Fire Apparatus, News

The State of EMS: A Historical View

Issue 1 and Volume 14.

As we make our way through the 4th decade of modern EMS, it’s good to look back at our history while we face the challenges of the future.

We can better appreciate the value of evidence-based medicine, technology that allows us to do more with more precision, and training that brings us opportunities to be better prepared for our jobs when we look back from where we all came.

While ambulance services can be traced back to Cincinnati General Hospital and Grady Memorial in Atlanta in the mid 1800s, modern EMS is really only about 35 years old. We began to move towards modern EMS with the 1966 publication of a report from the National Academy of Sciences entitled “Accidental Death and Disability, the Neglected Disease of Modern Society.”

This report identified “trauma” as a disease showing that prevention could keep it from happening and in a sense cure it. The effect of the report was immediate. EMS systems were designed, the Red Cross first aid training was redesigned and the blueprint of what would become EMS and trauma systems was coming together.

While paramedic training programs began between 1967 and 1970 in Miami, Los Angeles, Seattle and Columbus, there were not standardized curricula until 1969. The National Traffic Highway Safety Administration (NHTSA) brought together professionals from Hospitals and the field who worked together to develop standardized curricula and the EMT was born.

Soon after, NHTSA would release curricula for paramedics, EMT intermediates, first responders and emergency medical dispatchers. In that year, the so-called “Orange Book,” officially known as “Emergency Care and Transportation of the Sick and Injured,” was published. This book was prepared by the American Academy of Orthopedic Surgeons and, for many of us, was our first introduction to books specifically prepared for pre-hospital care providers. The first EMT courses began and modern EMS was on its way.

With the standards drawn up and the first textbook published, the need for evaluating the graduates of these programs and “certifying” EMTs was addressed by the National Registry of Emergency Medical Technicians in 1970. The idea of NREMT was to provide a nationally recognized EMT that could practice anywhere. While some states continued to have their own certification process, many states utilized the national registry from the beginning.

Advent Of 911

Next came the advent of 911. You may be surprised, but back when AT&T was the national phone company, they set aside 911 as a national emergency response number. While it took decades for 911 to be employed everywhere in the U.S., it began with the designation of this number 40 years ago.

For many Americans, EMS really came into existence when Johnny and Roy showed up for work. The television show “Emergency” aired for the first time in 1972 and Americans everywhere learned about what paramedics could do. In some ways the show worked too well to popularize the new profession. While paramedic programs existed in only a few places in the U.S. in 1972, because of the popularity of this television program, many Americans assumed that everyone working in ambulances was a paramedic.

Organized EMS systems came next and many in the profession trace the development of statewide EMS systems back to the work of Dr. David Boyd. In developing a statewide EMS system for Illinois in the early ’70s, he designed what became a national model.

Another report released in 1972 by the National Academy of Sciences stated that EMS was still one of the weakest links in American health care. These reports got the attention of President Nixon who, in his state of the union address in 1973, directed the Department of Health Education and Welfare to develop emergency medical services for all Americans.

A symbol of this new medical service was need and the Star of Life was designed by Dr. Leo Schwartz. Dr. Schwartz was the chief of the EMS branch of NHTSA in 1973. At the time of its design, the Star of Life was to become the symbol of EMS personnel and equipment not just in the U.S., but all over the world. In 1977 it was officially registered as the symbol of EMS. Each of its arms represents what at the time were recognized as the elements of EMS – detection, reporting, response, on-scene care, care during transport and transfer to definitive care.

While all of these things were building EMS as a profession, the big push came with the passing of the EMS Act. When Congress passed PL 93-154, the Department of Health Education and Welfare was directed to provide funding, planning and implementation and coordination of EMS systems. The EMS Act, as it came to be known, was signed into law by President Ford in 1974.

This act established a lead agency for EMS in the federal government, made grants available for system development, promulgation of the 15 EMS system requirements, technical assistance for system design and development and leadership to FICEMS, the federal EMS committee. This act was amended twice, in 1976 and 1979, to further advance the EMS profession.

The most important event in determining how we equip ourselves came in 1988. In that year the American College of Surgeons Committee on Trauma and the American College of Emergency Physicians prepared a recommendation on what equipment should be on all ambulances. This recommendation was updated in 2000.

Rebuilding EMS

During the 1980s and the 1990s, EMS became well organized and distributed all over the country. Educational programs began to move from hospital-based programs to colleges with professional educators and medical oversight. Manufacturers began to investigate new ways to serve our profession. Legislators worked to fund underserved and overworked systems and professionals began to study the effects of our practice.

While this time period saw all kinds of innovations and experimentation, the next decades would see a kind of retraction into practice and implements that are supported by science.

As the century turned, several initiatives looked at what was happening on the streets and in our classrooms and began to rebuild EMS from the classroom to protocols and the tools we use to do our jobs.

As for the future, the EMS educational agenda, the NREMT and the “State of EMS Education Research Project” defined how we are trained, what we are actually doing, how well our patients are doing and suggested ways to redesign EMS education and practice.

As I write this, the new EMS Education standards will give guidance on how we train professionals to provide EMS care. Protocols are being re-drawn to respond to the evidence of patient outcomes to give us our best chance of helping our patients. Processes are being put in place to push us to evaluate our practice globally and at the individual service level so that we are empowered to improve our practice at the street level.

The future will be driven by empowered EMS professionals accountable to their patients and responsive to the science mined from the data collected on their practice.

While we may be surprised by the results of studies like the recent information on airway and ventilation management, at the end of the day, our patients are going to do better because we learned from our history and looked forward with technology and education to determine our future.

Editor’s Note: Will Chapleau, who has 30 years of EMS experience, is the Advanced Trauma Life Support (ATLS) program manager for the American College of Surgeons. He is the former chief of the Chicago Heights (Ill.) Fire Department, has served since 1996 as the chairperson for the Prehospital Trauma Life Support (PHTLS) program of the National Association of Emergency Medical Technicians and has been a member of its international faculty since 1984. He is a board member of the National Association of EMS Educators.

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