The White Paper
As America prospered, and medical care improved, it was becoming increasingly apparent that prehospital care, particularly for motor vehicle trauma, was not keeping pace with the medical community. In 1960 President John F. Kennedy made the statement that "Traffic accidents constitute one of the greatest, perhaps the greatest, of the nation’s public health problems."17
At that time, the majority of ambulance service was provided by a variety of tow truck operators, hospital supply companies, and funeral homes. To illustrate the point, in the 1950s and 1960s over 50% of ambulances in the United States were owned and operated by some 12,000 morticians. Funeral hearses were often used as ambulances as they were the only public conveyance that could transport a patient horizontally on a stretcher.
From 1965 to 1966, two reports on highway safety were produced. One, by the National Academy of Sciences, entitled "Accidental Death and Disability: The Neglected Disease of Modern Society," discussed shortfalls in the nation’s EMS system.18-20 The other, the report of the President’s Commission on Highway Safety, entitled "Health, Medical Care and Transportation of the Injured," also echoed the problems EMS was experiencing.21
In 1966, President Lyndon B. Johnson signed into law the National Highway Safety Act. This act provided for federal funds as well as other improvements in highway safety.22 The Highway Safety Act, among its many provisions, created an EMS program within the Department of Transportation (DOT) and is seen as the first federal commitment to EMS.
Following the passage of the Highway Safety Act there was a flurry of activity in emergency medicine. For example, The American College of Emergency Physicians was formed in 1968, a group consisting of physicians who specialized in emergency medicine. These early physicians, pioneers in emergency medicine, provided medical oversight and control to the growing EMS community.
In support of the EMS community the federal DOT produced the first Emergency Medical Technician-Ambulance curriculum in 1969, a national standard curriculum for the training of ambulance drivers/attendants in new skills and life-saving techniques.
While the EMT curriculum was developed to deal with vehicular trauma, cardiologists were dealing with another threat to Americans: the heart attack. Physicians, like Dr. Barnard Lown, noted that when certain drugs, such as lidocaine, were given during a heart attack there was a decrease in the incidence of sudden cardiac death (SCD).
Another cardiologist, Dr. Paul M. Zoll (Figure 2-5), also theorized that an electrical current passed through the heart could terminate the lethal dysrhythmia called ventricular fibrillation. And in 1956 Dr. Zoll delivered the first external, 750-volt, alternating current countershock to a fibrillating heart, which effectively stopped the dysrhythmia. Shortly thereafter defibrillators, now battery-powered direct current (DC) defibrillators, were placed in service in many hospitals and emergency departments.
Prehospital Coronary Care
Dr. J. "Frank" Pantridge, of Belfast, Ireland, noted that 90% of young or middle-aged men who died from heart attacks did so due to ventricular fibrillation. These deaths usually occurred within one hour of onset of initial symptoms. Realizing the potential of rapid defibrillation in the field to reverse sudden cardiac death, Dr. Pantridge placed the "heart-shockers" into ambulances and staffed those ambulances with trained coronary care nurses.
STREET SMART
The defibrillators, some weighing over 100 pounds, were placed on top of mobile carts which had a tendency to roll over, or "crash," when pushed through the halls of the hospital; hence the term "crash carts."
The patient survival rates from sudden cardiac death were remarkable and Dr. Pantridge reported his success in the British medical journal Lancet in 1967. After reading of his success with prehospital defibrillation, the American College of Cardiology invited Dr. Pantridge to speak at its annual convention the following year.26
After learning of Dr. Pantridge’s success, physicians at Ohio State University started their own version of the mobile coronary care unit which they dubbed the "heartmo-bile." The heartmobile continued to operate through Ohio State University until July 1971 until it became a part of the Columbus Division of Fire as Squad 52.
Emergency Hits TV Screens
Robert A. Cindar was interested in emergency medical services, and particularly the advent of the Paramedic. Following his success with creating the television show Adam-12, Mr. Cindar approached then Captain James Page of the Los Angeles Fire Department and asked him if he would be the technical advisor for a new "reality" television program to be called Emergency.
Figure 2-6 Emergency Paramedics Jon Gage and Roy DeSoto.
The show was to be loosely based on the new Paramedic program. Subsequently, the crew of the television Squad 51 of the L.A. County Fire Department began to roll. These fire department Paramedics, or fire-medics, responded to all variety of emergencies, from fires to special and technical rescue to every imaginable medical emergency, always rendering expert medical care in the field. An entire generation of future Paramedics was raised watching the emergency medical care provided by Firefighter/Paramedics Gage and DeSoto (Figure 2-6).
EMS Act of 1973
In 1973 Congress passed the EMS Act, Public Law 93-154, an amendment to the Public Health Service Act of 1944, which offered technical assistance to regions and municipali-ties.27 The EMS Act of 1973 delineated the 15 aspects of an EMS system that needed improvement including education (both public as well as provider), improved communications (including public access), and system evaluation but offered little money to help make those improvements.
Federal EMS Efforts in the 1980s
The 1981 Omnibus Budget Reconciliation Act took monies previously earmarked for EMS and placed them under a broader rubric of preventive health money. The federal government provided the states with large "block" grants to fund various programs including EMS. While the intention was to continue to fund EMS, the effect was to turn control of EMS funding over to the states. The states then choose how to spend the allocated monies. Some states did not support funding for EMS to the same level as the federal government had.
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1500 B.C. Roman Wars |
1950-1970 Korean and Vietnam Wars |
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• Evidence of first treatment protocols. |
• Mobile Army Surgical Hospitals (MASH) were developed during the Korean and Vietnam conflicts in an attempt to save the most seriously injured patients through a transportation-dependent method of triaging. |
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• Romans and Greeks used chariots to remove wounded from the battlefield. |
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1797 The Napoleonic Wars |
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• Baron Dominique-Jean Larrey, Napoleon Bonaparte’s chief surgeon, constructed a horse-drawn carriage called the ambulance volante or "flying ambulance." |
• Transportation of wounded soldiers by helicopter to medical units, used first during the Korean War, was the genesis of modern aeromedical transportation. |
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1860s The U.S. Civil War |
• The HU-1 (Huey) helicopter used during the Vietnam War had a large patient compartment to allow emergency care to begin while in flight. |
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• The first ambulance service in the United States was developed by U.S. Army surgeon Jonathan Letterman, who reorganized the Army Medical Corp to include ambulances, similar to Baron Dominique-Jean Larrey’s flying ambulances. |
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1960s Development of an EMS System |
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• (1966) The National Academy of Sciences produced a white paper, "Accidental Death and Disability: The Neglected Disease of Modern Society" for President Kennedy. It stated that, to that date, more Americans had died on American Highways than in all of the U.S. wars. |
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• Clara Barton was a volunteer on the Civil War battlefields and saw the mayhem first hand. Returning from the Franco-Prussian War, where she witnessed the good work of the Red Cross on the battlefield, she founded the American Red Cross. |
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1865-1950 U.S. Ambulance Service |
• (1966) The National Highway Safety Act of 1966 encouraged states to begin organized EMS programs. |
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• (1865) Cincinnati established the first civilian ambulance service. |
• (1967-1968) The first paramedic services were established in Miami, Florida, using telemetry units designed by Dr. Eugene Nagel and Dr. John Hirchmann. |
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• (1869) New York City established an ambulance service with hospital interns riding in horse-drawn carriages designed specifically for the sick and injured. |
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• (1968) St. Vincent’s Hospital in New York City established the first coronary care unit in the United States, and Columbus, Ohio established mobile coronary units staffed with cardiology fellows from OSU. Both soon replace physicians with advanced trained EMTs. |
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• (1901) At the Pan American Expo in Buffalo, NY, the first electric-powered ambulance was demonstrated and used to transport people to the on-site hospital. |
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• (1910) One of the first ambulances, called the "Invalid’s Car," ran out of Iowa Methodist Hospital, Des Moines, Iowa, staffed with a nurse and resident from the hospital. |
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• (1969) The first nationally recognized EMT course was held in Wausau, Wisconsin. Dr. J. "Deke" Farrington was the course medical director. |
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• (1928) The Roanoke Life Saving and First Aid Squad was the first volunteer rescue squad in the United States. |
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• (1969) Dr. Leonard Cobb, Harborview Medical Center, and Seattle |
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1910-1940s The World Wars |
Fire Department established the Medic One paramedic program. |
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• An unmodified French fighter aircraft was used for air medical transport during the retreat of the Serbian army from Albania. |
1970s The Star of Life and Voice of EMS |
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• (1970) The National Registry of EMTs (NREMT), a national EMS certification organization that maintains a registry of certifications, was established. |
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• "Combat medics" cared for the wounded in the field with advanced procedures including intravenous solutions, crude antibiotics, and intraosseous (bone) needles. |
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• (1971) "Emergency!" debuted on television, putting a public face on EMTs and Paramedics providing expert medical care on the scene of an accident. The show increased public awareness of EMS and possibly influenced government funding of EMS. |
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• Improved systems for trauma care were established including field hospitals and forward first-aid stations. |
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• Mechanized ambulances with the characteristic Red Cross emblem on the side were used and the era of the ambulance driver had arrived. |
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• (1973) Star of Life was adopted as the national EMS symbol, representing the six points of the complete EMS system: detection, reporting, response, on-scene care, care in transit, and transfer to definitive care. The central staff with a serpent wrapped around it represents medicine and healing. |
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1950s Out of Hospital Medical Advances |
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• American Red Cross took the lead in providing basic medical training, making classes such as Standard and Advanced First Aid the standard of care for rescue squad members. |
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• (1973) U.S. Congress passed the Emergency Medical Services Systems Act (PL93-144), which identified 15 essential components of an EMS system and allocated federal funding for individual EMS regions to address these components. |
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• Cardiopulmonary resuscitation (CPR) was taught to civilians for the first time in the late 1950s and early 1960s. |
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• (1958) Mouth-to-mouth ventilation was demonstrated by Dr. Peter Safar using volunteers from the Baltimore Fire Department, who agreed to be paralyzed. |
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• (1975) National Association of EMTs (NAEMT) was formed to represent the needs of all EMTs to the public and government. |
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• (1958) Dr. Joseph K. "Deke" Farrington, known as the Father of EMS, and Dr. Sam Banks started a trauma training course for the Chicago Fire Department in what was to become the prototype of the EMT-Ambulance course. |
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• (1979) American Ambulance Association (AAA), a representative organization for the ambulance service industry and legislation affecting EMS, was founded. |
Figure 2-7 EMS Timeline.
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1970s-Present Iraq War |
• (1986) The Comprehensive Omnibus Budget Reconciliation Act (COBRA) prevented patient "dumping," or transferring patients incapable of paying for services. |
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• With an advanced skill set, the 68W healthcare specialist (a.k.a. Army medic) is prepared to treat combat casualties as well as civilian combatants. |
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• (1988) The National Highway Traffic Safety Administration initiated the Statewide EMS Technical Assessment program based on ten key components of EMS systems. |
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• Development and deployment of special blood-stopping dressings, one-handed tourniquets, and special surgical procedures for extremity injuries and burns. |
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• (1990) The Trauma Care Systems and Development Act of 1990 provided funding to states for trauma system planning, implementation and evaluation, encouraging development of inclusive trauma systems. |
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1980s-2000 Agenda for the Future—Education and Federal Funding |
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• (1981) The Omnibus Budget Reconciliation Act of 1981 consolidated EMS funding into state preventative health and health services block grants. Funding under the EMSS Act is eliminated. |
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• (1993) The Institute of Medicine published "Emergency Medical Services for Children," pointing out deficiencies in the healthcare system’s ability to address the emergency medical needs of pediatric patients. |
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• (1984) Medical Priority Dispatching began in Salt Lake City, Utah. |
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• (1984) EMS for Children (EMS-C) program, under the Public Health Act, was established, providing funds for enhancing the EMS system to better serve pediatric patients. |
• (1996) "The EMS Agenda for the Future" was released, outlining 14 essential attributes for future EMS development. |
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• (2006) The controversial report, "The Future of Emergency Care: Emergency Medical Services at the Crossroads" was released by the Institute of Medicine. |
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• (1985) The National Research Council published "Injury in America: A Continuing Public Health Problem," describing deficiencies in the progress in addressing the problems of accidental death and disability. |
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Table 2-1 Statement from the EMS Agenda for the Future
EMS Agenda for the Future
As shown in Figure 2-7, EMS has developed out of a long and rich history. In 1995, the National Association of State Emergency Medical Services Directors (NAEMSD) and the National Association of EMS Physicians (NAEMSP), with assistance from the National Highway Traffic Safety Administration (NHTSA), met to reflect upon the previous 25 years of EMS practice experience and to establish their vision for the future of EMS. Their intention was to guide EMS toward its own destiny. The product of those meetings was called the EMS Agenda for the Future (Table 2-1).
The EMS Agenda for the Future suggests that EMS will be more intimately intertwined with public health, as well as public safety, and continue to evolve along with health care. The EMS Agenda suggested that public expectations and demands of EMS will remain high. These expectations will be fueled in part by increasing media attention by the press, television, and Internet as well as consumer demand.
To meet those expectations, Paramedics and emergency physicians are going to need to make better decisions regarding what care provides the best patient outcomes in the most cost effective manner. The standard of care that was formerly provided may not be the best care that can be offered. In that case, the public is going to demand performance improvement and cost efficiency.
In other words, EMS practice is going to have to become more evidence-based (i.e., supported by the medical research). In situations where the evidence is lacking, EMS should review their experience and reflect upon those practices that have led to the most desirable outcomes and strive to replicate them. These practices are the so-called best practices.
Emergency Medical Services (EMS) of the future will be community-based health management that is fully integrated with the overall healthcare system. It will have the ability to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to the treatment of chronic conditions and community health monitoring. This new entity will be developed from redistribution of existing healthcare resources and will be integrated with other healthcare providers and public health and public safety agencies. It will improve community health and result in more appropriate use of acute healthcare resources. EMS will remain the public’s emergency medical safety net.28
EMS agencies should also strive to improve their operational preparedness. Proactive EMS agencies will look to the leaders in the EMS industry and use their operational practices as benchmarks. These benchmarks will rapidly become the standard of care and public officials will measure their EMS systems operations against the EMS standard of care.
To survive in a world of ever tightening fiscal constraints, and in order to remain the public’s "safety net," EMS will have to demonstrate its efficiency and effectiveness and its willingness to adapt to improved medical technology.
The EMS Agenda for the Future describes the attributes of an effective and efficient EMS system. The EMS Agenda for the Future was reviewed by 500 EMS organizations and individuals, who came to consensus about EMS excellence. The panel that created the EMS Agenda for the Future listed 14 attributes of EMS (Table 2-2) and noted that EMS needs to continue to develop those 14 attributes if it is to reach its greatest potential.
Table 2-2 Attributes of an EMS System According to the EMS Agenda for the Future
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1. |
Integration of Health Services |
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EMS Research |
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Legislation and Regulation |
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4. |
System Finance |
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5. |
Human Resources |
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6. |
Medical Direction |
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7. |
Education Systems |
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8. |
Public Education |
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9. |
Prevention |
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10. |
Public Access |
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11. |
Communication Systems |
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12 |
Clinical Care |
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13. |
Information Systems |
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1 4. |
Evaluation |
