Early history Throughout the evolution of pre-hospitalization care, there has been an ongoing association with military conflict. One of the first indications of a formal process for managing injured people dates from the
Imperial Legions of Rome, where aging
Centurions, no longer able to fight, were given the task of organizing the removal of the wounded from the
battlefield and providing some form of care. Such individuals, although not
physicians, were probably among the world's earliest
surgeons by default, being required to
suture wounds and complete
amputations. A similar situation existed in the
Crusades, with the
Knights Hospitaller of the
Order of St. John of Jerusalem filling a similar function; this organisation continued, and evolved into what is now known throughout the
Commonwealth of Nations as the
St. John Ambulance and as the
Order of Malta Ambulance Corps in the Republic of Ireland and various countries.
Early ambulance services While civilian communities had organized ways to deal with prehospitalisation care and transportation of the sick and dying as far back as the
bubonic plague in
London between 1598 and 1665, such arrangements were typically
ad hoc and temporary. In time, however, these arrangements began to formalize and become permanent. During the
American Civil War,
Jonathan Letterman devised a system of mobile
field hospitals employing the first uses of the principles of
triage. After returning home, some veterans began to attempt to apply what they had seen on the battlefield to their own communities, and commenced the creation of volunteer life-saving squads and ambulance corps. paramedics training in 1931 in Israel,
6 June 1948 These early developments in formalized ambulance services were decided at local levels, and this led to services being provided by diverse operators such as the local hospital, police, fire brigade, or even
funeral directors who often possessed the only local transport allowing a passenger to lie down. In most cases these ambulances were operated by drivers and attendants with little or no medical training, and it was some time before formal training began to appear in some units. An early example was the members of the
Toronto Police Ambulance Service receiving a mandatory five days of training from St. John as early as 1889. Prior to
World War I motorized ambulances started to be developed, but once they proved their effectiveness on the battlefield during the war the concept spread rapidly to civilian systems. In terms of advanced skills, once again the military led the way. During
World War II and the
Korean War battlefield medics administered painkilling
narcotics by injection in emergency situations, and pharmacists' mates on warships were permitted to do even more without the guidance of a physician. The Korean War also marked the first widespread use of
helicopters to evacuate the wounded from forward positions to medical units, leading to the rise of the term "
medevac". These innovations would not find their way into the civilian sphere for nearly twenty more years.
Pre-hospital emergency medical care By the early 1960s experiments in improving medical care had begun in some civilian centres. One early experiment involved the provision of pre-hospital
cardiac care by physicians in
Belfast, Northern Ireland, in 1966. This was repeated in
Toronto, Canada in 1968 using a single ambulance called
Cardiac One, which was staffed by a regular ambulance crew, along with a hospital
intern to perform the advanced procedures. While both of these experiments had certain levels of success, the technology had not yet reached a sufficiently advanced level to be fully effective; for example, the Toronto portable
defibrillator and
heart monitor was powered by
lead-acid car batteries, and weighed around . In 1966, a report called
Accidental Death and Disability: The Neglected Disease of Modern Society—commonly known as
The White Paper—was published in the United States. This paper presented data showing that soldiers who were seriously wounded on the battlefields during the
Vietnam War had a better survival rate than people who were seriously injured in motor vehicle accidents on
California's
freeways. Key factors contributing to victim survival in transport to definitive care such as a hospital were identified as comprehensive trauma care, rapid transport to designated trauma facilities, and the presence of medical corpsmen who were trained to perform certain critical advanced medical procedures such as
fluid replacement and
airway management. As a result of
The White Paper, the US government moved to develop minimum standards for ambulance training, ambulance equipment and vehicle design. These new standards were incorporated into Federal Highway Safety legislation and the states were advised to either adopt these standards into state laws or risk a reduction in Federal highway safety funding. The "White Paper" also prompted the inception of a number of emergency medical service (EMS)
pilot units across the US including paramedic programs. The success of these units led to a rapid transition to make them fully operational. Founded in 1967,
Freedom House Ambulance Service was the first civilian emergency medical service in the United States to be staffed by
paramedics, most of whom were Black. New York City's Saint Vincent's Hospital developed the United States' first Mobile Coronary Care Unit (MCCU) under the medical direction of William Grace, MD, and based on Frank Pantridge's MCCU project in Belfast, Northern Ireland. In 1967, Eugene Nagle, MD and Jim Hirschmann, MD helped pioneer the United States' first EKG telemetry transmission to a hospital and then in 1968, a functional paramedic program in conjunction with the City of Miami Fire Department. In 1969, the City of Columbus Fire Department joined with the Ohio State University Medical Center to develop the "HEARTMOBILE" paramedic program under the medical direction of James Warren, MD and Richard Lewis, MD. In 1969, the Haywood County (NC) Volunteer Rescue Squad developed a paramedic program (then called Mobile Intensive Care Technicians) under the medical direction of Ralph Feichter, MD. In 1969, the initial Los Angeles paramedic training program was instituted in conjunction with Harbor General Hospital, now
Harbor–UCLA Medical Center, under the medical direction of
J. Michael Criley, MD and James Lewis, MD. In 1969, the Seattle "Medic 1" paramedic program was developed in conjunction with the
Harborview Medical Center under the medical direction of Leonard Cobb, MD. The Marietta (GA) initial paramedic project was instituted in the Fall of 1970 in conjunction with Kennestone Hospital and Metro Ambulance Service, Inc. under the medical direction of Luther Fortson, MD. The Los Angeles County and City established paramedic programs following the passage of
The Wedsworth-Townsend Act in 1970. Other cities and states passed their own paramedic bills, leading to the formation of services across the US. Many other countries also followed suit, and paramedic units formed around the world. In the military, however, the required
telemetry and
miniaturization technologies were more advanced, particularly due to initiatives such as the
space program. It would take several more years before these technologies drifted through to civilian applications. In North America, physicians were judged to be too expensive to be used in the pre-hospital setting, although such initiatives were implemented, and sometimes still operate, in
European countries and
Latin America.
Public notability While doing background research at Los Angeles'
UCLA Harbor Medical Center for a proposed new show about doctors,
television producer Robert A. Cinader, working for
Jack Webb, happened to encounter "firemen who spoke like doctors and worked with them". This concept developed into the television series
Emergency!, which ran from 1972 to 1977, portraying the exploits of this new profession called paramedics. The show gained popularity with emergency services personnel, the medical community, and the general public. When the show first aired in 1972, there were just six paramedic units operating in three pilot programs in the whole of the US, and the term paramedic was essentially unknown. By the time the program ended in 1977, there were paramedics operating in all fifty states. The show's
technical advisor,
James O. Page, was a pioneer of
paramedicine and responsible for the UCLA paramedic program; he would go on to help establish paramedic programs throughout the US, and was the founding publisher of the
Journal of Emergency Medical Services (
JEMS). The
JEMS magazine creation resulted from Page's previous purchase of the
PARAMEDICS International magazine.
Ron Stewart, the show's
medical director, was instrumental in organizing emergency health services in southern California earlier in his career during the 1970s, in the paramedic program in Pittsburgh, and had a substantial role in the founding of the paramedic programs in Toronto and
Nova Scotia, Canada.
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". indicate the changing nature of the job. The training, knowledge-base, and skill sets of both paramedics and
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 (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
protocols occurring only after significant research demonstrated their need and effectiveness (an example being
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. 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 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,
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
IDF training, or
MADA training. Paramedics manage and provide medical guidelines in
mass casualty incidents. 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.
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 emergency ambulance staff. In increasing order of clinical skill these are:
emergency care assistants,
emergency medical technicians, and paramedics. 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, they must be registered with the
Health and Care Professions Council (HCPC), Additional qualifications, such as a masters degree in Advanced or Paramedic Practice, are a pre-requisite for paramedic prescribing, which has been permitted since government legislation was introduced in 2018. Paramedics work in various settings such as NHS and independent ambulance providers, air ambulances and emergency departments. 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. Critical care paramedics specialise in acute emergency incidents.
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. While many regionally accredited
community colleges offer paramedic programs and two-year associate degrees, a handful of universities also offer a four-year bachelor's degree component. 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. 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 bodies. 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.
Ukraine As a part of
Emergency Medicine Reform in 2017
Ministry of Healthcare introduced two specialties — "paramedic" and "
emergency medical technician". == Structure of employment ==