EMS MAGAZINE Celebrating 35 Years of Service

     For 35 years, EMS Magazine has proudly served the EMS industry. During that time, there have been many changes in the world of prehospital care, but at the same time, the more things change, the more they stay the same. While preparing content for this issue, the editorial staff spent hours reviewing back issues and the one thing that became clear is that many of the problems that plague EMS today are the same as those the industry faced in the late 1960s and early 1970s. As we celebrate the 35th anniversary of EMS Magazine, we renew our commitment to serve the industry by focusing on topics that directly impact the lives of EMS providers and patients. As you will see from the magazine covers featured on the cover of this issue and on the following pages, we have reported on every major industry development over the past 35 years and will continue to do so as we move into 2008. Within this special anniversary section, you will find a discussion of the major events to impact EMS over the last 35 years, a timeline of EMS history and a tribute to some of the founding fathers of EMS. We hope you enjoy this celebration of the EMS profession.

The 1960s & 1970s: The Birth of Modern-Day EMS
     You don't usually think of a publication as a "pioneer," but when Deborah Carver and Carol Summer, two San Fernando Valley, CA, businesswomen, premiered the first edition of EMS Magazine in 1972, emergency medical services, in its modern form, was only six years old.

     Eugene Nagel, MD, a physician long retired from the University of Miami and Miami Fire Department, was one of the magazine's original editorial advisory board members. He clearly remembers his ongoing argument with Dr. Peter Safar about the significance of the new technique called CPR in the provision of emergency care.

     "The thesis was that the 'white paper' that came out in the early 1960s woke the U.S. to the need for EMS, but I didn't think it caused more than a ripple," he says. "I also didn't think that funeral homes getting out of the EMS business was a major force for creating modern EMS. The major force, I felt, was CPR, and that's what Peter Safar and I argued about.

     "CPR really started in 1960," says Nagel. "It was developed at Johns Hopkins and taught to Boston Fire Department's rescue personnel. Two cardiologists-Leonard Scherlis and Don Dembo-from the Maryland Heart Association started teaching it, and then the American Heart Association took over and became the main promoter of CPR."

     In 1972, Nagel was asked to write a monthly column for EMS Magazine on subjects he thought would interest paramedics. The response was almost zero, he says, until he wrote about whether there should be SWAT paramedics.

     "I came out against the concept, and I immediately got crucified," he says. "We finally had a debate that resulted in many pages devoted to whether paramedics should cross-train as police officers."

     In 1973, the EMS Systems Act was first proposed, but was vetoed by President Richard Nixon. About 1973, says Nagel, the Robert Wood Johnson Foundation provided $15 million to 44 locations around the country to promote the 9-1-1 system.

     EMS has come a long way since the 1970s, says advisory board member Ken Bouvier, NREMT-P. Bouvier, immediate past president of NAEMT and administrative liaison for New Orleans EMS, got his start in 1974 as a volunteer for a small community in Louisiana.

     "At that time, few places were offering EMT classes," he says. "It only took 80 hours to be an EMT-Basic, and a lot of the people who were becoming EMTs and paramedics were former Vietnam medical corpsmen. I came from a fire department that just required us to have first aid training. When I overheard a police chief and a firefighter talking about whether they should start using that new technique called CPR, I decided to go to EMT school, because I realized we needed to know what we were doing."

     MAST trousers were popular in the late 1970s and early 1980s, says Bouvier. "There were no trauma centers at that time and no operating rooms or staff readily available, so we had to keep trauma patients alive until the staff got there." Other products that are no longer used include Plano 747 supplies boxes, which were large and cumbersome; air splints; and hand-pump suction devices. Paramedics gave only basic drugs, like morphine, epinephrine and atropine, sodium bicarbonate and D5W. EKGs were limited to 3-lead, defibrillators were large devices used only by paramedics, and communication with medical control was by way of a radio phone with limited distance capability and poor reception. Bloodborne pathogens standards were nonexistent, and intubation was done without any way to check if the tube had been placed correctly.

     A huge influence on EMS in those days was the television show Emergency!, with paramedics Johnny Gage and Roy DeSoto. "That program, which showed paramedics saving lives, did more to spread the concept of EMS into the hinterland than any other single thing," says Nagel.

     Both Nagel and Bouvier also credit EMS Magazine for providing quality education to providers and supporting the profession through sponsorships and conferences like EMS EXPO.
-Marie Nordberg, Associate Editor

The 1980s: New Practices Introduced
     As a new decade began, the EMS industry continued to grow. State EMS directors and emergency physicians created formal associations; the EMS for Children program was established; and the Department of Transportation published national standard curricula for EMT-Ambulance personnel, as well as EMTs at the Intermediate and paramedic levels. In 1981, the Omnibus Budget Reconciliation Act ended federal funding under the EMS Systems Act, consolidated it into block grants, and shifted the responsibility for developing and funding EMS systems to individual states.

     Although King County, WA, was the first service to train EMTs in defibrillation, training was scarce in much of the country, says Bernard Beckerman, MD, FACEP, attending physician at North Shore University Hospital ED in Manhasset, NY, and editorial advisory board member for EMS Magazine.

     "I still think back to the hearse ambulances that, when they weren't being used to transport patients, were used to transport bodies," he recalls. "Nobody rode in the back with the patient, and providers didn't have much training."

     As for technology, providers were equipped to take a pulse and blood pressure, and that was about it, says Beckerman. "We weren't defibrillating in the ambulance, and we certainly didn't have medication for things like supraventricular tachycardia. I think we still have MAST pants in protocol, but I haven't seen them applied in at least 10 years. We used to say that MAST pants provided autotransfusion of blood, but that's nonsense. We believed it because that's what we'd been told. Now, we're switching to evidence-based medicine in emergency care, and we have research to tell us what we do right or wrong and how to fix it.

     "I was one of the people who introduced intubation into the field," Beckerman adds. "The only way I got my colleagues on the Regional Medical Advisory Committee to go along with teaching prehospital intubation was by agreeing to do it first as a pilot program for paramedics only. We said we would try it for six months or a year and gather statistics to see if it worked. I knew it would, and we eventually brought it down to the EMT-CC level."

     Perhaps the one thing that made the biggest impact on medical care in the 1980s was Acquired Immune Deficiency Syndrome (AIDS), first reported by the CDC in 1981. Until that time, there was little use of personal protective equipment, or even awareness that it was needed.

     "In 1978, I had the National Library of Medicine do a literature search and found nothing related to infection control in the provision of emergency care," says Katherine West, BSN, MSEd, CIC, an infection control consultant with Infection Control/Emerging Concepts, Manassas, VA. "I had done a ride-along as part of my baccalaureate training and was asking, 'How do you clean this equipment? What do you use? What personal protective equipment do you have? What immunizations/vaccinations do you get?' and they looked at me like I had two heads. There was nothing nationwide, so I started lecturing about it and writing for publications. This was before AIDS, but there was hepatitis B, and that wasn't getting much attention. EMS wasn't really viewed as part of the healthcare team; they just brought the bodies in. People who were exposed in the hospital setting got follow-up; nobody bothered with EMS."

     Beckerman also remembers hearing about EMS crews' refusal to transport patients with AIDS. "None of us knew what we were dealing with," he says. "As we started to learn more about AIDS and other communicable diseases, we learned there wasn't much to be afraid of." Today, West adds, there is more awareness of the need for education about these diseases and use of personal protection.

     In spite of changes over the decades, providers haven't changed much, says Beckerman. "They were eager in the 1980s, and they're still eager," he says. "A lot of them are entering EMS now as a career, which it wasn't back then. We've finally become more accepted as a frontline service."

     Both West and Beckerman praise the contribution of publications like EMS Magazine. "I'm willing to bet a lot of the professors in the field today got their start after reading EMS Magazine," says Beckerman. "It's what influenced them to go in and take the first course."

     -Marie Nordberg, Associate Editor

The 1990s: Terrorism Comes of Age
     In a lot of ways, the 1990s were a transitional decade for EMS. The slow unraveling that commenced with the Omnibus Budget Reconciliation Act of 1981 accelerated, with all its concomitant problems. Eighties concepts like body substance isolation and the ubiquitous use of PPE grew into universality. And a series of major events gave a new urgency to communities' terrorism/mass-casualty preparedness efforts.

     The first was the bombing of the World Trade Center in February 1993. Islamic terrorists detonated a car bomb in a garage under Tower One, killing six and injuring more than 1,000. It wasn't the first act of Islamist terror against the U.S., but it was notice that their current struggle was about to go big-time.

     Next came Oklahoma City. In April 1995, disgruntled American Timothy McVeigh exploded a truck bomb in front of the city's Murrah Federal Building, killing 168-at the time, the deadliest act of terrorism perpetrated on U.S. soil.

     Four years later, students Eric Harris and Dylan Klebold took school violence to terrifying new levels with a shooting rampage that killed 13 at Columbine High School in Littleton, CO. School shootings weren't new, but the degree of violence at Columbine was fearsome and rare.

     There were other incidents throughout the decade, but these loom large as sentinel events for EMS and public safety. Terrorism in the U.S. came of age in the 1990s-and it was aiming for big body counts.

     This validated trends toward terrorism/disaster/MCI preparedness that for many began in the 1980s.

     "There had been pockets of people around the country working on these issues," recalls Gregg Lord, a medic since the early 1980s and now a senior policy analyst for the George Washington University's Homeland Security Policy Institute. "We developed NDMS back in the mid 1980s, and EMS special operations was taking hold. So when you look back at the genesis of what we now consider normal, it wasn't after Oklahoma City or the World Trade Center-people started recognizing our vulnerabilities before that."

     But the attacks of the 1990s energized efforts and drew needed attention and funds to the cause. In the aftermath of Murrah, Congress passed the Defense Against Weapons of Mass Destruction Act (bka Nunn-Lugar-Domenici), which required the federal government to develop systems to protect the public against terrorists. The late 1990s also saw the creation of the U.S. Commission on National Security in the 21st Century (the Hart-Rudman Commission) and the Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving Weapons of Mass Destruction (the Gilmore Commission, which included EMS Magazine editorial advisory board member Paul Maniscalco) to assess aspects of the problem and recommend courses of action.

     The education/training of EMS providers was also drawing increased attention and controversy. In 1994, the EMT-Ambulance National Standard Curriculum was revised into the first EMT-Basic NSC-a move toward assessment over diagnosis, it was derided by some as emphasizing training over education. Balancing the hows with the whys of EMS learning remains a challenge today.

     Other key events of the decade included Category 5 Hurricane Andrew in 1992; the 6.7-magnitude Northridge earthquake in 1994; the establishment of Project 25 interoperable radio standards in 1995; and the broad growth of public-access defibrillation programs.

     There was also publication of NHTSA's landmark EMS Agenda for the Future in 1996. This document assessed the first 30 years of modern American EMS and offered a road map for its continued development. More than a decade later, we can't say its vision has been fully realized, but it's provided both a durable framework for addressing our problems and a template for additional examinations of more specific challenges.

     "The biggest success of the Agenda, I'd say, is the derivatives it's spawned," says Vermont EMS director Dan Manz, who co-chaired project's steering committee. "It spawned the EMS Education Agenda for the Future, which is well down the road toward implementation. It spawned the Rural/Frontier Agenda. It spawned the National EMS Research Agenda. It spawned a number of focused looks at various pieces of EMS systems that have proven to be blueprints toward change for the future."

     Throughout the decade, EMS Magazine was there to report those developments and lend them real-world context. With portentous things happening, it was important to suss out their implications and help prepare those on the front lines.

     "I look at the trade journals as what Fox News and CNN are," says Lord. "I don't always agree with them, but the bottom line is, I wouldn't have known about it if they hadn't opened their mouths. And that's a good thing."
-John Erich, Associate Editor

The '00s: The Age of the Megadisaster
     As Y2K came and went, EMS had plenty on its plate. It was about to get more.

     The era of the megadisaster was upon us. It arrived on September 11, 2001, with the hijacking of jets for Islamist suicide attacks on the World Trade Center and Pentagon (a third target was spared when passengers fought back). Nearly 3,000 people were killed, including 343 fire and EMS personnel who were in the WTC when it collapsed. Others have since died of respiratory problems and other conditions linked to their work at the site.

     It's hard to overstate the impact of this event for America as a whole and EMS in particular. The Department of Homeland Security was created, and huge amounts of money were funneled to public safety (though not much of it got to EMS) and a broad array of other programs. September 11 also highlighted a general lack of public-safety communications interoperability, and sent agencies across the country scrambling to be able to talk to their neighbors.

     The attacks' sheer scale also forced reevaluation of what "big" could actually mean. Resultingly, mutual aid and regional assistance plans were ramped up, training got more inclusive, and a new emphasis was placed on issues like standardization and compatibility.

     "We always thought we were into regionalization, but we had no clue what it really was until after Sept. 11," says Prince William Co. (VA) Fire-Rescue chief Mary Beth Michos, whose career in nursing and EMS spans almost four decades. "Now, here in the national capital region, especially northern Virginia, we're almost like one big fire department. We've developed standard procedures, we train together, we share responsibility for caches."

     And then-as if anyone needed further impetus for bolstering their disaster plans-came the storm.

     Almost four years to the day after 9/11, Hurricane Katrina roared ashore near New Orleans, blitzing a wide swath of devastation across the U.S. Gulf Coast. Its worst ramification was the breaching of levees protecting the sub-sea-level city of New Orleans, which flooded most of the city, forcing its complete evacuation, and killed an estimated 1,800.

     Locally, EMS providers performed bravely, but systemic failures at all levels compounded the tragedy. No one fared worse in the fallout than the Federal Emergency Management Agency, which, after a humiliatingly sluggish and ineffective response, ended up with new leadership and a series of internal changes designed to make it more agile.

     A boatload of reports examined the failures of Katrina, but for EMS, the document of the decade was a long-awaited report from the Institute of Medicine. The IOM's 2006 Emergency Medical Services at the Crossroads report, one of three in its Future of Emergency Care series, presented a detailed accounting of the challenges facing EMS today and suggested directions and approaches for meeting them in the future.

     Among its major themes was regionalization: the idea of delivering patients to specialized facilities with the experience and capabilities to best treat their conditions. The current U.S. trauma system provides a model for the idea, which entails the development and designation of tiered resources within regions, and the integration of supporting systems to provide things like communications and medical control.

     "It's a systems concept," emphasizes EMS pioneer David Boyd, MD, who conceived the idea with Illinois' trauma system in the early 1970s, then applied it nationally as head of the Department of Health, Education and Welfare's late, lamented EMS Division. "It's not just about ambulances, but where do they go? What do they do? Who directs them? Who trains them? The operational elements all have to work cooperatively."

     Many of these supporting mechanisms are already established, thanks in no small part to Boyd's work in the '70s, but whether the regionalization model can be duplicated across the spectrum of medical specialties will be an important question of the future.

     Looking to the future, the challenges of homeland security and patient care will continue, but the preparation of EMS providers to serve will take a decidedly different look. New EMS education standards now under development will replace the U.S. DOT national standard curricula. These promise to be broader and allow instructors greater latitude in course design, and should facilitate emerging methods of delivery like distance learning. They are due to NHTSA next year.

     As 2007 winds down, EMS does indeed stand at a crossroads. There are many obstacles to overcome, but much promise to be realized. It remains the mandate of EMS Magazine and its family (EMS Product News, EMSResponder.com, EMS EXPO) to help our nation's providers fulfill that potential, and be all they can be. At the very least, we owe you that.
-John Erich, Associate Editor