A Pre-hospital Emergency Medical Service (PHEMS) is a vital component of a country’s health service because it provides early medical care to critically ill and injured persons in the field. There is evidence to show that early care reduces mortality and morbidity and offers the patient the best chance of survival and improved quality of life. Caribbean territories have been developing their PHEMS as part of a programme of health sector reform. In a study of PHEMS in 12 Caribbean countries, the Pan American Health Organization reported that there were no clear guidelines with respect to the roles and responsibilities of the physician in PHEMS in the majority of countries. In fact, a few countries had services where there was no direct physician involvement. We present a brief review of the internationally recognized roles and responsibilities of physicians in PHEMS, and make recommendations with particular reference to the Caribbean. We suggest that there is a need for direct and active involvement of physicians in the development of PHEMS because the Emergency Medical Technician is recognized as an extension of the physician in the field and is supposed to be protected by the physician’s licence to deliver medical care.