Introduction by Carl J. Post*

Nearly three decades ago, a brash and inventive senator lent his voice to those clamoring in print for better emergency healthcare systems. He had already authored four comprehensive health plans for the entire country, only to have them blocked and blunted by vested interests of one stripe or another in Congress. Edward Kennedy knew that healthcare access was the central issue even then.

EMS represented a major element in the access equation. In 1973, he had gotten behind federal initiatives for emergency care because rural emergency care was such a glaring oxymoron it stood out as a systems issue. Healthcare rationing began with denying essential entry into the system. EMS was a gateway into the health delivery system. EMS had to have a more systematic bent of its own if it were to feed into a larger system.

Senator Kennedy recognized this fact. He therefore eagerly shared his enthusiasm for EMS in this essay he wrote for the Jan/Feb 1982 issue of EMS Magazine. Federal initiatives for EMS were languishing at that point in time and would soon after be scaled down markedly. (The federal entitlement program for EMS was phased out.) But Edward Kennedy knew EMS was yet another cause worth championing and did so deliberately!

In the early 1970s, Congress became concerned that many communities lacked the ability to respond adequately to medical emergencies, a situation which posed a serious threat to the health of Americans. Emergency medical services are critical to the delivery of healthcare services in this country. Without ready access to these services, the availability of the best healthcare in the world would be of no avail to millions of Americans.

In rural areas, effective response to medical emergencies was hampered by a lack of medical resources and the difficulties posed by the wide dispersal of acute care facilities. In urban areas, duplication and maldistribution of resources and in some cases, competition among facilities to provide care to emergency victims impaired a coordinated and efficient response to medical emergencies. Of the country's 25,000 ambulances, 20,000 were of the station wagon type which were unsuitable for tending sick or injured people in transit. In many small towns the hearse and the funeral director also doubled as ambulance and attendant. The National Academy of Sciences (NAS) estimated that only 35% of the nation's 200,000 ambulance personnel were qualified at a minimal acceptable level.

The need for action was clear and the potential benefits great. The NAS estimated that 60,000 deaths from traumatic injury could be avoided through improved emergency medical services. The American Heart Association estimated that between 15% and 20% of prehospital coronary deaths are preventable if proper care were administered at the scene en route to an appropriate medical facility. It was also estimated that 5,000 deaths each year caused by drowning, poisoning and drug overdose could be prevented with improved EMS.

Despite the president's opposition to a federal role in improving EMS systems, Congress went forward to assist states and localities in upgrading their EMS activities. In November 1973 the Congress adopted P.L. 93-154, the Emergency Medical Services Systems Act of 1973, which authorized grants and contracts to communities for:

Feasibility studies and planning the establishment and operation of an EMS system;

The establishment and initial operation of EMS systems;

The expansion and improvement of EMS systems;

Research in emergency medical techniques, methods, devices, and delivery;

Training in techniques of EMS.

The focus of the Act was on the development of a coordinated, effective EMS system. All grant and contract applicants were required to provide 15 basic components of a comprehensive EMS system within a particular period, specified in the grant or contract application. The 15 basic components included: adequate manpower, appropriate training and education, centralized communications network, adequate transportation, adequate number of accessible EMS facilities, access to critical care units, effective participation of public safety agencies providing emergency services, and consumer participation. Applicants also were required to identify gaps in the community's ability to provide emergency medical services and the steps that the applicant would take to overcome those deficiencies.

To further the systems approach to the delivery of emergency medical services, the Act promoted the regionalization of service to assure that adequate resources were available to small local governmental units. The Act provided grants and contracts to both single governmental units and combinations of units, including regional arrangements, compacts or consortiums which assured that geographical areas of varying size, population and economic diversity could be served.

From the beginning, Congress envisioned that the EMS grants and contracts authorized would be made available for a limited time period. Once a system was in place, Congress intended that it should be fully supported by the communities it served. This intention was reinforced in the 1976 amendments, which required communities making applications for grants and contracts to assure continued financial support at the conclusion of federal support.

By 1976 it was clear that the EMS program needed to be continued. As a result, P.L. 94-573 was enacted, which extended the grant and contract program for three years. In addition, a new part B was added to the EMS program which authorized support activities demonstrating the effectiveness of various approaches to burn injury treatment, the carrying out of research and the provision of training in the treatment and rehabilitation of burn victims.

In 1979, the EMS Systems Act was again extended for three fiscal years. The amendments included in P.L. 96-142 also served to revise and improve the authorities for assistance. In addition, the amendments provided funding for trauma centers and poison control centers.

With federal support, we have seen great strides in the development of EMS systems nationally. There are now 300 EMS regions in the country. Two hundred and ninety-eight of these regions have already received some federal assistance. Today, there are over 350,000 ambulance attendants and over 800 of them have received the federally recognized training level of Emergency Medical Technician-Ambulance (EMT-A); the country is now served by 22,000 paramedics. There are now 27,500 ambulances, and 40% meet federal specifications. Eighty percent carry equipment recommended by the American College of Surgeons. Eighty-five percent can communicate with their base station and over 50% can communicate with the hospital.

These are significant accomplishments. At the same time, our goal of complete local self-sufficiency of EMS programs has not been fully achieved. However, local EMS programs can make their communities aware of the benefits of a comprehensive EMS system; stress can be put on the number of lives saved from death and the number of people spared the tragedy of permanent disability. With adequate public education programs directed at both the general public and the political sector, it is my hope that local EMS programs can continue their maturation to comprehensiveness and self-sufficiency.

Unfortunately, after eight years of federal assistance the Congress has to discontinue the categorical mechanism of support of EMS; instead, the Congress included EMS support in a block grant to the states. Consequently, it is to enhance its efforts to educate both state and local governments about the importance of EMS as an essential and integral part of health services delivery.

Those of us in the Congress who have recognized the need for EMS systems will be watching the actions of state and local governments in their efforts to complete a nationwide regionalized EMS system. At some point in the future, if we determine that the states are abandoning the effort to complete the EMS regional network, I am certain that Congress will reconsider its decision to transfer responsibility for the EMS programs to the states.

*Carl J. Post is an EMS Magazine advisory board member, author of Omaha Orange: A Popular History of EMS in America, and is presently teaching the History of Health Care in America for Capella University Online.