Editing Paramedic (section)

===Evolution and growth===
Throughout the 1970s and 1980s, the paramedic field continued to evolve, with a shift in emphasis from patient transport to treatment both on scene and en route to hospitals. This led to some services changing their descriptions from "ambulance services" to "[[emergency medical services]]".

[[File:Bicycle Paramedics.JPG|right|thumb|Bicycle paramedics in [[Los Angeles]] indicate the changing nature of the job.]]
The training, knowledge-base, and skill sets of both paramedics and [[emergency medical technicians|emergency medical technicians (EMTs)]] were typically determined by local medical directors based primarily on the perceived needs of the community along with affordability. There were also large differences between localities in the amount and type of training required, and how it would be provided. This ranged from in-service training in local systems, through community colleges, and up to university level education. This emphasis on increasing qualifications has followed the progression of other health professions such as [[nursing]], which also progressed from on the job training to university level qualifications.

The variations in educational approaches and standards required for paramedics has led to large differences in the required qualifications between locations—both within individual countries and from country to country. Within the UK training is a three-year course equivalent to a [[bachelor's degree]]. Comparisons have been made between paramedics and nurses; with nurses now requiring degree entry (BSc) the knowledge deficit is large between the two fields. This has led to many countries passing laws to protect the title of "paramedic" (or its local equivalent) from use by anyone except those qualified and experienced to a defined standard. This usually means that paramedics must be registered with the appropriate body in their country; for example all paramedics in the United Kingdom must by registered with the [[Health and Care Professions Council]] (HCPC) in order to call themselves a paramedic. In the United States, a similar system is operated by the [[National Registry of Emergency Medical Technicians|National Registry of Emergency Medical Technicians (NREMT)]], although this is only accepted by forty of the fifty states.

As paramedicine has evolved, a great deal of both the [[curriculum]] and skill set has existed in a state of flux. Requirements often originated and evolved at the local level, and were based upon the preferences of physician advisers and medical directors. Recommended treatments would change regularly, often changing more like a fashion than a scientific discipline. Associated technologies also rapidly evolved and changed, with medical equipment manufacturers having to adapt equipment that worked inadequately outside of hospitals, to be able to cope with the less controlled pre-hospital environment.

Physicians began to take more interest in paramedics from a research perspective as well. By about 1990, the fluctuating trends began to diminish, being replaced by outcomes-based research. This research then drove further evolution of the practice of both paramedics and the emergency physicians who oversaw their work, with changes to procedures and [[Guideline (medical)|protocols]] occurring only after significant research demonstrated their need and effectiveness (an example being [[Advanced life support|ALS]]). Such changes affected everything from simple procedures such as [[CPR]], to changes in drug protocols. As the profession grew, some paramedics went on to become not just research participants, but researchers in their own right, with their own projects and journal publications.  In 2010, the [[American Board of Emergency Medicine]] created a [[medical subspecialty]] for physicians who work in emergency medical services.<ref>{{Cite web|url=https://www.abem.org/public/become-certified/subspecialties/emergency-medical-services|title=Emergency Medical Services|website=www.abem.org}}</ref>

Changes in procedures also included the manner in which the work of paramedics was overseen and managed. In the early days medical control and oversight was direct and immediate, with paramedics calling into a local hospital and receiving orders for every individual procedure or drug. While this still occurs in some jurisdictions, it has become increasingly rare. Day-to-day operations largely moved from direct and immediate medical control to pre-written protocols or standing orders, with the paramedic typically seeking advice after the options in the standing orders had been exhausted.

====Canada====
{{Main|Paramedics in Canada}}
[[File:TorontoEMSactionshot.JPG|right|thumb|Firefighters assist while paramedics from the [[Toronto Paramedic Services]] load a patient into an ambulance.]]
While the evolution of paramedicine described above is focused largely on the US, many other countries followed a similar pattern, although often with significant variations. Canada, for example, attempted a pilot paramedic training program at [[Queen's University at Kingston|Queen's University]], [[Kingston, Ontario]], in 1972. The program, which intended to upgrade the then mandatory 160 hours of training for ambulance attendants, was found to be too costly and premature. The program was abandoned after two years, and it was more than a decade before the legislative authority for its graduates to practice was put into place. An alternative program which provided 1,400 hours of training at the [[community college]] level prior to commencing employment was then tried, and made mandatory in 1977, with formal certification examinations being introduced in 1978. Similar programs occurred at roughly the same time in [[Alberta]] and [[British Columbia]], with other Canadian provinces gradually following, but with their own education and certification requirements. Advanced Care Paramedics were not introduced until 1984, when [[Toronto]] trained its first group internally, before the process spread across the country. By 2010 the Ontario system involved a two-year community college based program, including both hospital and field clinical components, prior to designation as a Primary Care Paramedic, although it is starting to head towards a university degree-based program. The province of Ontario announced that by September 2021, the entry level primary care paramedic post-secondary program would be enhanced from a two-year diploma to a three-year advanced diploma in primary care paramedicine. Resultantly, advanced care paramedics in Ontario will require a minimum of four years of post-secondary education and critical care paramedics will require five years of post-secondary education.

====Israel====

In Israel, paramedics are trained in either of the following ways: a three-year degree in Emergency Medicine (B.EMS), a year and three months [[Israel Defence Forces|IDF]] training, or [[Magen David Adom|MADA]] training. Paramedics manage and provide medical guidelines in [[mass casualty incident]]s. They operate in MED evac and ambulances. They are legalized under the 1976 Doctors Ordinance (Decree). In a 2016 study at the Ben Gurion University of the Negev it was found that 73% of trained paramedics stop working within a five-year period, and 93% stop treating within 10 years.<ref>{{Cite web|url=http://www.israelhpr.org.il/h/1/&mod=download&me_id=2241|title=Study in Ben Gurion University with Magen David Adom|access-date=2021-01-16|archive-date=2018-01-21|archive-url=https://web.archive.org/web/20180121071413/http://www.israelhpr.org.il/h/1/%26mod%3Ddownload%26me_id%3D2241|url-status=dead}}</ref>

====United Kingdom====
{{Main|Emergency medical personnel in the United Kingdom}}
In the United Kingdom, ambulances were originally [[municipal]] services after the end of World War II. Training was frequently conducted internally, although national levels of coordination led to more standardization of staff training. Ambulance services were merged into county-level agencies in 1974, and then into regional agencies in 2006. The regional ambulance services, most often trusts, are under the authority of the [[National Health Service]] and there is now a significant standardization of training and skills. The UK model has three levels of ambulance staff. In increasing order of clinical skill these are: [[emergency care assistant]]s, [[emergency medical technician]]s, and paramedics.{{cn|date=April 2024}}

Today, university qualifications are expected for paramedics, with the current entry level being a [[Bachelor of Science]] degree in Pre-Hospital Care or Paramedic Science.  As the title "Paramedic" is legally protected, those utilising must be registered with the [[Health and Care Professions Council]] (HCPC),<ref>{{Cite web|url=http://www.hcpc-uk.co.uk/aboutregistration/protectedtitles/|title=HCPC - Health and Care Professions Council - Protected titles|website=www.hcpc-uk.co.uk|access-date=2016-02-08|archive-url=https://web.archive.org/web/20161020234236/http://hcpc-uk.co.uk/aboutregistration/protectedtitles/|archive-date=2016-10-20|url-status=dead}}</ref> and in order to qualify for registration you must meet the standards for registration, which include having a degree obtained through an approved course.<ref>{{Cite news |date=2015-04-23 |title=Entry requirements and training (paramedic) |url=https://www.healthcareers.nhs.uk/explore-roles/ambulance-service-team/roles-ambulance-service/paramedic/entry-requirements-and-training-paramedic |access-date=2018-03-19 |work=Health Careers |language=en}}</ref><ref>{{Cite web |title=HCPC - Health and Care Professions Council - Standards |url=http://www.hcpc-uk.org/publications/standards/index.asp?id=183 |access-date=2018-03-19 |website=www.hcpc-uk.org |language=en}}</ref> The change of entry requirements does not affect currently registered Paramedics, some of whom will still only have their entry qualification, but it is common for Paramedics to continue to progress through "top up" courses, for instance, to work towards a Bachelors of Science degree. This has led to Paramedics holding a wide range of qualifications, with some qualifications (such as master's degrees in Advanced or Paramedic Practice) being a pre-requisite for paramedic prescribing.<ref>{{Cite web |title=NHS England » Prescribing training for paramedics |url=https://www.england.nhs.uk/ahp/med-project/paramedics/prescribing-training/ |access-date=2024-02-14 |website=www.england.nhs.uk}}</ref>

Paramedics work in various settings including NHS and Independent Ambulance Providers, Air Ambulances, Emergency Departments and other alternative settings.  Some paramedics have gone on to become ''Paramedic Practitioners'', a role that practices independently in the pre-hospital environment in a capacity similar to that of a [[nurse practitioner]]. This is a fully autonomous role, and such senior paramedics are now working in hospitals, community teams such as rapid response teams, and also in increasing numbers in general practice, where their role includes acute presentations, complex chronic care and end of life management. They work as part of the [[allied health professional]] team including Doctors, Nurses, physician Associates, Physiotherapists, Associate Physicians, Health Care Assistant and Clinical Pharmacists. Paramedic Practitioners also undertake examinations modelled upon the MRCGP (a combination of applied knowledge exams, clinical skills and work place based assessment) in order to use the title "specialist". There are also now a growing number of these advanced paramedics who are independent and supplementary prescribers. There are also 'Critical Care Paramedics' who specialise in acute emergency incidents.  In 2018, the UK government changed legislation allowing Paramedics to independently prescribe,<ref>{{Cite web|url=https://www.collegeofparamedics.co.uk/news/legislation-changing-to-enable-patients-to-benefit-from-paramedic-independent-prescribers|title=Legislation changing to enable patients to benefit from paramedic independent prescribers {{!}} News|website=www.collegeofparamedics.co.uk|language=en|access-date=2018-03-19}}</ref> which will open new pathways to Paramedics to progress into. This came into force on 1 April 2018, but did not immediately affect practice as guidance was still being written.<ref>{{Cite web|url=https://www.collegeofparamedics.co.uk/publications/independent-prescribing|title=Independent Prescribing {{!}} Professional Development|website=www.collegeofparamedics.co.uk|language=en|access-date=2018-04-15}}</ref>

====United States====
{{Main|Paramedics in the United States}}
In the United States, the minimum standards for paramedic training is considered [[vocational]], but many colleges offer paramedic [[associate degree]] or [[bachelor's degree]] options. Paramedic education programs typically follow the U.S. NHTSA EMS Curriculum, DOT or National Registry of EMTs.<ref>{{cite web |url=http://www.ems.gov/mission.htm |title=Our Mission &#124; NHTSA EMS |access-date=2015-07-26 |url-status=dead |archive-url=https://web.archive.org/web/20150814114552/http://ems.gov/mission.htm |archive-date=2015-08-14 }}</ref> While many regionally accredited [[community college]]s offer paramedic programs and two-year associate degrees, a handful of universities also offer a four-year bachelor's degree component.<ref>{{cite web|url=https://www.naemt.org/about_ems/degreeprograms.aspx|title=Degree Programs in EMS|website=www.naemt.org|url-status=dead|archive-url=https://web.archive.org/web/20150626193038/https://www.naemt.org/about_ems/degreeprograms.aspx|archive-date=2015-06-26}}</ref> The national standard course minimum requires [[didactic]] and clinical hours for a paramedic program of 1,500 or more hours of classroom training and 500+ clinical hours to be accredited and nationally recognized.<ref>{{cite web|url=http://www.caahep.org/Content.aspx?ID=39|title=Emergency Medical Technician-Paramedic - CAAHEP|website=www.caahep.org|url-status=dead|archive-url=https://web.archive.org/web/20150708193936/http://www.caahep.org/Content.aspx?ID=39|archive-date=2015-07-08}}</ref><ref name="node"/> Calendar length typically varies from 12 months to upwards of two years, excluding degree options, EMT training, work experience, and prerequisites. It is required to be a certified Emergency Medical Technician prior to starting paramedic training.<ref>{{cite web|url=https://www.nremt.org/nremt/about/reg_para_history.asp#Entry_Requirements|title=National Registry of EMTs|access-date=2015-09-24|archive-date=2016-08-10|archive-url=https://web.archive.org/web/20160810121131/http://www.nremt.org/nremt/about/reg_para_history.asp#Entry_Requirements|url-status=dead}}</ref> Entry requirements vary, but many paramedic programs also have prerequisites such as one year required work experience as an [[emergency medical technician]], or anatomy and physiology courses from an accredited college or university. Paramedics in some states must attend up to 50+ hours of ongoing education, plus maintain Pediatric Advanced Life Support and Advanced Cardiac Life Support. National Registry requires 70 + hours to maintain its certification or one may re-certify through completing the written computer based adaptive testing again (between 90 and 120 questions) every two years.

Paramedicine continues to grow and evolve into a formal profession in its own right, complete with its own standards and body of knowledge, and in many locations paramedics have formed their own [[Professional association|professional bodies]].<ref>{{cite web|url=https://www.nremt.org/|title=National Registry of EMTs}}</ref>

The early technicians with limited training, performing a small and specific set of procedures, has become a role beginning to require a foundation degree in countries such as [[Australia]], [[South Africa]], the [[UK]], and increasingly in Canada and parts of the U.S. such as [[Oregon]], where a degree is required for entry level practice.<ref>{{cite web|url=http://study.com/paramedic_school_oregon.html|title=Paramedic Schools in Oregon with Training Program Overviews}}</ref>

====Ukraine====
As a part of [[Emergency Medicine Reform in Ukraine since 2016|Emergency Medicine Reform]] in 2017 [[Ministry of Healthcare (Ukraine)|Ministry of Healthcare]] introduced two specialties — "paramedic" and "[[emergency medical technician]]".<ref name="Аптека">{{cite web|url=http://www.apteka.ua/article/433521 |title=MOH order from&nbsp;09.08.2017&nbsp;р. №&nbsp;918 |date=November 1, 2017 |publisher=www.apteka.ua |language=uk}}</ref>