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].
1973: The Emergency Medical Services Systems Act
By 1973, several major lessons had emerged from the demonstration projects and the various studies undertaken during the preceding 7 years. Although federal activities had been limited to the 1968 DHEW regional demonstration projects mentioned earlier, significant progress had been made. The projects proved that a regional EMS system approach could work. However, because systems research was not a component of the DHEW program, the demonstration projects did not prove that a regional approach, or for that matter any particular approach, was more effective than another.
Many national organizations supported further federal involvement, both in establishing EMS program goals and in providing direct financial support. After several attempts at passing federal EMS legislation, a modified EMS bill was passed with support from numerous public and professional groups. President Nixon vetoed this bill in August 1973, based on the conservative philosophy that EMS was a service that should be provided by local government, and the federal government should neither underwrite operations nor purchase equipment. Additional congressional hearings led to the reintroduction of a bill proposing an extensive federal EMS program, based on the rationale that individual communities would not be able to develop regional systems without federal encouragement, guidelines, and funding. Finally, in November 1973, the Emergency Medical Services Systems Act was passed and signed. It was added as Title XII to the Public Health Service Act, to address EMS systems, research grants, and contracts. It also added a new section to the existing Title VII concerning EMS training grants [31].
The law was reauthorized in 1976, 1978, and 1979, with a continuing goal to encourage development of comprehensive regional EMS systems throughout the country. The available grant funds were divided among the four major portions of the EMS Systems Act: Section 1202 – Feasibility studies and planning; Section 1203 – Initial operations; Section 1204 – Expansion and improvement; and Section 1205 – Research. Applicants were encouraged to build on existing health resources, facilities, and personnel. The EMS regions were ultimately expected to become financially self‐sufficient. Therefore, a phase‐out of all federal funding initially targeted for 1979 was extended to 1982. This EMS program was administered in DHEW through the Division of Emergency Medical Services, with David Boyd, the medical director of the Illinois demonstration project, named as director. The law and subsequent regulations emphasized a regional systems approach, a trauma orientation, and a requirement that each funded system address the 15 “essential components” (Box 1.2). Medical oversight was not one of the 15 components, although subsequent regulations encouraged and then required medical oversight.
Box 1.2 The Fifteen Essential EMS Components.
1 Manpower
2 Training
3 Communications
4 Transportation
5 Facilities
6 Critical care units
7 Public safety agencies
8 Consumer participation
9 Access to care
10 Patient transfer
11 Coordinated patient record‐keeping
12 Public information and education
13 Review and evaluation
14 Disaster plan
15 Mutual aid
Source: Washington, DC: Department of Health, Education, and Welfare, Division of Emergency Medical Services, 1973.
1973–1978: Rapid Growth of EMS Systems
In 1974, the Robert Wood Johnson Foundation allocated $15 million for EMS‐related activities, the largest single contribution for the development of health systems ever made in the United States by a non‐profit foundation. Forty‐four areas of the country received grants of up to $400,000 to develop EMS systems [32]. This money was intended to encourage communities to build regional EMS systems, emphasizing the overall goal of improving access to general medical care, in addition to the original focus on trauma. The money was provided over a 2‐year period to establish new demonstration projects and develop regional emergency medical communications systems [33].
In early 1974, a newly reorganized DHEW Division of Emergency Medical Services began implementing the legislative mandate. Adopted from
