accredited hospitals in the country at the time, very few were prepared to meet the increased demand for volume and clinical care that developed between 1945 and 1965. From 1958 to 1970, the annual number of emergency department visits increased from 18 million to more than 49 million [16]. In addition, emergency departments were staffed by the least experienced personnel, who had little education in the treatment of multiple injuries or critical medical emergencies. Early efforts of the American College of Surgeons (ACS) and the American Academy of Orthopedic Surgeons (AAOS) to improve emergency care were largely unsuccessful because interest and support from the medical community were essentially non‐existent [17–20].
Box 1.1 Key findings of the 1966 NAS‐NRC report
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
