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Ch 1. A Brief History of Emergency Medical Services in the United States

Prehospital emergency care in the modern age is often de- scribed as a “hierarchy” of human and physical resources utilized in the acute setting to provide the best possible patient care until definitive care can be established. Like most hierarchies, the system in place today was forged one link at time, dating as far back as the Civil War. With widespread trauma, a systematic and organized method of field care and transport of the injured was born out of necessity. In 1865, the first civilian ambulance was put into service in Cincinnati, Ohio, followed by a civilian ambulance surgeon in New York 4 years later.1 The New York ser- vice differed slightly from the modern approach, as they arrived equipped with a quart of emergency brandy for each patient.

Military conflicts and necessity provided much of the impe- tus to develop innovations in the transportation and treatment of the injured. In the wake of World War I, the Roaring ‘20s saw the first volunteer rescue squads forming in locations such as Virginia and New Jersey. Control began to shift toward munici- pal hospitals or fire departments as funeral home hearses were slowly joined by fire departments, rescue squads, and private ambulances in the transportation of the ill and injured. Land- mark articles in the late 1950s and early 1960s began to detail the science and methods for initial cardiopulmonary resuscitation (CPR), forging yet another vital link in the chain as EMS began its first steps to transition from transport-only into the treatment of prehospital cardiac patients. Departments trained in cardiac resuscitation began to record successes in major urban areas such as Columbus, Los Angeles, Seattle, and Miami.
The 1960s provided another challenge to public health as traf- fic accidents began to lead to considerable trauma and death.
This “neglected disease of modern society”2 was detailed in the 1966 white paper, Accidental Death and Disability: The Neglected Disease of Modern Society. The paper, prepared by the National Academy of Sciences and the President’s Commission on High- way Safety, detailed the injury epidemic and the lack of appro- priate prehospital care and an organized system to treat patients suffering from critical traumatic injuries. Reforms were indicated in education and training, systems design, staffing, and response

in the nation’s ambulance services. The white paper gave way to the National Highway Safety Act of 1966, which established the Department of Transportation (DOT). The DOT and its daughter organization, the National Highway Traffic Safety Administra- tion (NHTSA), were critical in pushing for the development of EMS systems while standardizing education and curriculum stan- dards, encouraging involvement at the state level, and providing oversight into the creation of regional prehospital emergency systems and regional trauma center systems, forming the birth of trauma center accreditation by the American College of Sur- geons Committee on Trauma. For the first time in U.S. history, a curriculum standard was being set in skills and qualifications re- quired to become an emergency medical technician. Paramedic education arrived shortly afterward, but it still has a ways to go in terms of scope and depth.
The EMS Systems Act of 1973 provided funding for the cre- ation of more than 300 EMS systems across the nation and set aside funding for key future planning and growth. During this time, EMS grew alongside the development of emergency
medicine as a distinct specialty, with the first residency training program approved in 1970, at the University of Cincinnati1. By 1975, more than 30 EM residencies developed across the nation, preparing physicians who would interface with EMS at all levels: from responders and educators, all the way to medical directors.
Advances in care standards and education continued through-

out the 1980s with changes in the principles of EMS funding through the Omnibus Budget Reconciliation Act. The act estab- lished EMS funding from state preventative health block grants rather than funding from the EMS Systems Act. The role of EMS also began to change towards the front line of healthcare to include chronic diseases, pediatric patients and the underserved. EMS practice was no longer just for adult trauma and cardiac emergencies.
Recognizing the need to advance its own practice while cre- ating a cohesive integration with the health care landscape, the 1996 EMS Agenda for the Future was drafted. The EMS Educa- tion Agenda for the Future was published shortly thereafter and described more modern recommendations for core curriculum content, scope of practice, and certification of EMS profession- als.2
Within the past 20 years, EMS has become a focus of intense research of prehospital interventions into many commonly en- countered acute care issues seen in emergency medicine, such as acute respiratory distress, cardiac arrest, chest pain, and trau- ma. With increasingly integrated technology between prehospital care and the emergency department, patient data is beginning
to be transmitted real-time, allowing for earlier determination of patient severity and care management needs prior to arrival. Quality improvement with integrated electronic charting, in- cluding patient outcomes, is beginning to provide much-needed

feedback as EMS endeavors to become a dedicated subspecialty of emergency medicine. Within regional stroke centers, cardiac catheterization centers, and trauma systems, EMS has become the forefront of emergency medical care and can only serve to advance how emergency medicine is conducted in the future.
EMS has come a long way from the horse and buggy. Grow- ing alongside emergency medicine, there are opportunities for physicians to become involved in many different aspects of the system. While EMTs are not independent practitioners and gen- erally operate under a medical director’s authorization, the situ- ations they face require considerable problem-solving, judgment, and clinical decision-making skills. Physicians are needed at every step to help develop treatment protocols, provide quality im- provement, hold regular training sessions, and ensure all person- nel have the tools they need to perform high-quality prehospital care. In addition, EMS physicians may be called upon for situa- tions that require their presence on scene in the field including mass casualty incidents, high acuity and high-risk scenarios, tac- tical situations, or patients that require advanced skills such as surgical airways, pericardiocentesis, thoracostomy tubes, and others. Large-scale operations including concerts, conventions, and city events also benefit from physician input.
EMS will continue to be the front line of emergency medicine as the field expands in the coming future. Physicians involved with pre-hospital care will be paramount to providing the sup-

port and knowledge required to help EMS systems grow, as ev- idenced by the recent recognition of EMS as an official clinical subspecialty.
Involvement in the EMRA EMS Division will be a great oppor- tunity for EMRA members with a career interest in EMS as well as those seeking exposure to working with prehospital systems in the future. If you are interested, please feel free to contact us at emsctte@emra.org.

References

1. Zink BJ. Anyone, anything, anytime – a history of emergency medicine. 2006, Mosby Elsevier; Philadelphia, PA.
2. West Virginia Department of Education. “A Brief History of Emergency Medical Services.” http://wvde.state.wv.us/abe/Public%20Service%20Personnel/ HistoryofEMS.html.
3. NAEMT. “History of EMS.” http://www.naemt.org/about_ems/EMShistory.aspx.