SECTION 1: EMS Physician Scope of Practice

INTRODUCTION

This book is dedicated to the premise that emergency medical services (EMS) represent a bona fide field of physician subspecialty, that certain knowledge and skills are required, and that there is broad interest in learning about these matters. This chapter describes the subspecialty and begins the process of providing clarity to the roles of an EMS physician and the practice of EMS.

OBJECTIVES

• Define the scope of EMS medicine.

• Contrast EMS medicine to the practice of emergency medicine.

• Define EMS physician.

• Describe the necessary skill sets of an EMS physician.

THE BASIS FOR A SUBSPECIALTY

Indeed, since the earliest developments of EMS there have been physicians who applied their expertise to the nuances of providing care to the ill and injured in the field. They came from diverse clinical backgrounds, but they shared perspectives that optimal care provided as soon as a life-threatening condition could be recognized provided opportunities for improved outcomes. Though they may not have thought of themselves as such, they were the pioneer EMS subspecialists.

The next chapter will provide a historical overview of EMS. Among the various milestones of EMS development, there was generally a physician using his clinical knowledge, understanding of pathophysiology, and patients' needs to prompt innovation and advances of all sorts. Some might be considered logistical, such as when Jean Dominique Larry, Napoleon's chief military physician, built “ambulance volantes” to evacuate wounded soldiers from the battlefield.¹ Others might be considered clinical advances, such as the development of cardiopulmonary resuscitation (CPR) or Dr Frank Pantrindge's delivery of life-saving defibrillatory shocks to patients not yet at a hospital.^2,3 Still, others advanced the concept of medical oversight, as were the lessons of Drs Cobb and Copass in Seattle. Collectively, these examples help reveal the breadth of knowledge and skill required among EMS subspecialists.

Nevertheless, for some time there was a considerable struggle to define the nature of the EMS subspecialty and designate it as such. Among the challenges was the necessary distillation of a multifaceted and blended discipline to reveal and capture its clinical essence, upon which various administrative and health care management roles may be layered. That culminated on September 23, 2010, when the American Board of Medical Specialties (ABMS) officially recognized EMS as a physician subspecialty as requested by the American Board of Emergency Medicine (ABEM). The journey to that point is revealing, and in some respects is not unlike the path to recognition of emergency medicine as a specialty with its own unique fund of knowledge and purview.

The often-cited 1966 paper Accidental Death and Disability: The Neglected Disease of Modern Society pointed out a number of shortcomings in the American health care system related to trauma and emergency care.⁴ John M Howard, MD, was an army surgeon during the Korean Conflict and one of the paper's authors. He has recalled that the impetus for the study and a report of its findings was the observation by him and similar physicians that the lessons learned in Korea had not translated to home in the United States.⁵ The American health care system remained woefully ill prepared to deal with what was described as an injury epidemic.⁴ At the time, although new patterns of staffing hospital emergency departments were evolving, many hospitals required all medical personnel, regardless of specialty, to share emergency department responsibility. The 1966 paper proclaimed that no longer can emergency department responsibility be assigned to the least experienced member of the medical staff or solely to specialists who, by the nature of their training and experience, cannot provide adequate care without the support of other staff members.⁴ Indeed, emergency department care represented early intervention in the continuum of care required by seriously ill or injured people. It demanded special expertise and both breadth and depth of clinical skills and knowledge. Subsequently, the Emergency Medical Services Act of 1971, among other things, made “seed money” available to help develop new emergency medicine residency programs.⁶ Emergency medicine became recognized as a primary board by ABMS in 1979.

Part of the rationale for emergency medicine to be a distinct specialty rested in its interface with EMS systems and personnel. While care in an emergency department was undoubtedly early in the continuum, care in the field was earlier and it required active oversight by physicians with attentive interest and appropriate insights. At the time, EMS often represented the notion of taking the emergency department to the patient. Thus, by natural extension emergency physicians became the most active physician participants within EMS systems, offering a distinction from the rest of medicine.

EMS, as we know, has evolved. The need for specific expertise has intensified. It is no longer acceptable to uniformly bring the emergency department to every patient. Whether or not a specific intervention or pharmaceutical agent ought to be translated from the emergency department to out-of-hospital scenes requires careful analyses of risks and benefits and cost-effectiveness in the context of local circumstances. Decisions regarding use of thrombolytics, neuromuscular blocking agents, and even steroids are all examples. These sorts of analyses are done on a patient-by-patient basis numerous times a day by physicians of all genres. However, the knowledge and perspectives required by these specific questions and those like them have demanded special expertise and understanding the needs of EMS patients and the intricacies of often complex EMS care delivery systems.

As defined by the Institute of Medicine of the National Academies, EMS comprises the crucial early phases of the continuum of emergency medical care for acutely ill and injured persons. It encompasses prehospital and out-of-hospital emergency care, including 9-1-1 access and dispatch, field triage and initial stabilization, and treatment and transport in specially equipped ambulances or helicopters to hospitals or between medical facilities.⁷

EMS PHYSICIANS

EMS physicians provide emergency medical care for patients in out- of-hospital settings and medical oversight of EMS systems. According to ABEM, the unique clinical elements that characterize EMS medical practice stem from its position early in the continuum of patient care, its physical location outside of fixed medical facilities, and the relatively higher acuity of its patient population compared to emergency medicine. The treatments developed by EMS physicians, and either delivered or overseen by them, affect patients' ultimate outcomes as patient safety and proper treatment are ensured.⁸ It is the EMS physician who brings medical decision making to the patient's side at the site of accident or injury, ensuring appropriate care until arrival at a hospital or other advancement further in the continuum of care. According to ABEM, the purpose of subspecialty certification in EMS is to standardize physician training and qualifications for EMS practice, to improve patient safety and enhance the quality of emergency medical care provided to patients in the prehospital environment, and to facilitate integration of prehospital patient treatment into the continuum of patient care.⁸

In 2011, ABEM published The Core Content of EMS Medicine. It incorporates four principal topic categories (Table 1-1) that include more than 400 total elements.⁹ Each element relates to one or more core competencies as described by the Accreditation Council for Graduate Medical Education and ABMS, including patient care, medical knowledge, practice-based learning, professionalism, interpersonal skills, and system-based practice.¹⁰

In developing the core content, the ABEM EMS Examination Task Force surveyed clinically active EMS physicians to determine the frequency and importance of each element. The core content subsequently represents what those physicians perceive as relevant to their professional practice.¹⁰ Thus, it provides an excellent overview of the nature of knowledge and skills required of an EMS physician.

Another practical way of evaluating EMS physician skill sets is by considering them as related to clinical, medical oversight, or administrative issues. While there is typically substantial overlap among them, it can be helpful to think about them this way.

CLINICAL SKILLS

Among clinical knowledge and skills, there are several features of practice that distinguish EMS medicine from the general practice of emergency medicine or any other specialty for that matter. As already noted, the focus is at the earliest points in a patient's continuum of care after recognition of acute illness or injury. Thus, the culprit illness or injury is the least differentiated and earlier in its dynamic process of evolution. Further, the tools available to refine the differential are limited to what can be cost-effectively taken to the patient's side no matter where that might be. The environment of care has considerable influence, including such factors as ambient lighting, uncontrollable noise, temperature, and humidity. Each of these may present specific challenges to patient evaluation, treatment, and evacuation. For example, the noise and vibration of an EMS helicopter mandate a greater degree of technology-driven patient monitoring. Auscultation of blood pressure and lung sounds is not possible. Bright ambient light may affect the ability to perform laryngoscopy and adaptive or alternate tactics must be readily available.

In the final analysis, EMS physicians are responsible for understanding the appropriate prehospital or out-of-hospital care for the full spectrum of potential illness and injury among the entire extent of the population in their communities. As noted in the core content, some conditions are undoubtedly time or life critical, such as cardiac arrest, airway compromise, respiratory failure, hypotension, and shock. Others include the broadest range of trauma, respiratory, cardiac, and other medical illnesses; obstetrical and gynecologic emergencies; poisoning and toxicological emergencies with special attention to containment and decontamination; and communicable diseases.

The nature of some patients' illnesses or injuries mandate that EMS physicians are technically competent to perform or facilitate a number of procedures that, depending on local circumstance, may be required to sustain patients to definitive care and improve outcomes. These are outlined in Table 1-2.

MEDICAL OVERSIGHT

Medical oversight of EMS systems demands an understanding of applicable state laws, rules, and regulations and, in some cases, local ordinance. While there are several well-accepted tools or approaches, there is anything but a standard method of ensuring appropriate medical oversight for any given system. Instead, it is akin to any other form of management or leadership, where the leader adapts the style he or she is most comfortable with and pulls out the necessary tools when the time or situation is right.

EMS physicians must be skilled at providing direct medical oversight. This occurs via direct communication with EMS providers caring for a particular patient. In some cases, the physician may be present at the scene. The merits of medical director response to the field have been well described.¹¹ The advantages include contemporaneous direction of EMS personnel, observing the system and its personnel in action at the tip of the spear, so to speak (eg, what works well and not so well), delivering real-time education, and, when appropriate, participating in patient care. Most often, however, direct medical oversight occurs via radio, telephone, or audio/video communication with EMS providers caring for a patient. While this may often be in the purview of general emergency physicians, EMS physicians should provide expertise and guidance regarding both best ways to extract information from EMS providers and to provide the best possible direction. Asking questions or giving orders that are difficult to understand or not applicable to the field situation is not helpful. For example, an inquiry to get precise information might be to ask how many boxes wide a QRS complex is as opposed to asking whether or not a wide-complex rhythm is present or how many milliseconds wide it is. Giving an order to transport a patient who the EMS providers, by their report, are already transporting is redundant or inconsequential and could be construed as out of touch or insulting. Advising EMS providers to solicit law enforcement help to restrain a patient to enable transport is likely to be unhelpful unless there is precedent for such in the community.

Indirect medical oversight is about everything that happens off-line to affect the scope and quality of care provided by the EMS system. EMS physicians must be skilled at developing protocols and patient care procedures, overseeing quality improvement projects and programs, and assessing and improving the competency of the system and its people.

ADMINISTRATIVE SKILLS

The administrative skill set of EMS physicians is necessarily broad. It includes financial management and allocation of resources; working with administrative leaders, public officials, and elected representatives of the community; and human resources management.

Potentially, among the most necessary administrative skills of an EMS physician are those of political survival. Dr Norm Dinerman has described these as five political senses to be mastered over a career.¹² They are:

• Mission: knowing his or her mission, that of the specialty, and that of the agency and interfacing institutions

• Tradition: understanding the history of the community and service so that goals can be best integrated into the larger context of community and agency

• Position: understanding the position of the EMS physician within the agency structure and the agency relative to others in the community

• Humor: knowing when and how to bring an element of levity to a situation and not taking oneself too seriously

• Sense of timing: taking advantage of appropriate opportunities to advance new ideas, tactics, or strategies.

What differentiates EMS physicians from administrators elsewhere in the health care system is, again, the breadth of their necessary knowledge and influence in diverse environments, serving the most diverse of populations, and interfacing with an incredible array of other professionals and stakeholders. A hospital administrator may have incredible responsibility and authority. However, his or her primary focus is what is happening within or affects the physical plant he or she oversees. For an EMS physician, the realm of responsibility is as amorphous as the community he or she serves, with a constant state of flux, and personal interfaces that are potentially infinite. For a hospital administrator a discussion of safety probably conjures attempts to improve patient safety in the hospital. For an EMS physician, the topic could easily and immediately turn to issues of patient safety as well as personnel safety and the safety of the general public that is encountered as fellow motorists, bystanders, and future potential patients.

SUMMARY

EMS physicians are the clinical champions of the EMS system, possessing perspectives, expertise, and professional passion for prehospital care like no other member of the health care team. History has demonstrated the power of ideas to move certain care to the point soonest after recognition of an acute illness or injury and the value of physicians with clinical expertise, administrative skill, and attentiveness to medical oversight. Chapter 3 will lend further justification to the notion that EMS is a bona fide subspecialty with its own fund of knowledge and skill set focused on the earliest parts of the continuum of care for acute injury and illness as well as community health.

KEY POINTS

• The Core Content of EMS Medicine includes four categories: clinical aspects of EMS medicine, medical oversight of EMS, quality management and research, and special operations.

• Five political senses are needed by a successful EMS physician: mission, tradition, position, humor, and a sense of timing.

REFERENCES

INTRODUCTION

Emergency care of the sick and wounded in the field has deep historical roots as far back as the ancient times when Roman soldiers were carried off the field of battle on their own shields or by chariots and wooden carts. Homer describes medical care being provided in the field by surgeons for those who were too badly injured to be moved. The Brothers of the Benedictine Monastery of Saint Mary Latina began providing care in ad 1080, and later as the Knights Hospitaller¹ of the order of St John began rendering emergency medical care on the battlefield and evacuating the victims to a hospital for continued care. Historical references demonstrate stretcher movements of nonambulatory injured or sick persons in Native American North America, India, Egypt, and Europe throughout early history and into the more modern times.² In the 15th century, King Ferdinand and Queen Isabella of Spain established deployable field hospitals called ambulancia. George Washington's Continental Army possessed mobile field hospitals with organized systems for retrieving the wounded and delivering them to the field hospital for care. However, Napoleon's surgeon, Dominique-Jean Larrey, is credited with creating one of the first most recognizable EMS systems, centered on his ambulance volante (or flying ambulance) that had been inspired by his observation that the injured waited long time periods without care and that the same basic cart design was a proven mode for rapidly moving artillery.

OBJECTIVES

• Discuss key historical points in the evolution of EMS.

• Name key leaders and their contributions.

• Name key organizations and their contributions.

• Discuss the evolution and changing role of the EMS physician.

• Describe historical milestones for EMS physicians.

AMERICAN HISTORY OF EMS

The American Civil War offered more experience with triage, field care, and movement to field hospitals for damage control medicine before movement to a hospital. Due to the success of this concept the US Congress passed “an act to establish a uniform system of ambulances in the United States” (also known as the Ambulance Corps Act) in 1864. During this time American hospitals began to develop their own ambulance services. World War I saw the use of motorized ambulances as a regular part of military operations. Despite the existence of ambulance services, and even rescue squads (like the Roanoke Life Saving Crew, Roanoke, VA, est. 1928), modern EMS in the United States did not take form until the late 1960s and early1970s. This chapter will focus on key events and developments in the evolution of modern EMS in the United States.

THE LATE 1800s

In 1864, President Abraham Lincoln signed into law “an act to establish a uniform system of ambulances in the United States.” Around the same time in Europe (1863) the Red Cross of Europe was founded. The 1860s would also see the first hospital-based ambulance services. The first civilian hospital-based ambulance service in the United States was founded at the Commercial Hospital (now Cincinnati General) in Cincinnati, Ohio, in 1865. Four years later, Bellevue Hospital began ambulance service in 1869 under the direction of Dr Dalton. These services provided transportation of patients to the hospital, however, little care was provided until they arrived. Although paramedics would not exist until the 1970s, the first civilian prehospital care system staffed by nonphysicians (who provided care) began operation in 1872 in England under the direction of a surgeon by the name of Major Peter Shepard. In 1877, this service became St Johns Ambulance Association. Boston City Hospital began operation of its own ambulance service in 1892 and the first automobile ambulance began operation out of Michael Reese Hospital in Chicago in 1899.

THE EARLY 1900s

The 1900s saw the birth of air medical transport with one of the first air medical flights in1910 which took off from Fort Barrancas and unfortunately crashed after takeoff after about 500 yards of travel.³ In 1917, an injured English soldier was airlifted successfully in Turkey, and in 1918 two American officers successfully demonstrated the use of a modified Curtis JN-4 biplane for air medical evacuation.³ The US Army Air Corps designed and placed into service three air medical transport planes in 1929. These aircraft were designed to carry two patients and an attendant. Helicopters were placed in use in the Korean War for medical evacuation in 1951 and the value of this concept became apparent in both the military and civilian realms.

On the ground things had also been developing. During World War I (1914-1918), the US Army had assembled a fleet of motorized ambulances and in the civilian world, the first Rescue Squad known to have been formed in the United States was founded in Roanoke, Virginia. The Roanoke Life Saving Crew was formed in 1928. By 1939, the American Red Cross had nearly 5000 units and incorporated mobile aid units and training posts. These were typically manned by trained volunteers and had the ability to call upon local medical assets such as physicians and ambulances. By 1948 around 40,000 citizens were trained in First Aid by the American Red Cross.

In 1952, Dr Paul Zoll performed the first successful external electrical defibrillation at Beth Israel Hospital in Boston. This raised interest in the potential for improved responses to cardiac emergencies. In 1956, Drs Elan and Peter Zafar develop mouth-to-mouth resuscitation which further contributed to the interest in advancing emergency care. In 1959, Johns Hopkins developed the first portable defibrillator on record. These were some of the prerequisite elements needed to drive forward the early concept of prehospital medical care.

THE 1960s

In 1960, Dr Zoll further developed the use of defibrillation when he demonstrated external electrical countershock and showed it could successfully terminate supraventricular tachycardia (SVT) and ventricular tachycardia (VTach). In that same year (1960), Drs Kouwenhoven, Knickerbocker, and Jude published their report on the use of cardiopulmonary resuscitation (CPR). Los Angeles County Fire Department, in an effort to advance care in the prehospital setting, equipped every fire engine, ladder truck, and rescue truck with a resuscitator in 1960, signifying a significant commitment to the idea of prehospital emergency care. The year 1965 marked a dubious epidemiological point in American history when it was found that more people died in automobile accidents (50,000) than in 8 years of armed conflict during the Vietnam War. In response to this fact, and due to growing concern for public safety, President Lyndon Johnson signed into law the National Highway Safety Act of 1965. In an interesting turn of events, just 5 years later (1970) President Johnson was, himself, a patient of a newly formed rescue squad while visiting his son-in-law in Charlottesville, Virginia. The Charlottesville-Albemarle Rescue Squad, under the medical direction of Dr Richard Crampton, was the first volunteer paramedic agency in the county. The now famous white paper on trauma and motor vehicle related deaths entitled “Accidental Death & Disability—The Neglected Disease of Modern Society” was published by the National Research Council in 1966 and sparked continued interest and political efforts to address the need for improved emergency care in the United States. The following government acts, including the EMS Systems Act of 1973, were intended to create research, funding, and regulatory structure for EMS systems in America and in many ways have helped shape the development of modern EMS since the 1970s.

DEVELOPMENT OF ADVANCED PREHOSPITAL CARE

In 1966, Dr Pantridge developed coronary care ambulances and showed improved survival in out-of-hospital cardiac arrest in Belfast, Ireland. He had developed a portable defibrillator and much of his published work focused on the acute management of cardiac injury and arrest (Figure 2-1). One paper in 1977 describing the energy needed to successfully defibrillate patients in ventricular fibrillation reported data including shocks delivered by a Pantridge portable defibrillator.

In 1967, the American Ambulance Association published an article that claimed that around 25,000 Americans had been left permanently disabled due to the improper care that they had received from undertrained prehospital providers. That same year the City of Miami (Miami, Florida) Fire Department began training paramedics in what would be the first of such programs in the United States. Dr Eugene Nagal championed the development of prehospital cardiac care advocating for CPR and developing first radio ECG telemetry program with the help of a colleague, Dr Jim Hirschmann. These transmitted ECGs demonstrated the presence of cardiac rhythms in the victims likely responsible for their death, further illustrating the need to bring defibrillation to the prehospital arena.

In 1968, just 2 years after Dr Pantridge introduced a similar concept, Dr Grace of St Vincent's Hospital in New York City launched the United States' first mobile coronary care units. The program was originally designed with ambulances staffed by physicians. The year 1968 also saw three other important events in the development of American EMS. The same year as St Vincent's Hospital launched its new program, the American Telephone & Telegram Company (AT&T) began an initiative to systematically reserve the telephone digits 9-1-1 for planned use as a universal emergency number. At the same time, the state of Virginia made an important distinction recognizing ambulances and their unique role by establishing legislation regulating ambulances, required training, and providing permits for their use. And possibly what would prove to be the most significant pro-EMS event of 1968 and one that would help aid in the professional development of prehospital medicine was the establishment of the American College of Emergency Physicians.

In 1969, several other notable events related to the development of prehospital cardiac care were recorded. Dr Leonard Cobb from Harbor View Hospital in Seattle, Washington, formed a relationship with the Seattle Fire Department and together they developed the “Medic 1” program. They utilized firefighters with special training in a converted recreational vehicle that was equipped and dispatched from the hospital in response to calls for cardiac events. In Toronto, Canada, a program known as “Cardiac One” was established to provide advanced cardiac life support measures utilizing a hospital physician and a portable cardiac monitor. That same year, the Ohio State University Medical Center (Columbus, Ohio) placed a unit in service, staffed by three firemen and one physician, designed to respond to prehospital coronary events. The program was dubbed “The Heartmobile” and was later absorbed by the Columbus Division of Fire, then removing the physician from the standard crew (Figure 2-2). The Miami Fire Department (Miami, Florida) documented the first successful prehospital cardiac defibrillation in June 1969, resulting in the patient experiencing full recovery with normal neurological outcome at the time of hospital discharge. Notably, the Florida legislature passed 10-D-66 that same year, making the provision of prehospital emergency care legal under the laws of the State of Florida.

PARAMEDICINE IN THE MEDIA

In 1972, the American public began to have some additional exposure to the concept of advanced prehospital care and the relationship with emergency “room” physicians through the popularization of the concept by the television program “Emergency!” featuring two Los Angeles County Fire Department paramedics and their prehospital exploits. The characters of Johnny Gage (Randolph Mantooth) and Roy DeSoto (Kevin Tighe), and their now famous Squad 51, graced the screens of American televisions from January 1972 until 1979 with 5 years of regular broadcasts and six 2-hour specials and introduced the “paramedic” to most Americans who had never heard the term. The show introduced some basic concepts surrounding the relatively new concept of paramedicine, including emergency medical dispatching, advanced life support, and on-line medical control as well as introducing some to the concepts of CPR and first aid, that many Americans had never seen much less had received training. At the start of broadcast there were only six paramedic-level units in the country and by the end of production there was one in every state.⁴

AIR MEDICAL SERVICES

The first air medical evacuation in recorded history is that of a Serbian officer that was airlifted by the French Air Service during World War I. The French noted a reduction in battlefield mortality from 60% down to 10% using their fixed wing medical evacuation strategy. In 1917, a British soldier with a gunshot wound on his ankle made the trip to hospital in 45 minutes, when by ground the trip would have taken 3 days. In the 1920s, the French and English continued to experiment with military air medical evacuation. The French documented over 7000 air evacuations.⁵ The concept spread and became more widely adopted into the 1930s and World War II saw the first use of helicopters for the purpose, with the evacuation of three wounded British pilots by a US Army Sikorsky in Burma. The US Army continued use of helicopters in the Korean War and the French did as well in the First Indochina War. By the time the United States entered into the Vietnam War, medical corpsmen were incorporated into the air medical evacuation operation. This practice sparked the concept of civilian helicopter air medical programs and is a vital component of the military medical operation to this day.

Although civilian air medical evacuation had existed around the world since the 1920s, the United States did not see civilian air medical service until 1947. J Walter Schaefer started the program as an additional component of the Schaefer Ambulance Service in Los Angeles, California, and was the first FAA-certified air ambulance program. Prior to the point, air medical evacuation was typically based out of wilderness and remote locations and was done out of pure necessity. In the late 1960s, in response to the increasing interest in helicopter-based medical evacuation born of the military experience, the federal government funded two research programs to access the concept of civilian air medical helicopter programs.⁶ Project CARESOM was based in Mississippi in three separate communities (Figure 2-3). The project was found to be a success; however, only one of the sites chose to continue operation after completion of the project. In doing so, Hattiesburg, Mississippi, became the site of the first civilian medical helicopter program in the country.⁵ In 1969, the second demonstration project, based out of Fort Sam Houston in San Antonio, began operation by utilizing military aircraft to augment the civilian EMS system. The Military Assistance to Safety and Traffic (MAST) program was deemed a successful project and local governments recognized the value of employing helicopters in their EMS systems based on these results.

Flight for Life Colorado was the first hospital-based air medical helicopter program in the United States, beginning operation in 1972 out of St Anthony Central Hospital in Denver, Colorado. In 1977, the Ontario Ministry of Health began operation of a helicopter service in Toronto with a predominantly paramedic-based staffing and has grown to a service of over 30 aircraft.⁵ Air medical programs are now a standard, yet many times debated, component of EMS systems in the United States.

LEGISLATING THE MODERN EMS SYSTEM

In 1960, John F. Kennedy stated that: “Traffic accidents constitute one of the greatest, perhaps the greatest, of the nation's public health problems.”² This was one of the first public acknowledgments by the government for the need for improved organization, regulation, and funding of EMS from the federal government. In 1965, when Medicare was created by the Congress, funding for EMS as part of the reimbursement model was included. This was a key feature in the development of the system. In 1966, following the final report of the President's Commission of Highway Safety, President Lyndon Johnson's administration supported passage of what would become the National Highway Safety Act (Public Law 89-564) outlining the standards for the development of the EMS System in each state. Previously created by the National Traffic and Motor Vehicle Safety Act (Public Law 89-563), the National Traffic Safety Agency was merged with the National Highway Safety Advisory Committee (from Public Law 89-564) to form one body that was then moved under the newly formed Department of Transportation and was now overseen by Dr William J. Haddon, Jr.

President Richard Nixon's administration also contributed to the early development when in 1972 the Department of Health, Education and Welfare's (DHEW) EMS Division was focused on a more health care– oriented approach to the issues. Under the direction of Dr David R. Boyd, the Division of EMS provided funding to more than 300 demonstration projects across the United States.² These programs and structure were the result of the EMS Systems Act of 1973 (Public Law 93-154) and were enacted under President Gerald Ford, who appointed Dr Boyd to his position.

PHYSICIANS IN RECENT EMS HISTORY

Throughout the recent history of EMS there are many important individuals who have contributed greatly to the development of this field. Many of these individuals are not noted here; however, this listing is meant to provide some prospective on the importance of the contributions of individual physicians. These individuals are listed in alphabetical order.

BRYAN BLEDSOE, DO, EMT-P

Dr Bledsoe was born in 1955 and became an EMT in 1974 and a paramedic in 1976. As an EMS physician he has contributed much to the literature and to provider education. He is the principal author of Paramedic Care: Principles & Practice, Essentials of Paramedic Care, Intermediate Emergency Care: Principles & Practice, Critical Care Paramedic, Anatomy & Physiology for Emergency Care, Prehospital Emergency Pharmacology, and Pocket Reference for ALS Providers. Dr Bledsoe stands out because of his place in modern EMS education, as well as his ability to communicate important EMS medicine concepts to physicians, EMS providers, other health care providers, and to lay people. He is an internationally recognized and cited EMS physician.⁷

DAVID R. BOYD, MD

Dr Boyd began his career as a resident in surgery at Cook County where he and his colleagues sought to improve the management of gunshot wounds and automobile trauma. He became the Illinois State EMS Medical Director and oversaw the development of a comprehensive trauma system that coordinated prehospital and hospital assets from 1970 to 1974. Under his leadership the program realized successful improvements in communication and utilization of more advanced staffing on ground and air ambulances. In 1974, Boyd was appointed to oversee the Department of Health Education and Welfare EMS Division by President Ford. Under his direction a “wall-to-wall” nation-wide EMS system began to take shape. In addition, Dr Boyd successfully advocated for EMS to President Ford, resulting in the White House conferences on EMS and the declaration of EMS Week. He served in the office until 1981 when the position was dissolved in favor of state-administered block grant programs.

NANCY CAROLINE, MD (1944-2002)

Dr Caroline started her career in EMS during her training in critical care medicine under Dr Peter Safar at the University of Pittsburg. Safar had begun work on the Freedom House Ambulance Service and much of the responsibility of organization and training of participants to become paramedics was delegated to Dr Caroline. She excelled at paramedic education and authored a textbook to suite the unique curriculum and scope of practice entitled Emergency Care in the Streets. She was a courageous field provider and innovator. In addition to her work in the United States, she had also been a bush doctor in Africa and after leaving in the States in 1976 became one of the most influential individuals in the development of EMS in Israel. She worked with prehospital programs, developed terrorism medical response tactics, and served as the medical director of Magen David Adom. Her textbook for paramedics was the only dedicated educational text on the topic for a decade and is still one of the most well known to this day.⁸

LEONARD COBB, MD

In many ways Seattle is considered one of the epicenters of EMS advancement in the United States. One of the key figures in the development of that reputation is Dr Leonard Cobb. In 1967, Dr Cobb was practicing cardiology in Seattle when he learned of the work of Dr Frank Pantridge at the Royal Victoria Hospital in Belfast, Ireland. In an effort to bring this new prehospital cardiac intensive care concept to Seattle, he worked with colleagues to bring about a paramedic training program based on the fire service that could provide similar advance cardiac care in the field. The resulting program developed by the University of Washington, Harborview Medical Center, and the Seattle Fire Department began serving King County under the name Medic One.⁹

DAVID CONE, MD

Physicians practicing (and holding board certification in) EMS medicine have a number of key people to thank for the academic and political development of the subspecialty. One of the key concerns during the development of the subspecialty of EMS medicine was a lack of organized scientific productivity. In addition to his publications in peer-reviewed journals on EMS specific topics he also served to guide others in academic productivity in the field. Some of his notable positions from which he effectively served in this role have been as the editor-in-chief of the NAEMSP textbook, project leader for the development of the NAEMSP proposal that was used to petition the American Board of Emergency Medicine (ABEM) to pursue subspecialty board recognition, and also as the editor-in-chief of Academic Emergency Medicine. Dr Cone has provided significant mentorship to young EMS physicians in training and also served as the president of NAEMSP during a critical time in the development of the subspecialty. Dr Cone was the first chair of the Council of EMS Fellowship Directors.¹⁰

RICHARD CRAMPTON, MD

Dr Richard Crampton had worked with Dr William Grace who had founded the mobile coronary care unit at St Vincent's Hospital in Manhattan and he had taken the time to visit Dr Pentridge personally in order to better understand program developed there in Belfast, Ireland. He successfully implemented these concepts in Charlottesville, Virginia, and in doing so by 1971 the Charlottesville Rescue Squad was trained and certified in CPR and became the nation's second all-volunteer mobile coronary care unit. They operated in a rural environment. Dr Crampton's program did require a physician to respond in order to utilize the advanced coronary care concept.¹¹

J MICHAEL CRILEY, MD

Dr Criley is credited with founding the Los Angeles County Paramedic Program in 1969 at the time he served as the Chief of the Division of Cardiology at Harbor—UCLA medical center. One of his chief accomplishments was convincing medical and public safety stakeholders as well as politicians that a well-designed prehospital coronary care program could be performed by paramedics. Recognizing legislative shortfalls he successfully petitioned state government, including the then governor Ronald Reagan, to approve legislation making it legal for paramedic personnel to provide advanced level coronary care in the prehospital environment.¹²

RALPH FLEICHER, MD

Dr Fletcher, along with Dr Ernie Goodwin, is credited with forming the nation's very first paramedic-level volunteer rescue squad. The Haywood County volunteer rescue squad became a paramedic-level service offering advanced coronary care and the prehospital setting in 1969.^13,14

RAYMOND FOWLER, MD

In addition to participating in the formation of the National Association of EMS physicians he also served as one of the early presidents of the organization. He has contributed as an author and as an editor for a number of textbooks. He has worked diligently to develop multidisciplinary training programs for providers and educators at all levels in the fields of EMS, disaster medicine, tactical medicine, and emergency medicine.^15,16

WILLIAM GRACE, MD (-1974)

Dr William Grace is credited with founding the nation's first mobile coronary unit based on the program started in Belfast, Ireland, by Dr Pantridge. The program was based out of St Vincent's Hospital and Medical Center in New York. Dr Grace and his associate Dr John Chadbourn recognized the potential for improve survival if cardiac patients could be reached with advanced care in a more immediate fashion. In 1968, St Vincent's first mobile coronary care unit went into service in a van with a driver and attended, an attending physician, a resident physician, an emergency room nurse, an ECG technician, and a student nurse observer. The vehicle carried a portable battery power to defibrillator/ monitor, electrocardiograph, intravenous kit with drugs, and a resuscitation/oxygen kit. It was noted that it could take up to 25 to 30 minutes to reach the patient; however, the effect of the program's prehospital cardiac care was published with a reported reduction in mortality from 21% down to 8%.² Many consider this first American version of the mobile coronary care unit concept to have directly inspired the development of such programs around the country.^17,18

RICHARD LEWIS, MD

Dr Lewis is credited with participating in the development of the Heartmobile along with Dr James Warren. The City of Columbus Fire Services along with the Ohio State University Medical Center developed the Heartmobile paramedic program in 1969.¹³

NORMAN MCSWAIN, MD

Dr Mc Swain is best known for his work as a trauma surgeon. However, while on faculty at the University of Kansas he helped develop paramedic education and push for the development of the EMS system. At the time of his move to Tulane in New Orleans, he was credited with helping bring about the evolution of the Kansas EMS system to a point where 90% of citizens were covered by paramedic response in less than 10 minutes. While working with stakeholders in New Orleans he was selected to develop a comprehensive emergency medical services system for the city. This led to the introduction of BLS and ALS prehospital provider education and the development of a citywide EMS system. During his work with the American College of Surgeons Committee on Trauma (ACS-COT) he noted gaps in the education of prehospital providers as part of the trauma care team care team and was enlisted to help develop the Pre-Hospital Trauma Life-Support (PHTLS) program, a joint venture between the ACS-COT and the National Association of Emergency Medical Technicians (NAEMT).¹⁹

EUGENE NAGEL, MD

Dr Nagel is credited as being one of the first physicians to recognize that there was a potential impracticality to basing out of hospital coronary care on response of the physician to the field. Working with Miami-Dade fire officials and a cardiologist colleague, Dr Hirschman, to develop a system by which paramedics could transmit an ECG to the hospital and receive voice medical control by a physician. They enlisted the help of a little known company in developing their telemetry package with a defibrillator into a unit known as the Physio-Control LifePak 33. Although the LifePak device required redesign to allow for the rugged field environment, coupling this concept together with fire rescue personnel taught to defibrillate, provide intravenous medications, and advanced airway techniques proved to be a workable combination. At that time, however, there was no legal authority for them to implement their new paramedic skill set. It has been reported that Dr Nagel actually went to the city manager's office and allowed his newly trained paramedics to intubate him in the office to prove their skill set. Ultimately Dr Nagel was able to spearhead the creation of a law (10-D-66) in the state of Florida that made it illegal for paramedics perform the skills and is considered the cornerstone for EMS law in that state. Dr Nagel was also successful in advocacy at the national level and was one of the key individuals who petitioned successfully for the passage of the EMS Systems Act.^20,21

FRANK PANTRIDGE, MD (1916-2004)

In one very important way it could be said that Dr Pantridge is in fact the father of prehospital advanced coronary care. Dr Pantridge was a cardiologist working at Royal Victoria Hospital in Belfast, Ireland, when he determined that it would be most appropriate to deliver electrical therapy and advanced coronary care in the prehospital setting rather than delaying care until arrival at the hospital. In order to accomplish this, he developed a portable mobile defibrillator 1965. This was integrated into a prehospital care team which Pantridge then studied and published in the Lancet in 1967. The first prehospital advanced coronary care units in the United States were based on Pantridge's program.²²

PAUL PEPE, MD

Dr Pepe is an outspoken and prolific academic and lecturer in EMS medicine. He has held numerous prestigious positions, but is well known for his work to develop and popularize many of the clinical concepts focal to our understanding of modern prehospital care. Dr Pepe has been cited as authoring over 400 published papers and abstracts and has provided high-level medical direction in multiple major systems. He coordinates the Eagles Consortium, comprised of medical directors for the nation's major metropolitan areas. He has provided mentorship and leadership to numerous EMS and emergency medicine physicians and is considered by many to be the chief expert on EMS physician interaction with the media.²³

DEBRA PERINA, MD

Dr Perina is a notable EMS physician and educator who has served since 1999 as the EMS fellowship director at the University of Virginia. She has contributed greatly to the development of the subspecialty through her work at NAEMSP and as the president of the American Board of Emergency Medicine (ABEM). Her leadership was critical during the development of the application to the American Board of Medical Specialties (ABMS) to create the new subspecialty. Her mentorship and guidance (along with other key members of the EMS physician community) in the development of the subspecialty and training program certification process has led to the realization of ACGME-accredited fellowship training programs and board certification.²⁴

PETER SAFAR, MD (1923-2003)

Dr Safar is credited with popularizing the important concepts of CPR and developing the “ABCs” of resuscitation. In 1956, he and Dr James Elan invented mouth-to-mouth resuscitation after demonstrating the effectiveness of mouth-to-mouth rescue breathing through a series of experiments on human volunteers who had been paralyzed. He also advocated for and effectively showed that laypeople could serve as the initial prehospital rescuers for CPR. He partnered with Asmund Laerdal, who at the time was a doll maker, in the development of the initial (and now internationally recognized) prehospital cardiac training tool, Resusci Anne. Dr Safar is also credited with the successful development of one of the first modern ambulances, which he identified as a required replacement for the hearses and station wagons that were being used at the time. While working in the Baltimore system he trained fire department rescuers to add intubation skills to their CPR technique. He developed standards for emergency medical technician education and initiated the Freedom House Enterprise Ambulance Service in Pittsburgh in 1967. In 1976, he cofounded the World Association for Disaster and Emergency Medicine and in 1979 founded the International Resuscitation Research Center. He was nominated three times the Nobel Prize in Medicine.²⁵

RONALD STEWART, MD

Dr Stewart, although a now famous contributor to the development of emergency medicine and EMS medicine, began his career as a general practitioner in Neil's Harbour, Nova Scotia. After completing his training in emergency medicine he became the founding medical director of the Los Angeles County paramedic program and served that community until accepting a position in Pittsburgh, Pennsylvania, where he was the founding director of the Center for Emergency Medicine and the medical director of the Department of Public Safety of the City of Pittsburg. This program soon became one of the preeminent centers for the development of EMS medicine in the country. He eventually returned to Canada and continued to develop his role in the political landscape of health care after taking up a post at Dalhousie University. In 1993, Dr Stuart became a member of the Nova Scotia legislature and was eventually appointed as the Minister of Health and Registrar General for the province until 1996. Dr Stewart's influence on the development of EMS medicine is evidenced by many publications and the productivity of his former students and colleagues in various areas of emergency medicine and EMS.^26,27

ROBERT SWOR, DO

Like many of the former presidents of the National Association of EMS Physicians, Dr Swor has provided significant academic contributions to the field. He has been politically active in his advocacy for the development of EMS medicine and serves as an advisor to multiple key stakeholder organizations, including the National Highway Traffic Safety Administration and the American Heart Association.²⁸ His book on quality improvement was one of the first publications to address this area of medical direction in an organized and detailed fashion. He remains one of the most prominent EMS educators in the country.

JAMES WARREN, MD

Dr Warren of Columbus Ohio participated in the early development of advanced out-of-hospital coronary care through collaboration with the Ohio State University and the Columbus Division of Fire. In 1969, the Heartmobile program was initiated. The program included three firefighters and the physician responding in the Heartmobile from the hospital.²⁹ In 1971, it was apparently clear to Dr Warren that the firefighters could be trained to operate the Heartmobile without the on-scene presence of the physician. On July 1, 1971, the Columbus vision division of fire took over Heartmobile operations.

PAUL M. ZOLL, MD (1911-1999)

In 1952, Dr Zoll published his work on the use of “external electrical stimulation” (transcutaneous pacing). In 1956, he and his colleagues published the paper detailing the successful termination of ventricular fibrillation with “electric countershock” (transcutaneous defibrillation) and in the same year developed an oscilloscope-based cardiac monitor with built-in audible alerts. Dr Zoll is also credited with advancing the concept of using countershock (electrocardioversion) as a viable alternative to antidysrhythmic medications in the termination of dysrhythmias.

KEY PROFESSIONAL ORGANIZATIONS

A number of organizations have contributed to the evolution of modern emergency medical services in the United States and beyond. The International Association of Fire Chiefs (IAFC) was founded in 1873 as the National Association of Fire Engineers. The IAFC has a long history of advocacy and the development of standards and guidelines for fire and EMS operations and has supported the development of a number of other EMS organizations throughout the development of EMS systems and the evolution of the practice of prehospital emergency care. The National Registry of EMTs (NREMT) was formed in 1970 in response to President Lyndon Johnson's Committee on Highway Traffic Safety recommended the creation of a national certification agency. The NREMT focuses on the development and proliferation of national standards for education of EMS providers. The American Ambulance Association (AAA) was founded in 1979 and has contributed much to the early studies and more to ongoing political advocacy and the creation of industry guidelines. The American College of Emergency Physicians (ACEP), founded in 1968, was the primary voice of the new specialty of emergency medicine and spearheaded to creation of the specialty in 1979. Much of the unique nature of emergency medicine was tied directly to the developing prehospital emergency care in the nation.³⁰ The National Association of Emergency Medical Technicians (NAEMT) was founded in 1975 and served to provide significant educational programs to prehospital providers, including Pre-Hospital Trauma Life Support (PHTLS) and Advanced Medical Life Support (AMLS).³¹ NAEMT has a strong advocacy mission and supports political and scientific advancement in the field. The National Association of State EMS Officials (NASEMSO) was formed in 1980 and focuses on formation and development of policy and standards relating to oversight of EMS systems across the country. The Society for Academic Emergency Medicine (SAEM) was formed from University Association for Emergency Medicine (UAEM) and the Society of Teachers of Emergency Medicine (STEM) in 1989 and was instrumental in development of EMS Medicine fellowship curricula and funding of EMS research.³² National Association of EMS Physicians (NAEMSP) was founded in 1984 to represent a peer group of EMS physicians and to devise key resources to serve the EMS community. This organization has developed research, education, and advocacy programs that have had major influence in the evolution of EMS in North America and beyond. NAEMSP was a lead organization in the development of the proposals that ultimately led to the EMS Medicine board certification under ABMS and the advent of ACGME accreditation for EMS Medicine fellowship programs. The National Association of EMS Educators (NAEMSE) was founded in 1995 and is dedicated to the development of resources and advocacy directed at support EMS educators.³³

KEY POINTS

• In 1864, President Abraham Lincoln signed into law “an act to establish a uniform system of ambulances in the United States.”

• In 1966, Dr Pantridge developed coronary care ambulances and showed improved survival in out-of-hospital cardiac arrest in Belfast, Ireland.

• In 1968, Dr Grace of St Vincent's Hospital in New York City launched the United States' first mobile coronary care units.

• In 1965, funding for EMS as part of the reimbursement model was included in Medicare.

• In 1966, following the final report of the President's Commission of Highway Safety, President Lyndon Johnson's administration supported passage of what would become the National Highway Safety Act (Public Law 89-564).

• The American College of Emergency Physicians (ACEP) was founded in 1968.

• In 1973, the EMS Systems Act (Public Law 93-154) was enacted under President Gerald Ford.

• National Association of EMS Physicians (NAEMSP) was founded in 1984.

REFERENCES

INTRODUCTION

In the United States, over 15.9 million patients per year are transported to emergency departments (ED) by emergency medical services (EMS), and 40% of all hospital inpatient admissions arrive by ambulance.¹ Physicians have dedicated a significant portion of their practice to EMS since the late 1960s. EMS physicians acquired their expertise primarily by direct experience and together built the subspecialty through professional association, collaborative research, and standards development. EMS medicine has many roots, with growth spurts largely coming out of casualty care during warfare. Modern EMS started in Great Britain and Los Angeles in the early 1960s, driven by cardiologists who wanted a way to resuscitate cardiac arrest patients in the field.² In the late 1960s with Death and Disabilities white paper, EMS saw exponential growth at the hands of surgeons who wanted a rapid way to evacuate and treat trauma victims on the nation's highways similar to the care and resuscitation of trauma victims during the Vietnam War.³ The majority of these surgeons also worked and staffed the “accident units,” precoursers of today's ED. When emergency medicine became an organized specialty in the late 1970s, it was a natural transition for these “new kids on the block” to take an active role in EMS since the interface was far more than that for physicians from other specialties. The growth of EMS medicine actually parallels the growth of emergency medicine to a large degree.

OBJECTIVES

• Discuss education and training backgrounds of practicing EMS physicians.

• Describe available EMS medical director training courses.

• Describe formal EMS physician fellowship training.

• Describe the current state of EMS board certification and qualifications for examination.

• Describe scientific and educational conferences that provide EMS physicians with state-of-the-art EMS research and clinical practice CME.

• Discuss additional areas of training useful to EMS physicians fulfilling specific operational roles.

EMS PHYSICIANS

In 2003, the Institute of Medicine (IOM) convened the Committee on the Future of Emergency Care in the United States Health System “to examine the emergency care system in the U.S., to create a vision for the future of the system, and to make recommendations for helping the nation achieve that vision.” One volume of this IOM report focused exclusively on EMS.¹ The IOM noted that: “Delivery of clinical care in the field is quite different from delivering care in the hospital or other medical facility, and the oversight of EMS is complex.” Furthermore, the IOM acknowledged that EMS physician involvement improves the quality of care delivered by EMS systems.

As defined by the IOM, EMS comprises the crucial, early phases of the continuum of emergency medical care for acutely ill and injured persons including (a) 9-1-1 access and dispatch, (b) field triage and initial stabilization, and (c) treatment and transport in specially equipped ambulances or helicopters to hospitals or between medical facilities.

The term EMS system describes the organizational structure that integrates all of the essential components of EMS care. In their practice, EMS physicians provide direct emergency medical care for patients and medical oversight of EMS systems. They practice in every state, in a variety of different venues including industry, academia, private, municipal, fire-based and hospital-based systems. All states have regulations governing the role and responsibility of EMS physicians. Many states require specific medical director training which is often based on the national medical director curriculum developed by the National Highway Traffic Safety Administration (NHTSA).⁴

EMS medical practice is unique due to its position early in the continuum of patient care, physical location outside of fixed medical facilities, and relatively higher acuity of the patient population compared to emergency medicine. The majority of the most severely ill and injured patients presenting to ED arrive via EMS. EMS physicians provide direct patient care and medical oversight in unique settings such as mass gatherings, firefighting operations, disaster scenes, hazardous materials incidents, tactical law enforcement missions, and air medical and critical care inter-facility transports. As part of their clinical practice, EMS physicians are responsible for medical oversight of the EMS team. This includes daily direct medical decision making, control of care provided by EMS personnel, developing treatment guidelines, and ensuring procedural competency training of EMS personnel. EMS physicians also lead quality management activities relating to medical care delivered by the entire EMS system.

EMS physicians have developed treatments and techniques in the EMS environment that allow for patient safety and ensure proper treatment affecting the patient's final outcome.^5–9 Extensive peer-reviewed articles address the roles of EMS physicians in the science and practice of EMS.^10–18 EMS physicians are uniquely trained and positioned to provide the clinical care and leadership to mold prehospital- and hospital-based care into regionalized systems of care. The unique expertise gained from EMS physician field practice and system oversight improves patient safety and clinical outcomes.⁵

For over four decades, steadily increasing numbers of physicians have defined their professional practice as caring for patients in the EMS environment. Emergency medicine physicians comprise the principal physician group that has driven the growth of EMS practice since 1984. Current estimates are roughly 75% of EMS physicians are emergency medicine trained, 23% Family Medicine trained, with the remaining 2% being pediatricians, surgeons, and obstetrics and gynecology physicians. EMS physicians are often leaders in their communities concerned with meeting the needs of the public and provision of quality EMS care. Most academic emergency medicine departments employ an EMS physician who supervises the exposure of residents to EMS and engages in research activities to expand the scientific body of knowledge of this practice. EMS physicians hold key positions in several federal government agencies involved in EMS issues. Complex and sophisticated medical procedures previously only performed in hospitals, or completely unavailable a few decades ago, are now routinely integrated in EMS due to EMS physicians.^19–22

EMS physicians play many pivotal roles. They serve as providers, expert consultants, and educators. Many EMS physicians plan prevention efforts implemented through the EMS system, with goals directed at reducing the societal costs of injury and illness. They facilitate optimal care through education and continual oversight of providers. EMS physicians reduce variability in care, limit interventions that are of no benefit, and facilitate delivery of care that enhances patient safety and improves outcomes.^23–27 As the EMS subspecialty matures, patient outcomes will be further improved with continued advancement of scientific knowledge and treatments adding further sophistication to this area of practice.

EMS MEDICAL DIRECTOR TRAINING COURSES

EMS medical director training courses exist that are designed to allow physicians to acquire basic knowledge of EMS practice. These are primarily 1- to 3-day courses, and are offered by individual states or professional associations. These courses provide a basic introduction to EMS practice, EMS system quality improvement, and medical oversight. However, the content does not delve deeply into the clinical practice of EMS or its scientific basis due to intrinsic time constraints. Some are online, while others are delivered in classroom format. Many states require such training by regulation for physicians who wish to be EMS medical directors. These mandated courses are provided through each state and are frequently based on the National Highway Safety and Traffic Association (NHTSA) National Standard Medical Directors Curriculum. Both the National Association of EMS Physicians (NAEMSP) and the American College of Emergency Medicine (ACEP) have courses devoted to physician medical direction. NAEMSP offers the 2-day basic EMS medical director course and the 1-day advanced EMS medical directors course in conjunction with its annual scientific meeting. ACEP offers a preconference (Eagles conference) concentrating issues related to large EMS system management.

EMS PHYSICIAN FELLOWSHIP TRAINING

Presently at least 268 fellowship-trained EMS physicians are practicing in 41 states as well as several foreign countries. The first known EMS fellowship program was at Adam R Crowley Shock Trauma Institute, graduating one fellow in 1983. Three EMS fellowships sponsored by emergency medicine programs began in 1985, with the first of these fellows graduating from Wright State University in 1987. The number of graduates has steadily increased since that time (Figure 3-1). It is believed that there may be more graduates than represented by the graph as some original training programs are no longer in existence and no graduation records are accessible. EMS fellowships are located in most states across the country. Figure 3-2 depicts the location of all EMS fellowships, accredited and unaccredited. Most fellowship programs offer one to two positions per year. EMS fellowships are generally 1 year in length. Some programs offer an optional second year leading to an advanced degree (eg, MPH, MHA, MBA, MEd). A small minority of programs are 2-year training programs. ACGME-accredited programs (the first-round approvals were for the 2012-2013 academic year) were required to comply with a 12-month curriculum. The original round of accredited programs included 11 EMS medicine fellowships (3-1). As of a report generated from the ACGME Web site on October 15, 2014, there are now 40 accredited programs.

The EMS Medicine Core Content, first published in 1985 and revised several times since, describes the domain of EMS medicine and is the basis for fellowship training curricular development.²⁸ Fellowship curricula have become relatively standardized as a result of the work of the Society of Academic Emergency Medicine (SAEM) and NAEMSP.²⁹ The curriculum is designed to provide specific training in general and specific core competencies for EMS physicians, including medical knowledge, clinical expertise, operations, education, research, and administration. It contains all topic areas in the EMS Medicine Core Content covered through a combination of didactics, self-study, case review, and direct clinical experience. This was culminated in the official documents defining the core content and curriculum which now dictate content for ACGME-accredited programs. EMS fellows provide direct patient care in the prehospital setting, educate other physicians and allied health personnel, perform quality improvement activities of EMS systems, and create treatment guidelines for EMS systems. Participation in local and state EMS systems and specialty societies is required. The fellowships are designed to allow fellows to develop proficiency in managing the breadth of clinical conditions encountered by EMS systems in nontraditional health care settings with limited resources in uncontrolled circumstances. Specific procedural skills, such as patient extrication, airway management in water, use of alternative airway devices such as the King airway, spinal immobilization with long board and KED, application of Hare traction splint, and field triage are integrated into the training. Specific funding for EMS research fellowships is available. NAEMSP sponsors a resuscitation fellowship to prepare and train individuals for a career in prehospital resuscitation research, as well as a fellowship designed to encourage the development of high-quality medical director leaders. SAEM also sponsors and provides grant funding for an EMS research fellowship.

As of Spring 2013, there are 29 accredited EMS medicine fellowships, with 62 total in existence (Table 3-1). The Accreditation Council for Graduate Medical Education (ACGME), parent body of the Residency Review Committee for Emergency Medicine (RRC-EM), recognized EMS as a subspecialty area in June 2010 and opened the application process for fellowship programs in December 2012. The number of accredited programs will likely increase over the next several years. This will lead to greater standardization in training and promotion of consistent knowledge with the defined curriculum in fellowship graduates.

EMS MEDICINE BOARD CERTIFICATION

EMS medicine subspecialty certification recognizes the unique body of knowledge and clinical practice of EMS physicians and their important contributions to the safety and clinical outcomes of patients. Physician specialty and subspecialty certification is achieved through recognition by the American Board of Medical Specialties (ABMS) by request of a member Board who makes a case of need for the subspecialty. The journey to creation of the EMS subspecialty began in 1992 when the American Board of Emergency Medicine (ABEM) created the first subspecialty task force exploring the possibility of creating an ABMS application for recognition. EMS medicine was in its infancy at that time. There were few fellowship programs. The first EMS fellowship curriculum was not published until 1994.²⁹ The ABEM task force disbanded in 1995 concluding that EMS medicine needed more growth in scientific underpinnings of the specialty, number of fellowships, dedicated physicians in practice, and standardization of training. Between 1995 and 2001, dedicated EMS physicians furthered a research base, created fellowships, and attempted to standardize fellowship training. In 2001, it was felt that perhaps EMS had matured to the point that another attempt was possible. In 2001, joint collaboration between NAEMSP and the ACEP EMS Committee focused on addressing issues necessary to complete an EMS subspecialty application to forward to ABEM.

In 2003, the IOM report noted a lack of standardization in the training and qualifications of EMS physicians currently limited their impact in many parts of the country. For this reason, the IOM formally recommended that “… ABEM create a subspecialty certification in EMS. The certification would be analogous to those available in toxicology, sports medicine, and pediatric emergency medicine. Creating this type of designation would acknowledge the unique challenges and complexities introduced by the out-of-hospital environment. The certification would ensure that physicians providing medical direction are trained specifically in Prehospital EMS and are prepared to meet the challenges it consistently presents.”¹ This provided renewed interest and impetus for efforts to achieve board certification and subspecialty recognition for EMS physicians. Various committees and meetings contributed to this effort, with a completed EMS subspecialty application submitted to ABEM in 2008. This application went through several revisions before being finally accepted by ABEM in 2009 and forwarded to ABMS for subspecialty recognition.

Physician subspecialty certification is achieved through recognition by ABMS of a unique body of knowledge, scientific underpinnings for the specialty, sufficient training programs, and dedicated physicians to have a positive impact on patients and society. Every ABMS specialty board is concerned with setting and promoting the standards for quality patient care and practice in their field. As such, member boards are concerned that new specialties enhance quality in patient care, and where there is overlap with their specialty there is the ability of their diplomates to access training and certification should they wish to do so. Representatives from all other specialty boards must vote approval to create a new subspecialty such as EMS medicine. During the application process, the biggest hurdle faced was helping other boards understand what EMS medicine was and how it impacted their diplomates. ABMS unanimously voted to create the subspecialty of EMS medicine in September 2010.

The parent board for EMS medicine is ABEM. As such, ABEM is responsible for creating and administering the certification examination, the blueprint for the exam, and periodic revisions to the core content. As is customary for any new specialty, candidates will initially qualify through training in unaccredited EMS fellowship programs or by virtue of meeting practice hour requirements (practice track). Further information can be found on the ABEM Web site under subspecialty certification.³⁰ Eventually as the subspecialty matures, the only route to achieve board certification will be through completion of an ACGME-accredited EMS medicine fellowship. To become board certified, the candidate must successfully pass a secure proctored multiple-choice-question examination based on the core content. The first exam was conducted in October 2013.

The birth of the subspecialty will have many consequences. The ability to achieve board certification has already increased interest among residents in pursuing careers in EMS medicine. As we have seen in the growth of other specialties, over time board certified specialists will be sought for positions. State regulators and hospital credentialing committees will produce language requiring appropriate training and certification to practice in the specialty. Regulators will promote EMS specialists for medical direction positions on a state level, and over time EMS agencies and the public will seek the same. Greater coordination and communication between EMS physicians, EM physicians, and other specialties will enhance patient care and ultimately improve patient outcomes.

SCIENTIFIC MEETINGS AND CONTINUING EDUCATION

There are several EMS-related scientific meetings and continuing education opportunities available. The National Association of EMS Physicians (NAEMSP) was founded in 1984 to address the professional needs of career EMS physicians, provide leadership, and foster excellence in prehospital patient care.³¹ Since its inception, NAEMSP membership has grown from a handful of dedicated founders to include 827 physician members located in all 50 states, Puerto Rico, Guam, and Washington, DC. NAEMSP has secured multiple state and federal EMS-related grants, including EMS medical direction core content development, EMS medical directors' national standard training curriculum, and EMS research agenda that have shaped EMS system design and set national EMS patient care guidelines. It publishes Prehospital Emergency Care, the premier journal on EMS medicine. It also sponsors and runs the National EMS Medical Directors Course & Practicum in conjunction with its annual scientific meeting.

The Air Medical Physician Association (AMPA) is a physician organization dedicated to EMS medical practice involving air medical and critical care ground transports. AMPA has 342 members representing extensive expertise in these areas.³² AMPA offers opportunities for education and research promoting patient safety and quality patient care during transports. AMPA publishes the Air Medical Journal and sponsors the Air Medical Transport Conference and the Critical Care Transport Medicine conferences held annually. It also sponsors the two-part Air Medical Directors Core Curriculum course.

Other emergency medicine organizations have EMS committees or membership sections, and a portion of their annual scientific meeting content covers EMS related topics. These include the American College of Emergency Physicians (ACEP), Society for Academic Emergency Medicine (SAEM), and American Academy of Emergency Medicine (AAEM). ACEP EMS activities also include several committees (EMS and Disaster and Emergency Preparedness) and special-interest sections (EMS, Trauma Care and Injury Prevention, Air Medical and Tactical Medicine) which seek to address EMS issues and promote relationships with outside organizations. SAEM has EMS and disaster medicine interest groups. AAEM has an EMS committee that provides education to its membership on EMS-related topics and communicates prehospital medical issues to the general membership.

Almost all states have an EMS related statewide meeting that includes educational offerings for physicians. Team-based training is prevalent at these meetings, as well as operational specialized EMS training in which the physician may elect to participate (see the next section). Attendance at these meetings can not only be educational, but can afford networking opportunities as well as participation in statewide EMS meetings.

OPERATIONAL EMS TRAINING

There are several specialized areas in EMS where specific 1- to 2-day courses exist designed to provide in-depth operational understanding to the participant. Some of these courses lead to certificates of completion, and can be very helpful to EMS medical directors in gaining understanding of specific types of responses.

The Counter Narcotics and Terrorism Operational Medical Support (CONTOMS) course provides specialized medical training for civilian providers to support tactical law enforcement operations. It was first developed in the late1980s by the Casualty Care Research Center (CCRC) in the Department of Military and Emergency Medicine at the Uniformed Services University (USU). It is focused on the broad range of knowledge and skills required for crisis management medical response including care under fire; weapons of mass destruction (WMD); medical counterterrorism; counternarcotics; protective operations; hostage rescue; explosive ordnance disposal; maritime operations; civil disorder; and major national security events. The CONTOMS Program has become one of the academic and scientific anchors for tactical emergency medicine. To meet evolving aspects of the tactical medicine field, the CCRC has built on the CONTOMS Program to develop other evidence-based educational and applied science courses including EMT-Tactical: the Advanced School, the Public Safety Commanders course, the Medical Directors course, and the Tactical Medicine Instructor Development School.

Emergency Medical Dispatch (EMD) courses are designed to train dispatchers how to appropriately question callers and provide prearrival instructions to bystanders to render aid prior to EMS arrival. There are two basic sponsors of these courses: APCO Institute and Medical Priority. These courses are typically 4 to 6 days and include didactic and Web-based components leading to certification. Both programs require medical direction of dispatch centers to ensure proper oversight and quality management.

HAZMAT courses are designed for the student to understand OHSA requirements in the workplace as related to chemical, radiological, and biologicals, with emphasis on learning decontamination, proper storage and handling, and recognition of exposures. The Advanced HAZMAT Life Support (AHLS) course was developed and is cosponsored by the American Academy of Clinical Toxicology and the University of Arizona research center. It is designed to provide the critical skills needed to treat victims exposed to toxic substances.

Search and Rescue (SAR) courses are usually 2 to 3 days in length but may be up to a week. Most have both urban and wilderness components. Content can also include swift water rescue and structural collapse. Basic courses offer training in map and compass reading and basic search theory. Intermediate courses address search design, team leading, and practice searches.

Wilderness medicine has many educational course offerings per year often in wilderness locations. Educational objectives include acquiring an understanding of common wilderness injuries and illnesses with hands-on practical instruction for improvised treatments. There is also a certification course, Advanced Wilderness Life Support, developed by the University of Utah.

Confined space rescue is a subset of technical rescue operations that involves the rescue and recovery of victims trapped in a confined space. Classes typically cover the OSHA regulations along with all the typical equipment used in an entry. Rescue operations are explained and demonstrated, with students expected to have hands-on participation in scenarios practiced in simulators.

KEY POINTS

• Approximately 270 fellowship-trained EMS physicians in 41 states as of 2010.

• The first EMS fellowship at the Adam R. Crowley Shock Trauma Institute graduated its first fellow in 1983.

• ABMS recognized EMS as a subspecialty in 2010.

• EMS physicians have a wide background of primary medical specialty training including emergency medicine, family medicine, pediatrics, surgery, and obstetrics and gynecology.

• Newly accredited EMS fellowship programs are 1 year long.

• EMS medicine became a subspecialty of emergency medicine in 2010.

• EMS physicians are regulated by states and initial and recurrent training is frequently required.

• Multiple specialized training courses exist to help EMS physicians acquire additional knowledge concerning special responses (ie, confined space, HAZMAT, tactical).

• Accreditation of EMS fellowship programs began in 2012 and around 40 programs are now accredited.

• Certification examination for EMS medicine began through the American Board of Emergency Medicine in 2013.

REFERENCES