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". 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 (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 main article: paramedics in canada 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, 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 main article: 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 assistants, emergency medical technicians and paramedics. the original route to becoming a paramedic was to join an nhs ambulance service and work towards the position from non-emergency patient transport roles through to the emergency division as qualified ambulance staff and after qualifying those who wanted to increase their knowledge and skills joined the association of emergency medical technicians. this was an organisation run by members to promote and train paramedics. the aemt was supported by basics and large numbers of hospital doctors. training took place at various locations in members off duty time and at their expense. trainees followed a wide academic curriculum which led to a written exam. if successful they became associates and entered the clinical phase of training. attending hospitals they were trained in all the practical skills. the final examination was designed to put as much pressure on the candidate as possible. the hospital consultant would sign to say that he was happy for a passing candidate to treat their family. in the 1970s some ambulance service training departments started offering advanced skill training under the direction of peter baskett (consultant anaesthetist at frenchay hospital, bristol) and douglas chamberlain (consultant cardiologist in brighton). this was the inception of the paramedic service in the uk, and subsequently was developed across europe. in 1986 the nhsta introduced the certificate in extended ambulance aid. existing aemt paramedics were forced to sit a conversion examination. the curriculum for the new qualification was substantially smaller cutting out a lot of anatomy and physiology as well as pharmacology and obstetrics. in november 1986 the examinations took place with the first certificates issued alphabetically. the candidate with highest score received certificate 177 and was the only paramedic at huntingdon. training was introduced the following year but due to costs the time was kept to a minimum. the aemt folded in the 1990s as the training offered was no longer recognised by the ambulance services. equipment owned by the branches was given to hospitals. the nhs training authority, nhsta, (which became the nhs training directorate and then the nhs training division, which in turn became the institute of health and care development. the institute was acquired by the edexcel examination board in 1998, and edexcel was acquired by pearson in 2004. pearson continued to operate the ihcd 'brand' until 2016. this 'in-house' paramedic training was a modular programme, usually between 10 and 12 weeks, followed by time spent in a hospital emergency department, coronary care centre and operating theatre, assisting the anaesthetist and performing airway management techniques such as endotracheal intubation. completion of the course allowed the paramedic to register with the council for professions supplementary to medicine (cpsm), which was superseded by the health and care professions council (hcpc), a regulatory body. this route also took around 3 years if undertaken as quickly as possible. after the non emergency training, initially an 8-week clinical technician course was undertaken, with 750 mentored hours. staff usually had to be a qualified technician for 2 years before applying for paramedic training noted above, a further 750 hours mentored had to be undertaken to complete the paramedic course to practice and demonstrate the skills learnt during the hospital placements and residential course. prior to regulation and closure of the title, the term "paramedic" was used by a variety of people with varying levels of ability. paramedics could apply to register via a grandfather scheme which ended in 2002. however, university qualifications are expected for paramedics, with the entry level being an honours 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), and in order to qualify for registration you must meet the standards for registration, which include having a degree obtained through an approved course. it is common for paramedics to have master's degrees in advanced practice or paramedic practice and is indeed a requisite for paramedic prescribing. 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, 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. united states main article: 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