EMS in the
United States

Today's Emergency Medical Services (EMS) system operates as a critical cornerstone of the United States' healthcare infrastructure. It serves communities around the clock, demonstrating extraordinary dedication, resilience, and adaptability, particularly during the recent COVID-19 pandemic. Each day, the EMS system proves instrumental in saving countless lives and providing a healthcare safety net for millions of Americans, notably those without consistent access to primary care.

However, the current EMS system is traversing challenging terrain. Many see the system teetering on the brink of crisis, with states nationwide rigorously questioning its sustainability and seeking for new solutions to ensure its long-term viability. These challenges are not sudden anomalies but are rather the repercussions of a series of decisions and events deeply rooted in its multifaceted history.

This history includes significant contributions from visionaries like Dr. J.D. 'Deke' Farrington, a leading orthopedic surgeon, and Dr. Pete Safar, the father of critical care medicine and modern resuscitation science. It also highlights the ironic circumstance where ambulance services, once predominantly provided by funeral homes, underwent a significant transition. In the 1960s and 1970s, many funeral homes ceased these services, not predominately due to regulatory changes, but due to a failing financial model.

Pivotal moments included the attempts by the federal government to establish two parallel, yet unfortunately uncoordinated, nationalized EMS systems in the 1970s. These initiatives, backed by over $2 Billion (valued in 2023 dollars), led to federal agencies providing conflicting requirements to state officials. This lack of coordination, along with the military's considerable influence on EMS design and progression, has left enduring impressions on today's EMS landscape.

EMS pioneers strove to align the system's development with the conventional growth paths of other allied health professions. Yet, this aspiration was not consistently achieved nationwide. National standard curriculums and certification bodies established as early as the 1970s often found their influence overshadowed by local champions, who developed EMS agencies at the community level, fostering an aversion to national standards.

The abrupt changes and significant reduction in federal funding in 1981 forced communities to pursue alternative resources for their local ambulance services. This transition heightened skepticism towards any federal or national program. In EMS in the United States: Fragmented Past, Future of Opportunity, these historical trends and their implications on the current state of EMS are thoroughly examined.

Despite these challenges, EMS remains a critical element of the healthcare system today. The future holds opportunities to further unify the profession, leveraging tools such as the EMS Compact. With new technological advancements and the emergence of telehealth, there exists a new frontier for EMS to enhance health provision and perhaps create a sustainable financial model.

This book aims to serve as a comprehensive resource for aspiring EMS leaders and managers. It offers a detailed understanding of EMS's roots, the challenges it has faced, and the opportunities that lay ahead. The book explores historical developments, the roles of visionaries, the influence of Hollywood, and the significance of the emblematic Star of Life. It also scrutinizes systemic issues such as financial structures and disparities in access that underscore EMS operations.

Moreover, the book elucidates the certification, licensure, and credentialing processes, state sovereignty implications, and the promising prospects of telehealth and health equity in EMS. By tracing EMS's complex trajectory from its fragmented past to its opportunity-rich future, it invites readers to participate in informed discussions about the future of EMS.

EMS in the United States: Fragmented Past, Future of Opportunity provides an essential roadmap for aspiring EMS leaders and managers. It fosters a comprehension of the past to better manage the present and envision the future. This historical overview serves as a blueprint for understanding the present challenges and shaping the future of EMS. It advocates for a system that is efficient, equitable, and sustainable, thereby continuing its vital service to the American people.

Through this exploration, readers will gain insight into how the EMS system has evolved in the face of adversity and change. This knowledge equips future EMS leaders and managers with a historical perspective, vital for making informed decisions as they navigate the challenges and opportunities ahead.

In the age of technology and telehealth, EMS stands on the cusp of a new era. With the opportunity to further unify the profession through mechanisms such as the EMS Compact, there is potential for substantial growth and improvement. This book aims to highlight these opportunities and stimulate meaningful conversations about how to seize them effectively.

As we venture forward, it is important to remember that the history of our EMS holds the blueprint for its revival. Its future lies in the lessons learned from its past, the ingenuity of its present leaders, and the promise held by innovations yet to come. The EMS system's ongoing commitment to the well-being of the American people is a testament to its resilience and importance.

In the face of current challenges, we should be emboldened by the fact that the EMS system has always risen to meet every trial it has faced. Its fragmented past, marked by struggle and triumph, has forged a resilient system that continues to serve as a bedrock of our healthcare infrastructure.

The opportunity-rich future of EMS beckons, and this book invites all aspiring EMS leaders and managers to play a part in shaping it. It is a call to understand the past, manage the present, and envision a future where the EMS system continues to serve everyone with increased efficiency, equity, and sustainability.

Throughout my more than thirty-year EMS career, I have come to appreciate the significance of having experienced mentors and dependable resources to navigate the intricacies of our complex EMS system. When I initially assumed leadership roles at both the state and national levels, I was struck by the scarcity of resources that could bridge the knowledge gap between local EMS leadership and the broader state or national leadership — understanding the history, grasping an overview of the organization, and possessing a guide to traverse the layers of influence. I was fortunate enough to have exceptional mentors, yet I witnessed many ambitious emerging leaders falter, in part, due to gaps in their knowledge and resources.

To help address this gap, I authored this book as a resource to provide a historical context for pivotal decisions that have shaped contemporary EMS systems. It is conceived as a desk reference, with each chapter functioning independently. You may notice some repeated information across different chapters, but this is intentional, serving to provide additional context in relation to the specific issue or historical event being discussed. Furthermore, I impart some insights drawn from my personal experience in leadership and management.

From the birth of EMS in the United States to current challenges such as health equity and COVID-19, my objective is to offer you an overview of key historical decisions and demonstrate how they persistently influence the design and operations of EMS in our country.

It is my hope that this book will not only act as a resource for budding EMS leaders, but also enable you to comprehend the historical underpinnings as the EMS system continues to modernize and evolve. By illuminating key facets of our history that are often neglected, we can delve deeper into understanding how EMS has developed, recognizing that our current state is inherently linked to past decisions.

I am eager for you to embark on this journey with me, exploring the rich history, complex present, and opportunity-laden future of EMS in the United States. The work you undertake is critical for the health and safety of our communities. I am optimistic that this guide will prove to be an asset to you as you work tirelessly to enhance emergency medical care in the United States.

I would like to convey my deepest gratitude for the steadfast support and invaluable guidance I have received from countless mentors, friends, supervisors, and EMS leaders throughout my life. The myriad opportunities for learning and leadership, generously provided by various managers, have played a pivotal role in my development. For this, I remain profoundly thankful.

Looking back, I recognize that I often didn't fully appreciate the significance of the opportunities given to me. The privilege of engaging in meaningful dialogues, receiving mentorship, attending conference sessions, or simply sharing a cup of coffee with many visionaries who were instrumental in shaping my career and the modern EMS system, has been an inspiring journey. These luminaries, mentors, friends, and guides include numerous individuals, but I want to specifically acknowledge and appreciate Jeanne-Marie Bakehouse, Jeff Beckman, Gary Brown, Drew Dawson, Wayne Denny, Tim Dienst, Dia Gainor, Jon Krohmer, Debra McDonald, Scott Hayes, Susan McHenry, Norman McSwain, Rocco Morando, Jim Page, Rick Patrick, Peter Safar, Joe Schmider, Keith Wages, and Gam Wijetunge. I will forever be thankful for their willingness to generously share their time, historical insights, advice, and profound wisdom.

I am particularly grateful to the volunteers at Giles Rescue Squad who devoted their time to teach my first EMT class and initiate my journey into EMS. I'm also thankful to Cedarville University for entrusting me as the EMS Chief, which marked my first EMS leadership position. I extend my gratitude to numerous additional EMS agencies that provided me experience, opportunities, and guidance along the way: Cedarville University EMS, Cedarville Township Fire Department, Hamilton County EMS System, Riverview Hospital, Ivy Tech Community College, Westfield Fire Department, Med1, Falck, and the statewide system stakeholders in Louisiana and Colorado for their ongoing support and collaboration.

My appreciation also extends to the National Registry of EMTs for the opportunity to serve as the Chief Operating Officer and gain insights into national EMS leadership, the nuances of examinations and certification, and the chance to develop a national perspective on EMS. To the EMS Compact Commissioners, I extend my respect and gratitude for their pioneering efforts in setting a modern example of unity, professionalism, and standards in our field and the opportunity to learn and collaborate to make a difference.

I also wish to convey my heartfelt thanks to stakeholders and colleagues who have demonstrated remarkable understanding and grace during my moments of error. Your steadfast support and the learning opportunities offered have played a vital role in both my personal and professional development. I am extremely thankful to the many leaders who placed their trust in me, offering a novice like me an opportunity to contribute.

This book would not have been possible without the relentless efforts of those working tirelessly behind the scenes, providing invaluable fact-checking, guidance, and unwavering encouragement. To everyone who played a key role in this transformative journey, I extend my deepest gratitude. Your steadfast support has fostered my evolution in unimaginable ways.

While recognizing everyone's contribution is an impossible task, I want to express my heartfelt thanks to the following individuals who shared their invaluable feedback on this manuscript: Shawn Baird, Jeff Beckman, MD, David Bump, Sean Caffrey, Dia Gainor, John Moon, and Don Stanton. I would like to express special appreciation to Marc Pagan, Bill Siefarth, Joseph Schmider, and Douglas Wolfberg for their significant time devoted to feedback, edits, and critiques on the full manuscript.

I owe a profound debt of gratitude to my family as well. The sacrifices my parents made to ensure my access to education and the opportunity to chase my dreams have been nothing short of monumental.

Lastly, I must acknowledge my first employer, Burgess. His decision to hire a teenager evolved into an invaluable life lesson on problem-solving and overcoming preconceived limitations. His investment in me helped me understand the critical importance of investing in others. He taught me that by creating an environment conducive to success, minimizing the repercussions from failures, and prioritizing learning, one can indeed turn the impossible into the possible. This empowering approach enables individuals to reach previously unattainable heights. I am forever grateful for these lessons, which have profoundly influenced my outlook and actions.

Thank you, everyone, for being an integral part of this extraordinary journey and for contributing to my personal and professional growth.