Modernization Hub

Modernization and Improvement
Paramedic 1.01 – EMS Systems: History of EMS

Paramedic 1.01 – EMS Systems: History of EMS


In this module, we will explore the history
of EMS. Once completed with this module, you should
be able to describe key historical events that influenced the national development of
EMS systems. To begin our exploration of EMS history, we
will start with the period of time prior to World War I. Many advances in emergency medicine evolved
out of the need to treat wounded soldiers and many historians recognize the work of
the Knights of St. John (during the 11th century crusades) as some of the first emergency responders
in an EMS sense given their work in providing first aid to soldiers on the battlefield and
taking them to treatment tents located nearby. Over a period of four months, Catholic Monarchs
laid siege to the Spanish city of Málaga, eventually wresting control of the city from
the Muslims who held it prior. The conflict is significant for EMS as it
is the first such event where wounded soldiers were moved from the front lines to medical
tents via the use of bedded wagons. These wagons served as the period’s equivalent
to an ambulance for the transport of the injured. The catch, however, was that the wounded soldiers
had to wait until the battle was over before the wagons would venture onto the battlefield
to collect and transport the wounded. A few centuries later, Napoleon employed the
use of wagons on the battleground to aid in the treatment of fallen soldiers and his chief
physician, Dominique Jean Larrey, arranged for wounded soldiers to be picked up from
an active battlefield. Fast forward half a century or so to the American
Civil War and United States Surgeon General, William Hammond, enters the discussion. Under his leadership, the military created
a medical corps whereby litter bearers and ambulance-wagon drivers were responsible for
transporting wounded soldiers from the battlefield to Army hospitals. Shortly thereafter, in 1865, the first civilian
ambulance started operation at Commercial Hospital in Cincinnati, Ohio. In 1869, Bellevue Hospital in New York City
started an actual ambulance service with wagons and horse teams. The service responded to just over 1,400 runs
in their first full year of operation in 1870. In keeping with updated technology, it was
only a matter of time before horse-drawn carriages were replaced by mechanical vehicles and the
first motor-powered ambulance went in service at the Michael Reese Hospital in Chicago,
Illinois in 1899. Within the period of time from World War I
through World War II, EMS saw incremental improvements in terms of its availability
to the public as well as how it was provided. Evidence of emergency care from World War
I led to the introduction of traction splints for femur fractures, which often saved patients
from having to undergo an amputation of the affected extremity. Telegraph and telephones were being used to
contact police departments, which could then dispatch an ambulance. Communications were also improving and many
ambulances began utilizing two-way radios. During this period of time, we began seeing
ambulance services provided by entities other than hospitals. Prior to World War I, ambulance services were
predominantly hospital-based. In 1926, the Phoenix Fire Department began
providing “inhalator” services to the community, which marked the fire service’s
entrance into the realm of EMS. Just two years later, in 1928, Julian Stanley
Wise founded the first volunteer rescue squad in the country, the Roanoke Life Saving and
First Aid Crew. Once World War II was in full-swing, many
hospitals could not continue providing ambulance services as they once did because doctors
were in short supply due to the war effort and many were drafted into service. To fill this void, many municipalities began
utilizing their police and fire departments for providing EMS. With that being said, there were no uniform
training standards or education available, so the quality of care provided varied significantly
from agency to agency. In some agencies, fire departments in particular,
being an ambulance attendant was considered to be a form of punishment; it was not a desired
position. Ultimately, the vestiges of modern EMS really
started to blossom after World War II. Helicopters were used extensively in the Korean
War to transport over 18,000 wounded solders. Mouth-to-mouth resuscitation was developed
in 1956 and the first portable defibrillator was developed at Johns Hopkins Hospital in
1959. In 1960, the Los Angeles Fire Department began
incorporating medically-trained personnel on its engine, ladder, and rescue companies. Let’s pull away from our timeline for just
a moment and look at the impact that military conflicts have had on emergency medicine. Given that EMS was historically driven by
advancements out of the military, one can see a distinct decrease in injury mortality
rates from the Civil War through modern times. While different resources may fluctuate somewhat
on the numbers (and data can also look at the incidence of disease versus actual injuries,
the nature of the injury, and other factors in various mortality rate studies), mortality
rates of 1 out of every 8 solders wounded in battle during the Civil War appear commonplace
in the literature, resulting in a 14.3% mortality rate. In World War I, this number was reduced to
8.5%. The advent of helicopters for medical evacuation
yielded even greater reductions in battlefield mortality within the Korean and Vietnam Wars
with rates of 2.4% and 2.6%, respectively. In the modern day, the mortality rate has
climbed from the rates recorded in Korea and Vietnam, but that is often attributed to the
lethality of the weapons employed in the modern theatre of war in conjunction with more selective
and hazardous missions and other factors. Arguably, this decrease in battlefield mortality
rates are strongly correlated with the ability of the military to evacuate wounded soldiers
to definitive medical care. In the early years of the civil war, soldiers
had to self-evacuate the battlefield and walk to the nearest hospital, which could be dozens
of miles away. The timeframe associated with the delay in
definitive medical treatment from the occurrence of a soldier’s injury was 12 to 15 hours
in World War II. In Vietnam, that time had been reduced to
approximately two hours. In the recent middle-east military activities
in Iraq and Afghanistan, that time was reduced even further to somewhere between 30 to 90
minutes. While we have focused predominantly on military
data thus far, that focus began to shift in the mid-1960s when the National Academy of
Sciences published “Accidental Death and Disability: The Neglected Disease of Modern
Society.” Referred to simply as “The White Paper,”
this document is often referred to as a watershed publication in that it was responsible for
starting civilian EMS in the United States. For the first time at a national level, we
started looking at accidental civilian deaths and injuries and asked ourselves what could
be done to change some rather disheartening trends. In just 1965 alone, the document stated there
were 52,000,000 accidental injuries in which 107,000 people were killed, more than 10,000,000
were disabled, and 400,000 were permanently impaired, all at a cost of $18 billion (or
the equivalent of over $142 billion in 2018). The White Paper also called attention to several
systemic challenges within the United States at the time. There were no uniform laws and standards governing
EMS, ambulances and the equipment within them were of poor quality, communications between
EMS and the hospitals to which they were transporting were lacking or inadequate, emergency medical
personnel did not receive proper training, and hospitals routinely staffed emergency
departments with part-time personnel. At this time, the United States was knee-deep
in the Vietnam conflict and the data showed that more people died in automobile accidents
in one year (49,000 in 1965 alone) than had been killed in the Vietnam conflict up to
that time. (In totality, the Defense Casualty Analysis
System records the number of U.S. military fatal casualties in the Vietnam conflict as
58,220.) Given that the conflict in Vietnam would wage
for another ten years after the publishing of The White Paper, the comparison between
the two helped underscore the scope of the injury problem within the United States. Within the same timeframe as the publishing
of The White Paper, Congress passed the National Traffic and Motor Vehicle Safety Act and the
Highway Safety Act in September of 1966. The laws provided the federal government with
the means to set and administer new safety standards for motor vehicles and road traffic
safety while also creating the National Highway Safety Agency (which is now known as the National
Highway Traffic Safety Administration). As far as EMS is concerned, the law required
states to “have a highway safety program designed to reduce traffic accidents and deaths,
injuries, and property damage resulting therefrom.” These programs had to comply with uniform
standards promulgated by the Secretary of Commerce, which included, among other things,
emergency services. The law also empowered the Secretary of Commerce
to make funds available to states and local agencies for training or education of highway
safety personnel while also allowing for the funding of research fellowships in highway
safety and emergency service plans. The total appropriation of funds within the
law was $322 million over three years from 1967 through 1969. In case you were wondering, many resources
lump these two laws together as a single Act, but they were indeed two separate Acts passed
on the same day. Additionally, many associate the creation
of the United States Department of Transportation with these Acts, but that is not actually
the case. It was approximately a month later that Congress
passed the Department of Transportation Act (Public Law 89-670), which created the DOT
and moved the responsibilities associated with the National Traffic and Motor Vehicle
Safety Act from the Department of Commerce to the newly-created Department of Transportation. Ultimately, this law had a significant impact
on the development of EMS within the United States, especially given the requirement that
states include emergency services in their highway safety programs. The funding made available to train and educate
highway safety personnel was helpful as well. While motor vehicle accidents are only one
type of emergency to which modern EMS agencies respond, preventing and mitigating highway
deaths and injuries were the impetus behind the federal funding that laid the foundation
for EMS within the United States. Shortly after the passage of the National
Traffic and Motor Vehicle Safety Act, the Highway Safety Act, and the Department of
Transportation Act in 1966, the DOT published its uniform guidelines for state highway safety
programs. While all 13 guidelines are included on this
slide, the most important guideline to EMS was the eleventh, which called for state health
departments to employ a full-time person to work on emergency care of accident victims,
while also requiring the establishment of a statewide emergency medical services program. These guidelines included several categories
and subsequent recommendations. Under the regulation and policy category,
states were directed to establish the EMS program and designate a lead agency; outline
the lead agency’s basic responsibilities, including licensure and certification; require
comprehensive planning and coordination; designate EMS and trauma system funding sources; require
data collection and evaluation; provide authority to establish minimum standards and identify
penalties for noncompliance; and, provide for an injury/trauma prevention and public
education program. Where resource management is concerned, the
lead agency in each state should maintain a coordinated response and ensure that resources
are used appropriately throughout the state; provide equal access to basic emergency care
for all victims of medical or traumatic emergencies; provide adequate triage and transport of all
victims by appropriately certified personnel (at a minimum, trained to the basic EMT level)
in a properly licensed, equipped, and maintained ambulance; provide transport to a facility
that is appropriately equipped, staffed, and ready to administer to the needs of the patient;
and, appoint an advisory council to provide a forum for cooperative action and maximum
use of resources. As far as these categories are concerned,
human resources and training is really where the proverbial rubber hits the road in EMS
as police, fire, EMTs, paramedics, dispatchers, physicians, nurses, hospital administrators,
emergency managers, and others are all recognized as crucial individuals within the EMS system. As such, states should provide a comprehensive
statewide plan for stable and consistent EMS training programs with effective local and
regional support. Additional standards mandate that the state
ensure sufficient availability of adequately trained EMS personnel; establish EMT-Basic
as the state minimum level of training for all transporting EMS personnel; routinely
monitor training programs to ensure uniformity and quality control; use standardized curricula
throughout the state; ensure availability of continuing eduction programs; require instructors
to meet state requirements; develop and enforce certification criteria for first responders
and prehospital providers; and, require EMS operating organizations to collect data to
evaluate emergency care in terms of the frequency, category, and severity of conditions treated
and the appropriateness of care provided. Transportation is also of critical importance
to EMS and states should require safe and reliable ambulance transportation by developing
statewide transportation plans, including the identification of specific service areas. Additional suggestions include: implementing
regulations that provide for the systematic delivery of patients to appropriate facilities;
developing routine, standardized methods for inspection and licensing of all emergency
medical transport vehicles; establishing a minimum number of providers at the desired
level of certification on each response; coordinating all emergency transports within the EMS system,
including private, public, or specialty transport; and, developing regulations to ensure ambulance
providers are properly trained and licensed. To reduce mortality and morbidity rates, seriously
injured patients must be delivered to the closest appropriate facility in a timely manner. As such, states should ensure that both stabilization
and definitive care needs of the patient are considered; the determination is free of non-medical
considerations and the capabilities of the facilities are clearly understood by prehospital
personnel; hospital resource capabilities are known in advance, so that appropriate
primary and secondary transport decisions can be made; and, agreements are made between
facilities to ensure that patients receive treatment at the closest, most appropriate
facility, including facilities in other states or counties. An effective and reliable communications system
provides the means by which emergency resources can be accessed, mobilized, managed, and coordinated. Therefore, states should require the EMS communication
system to begin with the universal system access number, 911; strive for quick implementation
of enhanced 911 services that make possible, among other features, the automatic identification
of the caller’s physical location; provide for prioritized dispatch from dispatch-to-ambulance,
ambulance-to-ambulance, ambulance-to-hospital, and hospital-to-hospital; ensure that the
receiving facility is ready and able to accept the patient; and, provide for dispatcher training
and certification standards. Being as how traumatic injuries and deaths
provided the impetus for the Highway Safety Act, it should come as no surprise that the
DOT standards included several trauma-related provisions, such as the need for states to
maintain a fully functional trauma system to provide a high-quality, effective patient
care by including trauma center designations (using the American College of Surgeons Committee
on Trauma guidelines as a minimum); triage and transfer standards for trauma patients;
data collection and trauma registry definitions for quality assurance; mandatory autopsies
to determine preventable deaths; and, systems management and quality assurance. Public awareness and education about the EMS
system was recognized as being essential to maintaining a high-quality EMS system and
each state was encouraged to implement a public information and education plan to address
the components and capabilities of an EMS system; the public’s role in the system;
the public’s ability to access the system; what to do in an emergency (which would include
bystander first aid training); education on prevention issues, such as alcohol or drug
use and abuse, vehicle occupant protection, speeding, motorcycle safety, and bicycle safety;
the EMS providers’ role in injury prevention and control; and, the need for dedicated staff
and resources for public information and education programming. EMS is a medical care system in which physicians
delegate responsibilities to non-physician providers who manage patient care outside
the traditional confines of the office or hospital. As a result, physician involvement in all
aspects of the patient care system is critical for effective EMS operations and states should
require physicians to be involved in all aspects of the patient care system, including planning
and protocols, on-line and off-line medical direction and consultation, and audit and
evaluation of patient care. The last EMS element defined within the Highway
Safety Program’s Guideline #11 was the evaluation of the EMS system. To assess and improve a statewide EMS system,
EMS system managers should evaluate the effectiveness of services provided to victims of medical
or trauma-related emergencies; define the impact of patient care on the system; evaluate
resource utilization, scope of service, patient outcome, and effectiveness of operational
policies, procedures, and protocols; develop a data-gathering mechanism that provides for
the linkage of data from different data sources through the use of common data elements; and,
evaluate both process and impact measures on injury prevention, as well as public information
and education programs. Needless to say, the blueprint for modern
EMS was incorporated within those standards published all the way back in 1967. Within that same period of time, the inventor
of the portable defibrillator, cardiologist Dr. Frank Pantridge, began something known
as the “Pantridge Plan” by equipping ambulances in Belfast, Ireland with his invention of
a 70 kilogram “portable” defibrillator that operated from car batteries. Believe it or not, this pre-hospital coronary
care unit was copied within the United States and was actually credited with assisting United
States President Lyndon Johnson when he suffered a heart attack while on a visit to Virginia
in 1972. Given the impact of his efforts, Dr. Pantridge
has often been called the father of emergency medicine and we now take the science behind
defibrillators for granted. With The White Paper as a catalyst, changes
began occurring rapidly within the world of EMS. In 1967, Dr. Eugene Nagel worked with the
Miami Fire Department to implement the nation’s first recognized paramedic program with paramedics
routinely transmitting ECGs to Jackson Memorial Hospital by March of that year. Other paramedic programs were also starting
at the same time (or shortly thereafter) in larger metropolitan areas, such as Los Angeles,
California and Seattle, Washington. In 1968, the National Research Council published
the book Training of Ambulance Personnel and Others Responsible for Emergency Care of the
Sick and Injured at the Scene and During Transport. For those interested, the book is available
for free via download through The National Academies Press. This book was a mere 29 pages in length (with
several pages dedicated to introductory information and end-of-text references). By comparison, some current EMT textbooks
can exceed well over 1,500 pages! Also in 1968, given some insistence from the
FCC, the American Telephone and Telegraph Company (now simply known as AT&T) established
911 as the phone number that would be used to contact emergency services throughout the
United States. The number was chosen because it was brief,
easily remembered, could be dialed quickly, and was unique in that 911 had never been
used previously as an office, area, or service code. As reported by the National Emergency Number
Association, only about 17% of the United States population was served by 911 by the
end of 1976. This percentage increased to about 26% by
the end of 1979. It wasn’t until 1987 that approximately
half of the country’s population had access to 911 emergency service numbers. As of the current day, approximately 96% of
the geographic United States is covered by some type of 911 service. In 1970, the National Academy of Sciences
published the document, Medical Requirements for Ambulance Design and Equipment to help
define standards for ambulance design, along with required equipment and supplies. The 25 page document is still available online
through the Education Resources Center maintained by the Institute of Education Sciences within
the US Department of Education. The National Registry of Emergency Medical
Technicians was also started in 1970 and the “Highway Safety Act of 1970” created the
National Highway Traffic Safety Administration (replacing the previously existing National
Highway Safety Bureau). In 1971, the American Academy of Orthopedic
Surgeons published the first edition of its long-running textbook, Emergency Care and
Transportation of the Sick and Injured (which is currently offered in its 11th edition at
the time this presentation was produced). This marked the availability of the first
textbook for EMS personnel. (For clarification, some resources state that
this textbook was made available in 1967, but the AAOS states on its own website that
the text was first published in 1971. Additional resources have indicated that work
on the textbook began in 1967, which would explain the discrepancy in the dates.) In that same year, 1971, the AAOS also hosted
a national workshop on the training of emergency medical technicians in an attempt to consolidate
a lot of the work that had been completed previously at the national level. The culmination of efforts at this workshop
resulted in the 1972 NHTSA document Recommendations and Conclusions for an Approach to an Urgent
Problem, which included 12 recommendations for standardizing and improving EMS education. Believe it or not, EMS even garnered recognition
within President Nixon’s State of the Union address in which the Department of Health,
Education, and Welfare was directed to develop new ways to organize emergency medical services
within the country. This resulted in the Department of Health,
Education, and Welfare awarding $8.5 million in contracts for the development of model
EMS systems. We also saw the start of the nation’s first
civilian-based air medical transport program in 1972. Flight for Life was founded by St. Anthony
Hospital in Denver, Colorado and is still in operation today, providing regional air
medical and critical care transport to nine states in the Rocky Mountain region. The television show Emergency! also started
its eight year run in 1972. For those laypersons unfamiliar with emergency
medicine, the television show did a great job of introducing them to the profession
and ultimately served as the impetus for many kids growing up in that decade to pursue careers
in EMS and the fire service. Very early on, the Department of Transportation
recognized that it would be important for EMS systems, agencies, and providers to be
readily and distinctively identified for the benefit of both the public at large, as well
as the patients served by EMS. To meet this need, the DOT adopted and registered
the “Star of Life” symbol in 1972. Each bar on the “Star of Life” represents
one of the six functions of EMS: detection, reporting, response, on-scene care, care in
transit, and transfer to definitive care. The serpent and staff constitute the staff
of Asclepius, which represents medicine and healing. Asclepius was the Greed god of medicine and
the skin-shedding serpent, representing renewal, also has biblical significance given Moses
had crafted a bronze serpent mounted on a pole to heal people who were bitten by a serpent. Over the years, the “Star of Life” has
become associated with emergency medical care around the globe and is routinely used to
identify EMS agencies, providers, systems, and other related materials. A huge boost to EMS arrived in November of
1973 through the passage of the Emergency Medical Services Systems Act (Public Law 93-154). This law created an Interagency Committee
on EMS while also making $185 million in federal money available over the course of three years
to support several key initiatives related to EMS. The first initiative was to support projects
that study the feasibility of establishing (through expansion or improvement of existing
services or otherwise) and operating an EMS system, and planning the establishment and
operation of such a system. The second area of focus was to support the
establishment and initial operation of emergency medical services systems, with an emphasis
on the coordination of statewide systems. Funds under this provision could also be used
for the modernization of facilities, as well as other costs associated with establishment
and initial operation. The third topic of emphasis was research related
to EMS techniques, methods, devices, and delivery. Lastly, funding was also provided to schools
of medicine, dentistry, osteopathy, nursing, allied health disciplines, and other appropriate
educational entities to assist in meeting the cost of training programs in the techniques
and methods of providing EMS. Needless to say, these funds went a long way
in helping states establish (or improve) their own EMS systems. In addition to securing funding for the activities
defined in the previous slide, the EMS Systems Act of 1973 also included a list of 15 EMS
system requirements. As defined within the law, EMS systems shall
have or perform the following: Include an adequate number of health professions
and personnel with appropriate training and experience. Provide appropriate training (including clinical
training) and continuing education programs that are coordinated with other similar programs
in the system’s service area and emphasize recruitment of veterans with health care experience
and others with public safety experience to teach such offerings. Join the personnel, facilities, and equipment
of the system by a central communications system that uses emergency medical screening,
provides access through 911, and allows direct communication connections and interconnections
with the system’s personnel, facilities, and equipment, along with those of other systems. Ensure there are adequate numbers of ground,
air, water, and other vehicles to meet the needs of the system’s service area that
meet location, design, performance, and equipment standards while also providing trained and
experienced operators for those vehicles. Include an adequate number of easily accessible
emergency medical services facilities that are collectively capable of providing services
on a continuous basis, can be coordinated with other health care facilities within the
system, and meet appropriate standards relating to capacity, location, personnel, and equipment. Provide access (including appropriate transportation)
to specialized critical medical care units in the system’s service area or can arrange
access to such units in neighboring areas (if feasible). Provide for the effective utilization of the
appropriate personnel, facilities, and equipment of each public safety agency providing emergency
services in the system’s service area. Have an organizational structure that allows
laypersons in the community an adequate opportunity to participate in the making of policy for
the system. Provide medical services to all patients requiring
such service, regardless of whether the patient has the financial resources to pay for them. Provide for the transfer of patients to facilities
and programs that offer follow-up care and rehabilitation as necessary to effect the
maximum recovery of the patient. Maintain a standardized patient record-keeping
system that covers the patient’s treatment from initial entry into the system through
discharge while being consistent with ensuing records used in the patient’s follow-up
care and rehabilitation. Provide public education and information programs
that stress the general dissemination of information regarding appropriate methods of medical self-help
and first aid, including the availability of first aid training programs in the service’s
area. Provide for periodic, comprehensive, and independent
review and evaluation of the extent and quality of the emergency health care services provided
in the system’s service area. Maintain a plan to ensure the system can continue
to function in the case of a mass casualty, natural disaster, or national emergency. Lastly, support reciprocal service arrangements
with neighboring areas when such services would be more appropriate and effective in
terms of the services available, time, and distance. Subsequent to the passing of the EMS Systems
Act of 1973, the federal Department of Health, Education, and Welfare drafted Part 56a to
Title 42 of the Code of Federal Regulations governing grants for emergency medical services
systems. On July 1, 1974, the regulations went into
effect. An important thing to note is that this regulation
incorporated the newly developed (as of January 1974) General Services Administration KKK-A-1822
ambulance standards into the definition of a “ground vehicle” for transporting patients. Following the adoption of these regulations,
the federal Department of Health, Education, and Welfare also published the EMS Systems
Program Guidelines document in 1975 to assist applicants for contracts and grants funding
under the law in understanding the legislation, regulations, guidelines, and related administrative
procedures. This document further clarified the 15 requirements
of an EMS system as defined within the EMS Act. To evaluate the effectiveness of federal grant
funding related to EMS, NHTSA studied highway traffic safety performance nationwide over
a period of six years and published its Statewide Highway Safety Program Assessment in 1975. As far as EMS was concerned, there were some
interesting findings. EMS responses increased in the sample area
from 8.8 million to 12.2 million from 1969 to 1974, but the number of EMS agencies declined
from 18,000 to 16,900. This decline was attributed to funeral homes
discontinuing EMS activities. Volunteer fire and rescue groups grew to account
for 50% of total services providing EMS. The DOT had produced and offered an 81-hour
Basic Care Course that was supported through the grant funding, but only half of the EMTs
had received this updated training. In 1975, the American Medical Association’s
Section Council in Emergency Medicine, which was formed provisionally in 1973, became permanent. The American Board of Emergency Medicine was
incorporated in 1976 and emergency medicine was finally recognized as a specialty by the
American Board of Medical Specialties in 1979, 11 years after the creation of the American
College of Emergency Physicians; 7 years after emergency medicine had been recognized as
a specialty by the American Medical Association. The National Association of EMTs was formed
in 1975 and NHTSA also produced a Curriculum Guide to “provide a description of the curriculum
at a level of detail sufficient for most program planning purposes, short of actually teaching
the recommended contents.” At the same time, the University of Pittsburgh
and Nancy Caroline, MD, were awarded a contract to produce the first EMT-Paramedic National
Standard Curriculum (which was subsequently published by NHTSA two years later in 1977). In 1979, the educational functions associated
with the Department of Health, Education, and Welfare were transitioned over to the
newly formed Department of Education under the Department of Education Organization Act
of 1979. The name of the Department was also updated
in the Act to the Department of Health and Human Services. At the start of the 1980s, the federal government
passed the Omnibus Budget Reconciliation Act of 1981. This legislation enacted sweeping changes
related to financial policy within the United States to reconcile the 1982 fiscal year federal
budget. These changes impacted numerous industries
and topics, such as agriculture, banking, education, human services, energy, transportation,
Medicare and Medicaid, public assistance programs, and others. As far as EMS was concerned, the Omnibus Budget
Reconciliation Act of 1981 eliminated the EMS Systems Act’s categorial federal funding
to states and replaced it with block grants for preventative health and health services. The practical effect of this funding change
was that primary responsibility for EMS development and maintenance shifted from the federal level
to the states. States essentially had the ability to take
their grant funds and apply them however they saw fit, with EMS being just one part of the
larger picture. As a result, total funding for EMS decreased
significantly (as reported by the U.S. Congress, Office of Technology Assessment in 1989). As the block grants were no longer tied to
specific EMS-related criteria as they were under the 1973 EMS Systems Act, states began
developing and modifying their own systems apart from each other, which resulted in significant
diversity in EMS systems from state-to-state that still exists today. In October 1984, the Preventative Health Amendments
Act of 1984 was passed. This law included a section related to emergency
medical services for children that provided grant funding to support programs related
to the expansion and improvement of emergency medical services for children who need treatment
for trauma or critical care. The National Association of EMS Physicians
was also formed in 1984. In 1988, NHTSA rolled out its statewide EMS
technical assessment program to help states measure the effectiveness of their existing
(and proposed) EMS programs. The NHTSA Technical Assessment Program has
been updated since its formation in the late 1980s, but still uses the same 10 key components
in identifying EMS system strengths, needs, and strategies. These components are the same as those that
were included within the EMS category of the 1967 Highway Safety Program Guidelines and
are summarized as follows: Regulation and policy: Every state should
embody comprehensive enabling legislation, regulations, and operational policies and
procedures to provide an effective system of emergency medical and trauma care. Resource management: Every state should establish
a central lead agency at the state level to identify, categorize, and coordinate resources
necessary for overall system implementation and operation. Human resources and training: Each state should
ensure that its EMS system has essential trained persons to perform required tasks. Transportation: Each state should require
reliable ambulance transportation, which is critical to an effective EMS system. Facilities: It is imperative that the seriously
injured patient be delivered in a timely manner to the closest appropriate facility. Communications: An effective communications
system is essential to EMS operations and provides the means by which emergency resources
can be accessed, mobilized, managed, and coordinated. Trauma systems: Each state should maintain
a fully functional trauma system to provide a high quality, effective patient care system. Public information and education: Public awareness
and education about the EMS system are essential for a high quality system. Medical direction: Physician involvement in
all aspects of the patient care system is critical for effective EMS operation. Lastly, evaluation: Each state should implement
a comprehensive evaluation program to effectively assess and improve a statewide EMS system. Additional criteria exist within each of these
categories as well. Wisconsin EMS has participated in several
of these assessments, with the most recent being in 2012. In 1990, Congress passed the Trauma Care System
Planning and Development Act, which added a trauma care section to the existing Public
Health Service Act. This Act made federal grant funds available
to support states in further developing their trauma systems. Among other requirements and provisions, states
receiving funding under the Act had to adopt standards for the designation of trauma centers;
they had to adopt standards for triage, transfer, and transportation policies; and, they were
required to submit annual data to the Department of Health and Human Services, as well as identifying
rural areas that lacked certain emergency medical services. At the federal level, the law also created
an Advisory Council on Trauma Care Systems, along with a National Clearinghouse on Trauma
Care and Emergency Medical Services. A year later, in 1991, the Commission on Accreditation
of Ambulance Services established standards and benchmarks for ambulance services. In 1993, a formal national, multi-disciplinary
consensus process was utilized to develop the National EMS Education and Practice Blueprint. The purpose of the Blueprint was to establish
nationally-recognized levels of EMS providers, nationally-recognized scopes of practice,
a framework for future curriculum development projects, and a standardized pathway for states
to deal with legal recognition and reciprocity. In 1996, NHTSA published the EMS Agenda for
the Future document to provide guiding principles for the continued evolution of EMS, focusing
on out-of-facility aspects of the system. Within the EMS Agenda for the Future document,
NHTSA focused on fourteen EMS attributes that must be considered in planning for the future. When tasked with determining where EMS should
be in the future and how to get there, the document summarized key tasks within the 14
attributes as follows: Incorporate health systems within EMS that
address the special needs of all segments of the population. Develop collaborative relationships between
EMS systems, medical schools, other academic institutions, and private foundations. Address statutory and regulatory barriers
and needs to support EMS. Commit local, state, and federal attention
and funds to continued EMS infrastructure development. Provide a system for critical incident stress
management. Appoint state EMS medical directors. Ensure EMS educational programs are adequate
to meet the future needs of the system. Evaluate public education initiatives. Improve the ability of EMS to document injury
and illness circumstances. Collaborate with private interests to effect
shared purchasing of communication technology. Develop and update geographically integrated
and functionally-based EMS communications networks. Focus on patient outcomes when evaluating
clinical care. Provide feedback to those who generate data
within the system. Evaluate the effectiveness of EMS using appropriate
metrics. There were just a handful of the key tasks
identified within the document for moving EMS forward into the future. The document made many additional recommendations
related to the 14 EMS attributes that are important to consider in any future initiatives
impacting EMS. At the start of the new millennium, NHTSA
published the Education Agenda for the Future: A Systems Approach. This document was designed to steer the development
of an integrated system of EMS regulation, certification, and licensure. A year after that, in 2001, the National EMS
Research Agenda was published to address the fact that, despite EMS existing for about
30 years, existing practices for treating victims of illness and injury were not routinely
founded upon principles of evidence-based research. The document sought to elevate the science
of EMS and prehospital care to the next level by focusing on EMS research. 2001 was also the year in which the National
EMS Information System was started to provide a mechanism for national-level EMS data standardization
and collection. In 2003, 52 states and territories signed
a memorandum of understanding (drafted by the National Association of State EMS Officials)
agreeing to promote and support all EMS data initiatives within their states and to conform
to future national dataset definitions. In 2004, the National EMS Core Content was
produced to define the domain of out-of-hospital care. Congress determined in 2005 that we needed
a mechanism by which to ensure coordination among federal agencies that support local,
regional, state, tribal, and territorial EMS and 911 systems. To support these efforts, the Federal Interagency
Committee on EMS was established. The federal agencies involved on this Committee
included the Department of Defense, Department of Health and Human Services, Department of
Homeland Security, Federal Communications Commission, and the Department of Transportation. By strategically aligning EMS priorities within
these federal departments, the Committee hoped to improve the delivery of EMS services while
ensuring quality patient care throughout the nation. In 2007, NHTSA published the National EMS
Scope of Practice Model as part of its commitment to the EMS Agenda for the Future. The document was designed as part of an integrated,
interdependent system that endeavored to maximize efficiency, consistency of instructional quality,
and student competence. It is within the National EMS Scope of Practice
Model that four specific levels of EMS licensure were defined as ideal standards across the
country: Emergency Medical Responder, Emergency Medical Technician, Advanced EMT, and Paramedic. NHTSA stated that this system of EMS personnel
licensure should assist states in developing their Scope of Practice legislation, rules,
and regulations. By following this document, states could increase
the consistency of nomenclature and competencies of EMS personnel nationwide, facilitate reciprocity,
improve professional mobility, and enhance the name recognition and public understanding
of EMS. Also in 2007, the Institute of Medicine published
the document, Emergency Medical Services: At the Crossroads. The purpose of the document was to examine
the emergency care system in the United States; explore its strengths, limitations, and future
challenges; describe a desired vision for the system; and, recommend strategies for
achieving that vision. The EMS: At the Crossroads document is lengthy
and focuses on some very specific topics: the history and current state of EMS at the
time, building a 21st-century emergency and trauma care system, supporting a high-quality
EMS workforce, advancing system infrastructure, preparing for disasters, and optimizing prehospital
care through research. The committee did recognize several systemic
problems including insufficient coordination, disparities in response times, uncertain quality
of care, lack of readiness for disasters, divided professional identity, and a limited
evidence base for routine care practices. As we begin to approach the modern day, the
National EMS Advisory Council was established in 2007 to provide EMS-related advice and
recommendations to NHTSA and the Federal Interagency Committee on EMS. The National EMS Advisory Council provides
a forum for the development, consideration, and communication of information from a knowledgeable
and independent perspective; it does not exercise program management or regulatory development
responsibilities, nor does it make decisions directly affecting the programs on which it
provides advice. In 2008, NHTSA released the EMS Workforce
for the 21st Century: A National Assessment document, which reported on EMS workforce
research regarding whether or not the country will be able to provide an adequate EMS workforce
to address the systems needs. Research was conducted on how to attract new
workers to the EMS field and retain them across different geographic and population areas. More than 30 years after the first standardized
EMT-Paramedic curriculum was published in 1977, NHTSA produced the National EMS Education
Standards document. This document was designed to outline the
minimal terminal objectives for entry-level EMS personnel to achieve within the parameters
outlined in the National EMS Scope of Practice Model. NHTSA also released Instructional Guidelines
documents for the four nationally-recognized levels of EMS: Emergency Medical Responder,
Emergency Medical Technician, Advanced Emergency Medical Technician, and Paramedic. Taken together, along with the National EMS
Core Content, National EMS Scope of Practice, National EMS Certification (through the NREMT),
and National EMS Program Accreditation (through the Commission on Accreditation of Allied
Health Education Programs and the Committee on Accreditation of Educational Programs for
the Emergency Medical Services Professions), these elements were designed to allow diverse
implementation methods of the standards to meet local needs and evolving educational
practices in a less prescriptive format than the previous curriculum documents while allowing
for ongoing revision of content consistent with scientific evidence and community standards
of care. EMS instructors and educational programs would
have the freedom to develop their own curricula or use any of the widely-available lesson
plans and instructional resources provided by various publishers and other entities. Anyone familiar with EMS knows that there
is no EMS system without an ample supply of EMS providers. Unfortunately, there was no broad national
effort to develop, identify, or share best practices in EMS recruitment, retention, health
and safety, or other EMS workforce issues and the urgency of EMS workforce issues has
only increased over time. EMS worker shortages, problems with recruitment
and retention, declining volunteerism, low worker pay, poor employment benefits, and
concerns about worker health and safety issues has raised uncertainty about the viability
of the workforce. At the same time, both natural as well as
human-made disasters has underscored the vital roles EMS workers play in community health
and public safety. In 2011, the EMS Workforce Agenda for the
Future followed-up on the research conducted just a few years earlier within the EMS Workforce
for the 21st Century: A National Assessment document and envisioned a future in which
all EMS systems have a sufficient number of well-educated, adequately prepared, and appropriately
credentialed EMS workers who are valued, well-compensated, healthy, and safe. The document also identified four essential
components of a robust EMS workforce: health, safety, and wellness; education and certification;
data and research; and, workforce planning and development. In 2010, Congress passed the Patient Protection
and Affordable Care Act. One of the impacts this law had on EMS was
that it provided an incentive for health care organizations, hospitals in particular, to
work with EMS and other agencies to provide follow-up out-patient care, lest those organizations
lose Medicare reimbursements due to readmission of patients for similar ailments within a
specific timeframe from initial treatment. This provided the impetus for something known
as mobile integrated healthcare (also called community EMS or community paramedics). In an effort to provide more efficient and
cost-effective outpatient care management, Minnesota, in 2011, became the first state
to pass landmark legislation in the form of its Community Paramedics Bill to train community
paramedics and Hennepin Technical College in Eden Prairie, Minnesota graduated their
first cohort of 13 community paramedics shortly thereafter in July of 2012. (In subsequent years, efforts to fight the
nation’s opioid epidemic would provide even more urgency for developing community EMS
systems that provide more than traditional emergency medical services.) As part of NHTSA’s efforts to standardize
EMS education and credentialing across the nation, the National Registry of EMTs mandated
at the start of 2013 that all paramedic candidates must have graduated from a CAAHEP/CoAEMSP-accredited
program. As apparent from the timeline presented within
the presentation, EMS has evolved considerably over a relatively short period of time and,
only recently, have some EMS leaders started to question whether or not EMS is effectively
considering and mitigating the risk of harm to EMS personnel, patients, and members of
the community in routine activities. These concerns prompted NHTSA to publish the
Strategy for a National EMS Culture of Safety document in 2013. By focusing on the six core elements of just
culture, coordinated support and resources, EMS safety data system, EMS education initiatives,
EMS safety standards, and requirements for reporting and investigation, it is hoped that
safety considerations and risk awareness will permeate the full spectrum of EMS activities
everywhere, every day by design, attitude, and habit. The intent of the Strategy for a National
EMS Culture of Safety document is to change the status quo by creating, encouraging, and
supporting a cultural shift that improves the linked domains of responder, patient,
and community safety. We previously mentioned the triple-K federal
ambulance standards that were written in 1974 and had been updated over time through 2007. These standards were effectively replaced
in 2013 by the NFPA 1917 Standard for Automotive Ambulances. Updated in 2016, this standard defines minimum
requirements for the design, performance, and testing of new automotive ambulances intended
for use under emergency condition to provide medical treatment and transportation of sick
or injured people to appropriate medical facilities. In 2014, the National Association of State
EMS Officials (with funding from NHTSA) started its EMS Compass Initiative to create a process
for the continual design, testing, and evaluation of performance measures, in addition to providing
guidance for how local systems can use those measures to improve, so that EMS can continue
to provide the highest quality care to patients and communities in the future. That pretty much wraps up our brief overview
of the history of EMS within the United States. Where EMS as a profession goes from here is
anyone’s guess. With that being said, there are some emerging
topics that will probably have significant influence on EMS in the years to come. The first is the aging of the baby boomers
and the “gray tsunami” in which a high percentage of the nation’s workforce will
be retiring while also stressing the nation’s healthcare systems. Whether or not EMS will be able to find an
ample supply of workers to meet the demand created by pending retirements and increased
system utilization is the challenge facing EMS leaders in greater frequency across the
country. The opioid epidemic within the United States
is also stressing EMS agencies and hospital emergency departments across the country. States have been passing legislation allowing
the lay public to obtain and administer Narcan, with some requiring police departments to
carry the drug as well. Many EMS agencies have seen call volumes skyrocket
due to opioid-related overdoses and funding mechanisms do not readily accommodate those
agencies that find themselves administering Narcan and not transporting patients. The epidemic is also taking a toll on providers
who are seeing more overdose victims of all ages and socioeconomic backgrounds and are
powerless to affect significant change to reverse the trends. For the first time in our country’s history,
we have actually seen a decrease in American life expectancy due to the impact of opioid
overdose deaths. Some communities are trying to use community
EMS (mobile integrated healthcare) efforts to address some of these challenges. How will this growing epidemic continue to
impact EMS? Only time will tell. The nation has also had to come to grips with
the frequency and likelihood of active assailant incidents in which multiple victims are significantly
injured or killed by a single assailant with a weapon of some kind (often a firearm or
rifle) within a short period of time. Mass casualty shooting incidents at Columbine
High School (Colorado), the Pulse nightclub in Orlando, Florida; Sandy Hook Elementary
School in Newton, Connecticut; Virginia Tech in Blacksburg, Virginia; the Aurora, Colorado
movie theater shooting; the Las Vegas, Nevada Route 91 Harvest Music Festival shooting,
and others have forced EMS leaders to wonder whether “scene safety” is a somewhat flexible
and nebulous concept as EMS crews are finding themselves in positions where they must enter
an active assailant scene to save lives, even if the assailant has not been apprehended
or stoped by law enforcement yet. This has given rise to the concepts of rescue
task forces and tactical EMS. At some point, we may see training related
to these concepts built right into initial EMS education courses. Within the realm of provider safety, health,
and wellness, we are also starting to see more emphasis being placed on EMS provider
psychological wellbeing and several states have begun codifying presumptions and protections
for EMS providers who suffer cumulative or significant critical incident stress injury. As previously mentioned, the NREMT requires
all paramedic candidates for NREMT credentialing to have graduated from an accredited paramedic
program. It is suspected by many that accreditation
will “trickle down” from the paramedic level to AEMT and EMT education at some point. Lastly, as follow-up to the 1996 EMS Agenda
for the Future, NHTSA is developing an EMS Agenda 2050 document that dares to create
a bold plan and roadmap for the development of EMS over the next upcoming decades. At the time this presentation was prepared,
the EMS Agenda 2050 is going through the public comment period with an anticipated release
date of the final document in late 2018. As an EMS professional participating in initial
paramedic education, you will arguably have the opportunity to play an active role in
where the EMS profession goes in the years to come. Be active within the profession and constantly
strive to make the system better for providers, services, the patients we serve, and the public
at-large. That concludes this module and you should
now be able to describe key historical events that influenced the national development of
EMS systems. This presentation was prepared by Waukesha
County Technical College in Pewaukee, Wisconsin and is distributed with an attribution, non-commercial,
share alike 4.0 international Creative Commons license. Copyright 2018, Waukesha County Technical
College. For information on WCTC’s numerous fire
and EMS educational offerings, please visit us online at WCTC.edu.

Leave a Reply

Your email address will not be published. Required fields are marked *