A bit of background is necessary to set the stage for the principles covered in this orientation manual. Modern EMS systems evolved over the past four decades, so EMS is still a fairly young science. It is important to remember that the principles we hold as true today may be challenged in the future as additional research and evaluation are conducted. The EMS agency manager should be a leader in reviewing research and evaluation results at a local level. Agencies that become mired in tradition are resistant to change and often fall behind in terms of their policies, protocols, procedures, and even the quality of care provided. It is essential that each EMS agency continue to seek ways to improve its performance and service to its patients. However, this does not always mean that “more is better.” For instance, in many systems it is unclear that higher levels of training for EMS personnel result in better outcomes for the patient. Improvement may mean doing what we already do more efficiently and effectively, or it may mean doing something new or different. Regardless, it takes an effective EMS agency manager and engaged medical director to provide the leadership necessary to make those determinations.

EMS History
There are many fine historical accounts of the development of modern EMS systems. One of the most recent is contained in the Institute of Medicine’s (IOM) report titled Emergency Medical Services: At the Crossroads. The IOM (2006) report describes the EMS historical development as:

EMS dates back for centuries and has seen rapid advancements during times of war. At least as far back as the Greek and Roman eras, chariots were used to remove injured soldiers from the battlefield. In the late 15th century, Ferdinand and Isabella of Spain commissioned surgical and medical supplies to be provided to troops in special tents called ambulancias. During the French Revolution in 1794, Baron Dominique-Jean Larrey recognized that leaving wounded soldiers on the battlefield for days without treatment dramatically increased morbidity and mortality, weakening the fighting strength of the army. He instituted a system in which trained medical personnel initiated treatment and transported the wounded to field hospitals (Pozner et al., 2004).

This model was emulated by Americans during the Civil War. General Jonathan Letterman, a Union military surgeon, created the first organized system in the U.S. to treat and transport injured patients. Based on this experience, the first civilian-run, hospital-based ambulance service began in Cincinnati in 1865. The first municipally-based emergency medical service began in New York City in 1869 (NHTSA, 1996).

In 1910, the American Red Cross began providing first aid training programs across the country, initiating an organized effort to improve civilian bystander care. During World Wars I and II, further advances were made in emergency medical services, although typically these were not replicated in the civilian setting until much later (Pozner et al., 2004). Following World War II, city EMS services were often operated by municipal hospitals and fire departments. In smaller communities, funeral home hearses served as ambulances because they were the only vehicle in the town capable of quickly transporting patients on stretchers. With the advent of Federal involvement in EMS in the early 1970s, and the articulation of standards at the State and regional level, these services were gradually replaced by others, including third service providers, fire departments, rescue squads, and private ambulances (NHTSA, 1996).

By the late 1950s, prehospital emergency care in the United States was still little more than first aid (IOM, 1993). Around that time, however, advances in medical care began to spur the rapid development of modern EMS care. While the first recorded use of mouth-to-mouth ventilation was in 1732, it was not until 1958 that Dr. Peter Safar demonstrated mouth-to-mouth ventilation to be superior to other modes of manual ventilation. In 1960, cardiopulmonary resuscitation (CPR) was shown to be efficacious. These two clinical advances led to the realization that rapid response of trained community members to cardiac emergencies could improve outcomes. The introduction of CPR and the development of portable external defibrillators in the 1960s provided the foundation for advanced cardiac life support (ACLS) that fueled much of the development of EMS systems in subsequent years.

In 1965, a President’s Commission on Highway Safety was convened to look at the medical care and transportation of citizens who were injured on the Nation’s highways. The commission recommended a national program to reduce highway deaths and injuries. The following year, the National Academy of Sciences and National Research Council released Accidental Death and Disability: The Neglected Disease of Modern Society. (NAS and NRC, 1966) (p. 23)

The IOM (2006) goes on to further acknowledge Accidental Death and Disability as the beginning of modern EMS.

Many experts date the development of modern EMS systems in the United States back to the 1966 publication of the landmark report Accidental Death and Disability: The Neglected Disease of Modern Society (NAS and NRC, 1966). Following the publication of this report and subsequent congressional action, EMS systems rapidly developed across the country. However, momentum was lost in 1981 when direct Federal funding for planning and development of EMS systems ended and was replaced by block grants to States. Over the past 25 years, EMS systems developed in a haphazard manner nationwide, regulated by State EMS offices that have been highly inconsistent in their level of sophistication and control. The result has been a fragmented and sometimes balkanized network of controls, cannot or do not collect data to evaluate and improve system performance, fail to communicate effectively within and across jurisdictions, allocate limited resources inefficiently, and lack effective strategies and resources for recruiting and retaining personnel.

A significant lack of funding and infrastructure for EMS research has sharply limited studies of the safety and efficacy regarding many common EMS practices. Pressing questions remain about important issues, such as the value of Advanced Life Support (ALS) services, the safety and efficacy of many common EMS procedures, the optimal approach to managing multi-system trauma, and the cost effectiveness of public-access defibrillation programs. Barriers to data collection, a lack of standardized data elements and definitions, and a limited pool of researchers trained and interested in EMS all pose significant challenges to research in the field. As a result, the prehospital emergency care system provides a stark example of how standards of care and clinical protocols can take root despite an almost total lack of evidence to support their use.

Because of this lack of supporting evidence, EMS systems often must operate blindly in addressing such questions as how available EMS personnel should be deployed, what services should be provided in the out-of-hospital setting, and what approach to organizing the EMS system is best. Multiple models of EMS organization have evolved over time, including fire department-based systems, hospital-based systems, and other public and private models. However, there is little research to demonstrate whether any one of these approaches is more effective than the others.

Within the last several years, complex problems facing the emergency care system have become more visible to the public. Press coverage has highlighted instances of slow EMS response times, ambulance diversions, trauma center closures, and ground and air crashes during patient transport. This heightened public awareness of these problems, which have been building over time, clarified the need for a comprehensive review of the U.S. emergency care system. Although emergency care represents a vital component of the U.S. health system, to date, no study of the system has been conducted. The events of September 11, 2001, and more recent disasters, such as Hurricane Katrina and the subway bombings in London and Madrid, have further raised awareness… (p. 13).

EMS Agenda for the Future
In 1996, the National Highway Traffic Safety Administration (NHTSA) established an agenda for EMS system development into the 21st century. The EMS Agenda for the Future identified fourteen attributes that make up the modern EMS system including (NHTSA, 1996):

• Integration of health services
• Legislation and regulation
• System finance
• Human resources
• Medical direction
• Education systems
• Public education
• Prevention
• Public access
• Communications systems
• Clinical care
• Information systems
• Evaluation (pg. v).

Those same fourteen attributes serve as the organizational backbone for the discussion contained in this document.

Rural EMS Agenda for the Future
In 2004, the National Rural Health Association, with funding support from HRSA’s Office of Rural Health Policy, published a companion report to the 1996 EMS Agenda for the Future that specifically addresses issues, concepts, challenges and opportunities for rural EMS. That visionary document, titled Rural and Frontier EMS Agenda for the Future, provides a detailed discussion of the current status of EMS in rural America and offers some guidance about how rural systems might evolve to in the next few decades. The Rural and Frontier EMS Agenda for the Future describes the following vision for rural EMS (NRHA, 2004).

The rural/frontier EMS system of the future will [ensure] a rapid response with basic and advanced levels of care as appropriate to each emergency. It will also serve as a formal community resource for prevention, evaluation, care, triage, referral, and advice. Its foundation will be a dynamic mix of volunteer and paid professionals at all levels, as appropriate for and determined by its community. Fulfilling this vision requires the application of significant Federal, State, and local resources as well as committed leadership at all levels to address such issues as:

• Staff recruitment and retention
• The role of the volunteer
• Adequate reimbursement and subsidization
• Effective quality improvement
• Appropriate methods of care and transportation in remote, low-volume settings
• Assurance of on-line and off-line medical oversight
• Adequacy of data collection to support evaluation and research
• Adequacy of communications and other infrastructure
• Ability to provide timely public access and deployment of resources to overcome distance and time barriers

Rural/frontier EMS providers are acutely aware of the challenges that they face. This document is intended to arm EMS agency managers in these settings with information about future directions in which their services and systems might best head to [ensure] their survival, advancement, and growth. It is also, more importantly, targeted to local, State and National makers of policy and funding decisions to underscore the fragility of rural/frontier EMS, identify the barriers to success, propose solutions, and highlight successful practices that EMS agency managers must consider within the sphere of their influence (p. 3).

The three documents referenced in this section, Emergency Medical Services: At the Crossroads, Emergency Medical Services: Agenda for the Future, and Rural and Frontier Emergency Medical Services: Agenda for the Future provide much of the underpinning for this orientation manual. References to these documents are included in both the reference and resource sections of this publication. Access to all three of these publications is free and could be considered a required reading list for all EMS agency managers. Regional EMS and Trauma Needs Assessment: Benchmarks, Indicators and Scoring developed by the Critical Illness and Trauma Foundation with funding support from the State of Colorado also served as a key resource document.