Emergency Medical Services:
The Evolution Behind the System

Russell Keogler
CED 595: Project Seminar
May 3, 2011
Dr. Richard Gatteau

Abstract

The purpose of this study is to determine the evolutionary process of the emergency medical services system. The research explores the impact of war and prominent military figures on the development of emergency medical services as well as civilian efforts made to establish emergency services within the public sector. The research also discusses the ways in which major medical advancements and various reports and acts of legislation played a crucial part in the development of the modern day EMS system. Overall, results show that the EMS system as we know it today is a fairly modern creation based on centuries’ worth of ideas and discoveries.

Introduction

In modern day America the three digits 9-1-1 signify an accessible lifeline for individuals in need of emergency medical attention. The vast system is accessible from any telephone line and provides emergency services to even the most remote locations of the country. However, in spite of the simplistic process to initiate services, the emergency medical system is very complex. Thousands of independent agencies working in different capacities must coordinate efforts to insure that the system runs efficiently. Without effective cooperation by organizations the system would undeniably fail to meet the expectations of those calling for medical aid (Limmer & O’Keefe, 2005).
The efficiency that Americans have become accustomed to is a result of a long evolutionary process. Early emergency medical services were far different from the ambulance based system of today. In fact, an organized system providing emergency care dates back only fifty years. Prior to the 1960s the pre-hospital care most closely associated with modern EMS was highly diversified if it was available at all. Instead, it was the responsibility of civilians and communities to band together and organize efforts in order to provide emergency medical services to the general public through whatever means were available (Page, 1978). It was not until the introduction of the modern day ambulance, in conjunction with major medical breakthroughs, that the process of care was revolutionized.
In addition, to the surprise of many, some of the most important theories aiding in the creation of emergency services came from several centuries’ worth of medical and technological advancements made by prominent figures during times of military battle and warfare. The necessity to care for the wounded quickly and efficiently on the battlefield provided the impetus for ingenuity in the medical community. Moreover, the utilization of military technologies typically allocated for the mobilization of troops and supplies gave birth to the concept of mobile medical care and rapid extrication practices (Robbins, 2005).
Federal legislation also played a vital role in the initiation of modern day emergency medical services through the rules and regulations new laws established. Beginning with Lyndon B. Johnson’s presidential term, several federally supported reports and acts were implemented to combat the growing inadequacies of pre-hospital care (Institute of Medicine of the National Academies, 2007). The devotion by the United States federal government to create a well formulated emergency system ultimately gave rise to what is now considered the most sophisticated first response system in the world.
In order to create a thorough understanding of the evolution of emergency medical services over the centuries that will lead to a concrete awareness of the development of the EMS system, this paper focuses on the following questions:
1) What advancements in emergency medical services were established as a direct result of military conflicts and prominent military figures who took an active role in the warfare throughout the centuries?
2) What efforts were put forth by civilians to establish ambulances and emergency medical services that would be available to the public sector?
3) What major advances in the field of medicine brought about a significant change in the development of emergency medical services and ultimately shaped the future of services that EMS systems would provide?
4) Which key reports and pieces of legislation played a crucial role in the development of the modern EMS system?

Literature Review

Terminology
The development of the modern emergency medical system and its transportation system is based on a complex set of developments that extend from several distinct cultures. The complexity of the system extends to the terms that define its characteristics. While its lexicon has and will continue to evolve with new developments, it is imperative that certain terms be defined in order to decrease confusion.
System:
In accordance with public law 93-154, the EMS Systems Act of 1973 stipulates that an EMS system “provides for the arrangement of personnel, facilities, and equipment for the effective and coordinated delivery of health care services in an appropriate geographical area under emergency conditions” (Title XII Emergency Medical Service Systems, 1973, p. 2). To decrease ambiguity when exploring the history of emergency medical services, the term system will incorporate all aspects of the delivery of healthcare from first response to definitive care.
Ambulance:
Within this text the term ambulance will represent two unique definitions depending on its association. When defined under militaristic use, an ambulance is identified as a transportable hospital, capable of mobilizing with ground forces, that is used to provide initial medical care until patients can be transported to stationary facilities. For the purpose of civilian EMS an ambulance is defined as “a vehicle or other mobile mechanism, of any kind, which is used to transport the sick or injured from the site of occurrence or invalidity, to a medical or other treatment location or facility” (“Ambulance – Definition,” 2011)

Pre-hospital Healthcare Providers
Prior to the 1960s, the definition of an emergency medical technician was used to represent any healthcare provider who performed initial treatment and delivery of a patient to a hospital. However, following the initiation of an official emergency medical system, the broad use of the definition made distinguishing different levels of healthcare providers difficult. The division of the emergency medical technician into several distinct titles helped alleviate this problem.
First Responder
This term is used to describe the first person who arrives on the scene, which may include police officers, fire fighters, and other industrial health personnel who are certified. The responsibilities of the first responder are to control the scene, prepare for the arrival of the ambulance, and provide immediate care to any life-threatening injuries (Limmer & O’Keefe, 2005).
EMT Basic (EMT-B)
In most cases, the EMT Basic, or EMT-B, is the minimal certification one may hold for ambulance personnel. The curriculum for the EMT-B centers around the assessment and care of the ill or injured patient (Limmer & O’Keefe, 2005).
EMT Intermediate (EMT-I)

The responsibilities of the EMT-I are centered around the ability to provide some level of advanced life support to the patient, including the initiation of intravenous lines, advanced airway techniques, and administration of some medications (Limmer & O’Keefe, 2005).
Paramedic (EMT-P)

Paramedics at this level can perform the most advanced and invasive field care including insertion of endotracheal tubes, initiation of IV lines, administration of a variety of medications, and cardiac defibrillation (Limmer & O’Keefe, 2005).
The Early Years

The Military

Emergency medical services delivered to those in need dates back centuries and saw many rapid and crucial advances during times of war. Some of the earliest known uses of emergency medical services were employed by the Greeks and Romans who used chariots to remove the injured from battlefields. Although impressive for the time, the first concrete record of ambulances being used for emergency purposes was commissioned by Queen Isabella of Spain in 1487. These ambulancias, or mobile field hospitals, were set up in close proximity to the battlefield to reduce transport time from the site of injury to where help could be provided (Robbins, 2005). The ambulancias relocated often in order to follow the army and were stocked with surgical and medical supplies to be provided to troops. The drawback to these early ambulances was that injured soldiers were not picked up until the end of the battle, leaving many to die on the field before care could be provided (“Emergency Medical Services,” 2011). Over three hundred years later, in 1788, France enacted a “Royal Ordinance” for the improved transportation of the wounded in battle; however, major improvements in the field of emergency medicine for wounded soldiers were not actually seen until 1794. It was during the French Revolution that Baron Dominique-Jean Larrey recognized that more adequate treatment of soldiers was needed during battle. Larrey, who was the chief physician in Napoleon’s army, acknowledged that leaving wounded soldiers on the battlefield for days without treatment dramatically increased morbidity and mortality, weakening the fighting strength of the army (Institute of Medicine of the National Academies, 2007). Based on this concept, Larrey instituted the first pre-hospital care system that provided triage and transportation to the injured from the battlefield to strategically placed medical stations where aid could be given (Page, 1978). In order to do this, Larrey designed the ambulances volantes, or flying ambulance, that was a specialized vehicle that could go directly into the field of battle. These customized two- or four-wheeled horse-drawn covered wagons were designed to carry equipment, supplies, and medicine to aid in the transport of the patient, and were thus the first specialized and practical conveyance device to move the injured (Robbins, 2005). Crucial to Larrey’s system of care was the treatment soldiers received while on the battlefield before they were transported. In order to improve survival rates, Larrey enlisted a corps of surgeons and nurses who accompanied armies into battle and rendered care to soldiers before being transported. This system provided for all injured soldiers to be assessed while identifying those with the most serious injuries and allowing them to be transported first (Robbins, 2005). Consequently, it was Larrey’s work in the field that led him to become an expert in amputations and aided him in the discovery that “a wound would heal better, with less chance of infection, if it were cleaned and allowed to remain open for several days before being sutured” (Medical Discoveries: Dominique-Jean Larrey, 2011, p. 1). Larrey’s ambulances, medical units, and innovative medical treatments for the wounded both impressed Napoleon’s troops and boosted their morale, thus influencing the future treatment of patients both on and off the battlefield. Progressing in history to 1861, the United States Civil War began and was a time of great turmoil in which more people were killed than in any previous war in the country. Even though many lives were lost, several major advancements were made in the field of emergency medical services due in large part to prominent figures of the time. To begin with, at the outbreak of the war, private citizens including Henry Whitney Bellows and Dorothea Dix created The Sanitary Commission, which was officially sanctioned by the War Department on June 9, 1961. The Sanitary Commission handled most of the medical and nursing care of the Union armies, providing services at field hospitals and camps where women acted as nurses and organized medical services as needed (Long, 2008). Serving as the Superintendent of the Commission’s Army Nursing Corp, Dorothea Dix maintained patient records and death lists, the first time specific attention was paid to paperwork. These efforts by the Commission went far to decrease the number of casualties in the war while aiding in the development of emergency services and procedures. Organized field care and transport of the injured began after the first year of the Civil War and was led in large part by Jonathan Letterman. Letterman, assigned to the Army of the Potomac and eventually named medical director of the entire army in 1862, built upon the work of Dominique-Jean Larrey and designed a pre-hospital care system for soldiers that used new techniques and methods of transport (“History of the Ambulance,” 2011). The Letterman Ambulance Plan was a devised system in which ambulances of a division moved together, under a mounted line sergeant, with two stretcher-bearers and one driver per ambulance, to collect the wounded from the field, bring them to the dressing stations, and then take them to the field hospital (Schroeder-Lein, 2008). Through his Ambulance Plan, Letterman consequently started the very first Ambulance Corps in the United States that included the use of a field ambulance and medics to care for and transport the sick and injured (“Ambulance,” 1987).
Letterman also instituted the concept of triage for treatment of casualties and developed an evacuation system that consisted of three stations: a field dressing station that was located on or next to the battlefield where medical personnel would apply the initial medical services needed, such as dressings and tourniquets; a field hospital located close to the battlefield where emergency surgery could be performed and additional treatment given, usually in homes or farms; and a large hospital that was located away from the battlefield and provided for long term treatment of patients (Civil War Trust, 2011). The success of Letterman’s Ambulance Corps was proven throughout many battles during the war in which thousands of soldiers’ lives were spared due to the efficiency of the system that had been put into place. Many changes in the transportation of injured and wounded soldiers took place following Letterman’s creation of the Ambulance Corps. The Rucker Ambulance, designed by Brigadier General Henry Rucker, was used during the latter part of the Civil War to replace the ambulances previously used by Letterman. The Rucker ambulances consisted of a four wheeled design and were unique in their ability to transport patients in either the sitting or lying position (Richey, 2009). Other forms of transportation were ushered in as a result of new industrial feats during this time, including the large scale use of railroads and steamboats as a mass evacuation and triage system for the wounded (Richey, 2009). Finally, in March of 1864, Congress passed an act to create an official Ambulance Corps for all of the Union Armies that was a centralized organization and provided trained drivers and litter-bearers much better service and care for the wounded. These advances in the industry of transportation were only the start of government developed programs that would be used to improve the treatment and care for the wounded. The period from the Civil War to the Korean War saw marked advances in medical services, such as the use of traction splints during World War I to reduce morbidity and mortality of patients with leg fractures. However, the greatest advances in emergency medical services were done so through technological innovations in communication and transportation. Two-way radios became available shortly after World War I, enabling for more efficient radio dispatch of ambulances in some areas (“History of the Ambulance,” 2011). By World War II, improvements in military EMS organizations and operations occurred, marked by more well prepared fleets of specially designed, motorized ambulances. The use of aircraft later marked a significant turning point in the transportation of injured soldiers and was utilized in many countries throughout the world including the establishment of the Royal Flying Doctors Service by Australia in 1936, and by the large scale aeromedical operations employed by the Germans during the Spanish Civil War (Richey, 2009). In the United States, the Army Air Corps had organized and designed three planes by 1929 to perform the roles of ambulances which were used during future wars. The further proliferation of aeromedical operations in the United States was generated by the development of helicopters which were most heavily used for the rapid evacuation of casualties to treatment areas during the Korean and Vietnam Wars (Page, 1978). It is this use of more advanced forms of industrial transportation for the wounded during times of warfare that led to the development and use of similar methods by civilians for the care and transportation of public citizens.

Civilian EMS

The employment of emergency medical services by civilians in the public sector throughout the 19th and 20th centuries helped to shape many of the policies and procedures pertaining to hospitals and ambulances that are currently in place today. The ideas of the 19th century throughout various parts of the world brought about many of these advancements. To start off, in 1832 in London a transport carriage was used for cholera patients and is one of the first recorded uses of transportation of the sick to a medical facility by civilians. The statement on the carriage is also of importance as it proclaimed:
The curative process commences the instant the patient is put in to the carriage; time is saved which can be given to the care of the patient; the patient may be driven to the hospital so speedily that the hospitals may be less numerous and located at greater distances from each other. (Paramedic Spot, 2010, p. 1)
This tenet of ambulances providing instant care and allowing hospitals to be spaced further apart displays itself in modern emergency medical planning today. Following this, in approximately 1840, Scotland produced a specialized medical transport vehicle for use by civilians providing emergency medical care. This carriage, which became known as the Clarence Ambulance, named after the Duke of Clarence, could carry two to three patients at a time, along with an attendant nurse, and provided for a much smoother ride due to the suspension of the carriage from large elliptical springs (Robbins, 2005). These specialized vehicles also used polished butternut on the insides in order to make disinfecting them much easier. This helped to establish the importance of keeping conditions in an ambulance sanitary for both the patients and those working in the carriage. Major advances in America in regards to civilian emergency medical services took place between 1865 and 1869. The first general ambulance service for the public was provided by The Commercial Hospital and Lunatic Asylum of Cincinnati, now known as Cincinnati General Hospital, in 1865 (“Ambulance,” 1987). The second established emergency ambulance service occurred in 1869 and was provided by Bellevue Hospital in New York City. This ambulance system was organized by Dr. Edward L. Dalton who used the knowledge and experience he gained as a surgeon in the Civil War to create a more efficient system for treating and transporting patients. Dalton’s ambulance service is notable because it was staffed with physicians and included specialized equipment both at the scene and en route to the hospital (Robbins, 2005). The equipment available on the ambulances included such necessary medical supplies as tourniquets, bandages, small sponges, splint material, brandy, morphine, and stomach pumps. Bellevue Hospital also had an alarm system of sorts to notify drivers and physicians assigned to ambulances of emergency requests. This was done so through the use of the telegraph in which messages were first sent to local police departments and then forwarded to Bellevue (Robbins, 2005). Dalton also equipped the horses used for the ambulances with new harnesses that allowed the ambulances to be ready within thirty seconds of being dispatched. With all of the new changes in place, it was Dalton’s ambulance service that spearheaded the development of urban city ambulances to permit greater speed, enhance comfort, and increase maneuverability on city streets (National Association of EMS Physicians, 2002). Numerous other emergency medical services developed in countries overseas during the late 19th century. In Vienna, the “Wiener Freiwillige Rettungsgesellschaft”, or Viennese Voluntary Rescue Society, was founded on December 9, 1881, one day after the disastrous fire at the Vienna Ring Theater. This Rescue Society was established by Jaromir Mundy, along with his friends Hans Wilczek and Eduard Lameza, and provided the first organized system of transporting the sick in this country (Regal & Nanut, 2007). In June of 1887, the St. John Ambulance Brigade was established to provide first aid and ambulance services at public events in London and was modeled on a military-style command and discipline structure (“Emergency Medical Services,” 2011). The St. John Ambulance Brigade was later set up in the Guinness Brewery in St. James Gate in Dublin in 1903 by Dr. John Lamsden. This Ambulance Brigade provided first aid classes at the brewery and acted as an ambulance service during the Rising of 1916 and the Civil War of 1921 (Corcoran, 2009). Furthermore, an ambulance service was established in Queensland, Australia by military medic Seymour Warrian in 1892. Warrian founded the Queensland Ambulance Transport Brigade after witnessing a fallen rider worsen his broken leg when he was helped off the field by bystanders (“Emergency Medical Services,” 2011). It was the efforts of individuals such as Warrian, Mundy, and Lamsden that propelled ambulance and emergency medical services to grow to outstanding numbers in communities around the globe. The turn of the century brought with it numerous advances in the field of emergency medicine for civilian EMS systems. The first motorized ambulance was made in Chicago and was donated to Michael Reese Hospital by five local businessmen in 1899 (Robbins, 2005). This completely changed the scope of care that could be provided to civilians due to increased speed and space available inside the units. Following this in 1900, interns began to be routinely dispatched with ambulances in an attempt to provide quality care both on the scene and while transporting patients (Page, 1978). In 1910, the American Red Cross, which was founded in 1881 by Clara Barton, began providing first aid training programs across the country in an effort to improve bystander care by civilians (Institute of Medicine of the National Academies, 2007). By 1936, the American Red Cross had established approximately 900 posts along roads to aid in motor vehicle accidents, and by 1939 maintained 5,000 posts and mobilized units with trained volunteers (Robbins, 2005). The first volunteer land based rescue squad in the United States was the Roanoke Life Saving and First Aid Crew that was founded in 1928 in Roanoke, Virginia. Julian Stanley Wise founded the Roanoke Life Saving Squad when he witnessed two men drown in the Roanoke River after their canoe capsized in deep, rough water. Appalled that no onlookers were equipped or trained to offer much help, Wise vowed that “never again would I watch a man die when he could have been saved if only those around him knew how” (“70 Years: 1928 – 1998,” 2009, p. 1). The Roanoke crew initially geared their efforts towards teaching water safety and the recovery of drowned victims. Later on, crew members gained their first aid instructor certifications through the American Red Cross and began teaching first aid to firemen, police, and other groups throughout the city (“70 Years: 1928 – 1998,” 2009). The organization continued to take on many tasks throughout the years in an effort to improve pre-hospital emergency care in Virginia and to serve as a model for the rest of the world. The outbreak of World War II and the years in which it lasted saw an influx of community based emergency medical services whose goal was to care for the local civilians in a time of drastic need. As physicians were routinely drafted into the war, hospitals were unable to adequately staff their ambulances with qualified medical personnel, leaving hospitals to abandon their emergency services (Page, 1978). City governments therefore began to turn ambulance service over to the police and fire departments in order to maintain centrally coordinated programs that would still provide the necessary care civilians needed (Page, 1978). It was for this reason that funeral homes, commercial services, and volunteer rescue units began to offer community EMS services to local towns and cities in an effort to maintain adequate care for civilians. All of these efforts played a crucial role in the recognition for the need to organize systems for emergency pre-hospital care and to train personnel to provide it, forever affecting the development of community based EMS systems.

The Modern Era

Advances in the Field of Medicine

The 1950s and 1960s in the United States were a time of vast improvement in the field of medicine in regards to understanding the physiology of the human body and what life saving procedures could be done to increase a person’s chance of survival. The most efficient and effective use of artificial ventilation was one of the first major breakthroughs seen during the 1950s, but like many of the breakthroughs during this time, was based on the ideas and discoveries of others made over the centuries. Some of the earliest attempts in using artificial ventilation were seen during The Age of Enlightenment in the 18th century, which brought with it many unique ideas as to how to revive drowning victims. Some of the more obscene attempts used during this time included holding a person by the legs and rolling them backward and forward over a barrel, allowing the abdomen to be squeezed and letting air reach the lungs, as well as blowing tobacco smoke up a person’s rectum as it was thought that the tobacco would stimulate the person’s body to begin breathing again (Omato & Peberdy, 2005). The inventors of these ideas, as well as many other ideas that were developed between the 1767 and 1949, were wrong in their thinking that passive entrainment of air into the lungs was sufficient enough to maintain adequate oxygenation in a person’s body (Omato & Peberdy, 2005). It was not until the 1950s through the work of Dr. James Elam, an anesthesiologist, and Dr. Peter Safar, an Austrian physician, that two crucial discoveries were made concerning the use of artificial ventilation. Dr. James Elam was stimulated by the polio epidemic of the 1940s and ‘50s to prove that expired air, or exhaled air, was adequate enough to oxygenate a non-breathing victim because it could maintain a normal level of blood oxygen in the victim (Brennan & Krohmer, 2005). This thinking was contrary to the belief held by many for centuries that expired air did not contain enough oxygen to sustain life In 1954, Dr. Elam went on to prove his theory through studies he did involving post-op patients, whose anesthesia had not yet worn off, to demonstrate that expired air blown into the endotracheal tube maintained normal oxygen saturation levels in the body (Omato & Peberdy, 2005).
One of the greatest successes that ensured the eventual triumph of this technique was the combined resuscitation research efforts of Dr. Elam and Dr. Peter Safar. Together, Dr. Elam and Dr. Safar performed experiments in 1956 to prove that the exhaled air of a rescuer during mouth-to-mouth breathing could maintain satisfactory oxygen levels in the victim. These experiments consisted of anesthetizing human volunteers, mainly medical personnel, so that they were both paralyzed and unconscious, followed by the use of lay people, such as firemen and Boy Scouts, to act as the rescuer who would ventilate their subject (Ingram, 2010). These breakthroughs, combined with Dr. Safar’s discovery of the head tilt, chin lift technique, which is the most effective way to control a person’s breathing airway when performing mouth-to-mouth resuscitation, showed that mouth-to-mouth ventilation was far superior to the widely used manual methods at the time, and that lay people could effectively perform mouth-to-mouth breathing to save lives. (“Cardiopulmonary Resuscitation,” 2011). The use of mouth-to-mouth ventilation was endorsed and adopted by the United States Military and the American Medical Association in 1957 and 1958 respectively, helping to revolutionize the life saving procedures that are now used by EMS systems around the world as checking, treating, and maintaining a person’s airway is one of the first steps in emergency care. The importance of cardiac massage, or chest compressions, in the race to save a person’s life was an area of science that was not well understood prior to the 1950s. Some attempts at chest massage were made during the 19th and early 20th centuries, including those by Dr. Friedrich Maass, who performed the first equivocally documented chest compressions on two humans in 1891, and Dr. George Crile, who reported the first successful use of external chest compressions on a woman suffering from cardiac collapse in 1903 (American Heart Association, 2009). At the time, Dr. Crile believed that the pressured exerted on the chest led to an artificial pumping action of the heart that, in turn, produced peripheral blood flow (Brennan & Krohmer, 2005), and although his thinking would prove in later years to be correct, these earlier accounts of chest compressions were not credited and did little to promote the benefits of closed chest massage (Omato & Peberdy, 2005). It was not until 1960 at Johns Hopkins University that a team of researchers discovered the breakthrough resuscitation technique of chest compressions and the impact that cardiac massage could have in saving a person’s life. The team of researchers consisted of Drs. William Kouwenhoven, James Jude, and Guy Knickerbocker, who were actually doing research to develop an external defibrillator for electric companies. During one of the experiments, however, Dr. Knickerbocker noticed that when he applied the defibrillation paddles to the chest wall of a dog whose heart had stopped beating, the pressure applied caused a spike in the dog’s blood pressure, creating a pulse in the femoral artery (Brennan & Krohmer, 2005). Dr. Knickerbocker immediately consulted with Dr. Jude, a cardiac surgeon, who realized the importance of these findings. Drs. Kouwenhoven, Jude, and Knickerbocker expanded their research, refining a method to apply pressure through external cardiac massage in a way that could cause enough blood to move through the body to sustain vital organs, buying a person time until more advanced care could be given (Ingram, 2010). These experiments were eventually practiced with humans and reported in 1960, followed by the creation of a training video by all three doctors called “The Pulse of Life” (Ingram, 2010). It was through the work of Drs. Kouwenhoven, Jude, and Knickerbocker that the world was introduced to a breakthrough resuscitation technique that could be applied by any trained individual without any special equipment. With the establishment of mouth-to-mouth resuscitation as an effective technique for artificial ventilation in 1956, and the finding that external chest compressions were a valuable practice for artificial circulation in 1960, it was only a matter of time until someone discovered that these two methods could be brought together. This was accomplished in September of 1960 by Dr. Peter Safar who combined mouth-to-mouth resuscitation with closed-chest cardiac compression to develop the basic life support method of cardiopulmonary resuscitation, or CPR (Lemelson-MIT Program, 2004). Dr. Safar, while presenting his findings at the Maryland Medical Society, stated that “the two techniques of mouth-to-mouth ventilation and external chest compressions cannot be considered any longer as separate units, but as parts of a whole and complete approach to resuscitation” (Paradis, Halperin, Kern, Wenzel, & Chamberlain, 2007, p. 11). This statement stressed the importance that neither chest compressions nor mouth-to-mouth ventilation alone were sufficient in and of themselves in improving a person’s chances of survival.
In order to help in the efforts to train individuals in CPR, Dr. Safar approached toymaker Asmund Laerdal with the idea of developing a realistic, life-sized mannequin that those seeking training could practice on. Laerdal took up the challenge and created Resusci-Anne, commonly known today as Rescue Annie, which can receive mouth-to-mouth resuscitation and has an internal spring attached to its torso to allow for chest compressions (“Cardiopulmonary Resuscitation,” 2011). Following all of these developments, the American Heart Association started a program in 1960 to acquaint physicians with closed-chest cardiac resuscitation and became the forerunner of CPR training for the general public under the realization that the rapid response of trained community members to cardiac emergencies could help improve outcomes (American Heart Association, 2009). This became the basis for modern day emergency medical services as patients no longer had to wait to arrive at the hospital in order to receive life saving care. Now, life saving care could be provided wherever a victim was located by a trained professional who could perform the necessary reviving procedures. In an effective emergency cardiovascular care system, mouth-to-mouth ventilation and chest compressions are not always enough to restart a person’s heart. Many prominent figures throughout the 19th and 20th centuries became aware of this fact and with this realization developed the process of defibrillation in which an electric device provides and electric shock to the heart. Defibrillation arose through the efforts of numerous individuals over the years as the ideas of the past were built upon and the science of restarting a person’s normal heart rhythm was propelled forward John McWilliams wrote one of the first detailed descriptions concerning ventricular fibrillation, a severely abnormal heart rhythm that can be life threatening, based on his experiments with young and adult cats, rabbits, rats, mice, hedgehogs, eels, and chickens (Omato & Peberdy, 2005). Through his research with animals, McWilliams was able to postulate that fibrillation, or the rapid, irregular, and unsynchronized contraction of muscle fibers, particularly around the heart, is an important cause of sudden death in humans; however, despite this deduction, McWilliams never acted on it in an attempt to try to stop the fibrillations of a heart muscle (Omato & Peberdy, 2005). In 1899, while working with animals, Jean Louis Prevost and Frederic Battelli made the connection that an electric current passed through the heart would fibrillate the heart, but that a stronger electric current was capable of terminating fibrillation, thus re-establishing a normal cardiac rhythm (McLennan, 2008). These findings were not appreciated, however, until the 1920s when electric companies became concerned about the alarming number of utility workers who suffered fatal shocks while on the job. One such company, the Edison Electric Institute, hired William Kouwenhoven, Donald Hooker, and Orthello Langworthy to research the cause and possible prevention of the deaths of the utility workers. Dr. Kouwenhoven and his team conducted their study on the effects of electricity directly on the heart using animals as well, and came to the same conclusions as Prevost and Battelli that ventricular fibrillation was the cause of the utility workers’ deaths, but that an alternating electrical current applied directly to the heart could act as a cure and restore the heartbeat (Brennan & Krohmer, 2005). The period from 1947 to 1962 marked a significant turning point in the use and creation of defibrillators that would forever change the degree of care patients would receive from emergency medical services. In 1947, the first successful defibrillation of the heart was documented by Dr. Claude Beck during surgery on a 14 year-old boy. The boy had a congenital disorder and went into cardiac arrest towards the end of surgery when his chest was being closed. Dr. Beck reopened the chest and after trying to massage the heart for forty-five minutes, employed the use of a defibrillator. By applying the paddles directly to the boy’s heart, Dr. Beck was able to bring the heart out of fibrillation, allowing the boy to go on to make a full recovery (“Claude Beck,” 2011). The defibrillator used by Dr. Beck had been of his own creation, along with the assistance of his friend James Rand, and used alternating current directly from a wall, requiring a transformer so large it made moving it extremely difficult (Heart Rhythm Society, 2011). Despite the sheer size of the defibrillator and the fact that it could be used only for internal defibrillation, this was still a positive and promising beginning for defibrillation and its use for cardiac emergencies in humans.
In 1956, Dr. Paul Zoll was the first to demonstrate that successful defibrillation could be performed across the closed chest, a discovery that paved the way to who could be treated and where. The issue of the size of defibrillators still remained a problem, however, until 1960 when Dr. Bernard Lown addressed the portability issued and developed a defibrillator that used direct current (DC) rather than alternating current (AC). By doing this, Dr. Lown eliminated the need for a heavy transformer, allowing the defibrillator to be battery operated instead (McLennan, 2008). This considerably reduced the size and weight of the defibrillator, opening the door to solving the problem of out of hospital sudden death since defibrillators could now be transported to the patient (Brennan & Krohner, 2005). With the development of a portable defibrillator coinciding with the emergence of CPR, the means for keeping someone alive suffering from cardiac arrest dramatically increased and laid the foundation for advanced cardiac life support (ACLS) that fueled much of the development of EMS systems in subsequent years.

Reports, Legislation, and the Modern EMS System

Until 1965, the emergency system in the United States was disorganized, causing more harm than good to patients who were treated, and the need to establish a pre-hospital emergency medical service system for trauma and cardiac cases was imminent. Acting on this awareness, Congress chartered the National Academy of Sciences – National Research Council (NAS-NRC) to provide scientific advice to the federal government. The NAS-NRC went on to publish a report entitled “Accidental Death and Disability: the Neglected Disease of Modern Society,” also referred to as “the White Paper,” which identified key issues and problems facing the United States in providing emergency care (National Association of EMS Physicians, 2002). The report explicitly outlined the severity of the emergency medical care situation by noting 1) the lack of uniform and adequate Federal, State, and local laws and standards concerning the EMS system; 2) that ambulances were inappropriately designed, offering little room for the patient and attendant, and the equipment carried on board was of poor quality; and 3) personnel were severely lacking in training, if they had any formal training at all (Rockwood, Mann, Farrington, Hampton, & Motley, 1976). The report went on to make 29 recommendations for improving care for injured victims, 11 of which were directly related to pre-hospital emergency medical services. Some of these recommendations focused on developing federal standards for ambulances, including the design and construction of the ambulance, as well as the equipment and supplies carried on board (Institute of Medicine of the National Academies, 2007). Other recommendations pinpointed the need to prepare nationally acceptable texts, training aids, and courses of instruction for rescue squad personnel, policemen, firemen, and ambulance attendants, as well as the extension of basic and advanced first aid training to a great number of the lay public (Walz, Krumperman, & Zigmont, 2010). Furthermore, the report’s recommendations concentrated on the need to assign radio channels and equipment suitable for voice communications between ambulances and emergency departments, while exploring the feasibility of developing a single nationwide telephone number for summoning an ambulance (Institute of Medicine of the National Academies, 2007). Ultimately, the “Accidental Death and Disability” report put pressure on our country’s government to improve out of hospital emergency medical care for patients and served as the catalyst for a series of actions that would follow. In 1966, the growing concern for victims of motor vehicle accidents was at the forefront of issues that needed to be addressed in the United States. Building on the declaration of President John F. Kennedy in 1961 that “traffic accidents constitute one of the greatest, perhaps the greatest, of the nation’s public health problems” (Robbins, 2005, p. 36), the President’s Committee for Traffic Safety published the report “Health, Medical Care, and Transportation of the Injured” that recommended a national program to reduce highway deaths and injuries (Institute of Medicine of the National Academies, 2007). The recommendation in this report, along with those in the “Accidental Death and Disability” study that had been completed around the same time, were used when drafting two very important acts that were signed in 1966 by President Lyndon B. Johnson. The first act signed into law in 1966 was the National Traffic and Motor Vehicle Safety Act, Public Law 89-563, which provided for the coordination and financing for states to develop highway safety programs and to develop motor vehicle safety standards (Walz, Krumperman, & Zigmont, 2010). The second act, the Highway Safety Act of 1966, Public Law 89-564, specifically addressed the need to improve emergency medical systems related to highway accidents, highlighting emergency medical care as a necessary element to reducing death and disability associated with traffic accidents (Walz, Krumperman, & Zigmont, 2010). The Highway Safety Act led to the formation of the National Highway Traffic Safety Administration (NHTSA) within the Department of Transportation and was given the authority to fund improvements in emergency medical services. With this role, the NHTSA provided more than $48 million for EMS development between 1966 and 1973, and over $142 million by 1978 (Institute of Medicine of the National Academies, 2007). The Highway Safety Act created the first comprehensive description of an EMS system, including important components and standards as outlined in the Highway Program Safety Manual. This manual included 19 volumes, with Volume 11 including 8 chapters that provided the guidelines and descriptions of an EMS system’s elements (Robbins, 2005). Specific emphasis within these guidelines was placed on the standards and activities that were needed in order to improve both ambulance service and provider training. As a result, standards in ambulance construction were created by the General Services Administration in federal specifications KKK-A 1822 concerning such areas as the internal height of the patient care area in order to allow for an attendant to continue caring for the patient during transport, as well as equipment that was required to be available in every ambulance (National Association of EMS Physicians, 2002). In order for these updated ambulances to be dispatched to the public, the President’s Commission on Law Enforcement and Administration of Justice recommended the creation of a single number that could be used nationwide for reporting emergencies. The Federal Communications Commission met with AT&T in 1967 and created a solution one year later. At that time AT&T announced the designation of 9-1-1 as a universal emergency number because it was brief, easy to remember, dialed easily, and worked well with the phone systems in place at the time (“9-1-1,” 2011). This universal phone number was a big improvement in emergency services as callers knew that a call to 9-1-1 would connect them to the right people for emergency help.
Advancements were also made in regards to provider training as the Highway Safety Act included funds to create an appropriate training course for emergency care providers. In 1969, NHTSA developed a national EMS education curriculum, a 70-hour basic EMT course that became the first standard EMT training course in the United States, and shortly after paramedic education began with a focus heavily on cardiac care and cardiac arrest resuscitation (Institute of Medicine of the National Academies, 2007). In 1970, the National Registry of Emergency Medical Technicians was established in an attempt to unify examinations and certifications for EMTs on the national level. With this in place, the curriculum to become certified as an EMT evolved over the years with the introduction of different curricula for first responders, EMT-Basics, EMT Intermediates, and Paramedics, all part of the EMT-B curriculum that exists today (Institute of Medicine of the National Academies, 2007). These changes put in place were a positive attempt to provide effective prevention for those in motor vehicle accidents and contributed greatly to the impact of legislation on the future development of EMS systems; however, keeping up with the fast paced changes that were occurring was not always an easy task. In 1972, the NAS-NRC published a report “Roles and Resources of Federal Agencies in Support of Comprehensive Emergency Medical Services” that examined the current state of EMS systems. The report ultimately expressed concern that the federal effort to upgrade EMS systems in the United States had not kept up with what was needed (Institute of Medicine of the National Academies, 2007). In response to this report, as well as several demonstration projects and various studies conducted during previous years, President Richard Nixon signed the EMS Systems Act in November of 1973, Public Law 93-154, which amended the Public Health Services Act of 1944 by adding Title XII (National Association of EMS Physicians, 2002). The intent of the EMS Systems Act was to improve and coordinate care throughout the country through the creation of a categorical grant program run by the new Division of Emergency Medical Services within the Department of Health, Education, and Welfare (Institute of Medicine of the National Academies, 2007). Ultimately, this grant program aimed to encourage the development of comprehensive regional EMS systems throughout the country since funds would be targeted and distributed to smaller, more manageable regions in an attempt to ensure the money would be used more appropriately and effectively (Brennan & Krohmer, 2005). Under the act, comprehensive regional systems needed to have adequate medical staff, emergency facilities, transportation equipment, and other resources needed to provide emergency care to all people within the system’s service area. Millions of dollars were earmarked for EMS training, equipment, and research and with this federal support, states established a total of about 300 EMS regions, most covering several counties (O’Leary, 2005). One of the main components of the EMS Systems Act was the outline it provided concerning 15 essential components of an EMS system, all of which had to be addressed by a system in order for the region to receive federal funding. The 15 components included manpower, training, communication, transportation, emergency facilities, critical care units, public safety agencies, consumer participation, access to care, patient transfer, standardized record-keeping, public information and education, system review and evaluation, disaster planning, and mutual aid (Brennan & Krohmer, 2005). All of these components helped guide the development of models of service provided by the regional EMS systems by informing system functions such as medical direction, triage protocols, communication, and quality assurance. These guidelines provided in the act also helped set the tone of the EMS system’s interaction with the larger health care and public health systems (Institute of Medicine of the National Academies, 2007). Essentially, these ideal components of an EMS system guided the development of regional EMS systems that were fundamentally driven by local needs, characteristics, and concerns, creating a patchwork of EMS systems across the country. By the close of the 1970s, EMS systems were firmly established in the medical infrastructure of the United States as its own discipline and own science, defined now in terms of health care services and emergency conditions, rather than just to injuries sustained in motor vehicle accidents. The beginning of the 1980s marked a turning point for emergency medical service systems in regards to funding. Up to this point in time, regional EMS systems received funding directly from the federal government. However, in the summer of 1981, Ronald Reagan signed into law the Omnibus Budget Reconciliation Act, Public Law 97-35, which marked the end of categorical federal funding to states as established by the EMS Systems Act of 1973 (National Association of EMS Physicians, 2002). The Omnibus Act amended the Public Health Service Act by adding a new title, Title XIX, which consolidated funding into preventative health and health services block grants, lump sums of money to be used for broad program areas in the states. This change shifted responsibility for EMS systems from the federal government to the states, letting each state determine how much funding would be distributed locally to the development of EMS systems (Institute of Medicine of the National Academies, 2007). By default, regional and county EMS systems took the lead in designing and managing their EMS programs, resulting in systems that become more fractured along smaller and smaller local lines. As a result, greater diversity among EMS systems in the United States emerged over the years to focus on the particular needs of the area the system served while being funded by the state in which the system resided. In the late 1970s and early 1980s, the focus of emergency medicine began to shift to pediatric care and the need to provide better treatment to children and adolescents. This shift emerged out of the growing awareness by pediatricians and pediatric surgeons that the specialized care children required was being overlooked by EMS systems, resulting in poor outcomes for children across the country. With the realization, Dr. Calvin Sia, president of the Hawaii Medical Association, worked with U.S. Senator Daniel Inouye in generating legislation for an initiative on pediatric emergency medical services for children (New York State Department of Health, 2010). In 1984, Senator Inouye was joined by Senators Orrin Hatch and Lowell Weicker in sponsoring the first legislation that would focus specifically on emergency medical services for children. With this push from Congress, the EMS for Children Act, Public Law 98-555, was signed into law by President Reagan in an effort to provide assistance to states to reduce the mortality and morbidity of pediatric medical and trauma patients by improving the regional systems of care for the pediatric patient (South Carolina Department of Health and Environmental Control, 2011). The act worked to make this possible by ensuring the entire spectrum of emergency services is provided to children and adolescents, and that state of the art emergency medical care is available to ill and injured children and adolescents (Institute of Medicine of the National Academies, 2007).
Major accomplishments were seen throughout the country as a result of the EMS for Children Act including the improved availability of child-appropriate equipment in ambulances and emergency department, the creation of hundreds of programs to prevent injuries, and the advanced training of EMTs, paramedics, and other emergency medical care providers in pediatric emergency care (Institute of Medicine of the National Academies, 2007). The results of this piece of legislation benefitted not only children but the entire population of the country. It was due to this act that deficiencies in our health care system’s ability to address the emergency medical needs of diverse groups of patients has been brought to the forefront of emergency medicine in order to ensure that every patient has the best chance for survival.
In 1995, through the urging of then NHTSA Administrator Ricardo Martinez, the National Highway Traffic Safety Administration and Health Resources and Services Administration brought together representatives of federal agencies and 19 national organizations to develop a strategic plan for improving the future of EMS systems. The resulting report, “Emergency Medical Services Agenda for the Future,” was published in 1996 by the NHTSA and outlined a vision of an EMS system that is fully integrated with the overall health care system, including other health care providers and public health and public safety agencies (United States National Highway Traffic Safety Administration, 1996). “Agenda for the Future” ultimately aimed to connect EMS systems with other medical professions while providing community-based health management with the ability to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to the treatment of chronic conditions and community health issues (O’Leary, 2005). This report, now 15 years old, has been effective in placing a spotlight on the vital role played by EMS within the emergency and trauma care system in an effort to demonstrate that continuous attention needs to be paid from policy makers, organizations, and the public alike in order for the system to remain an established emergency safety net.

Conclusion
The field of emergency medicine, which is typically viewed as a relatively modern creation, is in actuality, an ever changing and evolving science that has developed as the result of ideas, inventions, and discoveries of many important people of the past few hundred years. Throughout history, the actions of prominent figures in the military as well as various efforts put forth by civilians in the public sector have formed the foundation for medical care and transportation that emergency medical services are based off of today. Major breakthroughs in artificial respiration, artificial circulation, and defibrillation during the 1950s and 1960s set the stage for modern EMS systems to develop as professionals and lay people became trained in these life saving techniques. Acts of legislation throughout the latter part of the 20th century contributed to the rise of the modern EMS system as state and regional EMS systems developed and grew because visionaries realized that a better quality of emergency medical care could be delivered if individual participants worked together in a coordinated system.
In the end, EMS defies simple explanation, both historically and today. EMS has served various functions in the past, and continues to serve the community in a plethora of ways as recognized on the “Star of Life” symbol that EMS services have been branded with. The Star of Life recognizes that EMS services provide detection, reporting, response, on-scene care, care in transit, and transfer to definitive care, making the EMS system worthy of being called the front line of health care. The integration of EMS into the health care system and the recognition of the key role it provides must persist in order for emergency medical services in the United States to continue experiencing explosive development and growth in the field, able to respond to the broad spectrum of situations it encounters while providing care to any individual in need.

References

70 years: 1928 - 1998. (2009, April 1). Retrieved March 15 2011 from http://www.roanokeems.org/Documents/70years.pdf 9-1-1. (2011). Wikipedia. Retrieved 11 April 2011 from http://en.wikipedia.org/wiki/9-1-1 “Ambulance.” (1987). World book encyclopedia. Chicago: World Book Inc.
“Ambulance - Definition." (2011). Dictionary and Thesaurus - Merriam-Webster Online.
Retrieved 6 March 2011 from http://www.merriam-webster.com/dictionary/ambulance
American Heart Association. (2009, July 05). History of CPR. Retrieved 5 April 2011 from http://www.americanheart.org/presenter.jhtml?identifier=3012990 Brennan, J., & Krohmer, J. (2005). Principles of EMS systems (Google eBook). Retrieved 2
April 2011 from http://books.google.com/books?id=yb3POJWHwdcC&pg=PA31&lpg=PA31&dq=EMS+Systems+Act&source=bl&ots=J8VTmsjeXK&sig=285VraNyMngyM_-ZHSpT5BmmVp8&hl=en#v=onepage&q=EMS%20Systems%20Act&f=false
Cardiopulmonary Resuscitation. (2011). Wikipedia. Retrieved 4 April 2011 from http://en.wikipedia.org/wiki/Cardiopulmonary_resuscitation Civil War Trust. (2011). Jonathan Letterman. Retrieved 11 March 2011 from http://www.civilwar.org/education/history/biographies/jonathan-letterman.html Claude Beck. (2011). Wikipedia. Retrieved 5 April 2011 from http://en.wikipedia.org/wiki/Claude_Beck Corcoran, T. (2009). The goodness of Guinness: a loving history of the brewery, its people, and the city of Dublin (Google eBook). Retrieved 11 March 2011 from http://books.google.com/books?id=05Ni_dhbZkAC&pg=PA69&dq=St.+John+Ambulance+Brigade&hl=en&ei=_XaTTZegHsGDtweY851e&sa=X&oi=book_result&ct=result&resnum=4&ved=0CFsQ6AEwAw#v=onepage&q=St.%20John%20Ambulance%20Brigade&f=false Emergency Medical Services. (2011). Wikipedia. Retrieved 2 March 2011 from http://en.wikipedia.org/wiki/Emergency_medical_services Field, J. (2009). The textbook of emergency cardiovascular care and CPR (Google eBook).
Retrieved 4 April 2011 from http://books.google.com/books?id=JaOoXdSlT9sC&pg=PA199&lpg=PA199&dq=john+mcwilliams%2Bventricular+fibrillation&source=bl&ots=QKMSJdXqC1&sig=dh96t72nsE6wTQsTbQVelhNG4i0&hl=en&ei=wySeTdGuHYyD0QGxj4iwBA&sa=X&oi=book_result&ct=result&resnum=1&ved=0CBQQ6AEwAA#v=onepage&q=john%20mcwilliams&f=false
Heart Rhythm Society. (2011). Notable figures: biography of Claude S. Beck. Retrieved 5 April
2011 from http://www.hrsonline.org/news/ep-history/notable-figures/claudebeck.cfm
History of the Ambulance. (2011). Wikipedia. Retrieved 2 March 2011 from http://en.wikipedia.org/wiki/History_of_the_ambulance Ingram, A. (2010). Engineer’s discovery leads to CPR rescue method!. Retrieved 2 April 2011 from http://www.scienceheroes.com/index.php?option=com_content&view=article&id=338:knickerbocker-g-guy&catid=25:general&Itemid=284

Ingram, A. (2010). Resusci-Anne to the rescue. Retrieved 2 April 2011 from http://www.scienceheroes.com/index.php?option=com_content&view=article&id=346&Itemid=292 Institute of Medicine of the National Academies. (2007). Emergency care for children: growing pains. Retrieved 11 April 2011 from http://books.nap.edu/openbook.php?record_id=11655&page=36
Institute of Medicine of the National Academies. (2007). Emergency medical services at the crossroads. Retrieved 6 March 2011 from http://www.nap.edu/openbook.php?record_id=11629&page=32 Lemelson-MIT Program. (2004, April). Peter Safar: cardiopulmonary resuscitation. Retrieved 4
April 2011 from http://web.mit.edu/invent/iow/safar.html
Limmer, D. & O'Keefe, M. (2005). Emergency care. New Jersey: Pearson Education.
Long, H. (2008). About medical advancements in the Civil War. Retrieved 11 March 2011 from http://www.ehow.com/about_4608397_medical-advancements-civil-war.html
McLennan, S. (2008). The development of CPR. The New Zealand Medical Journal, 121(1284).
Retrieved 2 April 2011 from http://www.nzma.org.nz/journal/121-1284/3312/
Medical discoveries: Dominique-Jean Larrey. (2011). Retrieved 11 March 2011 from http://www.discoveriesinmedicine.com/General-Information-and-Biographies/Larrey-Dominique-Jean.html National Association of EMS Physicians. (2002). Pre-hospital systems and medical oversight
[Third Edition] (Google eBook). Retrieved 6 March 2011 from http://books.google.com/books?id=ujVUnUVs9nQC&pg=PA7&lpg=PA7&dq=EMS+Systems+Act&source=bl&ots=R_zDBxHGdb&sig=fDmMUc-dR4VHojhkD_rtoNDmOGM&hl=en#v=onepage&q=American%20Red%20Cross&f=false
New York State Department of Health. (2010, August). Emergency medical services for children. Retrieved 13 April 2011 from http://www.health.state.ny.us/nysdoh/ems/emsc/index.htm
O'Leary, M. (2005, August 7). a historical overview of EMS system development in the U.S.: the
1990s and 2000s. Retrieved 13 April 2011 from http://www.semp.us/publications/biot_reader.php?BiotID=248
Omato, J., & Peberdy, M. (2005). Cardiopulmonary resuscitation (Google eBook). Retrieved 4
April 2011 from http://books.google.com/books?id=eyEiPrb_64AC&pg=PA82&dq=the+history+of+CPR&hl=en&ei=8KGbTcqNIY6atweFsMzWBw&sa=X&oi=book_result&ct=result&resnum=3&ved=0CDsQ6AEwAg#v=onepage&q=the%20history%20of%20CPR&f=false
Page, J. (1978). Emergency medical services. Boston: National Fire Protection Association.
Paradis, N., Halperin, H., Kern, K., Wenzel, V., & Chamberlain, D., (2007). Cardiac arrest: the science and practice of resuscitation medicine [Second Edition]. (Google eBook). Retrieved 5 April 2011 from http://books.google.com/books?id=inud-udaRFwC&pg=PA11&lpg=PA11&dq=cannot+be+considered+any+longer+as+separate+units,+but+as+parts+of+a+whole+and+complete+approach+to+resuscitation%E2%80%9D.&source=bl&ots=7FtB5q6NMf&sig=-hW7auX2K56hyWgPi6a5oxCxryY&hl=en&ei=OwaeTbqjHvCQ0QHp-LzVBA&sa=X&oi=book_result&ct=result&resnum=2&ved=0CBsQ6AEwAQ#v=onepage&q=cannot%20be%20considered%20any%20longer%20as%20separate%20units%2C%20but%20as%20parts%20of%20a%20whole%20and%20complete%20approach%20to%20resuscitation%E2%80%9D.&f=false
Paramedic Spot. (2010, November 26). The history of EMS. Retrieved 6 March 2011 from http://paramedicspot.com/?p=26 Regal, W. & Nanut, M. (2007). Vienna: a doctor's guide : 15 walking tours through
Vienna’s medical history (Google eBook). Retrieved 6 March 2011 from http://books.google.com/books?id=ARYNOecoznYC&pg=PA45&dq=Vienna+Rescue+Society&hl=en&ei=XnSTTa3AK5KUtweUrsRq&sa=X&oi=book_result&ct=result&resnum=1&ved=0CDEQ6AEwAA#v=onepage&q=Vienna%20Rescue%20Society&f=false
Richey, S. (2009). Advances in emergency and critical care medicine from the frontlines.
American College of Emergency Physicians, 10(1). Retrieved 15 March 2011 from https://apps.acep.org/SectionSite.aspx?LinkIdentifier=id&id=48823&libID=48852&fid=115162&Mo=No Robbins, V. (2005). A history of emergency medical services and medical transportation systems in America. Retrieved 15 March 2011, from https://www.monoc.org/bod/docs/history%20american%20ems-mts.pdf
Rockwood, C., Mann, C., Farrington, J., Hampton, O., & Motley, R. (1976). History of emergency medical services in the United States. The Journal of Trauma, 16 (April), 299-301.
Schroeder-Lein, G. (2008). The encyclopedia of Civil War medicine (Google eBook).
Retrieved 11 March 2011 from http://books.google.com/books?id=fVZeGtxiMcYC&pg=PA33&sig=Pjo0ou5pZtUDA4DwHcduEvvVmtM&hl=en#v=onepage&q&f=false
South Carolina Department of Health and Environmental Control. (2011). EMS for children.
Retrieved 12 April 2011 from http://www.scdhec.gov/health/ems/children.htm
Title XII Emergency Medical Service Systems, 594 § 1201 (1973). Print
United States National Highway Traffic Safety Administration. (1996). Emergency medical services agenda for the future (DOT HS 808 441). Retrieved 12 April 2011 from http://books.google.com/books?id=2UxRAAAAMAAJ&printsec=frontcover&dq=EMS+Agenda+for+the+Future&hl=en&ei=zi6mTeX2Jojj0gGEqu38CA&sa=X&oi=book_result&ct=result&resnum=3&sqi=2&ved=0CD0Q6AEwAg#v=onepage&q=EMS%20Agenda%20for%20the%20Future&f=true Walz, B., Krumperman, K., & Zigmont, J. (2010). Foundations of EMS systems (Google eBook). Retrieved 11 April 2011 from
http://books.google.com/books?id=VSAcgVcBes4C&printsec=frontcover&dq=Walz,+Krumperman,+%26+Zigmont,+2010&source=bl&ots=L_ObMC7ojh&sig=YA8Dw7n4ChsbHt1_iozLT3an_KY&hl=en&ei=Mp-0Te67AeLj0QHT1ZyzCQ&sa=X&oi=book_result&ct=result&resnum=1&sqi=2&ved=0CBYQ6AEwAA#v=onepage&q=Walz%2C%20Krumperman%2C%20%26%20Zigmont%2C%202010&f=false