From the start, Emergency Medical Services (EMS) has defied simple explanation. Its mission; to save lives of sick or injured people in emergency situations – seems simple enough. But EMS, and its unique history in both healthcare and public safety, is much more complex. It was born in the United States of several influential parents including trauma care, cardiology, resuscitation science and military medicine – and it continues to cross the boundaries of numerous disciplines, including healthcare, medical transportation, public health and homeland security.
Trauma and Tragedy
To understand where EMS is today, it is necessary to look back on its recent history, which, it might be argued, began 40 years ago, with the publication of the National Academy of Sciences (NAS) paper titled “Accidental Death and Disability: the Neglected Diseases of
Modern Society.” That paper reported that in 1965,
52 mil accidental injuries killed 107,000 Americans,
temporarily disabled more than 10 million and
permanently impaired 400,000 more at a cost of approximately $18 billion. Accidental injury is “the neglected epidemic of modern society” and “the nation’s most important environmental health problem,” the paper concluded.
The NAS recommended several solutions, including the establishment of standards for ambulance design and construction, emergency medical equipment and supplies, and training and supervision of ambulance personnel. The report also called for local “ways and means of providing ambulance services.
Congress responded to the NAS paper by enacting the National Highway Safety Act of 1966, which mandated the newly formed Department of Transportation (DOT) to establish minimum standards for provision of care for accident 
victims. It also empowered DOT to penalize states up to 10% of their federal highway funds they did not comply with the standards. DOT and the National Highway Traffic Safe Administration (NHTSA), a DOT
agency, took the federal leadership role in the creation funding of EMS
systems in the ensuing years, providing more than $48 million for EMS between 1966 and 1973, creating national standard curricula for EMT- Basics, Intermediates and Paramedics, and defining the necessary components of an EMS system.Science of the Heart
Although accidental injuries were the impetus for federal suppo
rt of EMS and trauma systems in the 1960s and 1970s, modern
emergency medical services also developed out of simultaneous
advances in both cardiology and resuscitation science, led by
in Pennsylvania and the University of Belfast in Ireland. Among
the early interventions advanced by researchers at these institutions
were mouth-to-mouth breathing, chest compressions and defibrillation.
Emergency physicians, then practicing a new medical specialty, recognized that these cardiac interventions could save more lives if they were brought out of the hospital into the ambulance. At the same time, medics returning from Vietnam recognized that lives could be saved by using trauma treatments once reserved for the hospital on patients in the field, thus reinforcing the notion that EMS is, in essence, an extension of in-hospital emergency medical care.
As a part of the larger healthcare system, EMS programs began to take shape in the federal government’s Department for Health and Human Services (HHS). Notable among these is the Health Resources Services Administration, formed in 1982, which is home to the federal Office of established in 1965 to help pay for ambulance transport are also a part of HHS.Funding Priorities
The funding mechanism for EMS system development changed drastically in 1981 when the Omnibus Budget Reconciliation Act of 1981 ceased funding under the federal EMS Systems Act of 1973, and consolidated EMS funding into state preventive health and health services block grants. This change put the burden on the states to develop and fund EMS systems based on state and local priorities and led to a great variety in the way EMS is delivered and funded from state to state.Allowing states to control and direct EMS system development continues to this day, and many sources of federal EMS grant money are disseminated through state EMS offices. NHTSA’s EMS office still retains its oversight role in provider curricula and EMS system development.
The Many Faces of EMS
While EMS originally was conceived to respond to accidental death and injury and cardiac conditions outside the hospital, its role has expanded to become the primary safety net for Americans requiring emergency care treatment to save their lives. Public health authorities are also turning to EMS to assist in prevention activities and the promotion and implementation of community-based health and wellness programs. Manmade and natural disasters in recent years also have changed the role of EMS, which today is expected to provide immediate emergency medical response and patient transport to large numbers of affected patients following a disaster. In fact, EMS has become the front line for public safety.
EMS defies simple explanation, both historically and today. EMS is out-of-hospital patient care. EMS is ambulance transport. EMS is an extension of emergency medicine, and an arm of public health. EMS is a safety net. EMS is prevention. EMS is first response and public safety.
The Historical Perspectives of EMS
The development of EMS has been based on tradition and, to some extent, on scientific knowledge. Its roots are deep in history. For example, the Good Samaritan bound the injured traveler’s wounds with oil and wine at the side of the road, and evidence of treatment protocols exists as early as 1500 B.C.
Although the Romans and Greeks used chariots to remove injured
soldiers from the battlefield, most credit Baron Dominique-Jean
Larrey, chief physician in Napoleon’s army, with institution of the
first prehospital system (1797) designed to triage and transport the
injured from the field to aid stations. Flying ambulances (dressing
stations) were made to effect transport, and protocols dictated much
of the treatment. In the United States, organized field care and transport
of the injured began after the first year of the Civil War, when neglect
of the wounded had been abysmal.
Military conflicts have provided the impetus for many of the innovations for treating and transporting injured people. Among the most obvious of these is the use of aircraft for medical transport. The first known air medical transport occurred during the retreat of the Serbian army from Albania in 1915. An unmodified French fighter aircraft was used. During World War I mortality was linked to the time required to get to a dressing station. Additionally, application reduction of mortality due to femur fractures from 80% to 20%. The use of rotary wing aircraft for rapid evacuation of casualties from the field to treatment areas was demonstrated during later conflicts, especially in Korea and Vietnam. Civilian ambulance services in the United States began in Cincinnati and New York City in
1865 and 1869, respectively. Hospital interns rode in horse drawn carriages designed specifically for transporting the sick and injured. The first volunteer rescue squads organized around 1920 in Roanoke, Virginia, and along the New Jersey coast. Gradually, especially during and after World War II, hospitals and physicians faded from prehospital practice, yielding in urban areas to centrally coordinated programs. These were often controlled by the municipal hospital or fire department, whose use of “inhalators” was met with widespread public acceptance. Sporadically,
funeral home hearses, which had been the common mode of transport,
were being replaced by fire department, rescue squad and private
ambulances.
By 1960, new advances to care for the sickest patients were being
made. The first recorded use of mouth-to-mouth ventilation had been
in 1732, involving a coal miner in Dublin, and the first major publication
describing the resuscitation of near drowning victims was in 1896.
However, it was not until 1958 that Dr. Peter Safar demonstrated mouth
to-mouth ventilation to be superior to other methods of manual ventilation.
Of note, Dr. Safar used Baltimore firefighters in his studies to perform
ventilation of anesthetized surgical residents. In 1960, cardiopulmonary
resuscitation (CPR) was shown to be efficacious. Shortly thereafter, model EMS programs were developed based on successes in Belfast, where hospital-based mobile coronary care unit ambulances were being used to treat prehospital cardiac patients. American systems relied on fire department personnel trained in the techniques of cardiac resuscitation. These new modernized EMS systems spurred success stories from cities such as Columbus, Los Angeles, Seattle, and Miami. Modern EMS in the United States
Demonstration of the effectiveness of mouth-to- mouth ventilation in 1958 and closed cardiac massage in 1960, combined to produce CPR, led to the realization that rapid response of trained community members to cardiac emergencies could help improve outcomes. The introduction of CPR provided the foundation on which the concepts of advanced cardiac life support (ACLS), and subsequently EMS systems, could be built. The result has been EMS systems designed to enhance the “chain of survival."
The 1966 white paper, Accidental Death and Disability:
The Neglected Disease of Modern Society prepared by the
Committee on Trauma and Committee on Shock of the
National Academy of Sciences— National Research
Council, provided great impetus for attention to be turned
to the development of EMS. It noted that, in most cases,
ambulances were inappropriately designed, ill-equipped,
and staffed with inadequately trained personnel; and
that at least 50% of the nation’s ambulance services were
being provided by morticians.
The paper made 11 recommendations for ultimately improving care and outcome for ill and injured patients outside of a hospital setting:
1) Extension of basic and advanced first aid training to greater numbers of the lay public.
2) Preparation of nationally acceptable texts, training aids, and courses of instruction for rescue squad personnel, policemen, firemen, and ambulance attendants.
3) Implementation of recent traffic safety legislation to ensure completely adequate standards for ambulance design and construction, for ambulance equipment and supplies, and for the qualifications and supervision of ambulance personnel.
4) Adoption at the state level of general policies and regulations for ambulance services.
5) Adoption at district, county, and municipal levels of ways and means of providing ambulance services applicable to the conditions of the locality, control and surveillance of ambulance services, and coordination of ambulance services with health departments, hospitals, traffic authorities, and communication services.
6) Pilot programs to determine the efficacy of providing physician-staffed ambulances for care at the site of injury and during transportation (which ultimately led to the paramedical personnel used in EMS today).
7) Initiation of pilot programs to evaluate automotive and helicopter ambulance services in sparsely populated areas and in regions where many communities lack hospital facilities adequate to care for seriously injured persons.
8) Delineation of radio frequency channels and of equipment suitable to provide voice communication between ambulances, emergency department, and other health-related agencies at the community, regional, and national levels.
9) Pilot studies across the nation for evaluation of models of radio and telephone installations to ensure effectiveness of communication facilities.
10) Day to day use of voice communication facilities by the agencies serving emergency medical needs.
11) Active exploration of the feasibility of designating a single nationwide telephone number to summon an ambulance (which today is 9-1-1).
In the same year, the Highway Safety Act of 1966 which established the Department of Transportation (DOT) was passed. The DOT was given authority to improve EMS, including program implementation and development of standards for provider training. States were required to develop regional EMS systems, and costs of these systems were funded by the Highway Safety Program. Over the next 12 years the DOT contributed more than $142 million for EMS system development. The Highway Safety Act of 1966 included funds to create an appropriate training course for emergency care providers, as recommended in Accidental Death and Disability: The Neglected Disease , and the first nationally recognized EMT-A curriculum was published in 1969. Shortly thereafter paramedic education began, but training focused heavily on cardiac care and cardiac arrest resuscitation, almost to the exclusion of other problems. Although national curricula have been developed and revised, training standards and certification requirements have continued to vary significantly in communities throughout the nation and updates have been made accordingly with the current EMT-B curriculum.
Title XII to the Public Health Service Act, The Emergency Medical Services Systems Act of 1973 , provided additional federal guidelines and funding for the development of regional EMS systems. The law established that there should be 15 components of the EMS systems
Manpower
Training
Communications
Transportation
Facilities
Critical care units
Public safety agencies
Consumer participation
Access to care
Patient transfer
Coordinated patient record keeping
Public information and education
Review and evaluation
Disaster plan
Mutual aid
The development of emergency medicine as a medical specialty has paralleled that of EMS. The first residency program to train new physicians exclusively for the practice of emergency medicine was established in 1972 at the University of Cincinnati.
By 1975 there were 32 such programs, and there are currently
112 accredited emergency medicine residency programs
graduating in excess of 800 emergency medicine physicians each
year. Since the late 1970s, pediatric emergency medicine fellowships
have provided physicians with specialized training in the management
of childhood emergencies. Pediatric emergency medicine became officially recognized as a subspecialty of pediatrics and emergency medicine in 1992. To varying degrees, emergency
physicians in training are exposed to the principles and practices of providing medical direction for EMS systems, and the Society of Academic Emergency Medicine has published a model EMS education curriculum for physicians. Although emergency physicians often fulfill the medical direction needs of EMS systems, other groups of physicians continue to significantly and positively influence EMS. They include pediatricians, cardiologists, surgeons, intensivists, family practitioners, and others.
Children and EMS
Federal legislation established the Emergency Medical Services for Children (EMS-C) program in 1984, as issues relating to children’s emergency
care required attention. Emergency Medical Services for Children
projects have represented the largest federal funding outlay for
EMS development since consolidation of funds in block grants.
Project efforts have involved systems development, injury
prevention, research and evaluation, improved training and education,
and other aspects of EMS. The results have been EMS improvements
benefitting not only children, but the entire population. The program
commissioned the 1993 Institute of Medicine Report, Emergency
Medical Services for Children which pointed out continuing deficiencies in our health care system’s abilities to address the emergency medical needs of pediatric patients. It noted that in 1988, 21,000 people under the age of 20 died from injuries; thousands more were hospitalized and millions more were treated in emergency departments. The report indicated that although EMS systems and emergency departments are widely assumed to be equally capable of caring for children and adults, this is not always the casThe EMS-C program continues to work to ensure that pediatric issues are better integrated into the EMS system.
Trauma and EMS
In 1985, the National Research Council’s Injury in America: A Continuing Public Health Problem described deficiencies in the progress of addressing the problem of accidental death and disability. Development of trauma care systems became a renewed focus of attention. HRSA Division of Trauma and EMS was created, inan effort to support the concept of a trauma system that addresses the needs of all injured patients and matches them to available resources. The act encouraged the establishment of inclusive trauma systems and called for the development of a model trauma care system plan, which was completed in 1992. More inclusive trauma care better serves the population’s needs.
Local EMS authorities assumed responsibility for establishing
trauma systems and designating trauma centers in an effort
to improve care for trauma victims.
Reprinted (in conjuction with updates and pictures) from:
http://www.naemt.org/aboutEMSAndCareers/history_of_ems.htm
HISTORY OF EMERGENCY MEDICAL SERVICES (EMS)
Dominique-Jean Larrey
| ||||||
Army Combat Medic Memorial
| ||||||
Sir Hugh Owen-Thomas
Owen-Thomas Splint
Modern Hare-Traction Splint
| ||||||
| ||||
NorthStar
Air Ambulance
| ||||
| ||||
Horse-drawn ambulance
| ||||
| ||||
| ||||
| ||||
| ||||
| ||||||
| ||||||
| ||||||
University Hospital, located in Newark, NJ is a Level 1 Trauma Center and has been designated as the state trauma center for New Jersey. NorthStar Air Medical flies out of this hospital.
