and comprehensive system must have resources sufficient in quality and quantity to meet a wide variety of demands, with the recognition that the discrete geographic regions established must have sufficient populations and resources to enable them to become self‐sufficient eventually.
Each state was also to designate a coordinating agency for statewide EMS efforts. Ultimately, 304 EMS regions were established nationwide. By 1979, 17 regions were fully functional and independent of federal money. However, of the 304 geographic areas, 22 had no activity and 96 were still in the planning phase [34].
In the regulations, David Boyd strictly interpreted the congressional legislative intent of the EMS Systems Act to mandate that all regions adopt all 15 essential components of the legislation. Regions were limited to five grants, and with each year of funding, progress toward more sophisticated operational levels was expected. By the end of the third year of funding, regions were expected to have basic life support (BLS) capabilities, which required no physician involvement. ALS capability, which was expected to perform traditional physician activities and have physician oversight, was expected at the end of the fifth year. The use of BLS and ALS terminology in the regulations spread widely. However, the original definitions that corresponded directly to the funded emergency medical technician‐ambulance (EMT‐A) and paramedic levels of training quickly became elusive as states created variations in the EMT‐A and paramedic levels. Nationally, the EMT‐A level required no medical involvement, but some states such as Kentucky did extend medical oversight to BLS because of insurance laws – laws making medical care and transportation across a county line virtually impossible without a physician’s approval over the radio.
Developing the geographic regions required to secure federal funding through the EMS Systems Act usually necessitated new EMS legislation at the state level. The state laws that developed throughout the 1970s varied markedly regarding the issues of medical oversight, overall operational authority, and financing. In some states, physician involvement was required. In others, medical oversight was not even mentioned in law or regulation. Often, responsibility for coordinating activities was assigned to a regional EMS council of physicians, prehospital personnel, insurance companies, and consumers who often had specific interests to protect. The level of physician input was inconsistent across the nation.
Personnel
A lack of appropriately trained emergency personnel at every level of care had been identified in the NAS‐NRC document [16]. After 1973, extensive effort and money were directed at addressing this educational deficiency. Serendipitously, a large number of medical corpsmen, physicians, and nurses were returning from Vietnam; they understood that trained non‐physicians could perform life‐saving tasks in the field. Many argued that rapid transport and early surgery could improve civilian trauma practice as it had done on the battlefield.
Physicians
In 1966 the NAS‐NRC document stated, regarding emergency care, “No longer can responsibility be assigned to the least experienced member of the medical staff, or solely to specialists, who, by the nature of their training and experience, cannot render adequate care without the support of other staff members” [16]. Thus the importance of physician leadership and training in EMS was identified early. During the 25 years following World War II, increasing demands for care were placed on hospital emergency departments. As a result, groups of physicians began focusing on exclusively practicing and improving emergency care. They identified the academic discipline and scientific rigor necessary to define a separate medical specialty: emergency medicine.
In 1968, ACEP was founded by those physicians interested in the organization and delivery of emergency medical care. In 1970, the first emergency medicine residency was established at the University of Cincinnati, and the first academic department of emergency medicine in a medical school was formed at the University of Southern California. Soon the directors of medical school hospital emergency departments founded the University Association for Emergency Medicine. Between 1972 and 1980, more than 740 residents completed training at 51 emergency medicine residencies throughout the country [35–37]. The first major step toward designation as a medical specialty occurred in 1973 when the AMA authorized a provisional Section of Emergency Medicine. In 1974, a Committee on Board Establishment was appointed, and a liaison Residency Endorsement Committee was formed [37]. Further impetus toward expansion of residency training in emergency medicine occurred with the formation of the American Board of Emergency Medicine (ABEM) in 1976 [38]. Before that time there was some hesitancy to create additional residency programs that might not lead to board certification.
In September 1979, emergency medicine was formally recognized as a specialty by the AMA Committee on Medical Education and the American Board of Medical Specialties. One of the strongest arguments in favor of the new specialty was that emergency physicians had a unique role in the oversight of prehospital medicine. ABEM gave its first certifying examination in 1980, which incidentally did not examine on any areas of prehospital care.
Although emergency medicine, emergency nursing, and prehospital care were all nourished by the funds distributed between 1973 and 1982, the first full‐time EMS medical director was not appointed until April 1981 in New York City. Previously, all had been part‐time, and many had been simply functionaries. Shortly thereafter, cities like Salt Lake City and Houston followed New York’s lead, and appointed full‐time EMS medical directors. Even then, EMS as a physician career choice was perceived by many as perhaps a risky career undertaking.
Prehospital Clinicians
The Highway Safety Act of 1966 funded EMT‐A training and curriculum development. By 1982, there were approximately 100,000 people trained at the EMT‐A level. They were trained to provide basic, non‐invasive emergency care at the scene and during transport, including such skills as CPR, control of bleeding, ventilation, oxygen administration, fracture management, extrication, obstetric delivery, and patient transport. The educational requirements, which began as a 70‐hour curriculum published by the AAOS in 1969, soon grew to 81 hours of lectures, skills training, and hospital observation; most of the increase in those hours were due to the addition of training in the use of pneumatic anti‐shock garments or military anti‐shock trousers. After working for 6 months, graduates were allowed to take a national certifying examination administered by the NREMT. Founded in 1970, the NREMT developed a standardized examination for EMT‐A personnel as one requirement for maintaining registration. Many states began to recognize NREMT registration for the purposes of state certification or licensure or reciprocity between states [29].
While the EMT‐A quickly became a nationally recognized standard, the development of national consensus at the paramedic level was slower, with marked differences in training from locality to locality. Paramedic practices became somewhat formalized with the adoption of a DOT emergency medical technician‐paramedic (EMT‐P) curriculum in the late 1970s. By 1982, EMT‐P training ranged from a few hundred to 2,000 hours of educational and clinical experience. Typical clinical skills included cardiac defibrillation, endotracheal intubation, venipuncture, and the administration of a variety of drugs. The use of these skills was based on interpretation of history, clinical signs, and cardiac rhythm strips. Telemetric and voice communications with physicians were usually required prior to initiating advanced level care. In the early days of paramedics, extensive “online” direct medical oversight was mandatory for all calls in most systems. With time, this requirement was modified by the introduction of protocols allowing for greater use of standing orders [39]. However, a great deal of variation in the use of direct medical oversight remained. As early as 1980, paramedics in decentralized systems, such as New York’s, used many clinical protocols, most of which had few indications for mandatory direct medical oversight. On the other hand, as late as 1992, many centralized systems, such as the Houston Fire Department, had only a few standing orders (mainly for cardiac arrest) that did not require contemporaneous discussion with a direct medical oversight physician.
The
