Administration and Leadership, Special Topics

How Illinois’ Trauma and EMS System of Care Helped Shape the Industry

Issue 3 and Volume 40.

The modern era of EMS Systems (EMSS) began in 1966. Many important concepts and components appeared and developed soon afterward. One essential element was the development of a professional class of prehospital first responders and medically trained ambulance personnel. At that time, ambulance services and personnel were neither reliable nor respected by the medical profession or the public. 

In 1966, the National Academy of Sciences published Accidental Death and Disability: The neglected disease of modern society, a publication focused primarily on trauma resulting from accidental injuries. The report stated, “Local political authorities have neglected their responsibility to provide optimal emergency medical services,” and, “Few are adequately trained in the advanced techniques of cardio­pulmonary resuscitation, childbirth, or other lifesaving measures, yet every ambulance and rescue squad attendant, policeman, firefighter, paramedical worker and worker in high-risk industry should be trained.”1

Through the Department of Transportation (DOT) and National Highway Traffic Safety Administration (NHTSA), the federal government established Standard 11: EMS in 1966, which included standards and funding for ambulances, EMTs and radio communications.2

BLS Training Begins

Deke Farrington, MD, and Sam Banks, MD, both thought the lessons learned during World War II and the Korean War could be brought into the EMS industry to improve civilian emergency medical care. They developed a trauma training school for the Chicago Fire Department, which served as the prototype of what later became the first EMT-ambulance (EMT-A) 81-hour training program.

EMTs were taught from Emergency Care of the Sick & Injured, the landmark introductory textbook. This book became an instant national standard and the basic text for EMT-As everywhere.3 The book’s methods strictly involved only external or noninvasive maneuvers and procedures, later to be classified as basic life support (BLS) measures. These practices became the expectation and intervention limit of first-responding, non-physician emergency personnel.

Early Notions of Prehospital Care

John Frank Pantridge, MD, a WWII hero in Belfast, North Ireland, recognized a remarkable number of acute heart attack patients were dying at home and
out-of-hospital, even though medical care in intensive coronary care units (CCU) was available.

In 1966, he published his loose findings in the popular medical journal The Lancet.4 Known as the “Pantridge Plan,” he outlined a prehospital response and mobile coronary care van, which was staffed by hospital residents in training to respond to emergencies directly at the patient’s home. The remarkable phenomenon was quickly copied in the U.S. by William Grace, MD, of New York City and Richard Crampton, MD,  of Charlottesville, Va.

Prehospital cardiac care programs utilizing EMS personnel were soon pioneered by Michael Criley, MD, of Los Angeles, Calif., and Leonard Cobb, MD, of Seattle, Wash. These programs used more optimally placed personnel and upgraded their training to include advanced life support (ALS).5 Gene Nagel, MD, an anesthesiologist, taught his Miami EMTs how to intercede in a broad spectrum of medical and surgical conditions and, most importantly, how to intubate patients in respiratory distress. He called these EMTs “paramedics.”

Also in 1966, the American Medical Association published the pamphlet Emergency Department: A handbook for the medical staff, which first utilized the term “emergency department”—the ED also became more important within hospital hierarchy.6 Emergency physicians soon became the trainers, mentors and medical directors for paramedic (EMT-P) programs.

Public opinion of EMS concepts and practices also grew favorably thanks to the popular TV show Emergency! in the 1970s. The television program, featuring a fictional EMS crew of the Los Angeles County Fire Dept. Station 51 working with local hospital staff, was an EMS program catalyst of immeasurable proportions until its end in 1977.

Regionalizing Trauma Care & EMSS

Robert J. Freeark, MD, and Robert J. Baker, MD, established the first civilian trauma unit in 1966 at Cook County Hospital (CCH) in Chicago.7 They revolutionized hospital care by consolidating the evaluation, stabilization and definitive care of trauma patients in CCUs staffed by surgeons. They also provided nursing staff with administrative and laboratory resources in a central location. The regionalization of trauma care and EMSS in Illinois established a platform for EMSS to develop throughout the U.S. and around the world.8

At the same time, former Illinois Gov. Richard B. Ogilvie asked me to write a plan for a statewide system of trauma centers with a supporting EMSS. As a surgical resident at CCH, I utilized lessons learned from my experience with the trauma unit to do this.9,10 The goal of these trauma centers was to provide an injured patient access to sophisticated surgical care in a regionalized system. This was critically important because Illinois Trauma/EMSS would be funded through the Governor’s Highway Safety Program. But I was tasked with developing a state-of-the-art EMS system to complement the trauma center program.

Hire the Vet—a Veterans Administration program—introduced me to senior Navy medical chiefs with 20 or more years of experience from Great Lakes Naval Base near Waukegan, Ill. These medical chiefs were the perfect fit and exceedingly qualified for trauma and EMSS administrative assistant positions. This group was modeled after our nation’s armed services casualty care team to provide statewide EMT coverage—and later paramedics—for urban communities.

We then established a trauma-EMS coordinator (T-EMS/C) position as a direct extension from the Korea and Vietnam conflicts.11 The T-EMS/C positions were filled by highly experienced, skilled and motivated veterans with knowledge and experience in casualty management, evacuation and follow-on care of wounded. There was no comparable group at that time. Utilizing their extensive network and experience, we handpicked the best available retiring Navy chiefs.

T-EMS/C personnel were stationed at trauma centers and worked with all aspects of the EMS organization in their area. They started EMT training; provided technical assistance and coordination of communications for ground and air transportation, data collection and public information; and rapidly established a prehospital system in their respective areas.

The T-EMS/C also negotiated ambulance acquisitions, demonstrated communications technology and installed disaster plans, drills and exercises among an array of other accomplishments. They were credible, popular and effective trauma and EMSS ambassadors. The role of T-EMS/Cs in the development of Illinois Trauma/EMSS can’t be underestimated.

We promoted new and nationally developed standards for ambulances, equipment and personnel and set out on an ambitious course of providing EMTs with nationally certified ambulances, and upgraded equipment and radio communications statewide.12,13

T-EMS/Cs established EMT training sites at all 40 trauma centers and trained over 5,000 EMTs in three years—exceeding our goal. These EMTs were trained to national standards and tested by the National Registry for EMTs (NREMT).

The Illinois Department of Public Health (IDPH) Trauma/EMSS office licensed trained EMTs, and the program paid their certification dues with federal funds.14 This provided financial resources to the NREMT at a critical time. We established an EMT training bus for hard-to-reach rural communities and trained every adult in small towns as an EMT. An EMT training site and ambulance service was created and operated out of a medium-security state prison in Vienna, Ill.

Using the trauma registry, we also documented many patients arriving at CCH in police vehicles in shock with obstructed airways and undressed wounds due to the lack of trained personnel and equipment.15 We reported our observations of these abysmal conditions at the National Medical Association.16 This caused a ruckus within Chicago’s city council and led to the removal of these “meat wagons” from minority neighborhoods.

The statewide conversion to an improved prehospital system was astonishing and the public responded with favor. The new EMTs looked professional and acted professionally while performing their duties in real-time and in view of the public—their toughest critics. EMTs became welcomed in trauma care EDs, various EMS committees and community councils. The traditional opposition to legislation for the prehospital sector changed and soon supported passage of ambulance standards legislation and IDPH EMSS regulation.17

ALS Paramedicine

The implementation of ALS paramedic programs started in the suburbs of northwest Chicago by the energetic family physician Stanley Zydlo, MD. Modeled after the Miami ALS paramedic program, it progressed to downstate metropolitan communities.

I began working with Zydlo on statewide legislation, modeled after the California Wedworth-Townsend Paramedic Act—this law provided ALS-EMS programs supervision by the county health officer.18 On the first reading, I realized I was going to be responsible for actions of every paramedic in the state—the education process, certification, supervision and discipline of an undetermined number of paramedics. It was clear we needed to regionalize the Illinois law and establish rules and responsibilities for the state and local governments, public health and safety agencies, and practicing ALS paramedic medical directors.

In this process, I was most concerned with two basic elements: public safety, and the protection of paramedics and their local EMS medical directors. Some were concerned with malpractice issues; I was more concerned with tort injury and felony charges. The paramedics and the ALS programs needed legal protection by an understandable set of rules for EMSS authorization and accountability.

The IDPH Trauma/EMSS agency created a regulatory process to ensure safety for the public and protection of all ALS personnel. The concept we devised was medical control and accountability of the prehospital ALS paramedic system in Illinois.19,20 New terms were coined: “off-line” and “on-line” medical directors, “resources base station and associate receiving hospitals,” “treatment, triage and transportation and operations protocols,” “quality assurance and improvement” reviews. These new concepts soon proved effective.

Later, as the national director of EMSS in the Departments of Health, Education and Welfare (DHEW) and Health and Human Services (DHHS), I required similar regulations to be in place prior to any funding from the EMSS Act of 1973 (PL 93-I54) and its amendments.21 The Illinois ALS paramedic law, operations policies, and medical control and accountability were taught at conferences and sent to every state and EMS program nationwide.

Today’s EMS Professionals

The first responders the public sees every day at the scene of an emergency are professionals. They earned this recognition through consistently exceptional performance and visible leadership roles in the community. The current generation finds it hard to realize that today’s EMSS wasn’t always in place and as structured and professional. It was the vision of a few and the hard work of many that brought about the societal change and acceptance of EMS. Today, there’s a reliable EMS response to every call by a cadre of qualified personnel, 24 hours a day, seven days a week, in all weather and terrain. I’m proud to have played a part in developing the role of the EMT and paramedic. I’m also humbled to have been recognized as an EMSS legacy, with the folk title of “father of trauma and EMSS” by many in the new generation of first responders.

I’ve also been pleased to assist many young EMS professionals develop further into various fields of medical practice and positions of EMSS administration. Thousands of EMTs, paramedics and other first responders now have a hero–like status in their communities—comparable to the respect afforded to servicemen and women. The gamble we took in 1966 paid off: Professional prehospital providers have become essential. 

References

1. Division of Medical Sciences, National Academy of Science, National Research Council. (1966.) Accidental death and disability: The neglected disease of modern society. Retrieved Jan. 7, 2015, from www.ems.gov/pdf/1997-Reproduction-AccidentalDeathDissability.pdf.
2. National Highway Traffic Safety Administration, Department of Transportation. (1966.) Emergency medical services, standard 11; Highway safety act. Retrieved Feb. 2, 2015, from www.nhtsa.gov/staticfiles/administration/programs-grants/Title_23_USC_Chap4_May2013.pdf.
3. Committee on Injuries, American Academy of Orthopedic Surgeons. Emergency care and transportation of the sick and injured. W.B Saunders Co.: Philadelphia, Pa., 1971.
4. Pantridge JF, Geddes JS. Cardiac arrest after myocardial infarction. Lancet.1966;1(7441):807–808.
5. Lambrew CT. Systems approach to emergency cardiac care. In: Boyd DR, Edlich RF, Micik SH (eds.), Systems approach to emergency medical care. Appleton-Century-Crofts: Norwalk, Conn., pp. 228–247, 1983.
6. American Medical Association Department of Hospitals and Medical Facilities: Emergency Department: A handbook for the medical staff. American Medical Association, Division of Medical Practice, Department of Emergency Medical Services: Chicago, Ill., pp.1–164,1976.
7. Boyd DR. Trauma systems origins in the United States. J Trauma Nurs. 2010;17(3):126–134. Retrieved Jan. 15, 2015 from www.advocatehealth.com/documents/trauma/Trauma_Systems_Orgins.pdf.
8. Flashner BA, Boyd DR. The critically injured patient: A plan for the organization of a statewide system of trauma facilities. IMJ Ill Med J. 1971;139(3):256–265.
9. Boyd DR, Dunea MM, Flashner BA. The Illinois plan for a statewide system of trauma centers. J Trauma. 1973;13(1):24–31.
10. Boyd DR. A symposium on the Illinois trauma program: A systems approach to the care of the critically injured. Introduction: A controlled systems approach to trauma patient care. J Trauma. 1973;13(4):275–320.
11. Boyd DR, Mains KD, Romano TL, et al. New health specialists for trauma patient care. J Trauma. 1973;13(4):295–300.
12. Boyd DR, McGrady MK, Anderson CE, et al. An ambulance strategy for Illinois. IMJ Ill Med J. 1973;144(5):487–492.
13. National Academy of Sciences, National Research Council, Division of Medical Sciences. (1968). Training of ambulance personnel and others responsible for emergency care of the sick and injured at the scene and during transport. Retrieved on Jan. 7, 2015 from http://files.eric.ed.gov/fulltext/ED027404.pdf.
14. Hanlon JJ. Medical services: New programs for an old problem. Health Serv Rep. 1973;88(3):205–212.
15. Boyd DR, Lowe RJ, Baker RJ, et al. Trauma registry: New computer method for multifactorial evaluation of a major health problem. JAMA. 1973;223(4):422–428.
16. Boyd DR, Flashner BA, Nyhus LM, et al. Clinical and epidemiologic characteristics of non-surviving trauma victims in an urban environment. J Natl Med Assoc. 1972;64(1):1–7.
17. Regulations issued by Illinois hospital licensing board and Illinois department of public health, Pub. L. no. 76–1858,
(1971). Print.
18. Public Act No. 77-2295, Mobile intensive care paramedic program, statewide, Illinois department of public health, Pub. L. no. 77–2295, (1972). Print.
19. Boyd DR, Micik SH, Lambrew CT, et al. Medical control and accountability of EMS systems: IEEE transactions on vehicular technology. 1979;28(4):249–262.
20. Boyd DR, Edlich RF, Micik SH. Medical control and accountability. In: Boyd DR, Edlich RF, Micik SH (eds.), Systems approach to emergency medical care. Appleton-Century-Crofts: Norwalk, Conn., pp.103–117, 1983.
21. Emergency Medical Services Systems Act of 1973, Pub. L. no. 93–154, (1973). Print.