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The Highway Safety Act of 1966 funded EMT‐A training and curriculum development. By 1982, there were approximately 100,000 people 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, obstetric 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; most of the increase in those hours were due to the addition of training in the use of pneumatic anti‐shock garments or military anti‐shock trousers. 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 state certification or licensure or reciprocity between states [29].

While the EMT‐A quickly became a nationally recognized standard, the development of national consensus at the paramedic level was slower, with marked differences in training from locality to locality. Paramedic practices became somewhat formalized with the adoption of a DOT emergency medical technician‐paramedic (EMT‐P) curriculum in the late 1970s. 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, venipuncture, and the administration of a variety of drugs. The use of these skills was based on interpretation of history, clinical signs, and cardiac rhythm strips. Telemetric and voice communications with physicians were usually required prior to initiating advanced level care. In the early days of paramedics, extensive “online” direct 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 [39]. 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 discussion with a direct medical oversight physician.

The concept of the EMT‐intermediate (EMT‐I) evolved as a clinician level positioned somewhere between EMT‐A and EMT‐P. Airway management, intravenous therapy, fluid replacement, rhythm recognition, and defibrillation were the most common “advanced” skills included in the EMT‐I curriculum, though significant variation existed from state to state. To meet perceived unique needs of care capabilities from state to state, states developed several levels of EMT‐I, often in a modular progression with formal bridge courses. By 1979, formally recognized prehospital personnel existed at dozens of levels, with highly variable requirements for medical oversight.