EMS is the extension of emergency medical care into the prehospital setting. The concept of bringing care to the sick or injured dates back to Roman times. However, today’s EMS systems have their roots in legislative and clinical developments of the 1960s and 1970s. The 1966 report “Accidental Death and Disability—The Neglected Disease of Modern Society” highlighted the deficiencies of prehospital care for trauma victims, which were attributable to inadequate equipment and provider training. Up until that time, more than half of ambulance services were run by funeral homes because hearses were among the few vehicles able to transport a stretcher. The National Highway Safety Act of 1966 established the Department of Transportation and made it the lead agency responsible for upgrading EMS systems nationwide.¹

In 1967, J. F. Pantridge began using a physician-staffed mobile coronary care unit in Belfast, Northern Ireland, to extend cardiac care into the prehospital setting. By doing so, he was able to reduce mortality among myocardial infarction patients.² Using physicians to staff ambulances never gained popularity in the United States. However, in the late 1960s and 1970s, nonphysician prehospital personnel in the United States began to learn advanced medical skills, including IV placement, administration of medications, cardiac rhythm interpretation, and defibrillation.³

The U.S. EMS Systems Act of 1973 set aside large federal grants to develop regional EMS systems across the country. Approximately 300 EMS regions were established and became eligible for federal funding. To receive funding, the Act required that EMS systems address 15 key elements (Table 1-1). These elements form the foundation of many EMS systems today.⁴

The 1970s became something of a Golden Age for EMS in the United States. The U.S. Department of Transportation developed curricula for emergency medical technicians, paramedics, and first responders. EMS communications systems were formalized. In 1972, the Federal Communications Commission recommended that 9-1-1 be implemented as the emergency telephone number nationwide. The concept of designated trauma centers within EMS systems was introduced, the idea being that EMS personnel would transport seriously injured patients preferentially to these facilities.

The Omnibus Budget Reconciliation Act of 1981 eliminated direct federal funding for EMS. Instead, federal funds were given to states in the form of block grants. The result was a decrease in overall funding of EMS as well as decreased coordination of EMS systems. EMS systems took on a decidedly local flavor, with great variation between systems within states and across the country. This trend has had long-term consequences for the field.¹

In 2011, the American Board of Emergency Medicine recognized EMS as its seventh subspecialty. The certification examination is based on the Core Content of EMS Medicine⁵ with four major content areas: Clinical Aspects of EMS Medicine, Medical Oversight of EMS, Quality Management and Research, and Special Operations.

A review of the 15 elements of EMS systems identified by the EMS Systems Act of 1973 (Table 1-1) provides insight into the current structure of EMS systems and the challenges they face.

MANPOWER

In most urban areas, paid public safety and ambulance personnel provide prehospital medical care. In contrast, suburban, rural, or wilderness EMS systems commonly use volunteers. Regardless of setting, EMS personnel fall into one of four levels of training, or licensure levels, in accordance with the National EMS Scope of Practice Model, set forth by the National Highway Traffic Safety Administration. These are emergency medical responder, emergency medical technician, advanced emergency medical technician, and paramedic. Each type of provider must master a minimum set of psychomotor skills. Emergency medical responders are usually first on the scene of a medical emergency. They are trained to perform CPR, spine immobilization, hemorrhage control, use of an automated external defibrillator, and other basic interventions while awaiting an ambulance. Emergency medical technicians function as part of an ambulance crew and are trained to take care of immediate life threats. Skills include oxygen administration; CPR; hemorrhage control; and patient extrication, immobilization, and transportation. They are also trained to assist patients in using some of their own medications and can administer to patients certain over-the-counter medications under medical oversight. Advanced emergency medical technician training includes additional assessment skills plus IV insertion, use of esophageal-tracheal multi-lumen airway devices, and administration of certain medications. Paramedics have the highest skill level, with greater training and broader scope of practice than advanced emergency medical technicians. Because of their advanced level of training, paramedics function under a designated physician’s medical license.⁶

TRAINING

Training includes initial provider training and continuing education. As EMS call volume increases, providers often care for a disproportionate number of patients with minor medical issues. Maintaining proficiency in skills needed to manage critically ill patients may be difficult. Innovative training methods to ensure skills retention must be sought. Use of computerized human patient simulators is one option, both for reviewing skills and learning new ones.

COMMUNICATIONS

The adoption of 9-1-1 as a nationwide emergency number in the United States has greatly facilitated public access to emergency medical care. In many systems, the local answering center or public safety answering point has enhanced equipment that provides the number and location of a caller (enhanced 9-1-1). Widespread use of cellular telephones has prompted the development of enhanced technology to identify and locate these callers as well, in accordance with Federal Communications Commission regulations. Emergency call takers are trained to collect the necessary information, dispatch appropriate resources, and offer first aid or prearrival instructions, while the ambulance is en route. Ambulance personnel should also be able to communicate with the destination hospital. Most EMS personnel operate under standing orders and protocols developed by physicians. However, there are times when providers may require online medical control, talking directly with a physician for direction.⁷ Historically, communications represent the weakest link in most disaster responses. It is therefore important that EMS communication systems have built-in redundancy to ensure uninterrupted service.

TRANSPORTATION

Ambulances have evolved from simple transport vehicles into mobile patient care vehicles. Ambulance design must enable EMS personnel to provide airway and ventilatory support while transporting the patient safely. Basic life support ambulances carry equipment appropriate for personnel trained at the emergency medical technician level, such as automated external defibrillators, oxygen, bag-mask ventilation devices, immobilization and splinting devices, and wound dressings. They do not carry medications and cannot transport patients requiring IVs or cardiac monitoring. Advanced life support ambulances are equipped for paramedics or advanced emergency medical technicians with supplies appropriate for their scope of practice, including IV fluids and medications, intubation equipment, cardiac monitors, and pulse oximeters. Ground transportation is appropriate for the majority of patients, especially in urban and suburban areas. However, air transport, generally by helicopter, should be considered for critically ill patients when the ground transport time would be dangerously long or if the terrain is difficult to navigate.⁴

FACILITIES AND CRITICAL-CARE UNITS

Patients are often transported to the closest appropriate hospital. In recent years, the number of specialty hospitals has increased. These include pediatric hospitals, trauma and spinal cord injury centers, burn centers, stroke centers, and centers with advanced cardiac or resuscitation capabilities.⁸ Tertiary care centers, often affiliated with medical schools, provide many of these services and may also have a large number of critical-care unit beds. The decision to bypass hospitals to go directly to a specialty center or a hospital with a large critical-care capacity, often at greater distances, is not a simple one. Although specialty hospitals often have more resources, transporting an unstable patient past an ED to get to the specialty hospital is not without risks. Furthermore, bypassing hospitals may have negative financial consequences for those facilities that are bypassed.¹ It is wise to solicit input from the local, regional, or statewide medical community before developing destination policies involving such specialty centers.