The history of Emergency Medicine is an inexact study. The actual beginning date is unknown. This paper attempts to combine the facts given from many different sources into one single overview of known history from approximate known dates.
It should also be stated that although Emergency Medicine Services, as a system exists all over the United States, it is in no way uniform. The laws governing emergency medical personnel and their actions differ greatly from state to state. This paper, when stating current Emergency Medicine Services conditions, will be referring to California for the most part.
Starting in the early 1960’s, many states passed legislation that protected individuals who stopped to help at the scene of an emergency. This legislation helped shield these individuals from liability. So long as the individual was providing assistance in good faith, and without gross negligence, he was protected (Department of Transportation, I-20).
In 1966 Congress created the National Highway Safety Administration under the already existent United States Department of Transportation. This new administration was given the authority to issue guidelines for state emergency medical systems and to formulate the emergency medical technician (EMT) training program. The administration established professional requirements for EMT’s, and their capabilities were expanded well beyond those of earlier ambulance personnel. (Emergency Medical Technicians, 1).
American Paramedics were originally trained military medical personnel who were first utilized in the Korean War. Under certain circumstances, these specialists were parachuted into hard-to-access locations. The name Paramedic came from a military medic who also was trained to parachute. Today the prefix “para” is taken to mean, “closely resembling” (Emergency Medical Technicians, 3).
The goal of the Department of Transportation was to package all the information gained from military experience of medical care in the field into a system able to be used in the private sector. This system must be able to train personnel who could provide field intervention medicine, or technical intervention that quickly turned near death victims into surviving patients (Department of Transportation, I-8).
In 1967 one of the first such systems was set up in Pittsburgh. “Unemployables” of the black ghetto were trained in basic life support for pre-hospital, ambulance use. For these individuals, who were not accustomed to the medical profession, the world of emergency care was a shock. Special stresses and constraints existed when rendering CPR in a crowded restaurant, childbirth in a city park, or patient care through the window of a wrecked automobile (Caroline, ix).
In California the Wedworth-Townsend Paramedic Act, passed in 1970, it provided permission for certain counties to establish experimental programs to test the use of Paramedics for emergency care in the field. It not only established advanced life support as the scope of practice for Paramedics, but also introduced the idea of a MICN. A Mobile Intensive Care Nurse, or MICN, is a registered nurse licensed by the county health department to provide emergency medical care or to give instructions. These instructions could be given either in person or by radio, to Paramedics working in the field. Originally, MICN’s worked in the field with Paramedics, but this was later found to be impracticable. Currently, MICN’s provide instructions to Paramedics from the hospital either by radio or phone (Calif. Health & Safety Admin., 1).
The concepts of field emergency medical care were just being recognized in 1971. (Heckman, pg. xiii) However, the need for easy identification and a unique symbol was recognized quickly. The fact that not many people were familiar with the new form of medical care made such identification necessary. It was decided that Emergency Medical Services, or EMS, would possess its own distinct symbol visible to the public. In 1973, the U.S. Department of Transportation adopted the “Star of Life” as the nationally recognized symbol for EMS. Its use to date by both state and federal offices has greatly contributed to the process of identification. Use of the symbol on highways and other areas has helped to alert citizens to the presence of the EMS system and the location for help (Department of Transportation, I-9).
For any medical care in the field to be effective, the personnel responding to help must first arrive at the scene. Early indications revealed that a dependence on lights and sirens was not only dangerous, but also unnecessary. An early U.S. Department of Transportation and EMS study titled “Ambulance Design Criteria” recommended the uniform use of specific colors and markings. Later, in 1974, The Department of Transportation developed the federal specifications for ambulances. The standard color is white. The standard markings are an orange stripe, blue lettering, and the “Star of Life.” The specifications prefer that any additional lettering be placed below the orange stripe, as not to distract from the basic markings (Department of Transportation, I-10). The colors changed in some cases later, when fire departments began to staff their own ambulances. In these cases, the ambulance is normally the same color as any of the department’s other fire apparatus.
In 1974, the then very experienced EMT’s in Pittsburgh began new training they became some of the first ambulance personnel trained in advanced life support, or the scope of medical practice for Paramedics. The doctors that accompanied the EMT’s in the field for training were also not accustomed to the out-of-hospital working conditions that the EMT has had first experienced seven years earlier. The sterile insertion of a needle in the hospital to establish an intovenious drug treatment became much more difficult in the streets of downtown or the moving ambulance speeding down Main Street (Caroline, ix).
Emergency Medical Technician-Paramedics were first recognized as an allied health organization in 1975. The recognition issued by the American Medical Organization opened the door for accredited entry-level educational programs geared for professional careers in EMS (EMS Programs, 45).
In 1975, the California Office of Statewide Health Planning and Development established pilot programs for another scope of practice termed limited advanced life support. Those operating in that field were labeled EMT-II’s. The lower level of training required being an EMT-II opened the opportunity for smaller, poorer communities to spend the money on the less expensive training programs. There are several differences between the level of training of an EMT-II and a Paramedic. EMT-II can administer eleven fewer drugs. Additionally there are certain airways, cardiac, and defibrillation maneuvers that an EMT-II cannot perform. Traditionally the EMT-II’s worked in the rural area while the Paramedics worked in the urban areas. This meant that EMT-II’s were spending more time in the ambulance en route to the hospital. It seemed paradoxical that the superior level of care available in the urban areas was not being used to its full potential. This led to a decline in EMT-II’s. The EMT-II classification still exists today although it is difficult to find training or employment. The superior level of care able to be provided by a Paramedic, in the end, outweighed the cost of training (Bishop 2-28).
Seeing the progression of EMS and the necessity to pass laws protecting and governing it, the governor of Michigan passed the Emergency Personnel Act in 1976. The act addressed not only the EMT, but also the EMT-Paramedic. The purpose of the new Michigan law was to license and regulate the emergency medical personnel practicing in that state. It also limited their liability under certain conditions, permitted local government to establish regulation, and provided penalties for violations (Law and Emergency Care, 51).
Nineteen seventy-six brought the concerted effort by many organizations to begin development of educational standards, or Essentials, that would be used to evaluate programs seeking to provide EMT-Paramedic accreditation. Several drafts of the Essentials were proposed. After wide distribution to the appropriate medical communities of interest, the American Medical Association Council on Medical Education finally adopted the Essentials. The adoption in 1978 represented a collaboration of many organizations other than the AMA, including the American College of Emergency Physicians, and American College of Surgeons (EMS Programs, 45).
The National Association of Emergency Medical Technicians, in 1978, issued “A Code of Ethics for Emergency Medical Technicians.” Among other things, the code states, “The fundamental responsibility of the EMT is to conserve life, to alleviate sufferings, and to promote health.” Although the code was established for the EMT, it also applies to the EMT-II and the EMT-Paramedic because their basic purpose is the same, even though they provide additional services (Department of Transportation, 1-10).
A broad based coalition of groups responsible for the various aspects of pre-hospital care cooperated in 1980 to formally establish a permanent EMS system in California. The act allowed the appointment of local EMS agencies, divided by counties, to administer local EMS systems for establishing statewide standards for pre-hospital emergency medicine. It set up the training required for licensed personnel and the operation of EMS systems. These standards, in the form of additions to the health code, went officially into effect the beginning of 1981. The stated purpose for such legislation was to establish an EMS authority that would coordinate and integrate all state wide activities concerning EMS (Calif. Health & Safety Admin., 2).
Seeing the many changes and confusion regarding the EMT, EMT-II and EMT-Paramedic curriculums, the United States Department of Transportation, National Highway Traffic Safety Administration choose to revise its national standards. The changes, made in 1984, provided a more concise working outline from which preparation could be made to create course-training programs (Heckman, xiii).
When an individual phones 911 requesting medical assistance there are several agencies notified. First, there is the private ambulance company, if the local fire department does not provide ambulance service. Second, there is the local fire department. Third, the local law enforcement may possibly respond. Depending on the first unit to arrive on scene, the personnel first coming in contact with the patient may have any one of several levels of training.
The first level of training would be the family members or public citizens who may or may not have any medical training. These individuals, or possibly a police officer or fireman, may have training limited to only basic first aid or CPR. Although early CPR is invaluable in cases of medically caused cardiac arrest, basic first aid is valuable in only the minor injuries.
The next level of care would be the First Responder. These individuals have attended a forty-hour course in CPR and the essentials of basic life support. This training is similar to an EMT although its scope of practice is significantly more limited. First Responders can give treatments of oxygen and provide basic airway management and circulation assistance. They also are able to secure the spine through cervical spine immobilization. Unlike EMT’s, though, First responders cannot give oral glucose to diabetics, transport to a hospital by ambulance, or communicate with hospital personnel. Their patient care is limited to basic life support until a more highly trained person arrives at scene (Bishop 2-28).
After the trained level of First Responder comes the EMT. They are licensed to provide full basic life support, including the use of oxygen and the administration of oral glucose. Oxygen and Glucose are the only two drugs an EMT can give to a patient. They can also transport a patient or patients to a medical facility via ambulance, communicating with the hospital personnel en route. There is a special classification of EMT that applies only to firefighters. It allows all the functions of an EMT to be performed, although transport to the hospital is not part of the training. This special classification allows the firefighter to work as an EMT in the fire service, but does not certify him to work at a private ambulance company (Bishop 2-28).
An EMT-D is a recent classification of EMS worker. A fully licensed EMT is able to not only provide basic life support, but also utilize the use of automatic defibrillators for patients experiencing cardiac arrest. To become an EMT-D requires an additional eight hours of training and the need for monthly refresher courses (Mathias 3-3).
EMT-II’s, although nearly extinct, are the next level of care available in the field. As mentioned earlier, a Paramedic can use eleven more drugs, as opposed to an EMT-II. Certain methods of providing a stable airway are also excluded from the EMT-II scope of practice. Additionally, certain treatments to the assist the heart are unavailable to the EMT-II (Mathias 3-3).
The final level of training for EMS in the field is the EMT-Paramedic, EMT-P, or just Paramedic. A Paramedic is able to establish an IV, use a monitor/defibrillator, and perform all airway stabilization functions. A Paramedic can administer many medications. Their level of care allows them to treat most patients at the scene, to more adequately stabilize a patient before transport to the hospital (Mathias 3-3).
All levels of EMS personal above, and including the EMT, communicate with the hospital to inform the doctors and MICN’s of the patient’s status and to receive orders. For all levels of EMS personnel, the purpose of their existence is to attempt to improve or stabilize the condition of their patient.
Those qualified EMS personnel working in the field are providing an invaluable level of treatment unheard of forty years ago. The advance of medicine since the beginning of civilized man has been slow progress. Although the level of care today is extremely more beneficial than the care of years past, it has taken hundreds of years to develop it.
The Emergency Medical Services program has been in existence for only about thirty-five years. In those thirty-five years, an ambulance has progressed from a taxi, to an advanced life support facility able to sustain life. Helicopters have gone from an aviation experiment, to an invaluable method of transferring patients quickly from the scene of an emergency to a hospital.
Advancements in pre-hospital patient care are endless. The use of external pacemakers is just now coming into use. For patients who have experienced massive blood loss, interosseous infusion, a new fluid replacement method, adds volume through the bone marrow, instead of by needle. Thrombolytics, drugs that eliminate clots in a matter of minutes, that have been in use in hospitals for several years are now being considered for field use to minimize damage to the coronary arteries and heart. Additionally, there are plans to allow the use of more potent diuretics to reduce inter-cranial swelling, and blood substitutes to combat blood loss. (Bishop 3-7)
Pre-hospital emergency medical care is an idea that has come of age and is still maturing. The existence of EMS personnel has saved, and will continue to save, many lives. Those who would have died several years ago from heart attacks in their homes are now easily surviving and living many more years that are healthful. Individuals, who may have died from trauma in years past, are now living because they are transported quickly to a trauma center.
If these are the things possible through medicine today, what lies ahead in the future? Could Surgery in the field, or the use of cryogenics to preserve a patient until repair to his body can be made, be a possibility? At this point, the level of care in the future is not known, but due to the desire to help and the challenge to heal, it can only be assumed that it will improve to incredible levels.
California Health and Safety Administration. Notice of Proposed Adoption of Regulations by the Emergency Medical Services Authority. Sacramento California. 1987.
Caroline, Nancy L. Emergency Care in the Streets. Pittsburgh Pennsylvania: Little, Brown and Company, third ed. 1989.
Department of Transportation. Emergency Medical Technician-Paramedic. Washington D.C.: U.S. Government, third ed. 1987.
“Emergency Medical Services”. Emergency Medical Services Programs. Denver Colorado, 1989 ed.
“Emergency Medical Technicians”. Law and Emergency Care. Sacramento California, 1988 ed.
“Emergency Medical Technicians”. The New Electronic Encyclopedia. 1990 ed.
Heckman, James D. Emergency Care and Transportation of the Sick and Injured. Park Ridge Illinois: American Academy of Orthopedic Surgeons, fifth ed. 1986.