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The Past, Present and Future of Emergency Medical Services

Less than two decades ago, professional prehospital medical care and emergency medical services (EMS) systems came into being largely in response to the appearance of two modern epidemics: coronary artery disease and trauma. Just after the mid-point of this century, these two processes suddenly were being recognized as being responsible for: nearly a million premature deaths annually in the United States; and for permanent disability in another million victims. Also, it became evident that what clearly differentiated these two epidemics from the classical epidemics involving infectious diseases was that they both required immediate attention— within minutes —if many of the deaths were to be prevented(l). "Sudden death" can be the first symptom in as many as a quarter of those with coronary artery disease and most of these sudden deaths are caused by potentially reversible ventricular dysrhythmias. Similarly, the earliest possible spinal immobilization and airway management, coupled with rapid evacuation to a specialized facility for the definitive care of internal hemorrhage are the primary mainstays of early injury management(2). And while these preventable causes of mortality and morbidity need attention and critical intervention within minutes, they also occur in venues far from the security of a medical facility such as homes, offices, and on dark, rain-slicked streets. Immediately, this brings a unique aspect and perspective to the medical care provided. Particularly in the management of sudden death and injuries, the medical care must be modified and tailored in accordance with the environment in which it is delivered. Factors such as difficult extrications, lifting and evacuation, weather, hostile crowds, hazardous conditions and limited resources change the priorities and limit one' s ability, not only to deliver optimal care, but also to recognize and monitor for potential complications of both medical problems and the medical care rendered. But, despite these logistical barriers of time, environment, and distance, a handful of pioneer physicians ventured forth, primarily from academic institutions, in the late 1960s and responded out into the out-of-hospital setting to challenge the notion that these two major epidemics were beyond the scope of medical practice(1,3)."Street-wise" and often bold in their approach, they demonstrated scientifically not only a definite life-saving effect of prehospital care, but also that even through the use of closely supervised intermediaries (the first EMTs and paramedics) , many of these deaths clearly could be prevented. To this day, one common element still can be found among all of those EMS systems which can document their ability to prevent deaths and provide quality of care for the sick and injured. The common element continues to be the intense involvement of academically-oriented physicians who understand the prehospital environment and who act as the driving forces for continuous improvements in prehospital emergency care and EMS systems management; physicians who view EMS as part of their personal practice of medicine and who uphold their own high standard of care among those EMS personnel to whom they delegate the direct "on-scene" responsibilities for that medical practice (1,3). It must be emphasized that most of the original pioneer training programs had that one important factor that would shape their eventual success. The physiciantrainers of the first paramedics were themselves extremely adept at dealing with the logistics of providing the most optimal medical care possible in the pre-hospital setting. The prehospital environment forces one to use modified tactics, priorities and judgments. In such circumstances, these physicians had to learn to single-