Читать книгу Emergency Medical Services - Группа авторов - Страница 33

The public health initiative for developing a national EMS system came to a gradual, quiet, and unceremonious demise after the 1981 legislative changes. In most regions, the remnants of the old DHEW program were left to die off slowly under the cloud of confusion occasioned by the Preventive Health Block Grants formula. In most (but not all) states, EMS regional programs were lost in the shuffle of competing health programs while the Reagan administration systematically eliminated federal support for all such programs. In fact, in most jurisdictions the regional EMS momentum present throughout the 1970s simply evaporated. Paradoxically, some individuals involved in EMS saw the end of DHEW era as an opportunity to develop and implement alternative approaches that would not previously have been permitted [60].

Organizations such as the NREMT, the National Association of EMTs (NAEMT), and NASEMSO stepped into the vacuum and endeavored to provide some degree of national infrastructure and EMS identity. At the state level, state EMS agencies managed to keep the momentum by sponsoring well‐attended statewide conferences. At the federal level, the DOT continued its support of EMS activities.

In 1984, the Emergency Services Bureau of the National Highway Traffic Safety Administration (NHTSA) was instrumental in creating the American Society for Testing and Materials (ASTM) Committee on Emergency Medical Services (F‐30). Through the ASTM, NHTSA sought to legitimize the promulgation of standards in many areas of EMS. Through a complex consensus process, thousands of ASTM technical standards were arrived at in many different industries, including construction and building. Although these standards have no federal mandate, they were often enforced at the local level, for example, in building codes. Since a confusing but enthusiastic beginning in 1984, more than 30 EMS‐related standards have been developed, including those for the EMT‐A curriculum, rotor‐wing and fixed‐wing medical aircraft, and EMS system organization. This last document outlined the roles and responsibilities of state, regional, and local EMS agencies. The resultant standards, although mandated by no authority, were considered by several state legislatures when state EMS laws or guidelines, written to obtain federal funding in the mid‐1970s, required updating. Many of the ASTM F‐30 standards have been withdrawn in recent years.

The F‐30 Committee prospered as long as physician involvement was evident and decisive, but it was clearly NHTSA’s decision what standard to expedite and when. The NREMT, NAEMT, and other interest groups joined the physicians, each to protect themselves. Although many physicians and physician groups eventually tired of the F‐30 exercise, NHTSA preserved some semblance of a central authority at the federal level.

As early as 1983, NHTSA began assuming some roles previously associated with old DHEW programs. Many of the original evaluation staff were hired on a part‐time basis to promote use of EMS management information systems. In 1988, NHTSA attempted to organize the electronic exchange of information among surviving EMS clearing houses, but those efforts eventually failed after 3 years. Because NHTSA had no specific legislative mandate to assume many of the roles previously performed by DHEW, some states tried to assume those roles but were often unsuccessful. One area that received less attention at the federal level was trauma research and systems development. That would remain so until the passage of the Trauma Care Systems Planning and Development Act in 1990 (Public Law 101‐590). This program was funded for several years by DHHS but subsequently also lost funding.

It would be incorrect to view the period since 1982‐1996 as simply stagnant. It might be better characterized as a time when varying forces confused attempts by the federal government and national organizations to define and standardize EMS. During this time, neither an operational consensus nor a discrete EMS development philosophy emerged. Across the country, local activists battled others in pursuit of diminishing funds. By 1992, patients had clearly emerged as customers, and, by the beginning of the Clinton administration, EMS was as conceptually unified, standardized, efficient, expensive, and confused as the rest of American health care. The Clinton health care plan of 1993 barely mentioned ambulance services, and it did not address EMS systems at all.