 In France, since 1986, fire department-based rescue ambulances have had the option of providing resuscitation service (reanimation) using specially trained nurses, operating on protocols, while SAMU-SMUR units are staffed by physicians and nurses

In countries with a physician-led EMS model, such as France, Italy, the German-speaking countries (Germany, Switzerland, Austria), and Spain, physicians respond to all cases that require more than basic first aid.In some versions of this model (such as France, Italy, and Spain), there is no direct equivalent to a paramedic, as ALS is performed by physicians.In the German-speaking countries, paramedics are assistants to ambulance physicians (called Notarzt).