The Early Years

The roots of EMS in the United States were planted in the horrors of war.

As late as the Civil War, standard practice was to wait for a battle to end before tending to the injured. Often times it would take days to remove the wounded, resulting in horrific suffering and many avoidable deaths.

In 1862, facing mounting battlefield losses, Dr. Jonathan Letterman tried a radical new approach. He established the US Ambulance Corps within the Army of the Potomac, where he was medical director.

His new strategy stationed ambulances close to the frontline to respond immediately to reports of wounded soldiers. Treated regardless of which side of the conflict they served, the wounded were triaged for severity of injury and transported to appropriate levels of care under the nation’s first system of emergency medical management.

Due to its success, the Ambulance Corps was later extended to all units of the Union Army.

This resulted in dramatically reduced mortality. It also resulted in increasing death and injuries among the Ambulance Corps members. Yet, they remained committed to saving the lives of their fellow soldiers despite the risk of being in battle without the ability to properly defend themselves.

The commitment, service and sacrifice of these ambulance attendants established the finest traditions of our nation’s modern EMS. To this day, those same unselfish principles drive our country's dedicated EMS providers to serve “so that others might live.” 

Dr. Letterman’s system of emergency medical management soon stretched beyond the battlefield. In 1865, Cincinnati, Ohio formed the first civilian ambulance service, and New York City followed suit in 1868.

The Middle Years

From the turn of the 20th Century through to the 1950s, emergency services spread across the United States. In the absence of formal organizing principles, localities implemented these services in a variety of ways and with varying levels of effectiveness.

The result was a hodgepodge of emergency services operated by fire departments, hospitals, funeral homes, towing companies, independent operators, and volunteers. Surprisingly, according to the West Virginia Department of Education, by the 1950s, funeral homes had begun caring for patients and provided nearly half of the country’s ambulances. Furthermore, across the nation, ambulances were equally varied in quality because there were no standards for safety or equipment.

In these formative years, most emergency service workers had little or no training. They were primarily tasked with transporting people to the hospital as fast as they could. What little help they could give, though well-intentioned, frequently caused additional injury and disablement to the people they were helping.

In fact, as late as 1972, according to the Ambulance Association of America, “Possibly as many as 25,000 persons a year may be permanently disabled due to mishandling by poorly trained ambulance personnel.” As the National Registry of Emergency Medical Technicians notes, the patient was being twice victimized: once by the injury or illness and once by failing to receive competent emergency medical care.

That began to change in the late 1950s with the medical community’s focus on cardiac health and the federal government’s growing concern about rising rate of deaths and injuries from accidents. These led to the watershed developments of the 1960s and 1970s that launched the modern US EMS service.

The Dawn of the Modern EMS System

In 1966, the National Academy of Sciences published Accidental Death and Disability: The Neglected Disease of Modern Society.

This landmark report would radically change emergency services and help launch the modern EMS system. It pulled no punches about the state of emergency services at that time:

“Few are adequately trained in the advanced techniques of cardiopulmonary resuscitation, childbirth, or other lifesaving measures, yet every ambulance and rescue squad attendant, policeman, fire-fighter, paramedical worker and worker in high-risk industry should be trained.”

“Data are lacking on which to determine the number of individuals whose lives are lost or injuries are compounded by misguided attempts at rescue or first aid, absence of physicians at the scene of injury, unsuitable ambulances with inadequate equipment and untrained attendants, lack of traffic control, or the lack of voice communication facilities.”

From 1966 to 1973, improvements in emergency medical services remained spotty. But the visibility of the situation remained high, and numerous organizations continued to work the issues.

In 1972, the National Academy of Science—National Research Council analysis showed that the federal government had yet to develop a cohesive policy, nor had it sufficiently advanced EMS. A year of intensive political activity following that report resulted in the EMS Services Development Act of 1973.

The Act signaled a major shift in EMS. Until then, it was under the purview of the Department of Transportation and was seen primarily as a transportation service. The Act designated the Department of Health, Education and Welfare as the lead responsible agency, which essentially shifted the emphasis from transportation to emergency medical services.

Another factor was the return of trained medics from service in Vietnam. With their training and experience, they provided a deep pool of talent for the new EMS direction.

Modernization began in earnest.

The Decades of Expansion

The 1980s and ‘90s saw accelerated transformation of the EMS system through formalized professional qualifications and integration as a front-line medical resource.

With national funding for EMS drying up at the start of the '80s due to the poor economy, state and local jurisdictions took more responsibility for funding. Standardization initially suffered, but was gradually restored and updated throughout the decade. By 1989, both the Department of Defense and the Department of Transportation had established standard criteria and required certification levels.

The increasing scope of services provided by EMS providers drove another major development in the ‘80s: physician oversight was necessary for effective first-line treatment coordinated as part of the medical-care continuum. The position of Emergency Medical Director arose with the primary responsibility and authority to provide medical oversight for all aspects of EMS in an effort to assure quality patient care.

In the 1990s, organizations associated with EMS recognized the need for nationally coordinated information sharing and a “unified EMS voice.” The National Highway Traffic Safety Administration, the National Association of State EMS Officials, and the National Association of EMS Physicians comprehensively reviewed and evaluated the current EMS landscape. They produced the EMS Agenda for the Future to prioritize ideas, legislation, goals and objectives for the coming decades.

Despite progress, the debate over licensing and certification of EMS providers continued through the mid-‘90s. The National Registry for EMTs analyzed practices in 1994 and 1999, leading to the development of the EMS Educational Agenda for the Future, which serves as the standard for developing EMS educational curricula.

The New Century

Developments throughout the 2000s continued to improve and expand EMS scope of service.

The National EMS Information System, established in 2001, helped standardize the storage and sharing of EMS data to improve analysis, research and performance at the local, regional and state levels. That work is not yet complete, however,  and the effort to effectively gather and use EMS-related data continues.

In 2005, the Enhanced 911 Act established the national 911 program to assess and improve public safety and communication services, and the Federal Interagency Committee on EMS was created to coordinate federal efforts and improve EMS systems nationwide.

More recently, intense research has focused on EMS pre-hospital interventions in some acute-care issues common to emergency medicine. These include acute respiratory distress, cardiac arrest, chest pain, etc. Better technical communication linking the EMS pre-hospital care and the emergency department promotes earlier determination of patient severity and care management prior to arrival.

From the earliest days of EMS service, providers have continually put themselves on the line “so that others might live.” It’s a high-risk profession. According to the US Bureau of Labor Statistics:

“EMTs and paramedics have one of the highest rates of injuries and illnesses of all occupations. They are required to do considerable kneeling, bending, and lifting while caring for and moving patients. They may be exposed to contagious diseases and viruses, such as hepatitis B and HIV. Sometimes they can be injured by combative patients…”

In 2018, recognizing the commitment, service and sacrifice of the lost or disabled members of the EMS Provider community, Congress passed Public Law 115-275 authorizing the National EMS Memorial Foundation to establish a fitting and permanent National EMS Memorial in Washington, DC.

The work continues.