Chapter 1 Robert R. Bass Early hunters and warriors provided care for the injured. Although the methods used to staunch bleeding, stabilize fractures, and provide nourishment were primitive, the need for treatment was undoubtedly recognized. The basic elements of prehistoric response to injury still guide contemporary EMS programs. Recognition of the need for action led to the development of medical and surgical emergency treatment techniques. These techniques in turn made way for systems of communication, treatment, and transport, all geared toward reducing morbidity and mortality. The Edwin Smith Papyrus, written in 1500 BC, vividly describes triage and treatment protocols [1]. Reference to emergency care is also found in the Babylonian Code of Hammurabi, where a detailed protocol for treatment of the injured is described [2]. In the Old Testament, Elisha breathed into the mouth of a dead child and brought the child back to life [3]. The Good Samaritan not only treated the injured traveler but also instructed others to do likewise [4]. Greeks and Romans had surgeons present during battle to treat the wounded. The most direct root of modern prehospital systems is found in the efforts of Jean Dominique Larrey, Napoleon’s chief military physician. Larrey developed a prehospital system in which the injured were treated on the battlefield and horse-drawn wagons were used to carry them away [5]. In 1797 Larrey built “ambulance volantes” of two or four wheels to rescue the wounded. Larrey had introduced a new concept in military surgery: early transport from the battlefield to the aid stations and then to the frontline hospital. This method is comparable to the way that modern physicians modified the military use of helicopters in Korea and Vietnam. Larrey also initiated detailed treatment protocols, such as the early amputation of shattered limbs to prevent gangrene. The Civil War is the starting point for EMS systems in the United States [6]. Learning from the lessons of the Napoleonic and Crimean Wars, military physicians led by Joseph Barnes and Jonathan Letterman established an extensive system of prehospital care. The Union Army trained medical corpsmen to provide treatment in the field; a transportation system, which included railroads, was developed to bring the wounded to medical facilities. However, the wounded received suboptimal treatment in these facilities, stirring Clara Barton’s crusade for better care [7]. The medical experiences of the Civil War stimulated the beginning of civilian urban ambulance services. The first were established in cities such as Cincinnati, New York, London, and Paris. Edward Dalton, Sanitary Superintendent of the Board of Health in New York City, established a city ambulance program in 1869. Dalton, a former surgeon in the Union Army, spearheaded the development of urban civilian ambulances to permit greater speed, enhance comfort, and increase maneuverability on city streets [8]. His ambulances carried medical equipment such as splints, bandages, straitjackets, and a stomach pump, as well as a medicine chest of antidotes, anesthetics, brandy, and morphine. By the turn of the century, interns accompanied the ambulances. Care was rendered and the patient left at home. Ambulance drivers had virtually no medical training. Our knowledge of turn-of-the-century urban ambulance service comes from the writings of Emily Barringer, the first woman ambulance surgeon in New York City [9]. Further development of urban ambulance services continued in the years before World War I. Electric, steam, and gasoline-powered carriages were used as ambulances. Calls for service were generally processed and dispatched by individual hospitals, although improved telegraph and telephone systems with signal boxes throughout New York City were developed to connect the police department and the hospitals. During World War I, the introduction of the Thomas traction splint for the stabilization of patients with leg fractures led to a decrease in morbidity and mortality. Between the two world wars, ambulances began to be dispatched by mobile radios. In the 1920s, in Roanoke, Virginia, the first volunteer rescue squad was started. In many areas, volunteer rescue or ambulance squads gradually developed and provided an alternative to the local fire department or undertaker. After the entry of America into World War II, the military demand for physicians pulled the interns from ambulances, never to return, resulting in poorly staffed units and non-standardized prehospital care. Postwar ambulances were underequipped hearses and similar vehicles staffed by untrained personnel. Half of the ambulances were operated by mortuary attendants, most of whom had never taken even a first aid course [10]. Throughout the 1950s and 1960s, two geographic patterns of ambulance service evolved. In cities, hospital-based ambulances gradually coalesced into more centrally coordinated city wide programs, usually administered and staffed by the municipal hospital or fire department. In rural areas, funeral home hearses were sporadically replaced by a variety of units operated by the local fire department or a newly formed rescue squad. Additionally, in both urban and rural areas, a few profit-making providers delivered transport services and occasionally contracted with local government to provide emergency prehospital services and transport. Before 1966, very little legislation and regulation applicable to ambulance services existed. Providers had relatively little formal training, and physician involvement at all levels was minimal. A number of factors combined in the mid-1960s to stimulate a revolution in prehospital care. Advances in medical treatments led to a perception that decreases in mortality and morbidity were possible. Closed-chest cardiopulmonary resuscitation (CPR), reported as successful in 1960 by W.B. Kouwenhoven [11] and Peter Safar [12], was eventually adopted as the medical standard for cardiac arrest in the prehospital setting. New evidence that CPR, pharmaceuticals, and defibrillation could save lives immediately created a demand for physician providers of those interventions in both the hospital and prehospital environments. Throughout the 1960s, fundamental understanding of the pathophysiology of potentially fatal dysrhythmias expanded significantly. The use of rescue breathing and defibrillation was refined by Peter Safar, Leonard Cobb, Herbert Loon, and Eugene Nagel [13]. Safar persuaded many others that defibrillation and resuscitation were viable areas of medical research and clinical intervention. In 1966 Pantridge and Geddes pioneered and documented the use of a mobile coronary care unit ambulance for prehospital resuscitation of patients in Belfast, Ireland. Their treatment protocols, originally developed for the treatment of myocardial infarction in intensive care units, were moved into the field [14]. Because the medical team was often with the patient at the time of cardiac arrest, the resuscitation rate was a remarkable 20%. Their “flying squads” added a dimension of heroic excitement to the job of being an ambulance attendant, and their performance data helped convince American city health officials and physicians that a more medically sophisticated prehospital advanced life support (ALS) system was possible. The modern era of prehospital care in the United States began in 1966. In that year, the recognition of an urgent need, the crucial element necessary for development of prehospital systems nationwide, was heralded by a report generated by the National Academy of Sciences National Research Council (NAS-NRC), a non-profit organization chartered by Congress to provide scientific advice to the nation. Accidental Death and Disability: The Neglected Disease of Modern Society documented the enormous failure of the United States health care system to provide even minimal care for the emergency patient. The NAS-NRC report identified key issues and problems facing the United States in providing emergency care (Figure 1.1). Its summary report listed recommendations that would serve as a blueprint for EMS development, including such things as first aid training for the lay public, state-level regulation of ambulance services, emergency department improvements, development of trauma registries, single nationwide phone number access for emergencies, and disaster planning [15]. This document established a benchmark against which to measure subsequent progress and change. Figure 1.1 Key findings of the 1966 NAS-NRC report. Adapted from Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, DC: National Academy of Sciences, 1966, National Academy Press. The 1966 NAS-NRC document described both prehospital services and hospital emergency departments as being woefully inadequate. In the prehospital arena, treatment protocols, trained medical personnel, rapid transportation, and modern communications concepts, such as two-way radios and emergency call numbers, were all identified as necessities that were simply not available to civilians. Although there were more than 7,000 accredited hospitals in the country at the time, very few were prepared to meet the increased demand that developed between 1945 and 1965. From 1958 to 1970, the annual number of emergency department visits increased from 18 million to more than 49 million [15]. In addition, emergency departments were staffed by the least experienced personnel, who had little education in the treatment of multiple injuries or critical medical emergencies. Early efforts of the American College of Surgeons (ACS) and the American Academy of Orthopedic Surgeons (AAOS) to improve emergency care were largely unsuccessful because medical interest was essentially non-existent [16–19]. The 1966 NAS-NRC document was the first to recommend that emergency facilities be categorized. It also emphasized aggressive clinical management of trauma, suggesting that local trauma systems develop databases, and that studies be instituted to designate select injuries to be incorporated in the epidemiological reports of the US Public Health Service. Changes were also recommended concerning legal problems, autopsies, and disaster response reviews. Trauma research was especially emphasized, with the ultimate goal of establishing a National Institute of Trauma [15]. Another problem identified in the report was the broad gap between existing knowledge and operational activity. The NAS-NRC was not the first report in which many of these issues were raised. The President’s Commission on Highway Safety had previously published a report entitled Health, Medical Care, and Transportation of Injured [20], which recommended a national program to reduce deaths and injuries caused by highway accidents. Its findings were complemented by and consistent with the NAS-NRC report. The recommendations in both documents were used when the Highway Safety Act of 1966 was drafted. This law established the cabinet-level Department of Transportation (DOT) and gave it legislative and financial authority to improve EMS. Specific emphasis was placed on developing a highway safety program, including standards and activities for improving both ambulance service and provider training [21]. The Highway Safety Act of 1966 also authorized funds to develop EMS standards and implement programs that would improve ambulance services. Matching funds were provided for EMS demonstration projects and studies. All states were required to have highway safety programs in accordance with the regulatory standards promulgated by DOT. The standard on EMS required each state to develop regional EMS systems that could handle prehospital emergency medical needs. Ambulances, equipment, personnel, and administration costs were funded by the highway safety program. Regional financing, as opposed to county or state funding, was a new concept that would be echoed in federal health legislation throughout the remainder of the decade [21]. With the Highway Safety Act as a catalyst, DOT contributed more than $142 million to regional EMS systems between 1968 and 1979. A total of roughly $10 million was spent on research alone, including $4.9 million for EMS demonstration projects. A number of other federal EMS initiatives in the late 1960s and early 1970s poured additional funds into EMS, including $16 million in funding from the Health Services and Mental Health Administration, which had been designated as the lead EMS agency of the Department of Health, Education, and Welfare (DHEW), to areas of Arkansas, California, Florida, Illinois, and Ohio for the development of model regional EMS systems [22]. In 1969 the Airlie House Conference proposed a hospital categorization scheme [23]. The AMA Commission on EMS urged facility categorization and published its own scheme, which identified staffing, equipment, services, and personnel types [24]. This became known as “horizontal categorization.” Although it was supported by professional and hospital associations, many hospitals and physicians feared hospitals in lower categories would suffer a loss of prestige, patients, or reimbursement. DHEW EMS program developed a categorization scheme based on hospital-wide care of specific disease processes. Known as “vertical categorization,” this concept was ultimately embraced by many regional programs as a major theme in the development of EMS systems. By the late 1960s, drugs, defibrillation, and personnel were available to improve prehospital care. As early as 1967, the first physician responder mobile programs morphed into “paramedic” programs using physician-monitored telemetry as a modification of the approach by Pantridge in Belfast. The “Heartmobile” program, begun in 1969 in Columbus, Ohio, initially involved a physician and three EMTs. Within 2 years, 22 highly trained (2,000 hours) paramedics provided the field care, and the physician role became supervisory. Similarly, in Seattle, physicians supervised highly trained paramedics, increasing the survival rate from 10% to 30% for prehospital cardiac arrest patients whose presenting rhythm was ventricular fibrillation. The Seattle story was also one in which fire department first responders played a crucial role in building what is now called a chain of survival. In Dade County, Florida, rapid response of mobile paramedic units was combined with hospital physician direction via radio and telemetry for the first time [25]. In Brighton, England, non-physician personnel provided field care without direct medical oversight. Electrocardiographic data were recorded continuously to permit retrospective review by a physician [26]. National professional organizations such as the ACS, the AAOS, the American Heart Association (AHA), and the American Society of Anesthesiologists (ASA), in concert with other groups, provided extensive medical input into the early development of EMS. New organizations were formed to focus on EMS, including the AMA’s Commission on EMS, the AHA’s Committee on Community Emergency Health Services, the American Trauma Society, the Emergency Nurses Association, the Society of Critical Care Medicine, the National Registry of Emergency Medical Technicians (NREMT), and the American College of Emergency Physicians (ACEP). In the years prior to 1973, such groups made significant but uncoordinated efforts toward the reorganization, restructure, improvement, expansion, and politicization of EMS [23,24,27,28]. In 1972, the NAS-NRC published Roles and Resources of Federal Agencies in Support of Comprehensive Emergency Medical Services, which asserted that the federal government had not kept pace with efforts by professional and lay health organizations to upgrade EMS. The document endorsed a vigorous federal government role in the provision and upgrading of EMS. It recommended that President Nixon acknowledge the magnitude of the accidental death and disability problem by proposing action by the legislative and executive branches to ensure optimum universal emergency care. It urged the integration of all federal resources for delivery of emergency services under the direction of a single division of DHEW, which would have primary responsibility for the entire emergency medical program. It also recommended that the focal point for local emergency medical care be at the state level, and that all federal efforts be coordinated through regional EMS programs [29]. By 1973 several major lessons had emerged from the demonstration projects and the various studies undertaken during the preceding 7 years. Although the federal initiative had been limited to the 1968 DHEW regional demonstration projects mentioned earlier, significant progress had been made toward clearly defining a potential program goal. The projects proved that a regional EMS system approach could work. However, because systems research was not a component of DHEW program, the demonstration projects did not prove that a regional approach, or for that matter any particular approach, was more effective than another. By early 1973 many national organizations supported further federal involvement, both in establishing EMS program goals and in providing direct financial support. The first efforts at passing federal EMS legislation were defeated, but a later modified EMS bill passed with support from numerous public and professional groups. President Nixon vetoed this bill in August 1973. The standard conservative philosophy was that EMS was a service that should be provided by local government, and the federal government should neither underwrite operations nor purchase equipment. Additional congressional hearings led to the reintroduction of a bill proposing an extensive federal EMS program, based on the rationale that individual communities would not be able to develop regional systems without federal encouragement, guidelines, and funding. Finally, in November 1973, the Emergency Medical Services Systems Act was passed and signed. It was added as Title XII to the Public Health Service Act, wherein it addressed EMS systems, research grants, and contracts. It also added a new section to the existing Title VII concerning EMS training grants [30]. Although the law was amended to reauthorize expenditures in 1976, 1978, and again in 1979, its goal remained to encourage development of comprehensive regional EMS systems throughout the country. The available grant funds were divided among the four major portions of the EMS Systems Act: Section 1202 – Feasibility studies and planning; Section 1203 – Initial operations; Section 1204 – Expansion and improvement; and Section 1205 – Research. Applicants were encouraged to use existing health resources, facilities, and personnel. The EMS regions were ultimately expected to become financially self-sufficient. Therefore, a phase-out of all federal funding was targeted for 1979 but later extended to 1982. The program was administered in DHEW through the Division of Emergency Medical Services (DEMS), with David Boyd, the medical director of the Illinois demonstration project, named as director. The law and subsequent regulations emphasized a regional systems approach, a trauma orientation, and a requirement that each funded system address the 15 “essential components” (Figure 1.2). It should be noted that medical oversight was not one of the 15 components, although subsequent regulations encouraged medical oversight. Figure 1.2 The Fifteen Essential EMS Components. Washington, DC: Department of Health, Education, and Welfare, Division of EMS, 1973. In 1974 the Robert Wood Johnson Foundation allocated $15 million for EMS-related activities, the largest single contribution for the development of health systems ever made in the United States by a non-profit foundation. Forty-four areas received grants of up to $400,000 to develop EMS systems [31]. This money was intended to encourage communities to build regional EMS systems, emphasizing the overall goal of improving access to general medical care. The money was provided over a 2-year period to establish new demonstration projects and develop regional emergency medical communications systems [32]. In early 1974 a newly reorganized DHEW-DEMS began implementing the legislative mandate. Adopted from earlier experiences, the basic principles were that an effective and comprehensive system must have resources sufficient in quality and quantity to meet a wide variety of demands, and the discrete geographic regions established must have sufficient populations and resources to enable them to eventually become self-sufficient. Each state was to designate a coordinating agency for statewide EMS efforts. Ultimately, 304 EMS regions were established nationwide. By 1979, 17 regions were fully functional and independent of federal money. However, of the 304 geographic areas, there were 22 that had no activity and 96 that were still in the planning phase [33]. Testimony was given before the congressional committee considering extension of funding, and an additional year of funding was authorized as the 1202b program for planning. In the regulations, David Boyd strictly interpreted the congressional legislative intent of the EMS Systems Act to mandate that all communities adopt the 15 essential components. Regions were limited to five grants, and with each year of funding, progress toward more sophisticated operational levels was expected. By the end of the third year of funding, regions were expected to have basic life support (BLS) capabilities, which required no physician involvement. ALS capability, which was expected to perform traditional physician activities, was expected at the end of the fifth year. The use of BLS and ALS terminology in the regulations spread widely. However, the original definitions that corresponded directly to the funded emergency medical technician- ambulance (EMT-A) and paramedic levels of training quickly became elusive as variations in the EMT-A and paramedic levels emerged. The EMT-A level required no medical input, but some states such as Kentucky did extend medical oversight to BLS because of insurance laws – laws making medical care and transportation across a county line virtually impossible without a physician’s approval over the radio. Developing the geographic regions required to secure federal funding through the EMS Systems Act usually necessitated new EMS legislation at the state level. The state laws that developed throughout the 1970s varied markedly in regard to the issues of medical oversight, overall operational authority, and financing. In some states, physician involvement was required. In others, medical oversight was not even mentioned. Often, the responsibility for coordinating activities was assigned to a regional EMS council of physicians, prehospital providers, insurance companies, and consumers who often had interests to protect. Commonly, physician input was somewhat removed from the medical mainstream. A lack of appropriately trained emergency personnel at every level of care had been identified in the NAS-NRC document [15]. After 1973, extensive effort and money were directed at correcting this educational deficiency, and serendipity played a role. A large number of medical corpsmen, physicians, and nurses, who understood that trained non-physicians could perform life-saving tasks in the field, were returning from Vietnam. Many argued that rapid transport and early surgery could improve civilian trauma practice. In 1966 the NAS-NRC document stated, “No longer can responsibility be assigned to the least experienced member of the medical staff, or solely to specialists, who, by the nature of their training and experience, cannot render adequate care without the support of other staff members.” [15] Thus the importance of physician leadership and training in EMS was identified early. During the 25 years following World War II, increasing demands for care were placed on hospital emergency departments. Not surprisingly, a branch of medicine evolved with its focus on the critically ill. The academic discipline and scientific rigor necessary to define a separate medical specialty began to develop. In 1968 ACEP was founded by physicians interested in the organization and delivery of emergency medical care. In 1970 the first emergency medicine residency was established at the University of Cincinnati, and the first academic department of emergency medicine in a medical school was formed at the University of Southern California. Soon the directors of medical school hospital emergency departments founded the University Association for Emergency Medical Services. Between 1972 and 1980 more than 740 residents completed training at 51 emergency medicine residencies throughout the country [34–36]. The first major step toward certification as a specialty occurred in 1973 when the AMA authorized a provisional Section of Emergency Medicine. In 1974 a Committee on Board Establishment was appointed, and a liaison Residency Endorsement Committee was formed [36]. Further impetus toward expansion of residency programs in emergency medicine occurred with the formation of the American Board of Emergency Medicine (ABEM) in 1976 [37]. Before that time there was some hesitancy to create residency programs that might not lead to board certification. In September 1979, emergency medicine was formally recognized as a specialty by the AMA Committee on Medical Education and the American Board of Medical Specialties. One of the strongest arguments in favor of the new specialty was that emergency physicians had a unique role in the oversight of prehospital medicine. The ABEM gave its first certifying examination in 1980, which incidentally did not touch on any areas of prehospital care. Although emergency medicine, emergency nursing, and prehospital care were all nourished by the funds distributed between 1973 and 1982, the interest of ACEP in EMS activities lagged, perhaps because individual physician interest lagged. The first full-time EMS medical director was not appointed until April 1981. Previously, all had been part-time, and some had simply been functionaries. Shortly thereafter, cities like Salt Lake City and Houston followed New York’s lead, and appointed full-time EMS medical directors. Even then, EMS as a physician career choice was perceived by many as too limited and perhaps a risky career undertaking. The Highway Safety Act of 1966 funded EMT-A training and curriculum development. By 1982, there were approximately 100,000 providers trained at the EMT-A level. They were trained to provide basic, non-invasive emergency care at the scene and during transport, including such skills as CPR, control of bleeding, ventilation, oxygen administration, fracture management, extrication, obstetrical delivery, and patient transport. The educational requirements, which began as a 70-hour curriculum published by the AAOS in 1969, soon grew to 81 hours of lectures, skills training, and hospital observation, with most of the increase in hours being due to the addition of training in the use of pneumatic anti-shock garments. After working for 6 months, graduates were allowed to take a national certifying examination administered by the NREMT. Founded in 1970, the NREMT developed a standardized examination for EMT-A personnel as one requirement for maintaining registration. Many states began to recognize NREMT registration for the purposes of reciprocity or state certification or licensure [28]. While the EMT-A quickly became a nationally recognized standard, the development of national consensus at the paramedic level lagged behind, with marked differences in training from locality to locality. Paramedic practices became somewhat formalized with the adoption of DOT emergency medical technician – paramedic (EMT-P) curriculum. By 1982, EMT-P training ranged from a few hundred to 2,000 hours of educational and clinical experience. Typical clinical skills included cardiac defibrillation, endotracheal intubation, venepuncture, and the administration of a variety of drugs. The use of these skills was based on interpretation of history, clinical signs, and rhythm strips. Telemetric and voice communications with physicians were usually required. In the early days of paramedics, extensive “online” medical oversight was mandatory for all calls in most systems. With time, this requirement was modified by the introduction of protocols allowing for greater use of standing orders [38]. However, a great deal of variation in the use of direct medical oversight remained. As early as 1980, paramedics in decentralized systems such as New York’s used many clinical protocols, most of which had few indications for mandatory direct medical oversight. On the other hand, as late as 1992, many centralized systems, such as the Houston Fire Department, had only a few standing orders (mainly for cardiac arrest) that did not require contemporaneous instruction from direct medical oversight. The concept of the EMT-Intermediate (EMT-I) evolved as a provider level located somewhere between EMT-A and EMT-P. Airway management, IV therapy, fluid replacement, rhythm recognition, and defibrillation were the most common “advanced” skills included in the EMT-I curriculum, though significant variation existed (and still does) from state to state. Many states developed several levels of EMT-I, often in a modular progression with formal bridge courses. By 1979, formally recognized prehospital providers existed at dozens of levels, with highly variable requirements for medical oversight.
History of EMS
Before 1966: historical perspectives
1966: the NAS-NRC report
1973: the Emergency Medical Services Systems Act
1973–1978: rapid growth of EMS systems
Personnel
Physicians
Prehospital providers
Public education
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