medically related service complaints, and may often have the ability to de-certify individual paramedics for cause. Medical directors will also act as advocates for their paramedics, advising elected officials and building support within the medical community for expanded scopes of practice when appropriate. Finally, medical directors will act as expert advisors to those in the EMS system administration and government administration, with respect to policies and legislation required by the EMS system, and in guiding its future direction. In this model, the paramedic is very much seen as an 'extender' of the emergency physician's reach. It is rare to see physicians in the field, unless they are precepting new paramedics or performing quality assurance activities, or are residents in emergency medicine training programs, gaining required field experience or conducting research. Medical directors and ED physicians will occasionally go into the field for large incidents, such as multi victim accidents and disasters to assume on site medical command. Autonomous practice In some parts of the world, most notably the U.K., Australia and South Africa some paramedics have evolved into a role of autonomous practitioners in their own right. In such cases, individual paramedics may function in much the same manner as Physician assistants or Nurse Practitioners, assessing patients and making their own diagnoses, clinical judgments, and treatment decisions. In all such cases, a scope of practice is predetermined for the role, and within that scope of practice all treatment decisions are made and care rendered at the discretion of the individual paramedic. In many cases, the scope of practice will focus more heavily on primary care, although providing a more comprehensive level of care, such as suturing, or the management of long-term conditions, such as diabetes or hypertension, than is normally permitted to the paramedic. In some jurisdictions, such practitioners even have the authority to both prescribe and dispense a limited and defined set of medications. In such circumstances, these Paramedic Practitioners or Emergency Care Practitioners are almost always very senior and experienced ALS providers, and retain their ability to practice these skills. In many cases, the practice of these individuals has gone well beyond what we normally consider to be the role of traditional EMS. There are locations in which these practitioners are providing E/R leadership after hours in small, rural hospitals (Australia and the U.K.), while in other locations these practitioners are actually taking night 'call' for group medical