis, can still affect the cardiovascular system. Epinephrine interacts with alpha and beta blockers, and refractory hypotension may require glucagon to restore cardiac function. These complexities highlight the burden paramedics face when managing emergency medications beyond their core training [13–16]. Parenteral routes are often used for rapid therapeutic effect. A Saudi Arabian study (August 2023) found 28.7% of critically ill patients had prehospital IV access, with 50% utilization, mostly for fluids. However, 73.1% of IV lines were replaced upon hospital arrival due to protocol, revealing EMS-hospital inefficiencies [17]. Similarly, an Israeli study (1997–2013) reported an 82% IV access success rate, with higher mortality in patients without successful access, recommending a two-attempt limit to reduce delays [18].

Australian paramedic’s experience showed that they have faced intensified stress during the COVID‑19 pandemic, highlighting the need for organizations to review internal practices and provide appropriate mental‑health support [19]. A Finnish study (2023) showed 70% diagnostic agreement between paramedics and physicians, with higher accuracy linked to bachelor-level education and self-assessment, especially in mental illness and stroke cases [20]. Despite their critical role, paramedics remain under-researched, with studies often isolated and lacking continuity. A 2023 narrative review identified barriers in prehospital research and proposed solutions like EMS-hospital collaboration, mobile health integration, simulation training, and increased funding [21].

As per our understanding, no studies have specifically explored the medication practices and awareness of ambulance paramedic staff in cardiovascular emergency care, despite its clinical significance and complexity in prehospital settings. This study aimed to address that gap by using open-ended, semi-structured interviews to evaluate paramedics’ medication practices and uncover their knowledge and experience in managing cardiovascular emergencies. Given the unpredictable nature of prehospital environments and the challenges in consistent monitoring, understanding real-world practices is essential for improving ambulance services. The research sought to answer: How do ambulance paramedic staff in the United Arab Emirates (UAE) practice cardiovascular emergency care with underlying medication awareness? and What recommendations can enhance their awareness and practice?

Methods

Study design

This study employed a phenomenology qualitative research design using semi-structured, open-ended interview questions to explore paramedics’ medication practices and awareness in cardiovascular emergency care. Thematic analysis was applied to identify key themes and examine their interconnections, thereby deepening the understanding of emergency medicine practices among paramedical staff in the UAE. As an exploratory investigation, the study aimed to generate novel insights that could inform future policy development and professional practice improvements.

Study setting

Interviews were conducted at various ambulance stations located across multiple sectors of the UAE. These sectors were purposefully selected to ensure diverse representation, although specific locations remain undisclosed to maintain confidentiality. Most interviews took place within the buildings or offices of the ambulance stations, providing a familiar and accessible environment for participants. One interview was conducted at the headquarters office of a healthcare sector, based on participant availability and logistical considerations.

Participant selection

Paramedics were interviewed from an initial pool of fifteen screened candidates until to achieve thematic saturation. Although fifteen interviews were conducted, only six were included in the final analysis because saturation was achieved after the sixth interview. The remaining interviews were retained for confirmatory purposes but were excluded from coding, as they did not contribute additional concepts or variations relevant to the study aims. Saturation was assessed through repetition of codes across successive transcripts and the absence of new categories or insights after Interview 6, indicating that further coding would not meaningfully expand the analytic framework. Participants were selected through purposive sampling, based on their availability at designated coverage sites (convenience), willingness to participate, and compliance with predefined inclusion and exclusion criteria. Inclusion criteria required participants to be licensed paramedics actively working in the UAE during the study period, with a minimum of one year of experience in prehospital emergency care. All scopes of paramedical practice operating below the designation of emergency physicians were considered eligible.

Exclusion criteria included paramedics with less than one year of experience, emergency physicians working in prehospital settings, due to their advanced clinical training which could skew the findings. To ensure fresh perspectives, any paramedic who discussed the interview process with peers who had already been interviewed was excluded from participation. Additionally, any interviews lacking formal consent or involving participants who withdrew were excluded from the final analysis.

Data collection tools and procedure

Participants were not informed of the interview questions in advance. Both the ambulance coverage points and the participants were purposefully selected to support the study’s objectives. Site visits were conducted between March and July 2025, on various days and at different times. All paramedics were interviewed while on duty, except for one advanced paramedic who, due to scheduling constraints, was interviewed by appointment at a healthcare sector headquarters. Although this participant was aware of the general research topic, he like all others had no prior knowledge of the specific interview questions. Any interview that were short or interrupted were set aside in the pool of interviews without necessary coding.

Employers of all participants were fully informed about the research and provided written consent via email for their staff to participate. Interviews were conducted at selected ambulance points across the UAE during active duty shifts, with the exception of the advanced paramedic, who was interviewed off duty. Interviews concluded either upon the arrival of dispatch calls or the natural end of the conversation. To ensure participant comfort and expressiveness, interviews were conducted in either Arabic or English, depending on the participant’s preference.

To minimise potential bias arising from the researcher’s professional role, several safeguards were implemented. The researcher had no supervisory or reporting relationships with the participating paramedics, which reduced the likelihood of perceived authority or role‑based influence. All interviews were conducted confidentially, and participants were assured that their responses would not be shared with unit leadership or linked to their identities, helping to promote open and candid accounts. The researcher’s position as a clinical pharmacist, rather than a paramedic, also created professional distance, limiting the risk of insider bias while still enabling contextual understanding. Reflexive practices, including ongoing documentation of assumptions and decision‑making were used to further mitigate role‑related bias, power dynamics, and interpretive preconceptions throughout data collection and analysis.

All interviews were audio-recorded using smartphone applications (Voice Recorder & Voice Memos), with the full awareness and consent of all fifteen participants. The semi-structured, open-ended interview format encouraged interactive and expressive dialogue. The questions were initially drafted by the researcher, who has over ten years of experience in outpatient pharmacy, one year in ambulance service pharmacy, and specialization in cardiology clinical pharmacy. These questions were then reviewed and validated by the research supervisor, a clinical pharmacy and drug information expert with over 20 years of experience and specialization in kidney pharmacotherapy. The researcher also served as the sole interviewer.

English-language interviews were manually transcribed by the researcher into Microsoft Word documents. Because some interviews were conducted Arabic, several steps were taken to ensure linguistic accuracy and conceptual equivalence. All Arabic transcripts were first translated into English by the researcher and then subjected to an independent review by a bilingual expert to verify meaning. Any discrepancies were discussed and resolved through consultation with the bilingual expert familiar with the clinical and paramedic context, ensuring that technical terminology and culturally embedded expressions were preserved. Even the participants interviewed in Arabic knew local English usage. Arabic was used only for convenience. Back-translation did not seem necessary as participants agreed with summary of the findings in English. Transcriptions were done verbatim; however, minor grammatical adjustments were made to address accent-related issues and occasional inaudibility. Some words were omitted when recordings were unclear. The Microsoft Word voice dictation tool was not used, as it could not accurately capture the spoken content or construct coherent sentences, particularly when multiple voices overlapped or were distant from the recording device.

To strengthen rigor and trustworthiness, additional steps were taken to ensure transparency in the analytic process. Coding decisions were guided by an iterative, reflexive approach in which the researcher documented analytic choices and compared emerging patterns across transcripts to maintain consistency in interpretation. Preliminary codes and candidate themes were reviewed in consultation with the research supervisor to support analytic validation and reduce the influence of individual bias. Thematic analysis was conducted using ATLAS.ti Version 24.1.1, a widely used software for qualitative data analysis.

Ethical considerations

All participants provided informed consent and voluntarily participated in the interviews of their own free will while they were on duty. To maintain confidentiality, participants were anonymized and referred to by numerical identifiers. No identifying details regarding participants, their employers, or workplaces were disclosed at any stage of the study. Employers of all participants were fully informed about the research and confirmed their agreement via written email correspondence. Prior to each interview, participants were made aware of the audio recording process and provided explicit consent. They were also informed that their employers had approved the research and that they retained the right to withdraw from the study at any time without consequence. Although employers were informed to facilitate access, voluntary participation was safeguarded by ensuring that all recruitment and communication occurred solely through the researcher, with no disclosure of participant identities to employers and clear assurances that involvement was optional, confidential, and unrelated to job performance. Institutional review board approval details are provided in the declaration.

Results

Demographic and professional background

Participants varied in demographics; two of the six paramedics were female, two were Emiratis, two were Egyptians, one was Filipino, and one was Indian. Three hold bachelor’s in nursing, one bachelor’s in emergency and trauma care technology, one bachelor’s in emergency medical services, and the last one holds a diploma in advanced emergency medical technology. Table 1 provides more information.

Table 1.

Participants’ characteristics

Participant Code	Gender	Years of Experience	Scopes of practice
P1	Male	2	Advanced Emergency Technician
P2	Female	Unmentioned	Emergency Technician
P3	Male	8	Emergency Technician
P4	Male	16	Emergency Technician
P5	Female	4	Specialized paramedic
P6	Male	22	Advanced paramedic

Frequency of key concepts

Totalizing all documents, (medication) was the top-most appeared conceptual word; 258 times, followed by (patient) 186 times, (effect) 115 times, (case) 105 times. Figure 1 shows the most repeated words. A total of 265 unique quotations were coded, with 25 codes repeated multiple times across different segments of the data. From these codes, six core themes were identified and grouped into two main categories, they are categorized in Table 2.

Fig. 1.

Most repeated words

Table 2.

Main themes categorized to challenges and strengths

Group 1: Challenges in Medication Use	Group 2: Strengths and Opportunities for Improvement
Highly Demanding	Value-Laden
High Stake – High Risk Medication	Medicines Steward
Tight Scope of Practice	Enhanced Scope of Practice

Six major themes emerged from the research: three challenges and three strengths or opportunities related to medication use by the paramedics studied. The challenges were a Highly Demanding job, High-Stake – High-Risk Medications, and a Tight Scope of Practice. The positives were Value-Laden line of work, Working as Medicines Steward, and the need for an Enhanced Scope of Practice.

These themes were found to be interconnected in a progressive sequence, forming a “Value-based Care Ladder,” an illustration of the path ambulance staff can follow to improve their perception and clinical decision-making regarding medication use in prehospital settings. Figure 2. A Sankey diagram was additionally used to visualize the co-occurrence of themes and show the strength of connections between the Challenges in Cardiovascular Medication Use theme and Strengths and Opportunities for Improvement in Practice themes, Fig. 3. The analysis of theme co-occurrence- how often themes appeared together within the same quotations across the coded data- shows significant relationships between Challenges in Cardiovascular Medication Use and Strengths and Opportunities for Improvement in Practice themes.

Fig. 2.

Value-based care ladder for development of paramedic staff

Fig. 3.

Sankey diagram of themes in the value-based care ladder

These results show a frequent overlap between the two main themes and subsequently the six core codes, which suggest that participants often expressed moral aspects, clinical judgment, and responsibility in handling cardiovascular medications as much as they are also concerned about the nature of the duty stress, risks of administering cardiovascular medications, and limitations in their scopes of practice. These patterns highlight how vital and heavy paramedics’ duties and responsibilities may be, which can affect their clinical judgments, desires for continuous education, and the enhancement of the scope of practice.

The frequency with which the theme-based code was applied for each theme among the six participants. Participant P3 made the highest individual contribution (Gr = 143), particularly excelling in High-Stakes Medication and Value-laden themes, which may be attributed to a more thorough and extended conversation, expanded clinical experience, and/or individual personality variation. In contrast, P6 showed a balanced distribution, with a clear pinpoint on Enhanced Scope of Practice and High-Risk Medication. Interestingly, Value-laden themes were more concentrated among P3, P4, and P6, while Tight Scope of Practice appeared heavily in P2 (Gr = 33) and P5 (Gr = 21), indicating differences in years of professional and personal experiences, confidence among staff in handling high-stake medications and medical cases, and limitations in the scopes of practice.

These data suggest that, while all themes are clearly present across the sample, certain participants strongly emphasized specific themes, highlighting the need for tailored training and continuous education for each professional paramedic, as well as enhancements in the scope of practice and clinical practice guidelines.

Sample quotations categorized by theme

Selected Quotations from each participant which are referred to as [P] and numbered from 1 to 6; are provided below under their matching emerged themes.

Highly demanding

Depending on the type and case I have on me, is the patient hypotensive where I must administer more fluids, or did he lose lots of blood where I need to give more fluids, so the blood pressure would build up this would be my main priority. [P3]

I have seen a patient last winter on the water canal, so his brother dived into the water canal and he jumped after him to rescue him, however; his brother died …but we have rescued him …and you are correct he was bradycardic with low SPO2 and we have managed him with fluids, warming up with a blanket and we did transfer him to the hospital. [P5]

As paramedics we need to treat the patient, return dispatch calls, there is also patient’s family stress, so it is everything that stresses us out. [P5]

Value-laden

When we get any cardiac cases, it will be a priority, high priority, so they will activate us; like an EMT advanced or paramedics. [P1]

Honestly speaking, sometimes, most of us here are relying on telemedicine even though our hearts say give if. I cannot blame them…because of what experience they have, but for me as long as the patients’ life is on the line, for me, I am giving them. [P4]

No, patient’s life is a huge responsibility and is not an option for me. I can use it under my scope of practice, but if I do have doubts, I would call the telemedicine. [P5]

I give any IV medication, my way of doing it is, I always dilute all medications, specifically when it comes to narcotics all the medications will be diluted, morphine will have 10 mg in 1 ml.so I used to dilute in 9 ml in normal saline, to make it a 10 ml, so diluted, so 1 ml contain 0.1 mg, which will be easier also, because if I have a lesser age group; like; pediatrics and I want to give low dose I dilute it will be much easier to administer… [P6]

High stake – high risk medication

I feel that the IV is faster in the effect, some medications if given IV, for example, I have seen previously a case who was administered a potassium and the patients died in a second, so it is dependent on the medication and the time I do attend the patient, give the antidote or not. [P2]

I cannot give it as a push, and if it should be given in a specific rate for example; should be given in 2 to 3 h, it is not possible to administer it in a 15 min period, and if it should be given in 15 min it isn’t possible to be given in one shot…because the adverse effect will be extreme, especially in “high risk medications” that could cause sudden cardiac arrest, by which I may have killed my patient, like the potassium for instant. [P3]

I have one female patient before when I asked if she has allergies, she answered no, when she reached the hospital, she mentioned allergies from this and that, and I thanked God I did not administer any. [P5]

Whichever patient fall under the severe pain category; they are eligible to receive morphine …but, sometimes I am used to giving it, especially for trauma patients but, I reduce the use of morphine because you know morphine has side effects of nausea, so sometimes the patient vomits …it can happen, so I alternate to pethidine for those patients whom I immobilize on spine board, because if they feel nauseated and want to vomit it will be … [P6]

Medicines steward

Ok first to lower the BP, or these patients, especially in the emergency, you cannot lower it, first within first 12 h should be lowered to 25% and then to 50% I think… [P1]

If taken in the therapeutic dose, I do not think it would affect, unless the patient has a contraindication to the use; if he has a cardiac problem, and the medication to be taken has a side effect of cardiovascular of some sort, of course this medication would be contraindicated to this patient. [P3]

Everything in case of obesity is different than normal weight people, as the kg is high and the amount that the drug would have an effect on is higher as well, so the dose should be calculated for sure. [P3]

For me to be honest, whenever we give medicine, we bring the patient to the hospital, we are not giving any medicine like ok, you are in pain, khalas (Arabic), you are not going to hospital any more when we give you medicine, to be honest we are giving medicine …in spite of that we are bringing the patient to the hospital, so any adverse or side effect, may encounter, now he is in the hospital, you can see much bigger picture, unlike us it is only, basic that we are seeing, for example furosemide, especially with patient with pulmonary edema, we cannot check the levels of electrolytes…[P4]

We have the clinical practice guidelines, and according to that we have a matrix so depending on the scope of practice they have list of the medications for advance paramedics all the drug available are allowed for us to be used by advanced paramedics, except the narcotics because when it comes to narcotics like morphine and pethidine …and also those medications, we can use, but under the guidance of emergency physicians …so where we have 24/7 telemedicine operating, so when we have a case narcotic that needs to be administered, for example I have acute chest pain, where the pain is very severe, I want to use morphine for this patient, so I call telemedicine, and provide them with details about the patient and what I need to give and the dosage, and then the doctor will us an approval whether I can go ahead to administer and what, how much dosage, and how I need to give, based on that, we will be administering. [P6]

Tight scope of practice

Actually clopidogrel; I did not have chance to use it. I did not have a chance with any patient that is having allergy from aspirin, so I can use the clopidogrel on them, or the overall scenes’ situation did not help me so that is why I did not have a chance …some of them got the chance of course, but for me I did not get the chance, from the SVT case, all the SVT cases that I got, I did not have the chance also to use Adenosine on them, because all of them reverted from the Valsalva maneuver, or the Carotid massage, so all of them reverted so I did not have a chance to use Adenosine. [P1]

I did not encounter such cases. Metoclopramide, ummm what I do not remember, I have not seen side effects on my cases, I do not remember giving it and seeing a clear side effect on any, I do not remember, honestly, I might have seen some, but I do not remember right now, and I cannot remember a case where the side effects were very clear on them. [P2]

Well, all these things are things that I know but, for example, the electrolyte imbalance is a subject that I do not read and revise regularly, so I feel like I have forgotten it. [P2]

At three different instances, the respondent expressed: I do not remember this. I need to revise all this information. [P2]

Here, the scope of practice is limited, for example, the adrenaline is essential, sometimes if there is an emergency physician during the shift or if we ask for help from the telemedicine, we could use amiodarone and other medications that are used in cardiac arrest. But the main medication which previously was out of our scope as EMT but then they included it in our scope and helped us a lot is the adrenaline, limitation to the use of cardiovascular medication in the scope of practice limits the ability to practice cardiovascular medications, adrenaline is recently introduced to the scope of practice of EMT, amiodaron and some other medications that are out of the scope, can be used with telemedicine permission. [P3]

As of now, our scope of practice restricts us, so we cannot remember many things as we do not use them regularly. Furosemide sure, but we do not use them at all, I have been practicing here for 7, 8 years I have not broken a single ampule…[P3]

Never gotten a case, and even if any case was there, a physician call would be activated, I cannot remember this information right now. truly no idea about this medication. if we use any strong medicines, they should be under the telemedicine supervision which consists of, as you know, emergency physicians and they are available 24/7, but it is not under your scope, only the emergency physicians. [P5]

See mostly with the current thing like we do intubation for a patient who is completely unconscious, you know there this no resistant or muscles are smoothly, completely relaxed that’s the patient we do, we do not do rapid sequence intubation since we do not have medications currently, all we have is ketamine which has been recently introduced, but we just follow the CPG so currently, CPG does not highlight for us to use as RSA, ketamine to be used, so again, we use stat also for, you know, to anesthetize the patient, like that, so that’s why we use, but currently, we, if the situation is like that, we just back the patient and transfer the patient… [P6]

Enhance scope of practice

I like the scope and further study more…[P1]

To me the only gap that I feel is missing is in the medications that are not under our scope, personally those medications are considered as number of ampule I have in the bag that I check regularly in case I needed it. I know If am to administer a medication I need to be reading about it perfectly, all indications and contraindications. [P3]

So, these would be implemented in the future? because we need more practice in the medications. [P5]

I’m an advanced paramedic I’ve been practicing as advanced paramedic for last 22 years advanced paramedic completed by bachelors in emergency and trauma care technology it’s a paramedic program itself and then I did master in healthcare management plus I’m also on faculty for life support training courses I do teach basically support advanced cardiac life support pediatric advanced life support trauma life support ECG courses and support like this. [P6]

Discussion

This study examined the perceptions, challenges, and reasoning of ambulance paramedical staff in the UAE regarding medication practices and awareness in cardiovascular emergency care. Fifteen participants were recruited, with six selected for final analysis. Using semi-structured interviews and thematic analysis via ATLAS.ti, six core themes emerged, grouped into two overarching categories: Challenges in Cardiovascular Medication Use (Highly Demanding, High Stake – High Risk Medication, Tight Scope of Practice) and Strengths and Opportunities for Improvement (Value-laden, Medicines Stewardship, Enhanced Scope of Practice). These informed a conceptual framework—the Value-based Care Ladder—proposed to guide future improvements in paramedic medication practice.

The theme Highly Demanding reflected the emotional and cognitive strain paramedics face in urgent, high-pressure scenarios, often compounded by interactions with distressed family members. This aligns with UK-based research showing high burnout rates among paramedics, especially those with over 10 years of experience [22]. Similar findings in Saudi Arabia highlighted challenges in managing patients with sensory impairments, linking confidence to training [23]. A 2023 meta-analysis reported a 20% PTSD prevalence among paramedics, underscoring the psychological toll of repeated trauma exposure [24]. Studies across Europe and England revealed systemic gaps in EMS protocols, documentation, and end-of-life care training, emphasizing the need for standardized systems and improved access to essential resources [25, 26].

The theme High Stake – High Risk Medication emphasized the cautious approach paramedics take with high-alert drugs, reinforcing the need for advanced training and evidence-based guidelines. This aligns with a 2023 review on prehospital analgesia and sedation, which called for flexible protocols and enhanced education to reduce errors and improve safety [27].

Tight Scope of Practice captured frustrations among EMTs regarding limited access to advanced medications and reliance on emergency physicians. While scope boundaries promote safety and role clarity, they may hinder rapid response in complex cases. Simulation research using telemedicine tools like ETA showed timing differences across specialties, suggesting potential for improved decision-making support [28]. A 2018 UK survey found paramedics favored independent prescribing to overcome limitations of Patient Group Directions, though concerns remained about system readiness and access to patient records [29].

The themes grouped under Strengths and Opportunities for Improvement in Practice reflected flexibility, responsibility, and professional growth among paramedics. Medicines Stewardship emerged as the most frequent theme, indicating paramedics’ awareness of high-stake medications, their therapeutic and toxic effects, and the importance of adhering to clinical guidelines. The Value-laden theme highlighted how ethical values, interpersonal skills, and patient-centered concern influence clinical decisions, reinforcing the link between protocol adherence and personal accountability. Enhanced Scope of Practice revealed paramedics’ desire for expanded access to advanced medications through improved clinical guidelines and hands-on experience.

These themes collectively demonstrated a balance between caution and confidence, and a strong motivation for system-level improvements. A descriptive study in Switzerland traced the evolution of paramedics from basic transporters to highly trained professionals delivering 80–90% of prehospital care independently, supported by formal training and interprofessional collaboration [30]. A 2020 Swiss randomized controlled trial showed that the PedAMINES mobile app reduced pediatric medication errors by 68% and accelerated drug delivery, underscoring the value of technology in enhancing paramedic performance [31].

Empirical evidence from participants revealed that even under stress, paramedics exhibit ethical awareness and responsible medication handling, reinforcing the Value-based Care Ladder framework. This model advocates integrating ethical values into paramedic training, followed by continuous education and hands-on experience with high-risk medications, regardless of scope limitations. It also calls for system-level planning to monitor medication practices and support individualized professional growth. Based on the study’s findings, we recommend strengthening paramedics’ medication awareness, further training and expanded scope of their practice.

A similar qualitative study in Michigan (2020) identified key factors for improving out-of-hospital cardiac arrest care, including workload, communication, education, and continuous quality improvement [32]. A longitudinal multimethod study launched in 2022 aims to assess the impact of team training on medication errors and teamwork dynamics, though results are pending [33].

The Value‑based Care Ladder is positioned as an integrative conceptual framework that extends existing work on medication stewardship, paramedic clinical judgement, and prehospital decision‑making by illustrating how paramedics progressively navigate the interplay between occupational pressures and professional values. While prior models in paramedicine have emphasized cognitive heuristics, risk management, or protocol‑driven reasoning, the Ladder uniquely synthesizes these strands by mapping how practitioners move from the constraints of a highly demanding job and high‑risk medication environment toward more reflective, value‑oriented stewardship practices. This aligns with literature describing paramedics as evolving autonomous clinicians yet offers a more explicit articulation of how professional identity, perceived responsibility, and scope of practice interact to shape medication‑related decisions [30–33]. Its emphasis on values‑driven progression suggests potential transferability to other high‑acuity, protocol‑bound settings where clinicians similarly balance risk, autonomy, and stewardship.

Limitations

This study was conducted in a single city within the UAE, and while the findings offer valuable insights into paramedical practice in cardiovascular emergency care, they may not be generalizable to other regions or countries. While sampling strategy was mainly purposive, convenience was also taken into consideration which was practically feasible. Back-translation was not performed as the participants also knew English, but some part of the interview was in Arabic only for convenience. The researcher is also bilingual, understands both regional Arabic and English. Interviews took place during duty hours at ambulance sites, which may have influenced participants’ openness due to operational demands; however, efforts were made to create a comfortable and professional environment for discussion. As with all qualitative research, the findings reflect participants’ perspectives at a specific point in time and may evolve with future training or policy changes. A follow-up study involving emergency physicians is planned to explore their experiences with high-alert medications and their role in supporting paramedical staff.

Conclusion

This study identified six major themes reflecting paramedics’ practice and awareness in cardiovascular emergency care. Three challenges were Highly Demanding job, High-Stake High-Risk Medications, and Tight Scope of Practice. Three strengths or opportunities were Value-Laden line of work, Working as a Medicines Steward, and the need for an Enhanced Scope of Practice. To the best of our knowledge, no prior research has qualitatively examined these aspects among ambulance staff in the UAE. By addressing clinical, professional, and ethical dimensions of paramedic practice, this study fills a critical gap and offers valuable insights to support the development of paramedics in delivering optimal out-of-hospital cardiovascular care.

Abbreviations

BP

Blood Pressure

EMS

Emergency Medical Service

EMT

Emergency Medical Technician

ETA

Emergency Talk Application

HR

Hazard Ratio

P

Participant

PTSD

Post-Traumatic Stress Disorder

PedAMINES

(is a mobile app)

SVT

Supraventricular Tachycardia

UAE

United Arab Emirates

UK

United Kingdom

Author contributions

SB conceptualized the study, designed the methodology, coordinated data collection, and led the analysis and interpretation of the findings, while DT contributed to refining the study design, and validated the analysis. SB drafted the initial version of the manuscript, and DT substantially revised it for clarity and academic rigor. Both authors read and approved the final manuscript.

Funding

No funding was received for this research.

Data availability

Data are included in the article; additional data are available on request to the corresponding author.

Declarations

Ethics approval and consent to participate

Research has been conducted in accordance with the Declaration of Helsinki. The Gulf Medical University Institutional Review Board approval was obtained for this study (IRB-COP-STD-43-Oct-2024) was obtained on October 07, 2024. Institutional permission was obtained from the site section head. Written informed consent was taken from all study participants.

Consent for publication

Both authors and their institutions consent for publication.

Competing interests

The authors declare no competing interests.