In the United States, over 15.9 million patients per year are transported to emergency departments (ED) by emergency medical services (EMS), and 40% of all hospital inpatient admissions arrive by ambulance.¹ Physicians have dedicated a significant portion of their practice to EMS since the late 1960s. EMS physicians acquired their expertise primarily by direct experience and together built the subspecialty through professional association, collaborative research, and standards development. EMS medicine has many roots, with growth spurts largely coming out of casualty care during warfare. Modern EMS started in Great Britain and Los Angeles in the early 1960s, driven by cardiologists who wanted a way to resuscitate cardiac arrest patients in the field.² In the late 1960s with Death and Disabilities white paper, EMS saw exponential growth at the hands of surgeons who wanted a rapid way to evacuate and treat trauma victims on the nation’s highways similar to the care and resuscitation of trauma victims during the Vietnam War.³ The majority of these surgeons also worked and staffed the “accident units,” precoursers of today’s ED. When emergency medicine became an organized specialty in the late 1970s, it was a natural transition for these “new kids on the block” to take an active role in EMS since the interface was far more than that for physicians from other specialties. The growth of EMS medicine actually parallels the growth of emergency medicine to a large degree.

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  Discuss education and training backgrounds of practicing EMS physicians.

  
  
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  Describe available EMS medical director training courses.

  
  
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  Describe formal EMS physician fellowship training.

  
  
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  Describe the current state of EMS board certification and qualifications for examination.

  
  
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  Describe scientific and educational conferences that provide EMS physicians with state-of-the-art EMS research and clinical practice CME.

  
  
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  Discuss additional areas of training useful to EMS physicians fulfilling specific operational roles.

In 2003, the Institute of Medicine (IOM) convened the Committee on the Future of Emergency Care in the United States Health System “to examine the emergency care system in the U.S., to create a vision for the future of the system, and to make recommendations for helping the nation achieve that vision.” One volume of this IOM report focused exclusively on EMS.¹ The IOM noted that: “Delivery of clinical care in the field is quite different from delivering care in the hospital or other medical facility, and the oversight of EMS is complex.” Furthermore, the IOM acknowledged that EMS physician involvement improves the quality of care delivered by EMS systems.

As defined by the IOM, EMS comprises the crucial, early phases of the continuum of emergency medical care for acutely ill and injured persons including (a) 9-1-1 access and dispatch, (b) field triage and initial stabilization, and (c) treatment and transport in specially equipped ambulances or helicopters to hospitals or between medical facilities.

The term EMS system describes the organizational structure that integrates all of the essential components of EMS care. In their practice, EMS physicians provide direct emergency medical care for patients and medical oversight of EMS systems. They practice in every state, in a variety of different venues including industry, academia, private, municipal, fire-based and hospital-based systems. All states have regulations governing the role and responsibility of EMS physicians. Many states require specific medical director training which is often based on the national medical director curriculum developed by the National Highway Traffic Safety Administration (NHTSA).⁴

EMS medical practice is unique due to its position early in the continuum of patient care, physical location outside of fixed medical facilities, and relatively higher acuity of the patient population compared to emergency medicine. The majority of the most severely ill and injured patients presenting to ED arrive via EMS. EMS physicians provide direct patient care and medical oversight in unique settings such as mass gatherings, firefighting operations, disaster scenes, hazardous materials incidents, tactical law enforcement missions, and air medical and critical care inter-facility transports. As part of their clinical practice, EMS physicians are responsible for medical oversight of the EMS team. This includes daily direct medical decision making, control of care provided by EMS personnel, developing treatment guidelines, and ensuring procedural competency training of EMS personnel. EMS physicians also lead quality management activities relating to medical care delivered by the entire EMS system.

EMS physicians have developed treatments and techniques in the EMS environment that allow for patient safety and ensure proper treatment affecting the patient’s final outcome.^5–9 Extensive peer-reviewed articles address the roles of EMS physicians in the science and practice of EMS.^10–18 EMS physicians are uniquely trained and positioned to provide the clinical care and leadership to mold prehospital- and hospital-based care into regionalized systems of care. The unique expertise gained from EMS physician field practice and system oversight improves patient safety and clinical outcomes.⁵

For over four decades, steadily increasing numbers of physicians have defined their professional practice as caring for patients in the EMS environment. Emergency medicine physicians comprise the principal physician group that has driven the growth of EMS practice since 1984. Current estimates are roughly 75% of EMS physicians are emergency medicine trained, 23% Family Medicine trained, with the remaining 2% being pediatricians, surgeons, and obstetrics and gynecology physicians. EMS physicians are often leaders in their communities concerned with meeting the needs of the public and provision of quality EMS care. Most academic emergency medicine departments employ an EMS physician who supervises the exposure of residents to EMS and engages in research activities to expand the scientific body of knowledge of this practice. EMS physicians hold key positions in several federal government agencies involved in EMS issues. Complex and sophisticated medical procedures previously only performed in hospitals, or completely unavailable a few decades ago, are now routinely integrated in EMS due to EMS physicians.^19–22

EMS physicians play many pivotal roles. They serve as providers, expert consultants, and educators. Many EMS physicians plan prevention efforts implemented through the EMS system, with goals directed at reducing the societal costs of injury and illness. They facilitate optimal care through education and continual oversight of providers. EMS physicians reduce variability in care, limit interventions that are of no benefit, and facilitate delivery of care that enhances patient safety and improves outcomes.^23–27 As the EMS subspecialty matures, patient outcomes will be further improved with continued advancement of scientific knowledge and treatments adding further sophistication to this area of practice.

EMS medical director training courses exist that are designed to allow physicians to acquire basic knowledge of EMS practice. These are primarily 1- to 3-day courses, and are offered by individual states or professional associations. These courses provide a basic introduction to EMS practice, EMS system quality improvement, and medical oversight. However, the content does not delve deeply into the clinical practice of EMS or its scientific basis due to intrinsic time constraints. Some are online, while others are delivered in classroom format. Many states require such training by regulation for physicians who wish to be EMS medical directors. These mandated courses are provided through each state and are frequently based on the National Highway Safety and Traffic Association (NHTSA) National Standard Medical Directors Curriculum. Both the National Association of EMS Physicians (NAEMSP) and the American College of Emergency Medicine (ACEP) have courses devoted to physician medical direction. NAEMSP offers the 2-day basic EMS medical director course and the 1-day advanced EMS medical directors course in conjunction with its annual scientific meeting. ACEP offers a preconference (Eagles conference) concentrating issues related to large EMS system management.

Presently at least 268 fellowship-trained EMS physicians are practicing in 41 states as well as several foreign countries. The first known EMS fellowship program was at Adam R Crowley Shock Trauma Institute, graduating one fellow in 1983. Three EMS fellowships sponsored by emergency medicine programs began in 1985, with the first of these fellows graduating from Wright State University in 1987. The number of graduates has steadily increased since that time (Figure 3-1). It is believed that there may be more graduates than represented by the graph as some original training programs are no longer in existence and no graduation records are accessible. EMS fellowships are located in most states across the country. Figure 3-2 depicts the location of all EMS fellowships, accredited and unaccredited. Most fellowship programs offer one to two positions per year. EMS fellowships are generally 1 year in length. Some programs offer an optional second year leading to an advanced degree (eg, MPH, MHA, MBA, MEd). A small minority of programs are 2-year training programs. ACGME-accredited programs (the first-round approvals were for the 2012-2013 academic year) were required to comply with a 12-month curriculum. The original round of accredited programs included 11 EMS medicine fellowships (3-1). As of a report generated from the ACGME Web site on October 15, 2014, there are now 40 accredited programs.

The EMS Medicine Core Content, first published in 1985 and revised several times since, describes the domain of EMS medicine and is the basis for fellowship training curricular development.²⁸ Fellowship curricula have become relatively standardized as a result of the work of the Society of Academic Emergency Medicine (SAEM) and NAEMSP.²⁹ The curriculum is designed to provide specific training in general and specific core competencies for EMS physicians, including medical knowledge, clinical expertise, operations, education, research, and administration. It contains all topic areas in the EMS Medicine Core Content covered through a combination of didactics, self-study, case review, and direct clinical experience. This was culminated in the official documents defining the core content and curriculum which now dictate content for ACGME-accredited programs. EMS fellows provide direct patient care in the prehospital setting, educate other physicians and allied health personnel, perform quality improvement activities of EMS systems, and create treatment guidelines for EMS systems. Participation in local and state EMS systems and specialty societies is required. The fellowships are designed to allow fellows to develop proficiency in managing the breadth of clinical conditions encountered by EMS systems in nontraditional health care settings with limited resources in uncontrolled circumstances. Specific procedural skills, such as patient extrication, airway management in water, use of alternative airway devices such as the King airway, spinal immobilization with long board and KED, application of Hare traction splint, and field triage are integrated into the training. Specific funding for EMS research fellowships is available. NAEMSP sponsors a resuscitation fellowship to prepare and train individuals for a career in prehospital resuscitation research, as well as a fellowship designed to encourage the development of high-quality medical director leaders. SAEM also sponsors and provides grant funding for an EMS research fellowship.