retylium for example, illustrate this. In some respects, the development seemed almost faddish. Technologies also evolved and changed, and as medical equipment manufacturers quickly learned, the pre-hospital environment was not the same as the hospital environment; equipment standards which worked fine in hospitals could not cope well with the less controlled pre-hospital environment. Physicians began to take more interest in Paramedics from a research perspective as well. By about 1990, most of the 'trendiness' in pre-hospital emergency care had begun to disappear, and was replaced by outcome-based research; the gold standard for the rest of medicine. This research began to drive the evolution of the practice of both paramedics and the emergency physicians who oversaw their work; changes to procedures and protocols began to occur only after significant outcome-based research demonstrated their need. Such changes affected everything from simple procedures, such as CPR, to changes in drug protocols. As the profession of paramedic grew, some of its members actually went on to become not just research participants, but researchers in their own right, with their own projects and journal publications.
Changes in procedures also included the manner in which the work of paramedics was overseen and managed. In the earliest days of the field, medical control and oversight was direct and immediate, with paramedics calling into a local hospital and receiving orders for every individual procedure or drug. This still occurs in some jurisdictions, but is becoming very rare. As physicians began to build a bond of trust with paramedics, and experience in working with them, their confidence levels also rose. Increasingly, in many jurisdictions day to day operations moved from direct and immediate medical control to pre-written protocols or 'standing orders', with the paramedic typically only calling in for direction after the options in the standing orders had been exhausted. Medical oversight became driven more by chart review or rounds, than by step by step control during each call.
Evolution in other jurisdictions[change | edit source]
In other places, the evolution of paramedicine occurred somewhat differently. In Canada, for example, there was an early, but unsuccessful attempt to introduce paramedicine. In 1972, a pilot paramedic training program occurred at Queen's University, located in Kingston, Ontario. The program, intended to upgrade the mandatory 160 hours of training then required for 'ambulance attendants', was found to be too costly and premature. While the program operated for two years and produced a number of graduates, it would be more than a decade before the legislative authority for them to practice was put into place. The program then moved in another direction, providing 1,400 hours of training at the community college level, prior to commencing employment. This change was made mandatory in 1977, with formal certification examinations being introduced for the first time in 1978. Similar, but not identical, programs occurred at roughly the same time in the Province of Alberta, and in British Columbia, through its Justice Institute. Other Canadian provinces gradually followed, but with their own education and certification requirements. Advanced Care Paramedics were not introduced until 1984, when Toronto trained its' first group internally, and the process continued to spread across the country. The current model in Ontario calls for a two year community college based program, including both hospital and field clinical components, prior to designation as an Advanced Care Paramedic, although this is gradually evolving in the direction of a university degree-based program. Some services, such as Toronto EMS, continue to train paramedics internally (indeed, Toronto EMS is accredited in its own right by the Canadian Medical Association as an Advance Care Paramedic training academy).
In the United Kingdom, ambulance services became largely municipal services, with some exceptions, shortly after the end of World War Two