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The purpose of this paper is to describe and analyse two approaches to paramedic service clinical governance and quality management from the perspective of two groups of paramedics and paramedic managers working in North America.

A case study approach was utilised to describe and analyse paramedic service medical direction in North America and contrast this with the professional self-governance and clinical governance systems operating in other high-income countries. Researchers interviewed participants at two remote North American sites, then completed transcription and thematic analysis.

Participants identified three themes: first, resourcing, regulatory frameworks and fragmentation; second, independent practice facilitators and barriers; and third, paramedic roles and professionalisation. Those trained outside North America tended to identify self-regulation and clinical governance as the preferred approach to quality management. Few participants had considered paramedicine becoming a self-regulating health profession.

In North America, the “medical direction” model is the dominant approach employed to ensure optimal patient outcomes in paramedic service delivery. In contrast, other comparable countries employ paramedic self-regulatory systems combined with clinical governance to achieve the same ends. This is one of two studies to examine medical direction from the perspective of paramedics and paramedic managers.

In North America, delegated practice “medical direction” models are often used as a proxy for clinical quality and safety in paramedic services. Other developed countries favor a combination of professional regulatory boards and clinical governance frameworks that feature paramedics taking lead clinician roles. The purpose of this paper is to bring together the evidence for medical direction and clinical governance in paramedic services through the prism of paramedic self-regulation.

This narrative synthesis critically examines the long-established North American Emergency Medical Services medical direction model and makes some comparisons with the UK inspired clinical governance approaches that are used to monitor and manage the quality and safety in several other Anglo-American paramedic services. The databases searched were CINAHL and Medline, with Google Scholar used to capture further publications.

Synthesis of the peer-reviewed literature found little high quality evidence supporting the effectiveness of medical direction. The literature on clinical governance within paramedic services described a systems approach with shared responsibility for quality and safety. Contemporary paramedic clinical leadership papers in developed countries focus on paramedic professionalization and the self-regulation of paramedics.

The lack of strong evidence supporting medical direction of the paramedic profession in developed countries challenges the North American model of paramedics practicing as a companion profession to medicine under delegated practice model. This model is inconsistent with the international vision of paramedicine as an autonomous, self-regulated health profession.

This piece argues that television families’ shift away from the traditional nuclear family form is crucial to understand the relatively rapid acceptance of same-sex marriage in mainstream politics. Released in the early 2010s, The Americans focusses on a KGB-created family composed of two Soviet spies, total strangers who ultimately have two children to further their cover as an innocent American family running a DuPont Circle travel agency and living in a Virginia suburb of Washington D.C. Rather than being idealised or sought after, The Americans reveals that the nuclear family is legally, socially, and politically constructed, and, in the end, doomed to failure. Sex and love and even children are instrumentally manipulated on a regular basis to further political goals, transforming basic assumptions about how marriage and family life really work beyond the façade of suburban America. This opens space for consideration and acceptance of alternative family forms, including same-sex marriage.

In a full blaze of comings and goings, it is unnecessary to remind ourselves that the holiday season is upon us; mass travel to faraway places. The media have for months, all through the winter, been extolling a surfeit of romantic areas of the world, exspecially on television; of colourful scenes, exotic beauties, brilliant sunshine everywhere; travel mostly by air as so‐called package tours — holidays for the masses! The most popular areas are countries of the Mediterranean littoral, from Israel to Spain, North Africa, the Adriatic, but of recent years, much farhter afield, India, South‐east Asia and increasingly to the USA.