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Transportation of the critically ill or injured patient rapidly improved after 1973. Although national standards for ambulance equipment were developed in the early 1960s, a 1965 survey of 900 cities reported that fewer than 23% had ordinances regulating ambulance services. An even smaller percentage required an attendant other than the driver, and only 72 cities reported training at the level of an American Red Cross advanced first aid course, the nearest thing to a standard ambulance attendant course before the advent of EMT‐A in 1969 [46]. The hearses and station wagons used in the 1960s did not allow personnel room to provide CPR or other treatments to critically ill patients. The vehicles were designed to carry coffins and horizontal loads, not a medical team and a sick patient. In the 1960s, two reports focused national attention on the hazardous conditions of the nation’s ambulances [16, 47]. In addition to inadequate policies, staff training, and communications, ambulance design was faulty, and equipment absent or inadequate. Morticians ran 50% of the ambulance services because they owned the only vehicles capable of carrying patients horizontally. No U.S. vehicle manufacturer built a vehicle that could be termed an ambulance.

As early as 1970, DOT and the ACS had developed ambulance design and equipment recommendations [48, 49]. In 1973, DHEW released the comprehensive guide, Medical Requirements for Ambulance Design and Equipment, and a year later the U.S. General Services Administration issued federal specifications KKK‐A 1822 for ambulances [50]. Although the KKK specifications were originally developed for government procurement contracts, local EMS agencies were often politically obligated to meet or exceed the specifications when ordering new ambulances. A 1978 study described the status of ambulance services within 151 of the regions. Only 65% of the 13,790 ambulances in those regions met the federal KKK standards. Eighty‐one regions used paramedics and 72 had some type of air ambulance capability. Response time was often longer than 10 minutes in urban areas and as much as 30 minutes in rural areas [51].