History of EMS

Major developments in civilian prehospital care did not begin until the 1960’s based on medical research in resuscitation from the latter half of the 1950’s and support from two American presidents. Prior to this period patient’s virtually had no chance of surviving in-hospital cardiac arrest and prehospital arrest was not even considered. The general attitude toward the organization of prehospital care was that it was a waste of time because the patient still had to come to the hospital.1 Advances in science and political support provided

In 1960, President Kennedy stated, “traffic accidents constitute one of the greatest, perhaps the greatest of the nation’s public health problems.”2 Then President Johnson followed in the steps of his predecessor and stated that he would send a Traffic Safety Act, in his 1966 State of the Union Address. In 1966 the National Academy of Sciences/National Research Council had published the white paper, ‘Accidental Death and Disability: The Neglected Disease of Modern Society” which addressed the senseless fatalities occurring on American highways and the poor prehospital medical care to deal with the automobile trauma patients.³

On September 9, 1966 the National Highway Safety Act was signed into law. The act provided funding through the Department of Transportation to develop highway safety programs in each state. Approximately $140 million was appropriated to improve emergency care. The first Emergency Medical Technician (EMT) curriculum was developed from funding of this act for training of prehospital personnel.

While the United States was focusing on preparing trained medical resuers to manage trauma from traffic accidents the first Mobile Cardiac Care Unit was being tested in Ireland. On January 1, 1966 a Mobile Cardiac Care Unit (MCCU) was established in Belfast from a grant provided by the British Heart Foundation. The MCCU unit was staffed with a physician and nurse and equipped identical to the hospital cardiac care unit. On August 5, 1967 Lancet had reported findings from the Belfast experience with 312 patients during a 15 month period.⁴ The concept of a mobile coronary care unit published in Lancet had created a great deal of intrigue and within 2 years similar programs began emerging in other countries such as N. Ireland, Great Britain, Australia and the USA. The program in Ireland was an example for the development of an American paramedic system.

Paramedics in the United States

William Grace at St. Vincent’s hospital in New York City started the first program in the United States in 1968. Using money from a federal grant Grace purchased equipment and staffed the ambulance with a driver and assistant, attending physician, resident, ED nurse, ECG technician and student nurse observer. The system was designed to have all chest pain calls received by the 911 police dispatch center to be transferred to St. Vincent’s. The ambulance team was paged and had 4.5 minutes to take their equipment and get into the ambulance from wherever they were in the hospital.

The concept of the physician staffed MCCU was quickly determined not to be the best utilization of physicians or cost-effective in the United States. .

Five paramedic programs were organized independent of one another and all with in months of each other in 1969. The paramedic programs utilized existing personnel and resources to develop their programs. The programs in Miami, Seattle, Los Angeles and Columbus used the existing fire department ambulance service to create paramedic programs. The Portland system used the existing private ambulance service and the Nassau County police based ambulance service in New York trained paramedics.

The programs in Miami and Seattle deserve distinction because of their additional contribution to the development of the EMS system concept. Dr. Eagen Nagel trained Miami firefighters to deliver CPR in 1966. The were many skeptics that firemen could do medical procedures that most believed should only be done by physicians. However, Dr. Nagel was able to successfully demonstrate that properly trained paramedics under physician oversight could perform the same medical procedures in the prehospital setting as physicians.

The contribution of the Seattle paramedic program went beyond providing trained personnel at the side of a cardiac arrest victim. To increase the chance of out of hospital cardiac arrest Chief Vickery of the Seattle fire department had the idea to train citizens in CPR. This was a novel idea considering that in the early 1960’s CPR was considered a “medical procedure” only to be performed by physicians. In 1965 CPR was reclassified as an “emergency procedure” to be performed by physicians, nurses and trained ambulance personnel.. The Seattle EMS program has become renowned for its impressive out-of-hospital cardiac arrest survival rate and is considered to be one of the best EMS systems in the world.5

Emergency Medical Services Systems Act

In 1973, the United States Congress passed the Emergency Medical Services Systems Act that provided funding and guidelines for the development of regional EMS systems.6 The 15 required components of an EMS system described in the law were the first criteria published for EMS system development in the United States. The funding provided by the 1973 EMS Act ended in 1981 and money was provided through public health fund block grants to the individual states that became responsible for the organization of EMS systems in their jurisdiction.

Since 1981 improvements were made to the EMT and paramedic curriculums.

Today there are national curriculums for first responders, emergency medical technicians and paramedics in the United States. There also exists a national exam and requirements for EMT’s and paramedics to take continuing education courses and recertify every three years.