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Inadequacies of Prehospital Care in 1966

1 The general public is insensitive to the magnitude of the problem of accidental death and injury.

2 Millions lack instruction in basic first aid.

3 Few are adequately trained in the advanced techniques of cardiopulmonary resuscitation, childbirth, or other life‐saving measures, yet every ambulance and rescue squad attendant, policeman, firefighter, paramedical worker, and worker in high‐risk industry should be trained.

4 Local political authorities have neglected their responsibility to provide optimum emergency medical services.

5 Research on trauma has not been supported or identified at the National Institutes of Health on a level consistent with its importance as the fourth leading cause of death and a primary cause of disability.

6 The potentials of the U.S. Public Health Service Program in accident prevention and emergency medical services have not been fully exploited.

7 Data are lacking on how to determine the number of individuals whose lives are lost through injuries compounded by misguided attempts at rescue and first aid, absence of physicians at the scene of the injury, unsuitable ambulances with inadequate equipment and untrained attendants, lack of traffic control, or the lack of voice communication facilities.

8 Helicopter ambulances have not been adapted to civilian peacetime needs.

9 Emergency departments of hospitals are overcrowded, some are archaic, and there are no systematic surveys on which to base requirements for space, equipment, or staffing for present, let alone future, needs.

10 Fundamental research on shock and trauma is inadequately supported; medical and health related organizations have failed to join forces to apply knowledge already available to advanced treatment of trauma, or educate the public and inform Congress.

Source: Adapted from Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, DC: National Academy of Sciences, 1966.

The 1966 NAS‐NRC document was the first to recommend that emergency facilities be categorized. It also emphasized aggressive clinical management of trauma, suggesting that local trauma systems develop databases, and that studies be instituted to designate select injuries to be incorporated in the epidemiological reports of the U.S. Public Health Service. Changes were also recommended concerning legal problems, autopsies, and disaster response reviews. Trauma research was especially emphasized, with the ultimate goal of establishing a National Institute of Trauma [16]. Another problem identified in the report was the broad gap between existing knowledge and operational activity. This white paper contains very good conceptual discussions that remain relevant for EMS physicians today.

In addition to the NAS‐NRC white paper, other reports raised many similar issues. The President’s Commission on Highway Safety had previously published a report entitled Health, Medical Care, and Transportation of Injured, which recommended a national program to reduce deaths and injuries caused by highway crashes. Its findings were complemented by and consistent with the NAS‐NRC report [21]. The recommendations in both documents were used when the Highway Safety Act of 1966 was drafted. This law established the cabinet‐level Department of Transportation (DOT) and gave it legislative and financial authority to improve EMS. Specific emphasis was placed on developing a highway safety program, including standards and activities for improving both ambulance service and attendant training, with particular focus on motor vehicle crashes [22]. This focus led to improvements in both transportation capabilities and clinical care.

The Highway Safety Act of 1966 also authorized funds to develop EMS standards and implement programs that would improve ambulance services. Matching funds were provided for EMS demonstration projects and studies. All states were required to have highway safety programs in accordance with the regulatory standards promulgated by DOT. The standard on EMS required each state to develop regional EMS systems that could handle prehospital emergency medical needs. Ambulances, equipment, personnel, and administration costs were funded by the highway safety program. Regional financing, as opposed to county or state funding, was a new concept that would be echoed in federal health legislation throughout the remainder of the decade [22].

With the Highway Safety Act as a catalyst, DOT established a division of emergency medical care and contributed more than $142 million to regional EMS systems between 1968 and 1979. A total of roughly $10 million was spent on research alone, including $4.9 million for EMS demonstration projects. A number of other federal EMS initiatives in the late 1960s and early 1970s poured additional funds into EMS. This included $16 million in funding from the Health Services and Mental Health Administration, which had been designated as the lead EMS agency of the Department of Health, Education, and Welfare (DHEW), to areas of Arkansas, California, Florida, Illinois, and Ohio, for the development of model regional EMS systems [23].

In 1969, the Airlie House Conference proposed a hospital categorization scheme [24]. The American Medical Association (AMA) Commission on EMS urged facility categorization and published its own scheme, which identified staffing, equipment, services, and personnel types [25]. This became known as “horizontal categorization.” Although it was supported by professional and hospital associations, many hospitals and physicians feared hospitals in lower categories would suffer a loss of prestige, patients, or reimbursement. The DHEW EMS program developed a categorization scheme based on hospital‐wide care of specific disease processes. Known as “vertical categorization,” this concept was ultimately embraced by many regional programs as a major theme in the development of EMS systems.

By the late 1960s, drugs, defibrillation, and personnel were available to improve prehospital care. As early as 1967, the first physician‐responder mobile programs morphed into “paramedic” programs staffed with non‐physicians using physician‐monitored telemetry capabilities as a modification of the physician‐staffed approach by Pantridge in Belfast.

The “Heartmobile” program, begun in 1969 in Columbus, Ohio, was initially staffed with a physician and three EMTs. Within 2 years, 22 highly trained (2,000‐hour program) paramedics provided the field care; the physician role became supervisory. Similarly, in Seattle, physicians supervised highly trained paramedics providing care in the field, increasing the survival rate of 10‐30% for prehospital cardiac arrest patients whose presenting rhythm was ventricular fibrillation. The Seattle model was also one in which fire department first‐responders played a crucial role in building what is now called a chain of survival. In Dade County, Florida, rapid response of mobile paramedic units was combined with hospital physician direction via radio and telemetry for the first time [26]. In Brighton, England, non‐physician personnel provided field care without direct medical oversight. Electrocardiographic data were recorded continuously to permit retrospective review by a physician [27].

National professional organizations such as the ACS, the AAOS, the American Heart Association (AHA), and the American Society of Anesthesiologists, in concert with other groups, provided extensive medical input into the early development of EMS. New organizations were also formed to focus on EMS, including the AMA’s Commission on EMS, the AHA’s Committee on Community Emergency Health Services, the American Trauma Society, the Emergency Nurses Association, the Society of Critical Care Medicine, the National Registry of Emergency Medical Technicians (NREMT), and the American College of Emergency Physicians (ACEP). In the years prior to 1973, such groups made significant but uncoordinated efforts toward the reorganization, restructure, improvement, expansion, and politicization of EMS [24, 25, 28, 29].

One of the most difficult issues with the development of paramedic programs was that most medical practice acts prevented these non‐physicians from performing procedures and skills that had historically been restricted to physicians (and in some cases nurses). Early in the development of the Los Angeles County program, the physician leadership realized that they had to seek legislative changes to allow paramedics to provide the clinical care desired. Following prolonged and contentious discussions, the Wedworth‐Townsend Act was signed by Governor Ronald Reagan in 1970, the first paramedic act in the nation. Additional states followed that example over the next decade.

The first widely recognized national awareness of the concept of paramedics and organized emergency medical services came to national attention in 1971 with the syndicated television show EMERGENCY. This show depicted the activities of Los Angeles County Fire Department (LACFD) paramedics Johnny Gage and Roy Desoto providing care in the field, supported by the hospital staff at Rampart General Hospital (modeled after the Los Angeles County General Hospital) in the characters of doctors Kelly Bracket, Joe Early, and Mike Morton, and nurse Dixie McCall. With technical advisors LACFD Captain Jim Page and Drs J. Michael Criley and Ronald Stewart, the show gave the citizens of the United States the concept of ALS care in the field and during transport to a specialty care hospital facility. Although presenting very positive impressions of EMS, it also led communities to the misconception that this level of care was uniformly available around the country, an expectation not yet achieved. Having said that, this show was instrumental in helping move understanding of EMS forward and served as a model for EMS systems development and a desire by many viewers to become emergency care clinicians.

In 1972, the NAS‐NRC published Roles and Resources of Federal Agencies in Support of Comprehensive Emergency Medical Services, which asserted that the federal government had not kept pace with efforts by professional and lay health organizations to upgrade EMS [30]. The document endorsed a more vigorous federal government role in the provision and upgrading of EMS. It recommended that President Nixon acknowledge the magnitude of the accidental death and disability problem previously reported by proposing action by the legislative and executive branches to ensure optimum universal emergency care. It urged the integration of all federal resources for delivery of emergency services under the direction of a single division of DHEW, which would have primary responsibility for the entire emergency medical program. It also recommended that the focal point for local emergency medical care be at the state level, and that all federal efforts be coordinated through regional EMS programs [30].