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CHAPTER 134 ■ PREHOSPITAL CARE
TONI K. GROSS, THERESA A. WALLS, GEORGE A. (TONY) WOODWARD

EMS SYSTEMS
The term Emergency Medical Services (EMS) is used to refer to emergency or lifesaving care that takes place out
of the hospital. This could represent the entry point into the continuum of emergency care, interfacility transports,
and medical care delivered in austere environments. This chapter will cover prehospital EMS care, encompassing
the initial response to emergency calls, the dispatch of personnel, as well as the triage, treatment, and transport of
patients. EMS operates at the intersection between health care, public health, and public safety ( Fig. 134.1 ), but
its primary mission is emergency medical care.
EMS systems in the United States were initially developed primarily to treat medical problems that are
prevalent in adults, with limited attention to the special needs of children. Despite this, many sick or injured
children will enter the EMS system for initial evaluation, treatment, and transport to the hospital. Acutely ill
pediatric patients may represent a challenge to many EMS systems and providers. They represent a lowfrequency, high-intensity patient population. They may be too small for conventionally available EMS
equipment. They may be one part of a large family unit needing care, and may present an emotional challenge to
the provider. Despite these difficulties, the goal is to seamlessly integrate the care of children in the prehospital
environment into EMS systems that were originally designed to care for adults.
EMS for children (EMSC) is a concept for an all-encompassing, multidisciplinary care system that includes
parents, primary care providers, prehospital care providers and transport systems, community hospital and tertiary
care referral center emergency departments (EDs), and pediatric inpatient units, including critical care facilities.
The elements of this system should be linked by effective communication and transportation systems and
governed by well-established policies and procedures. The provision of pediatric EMS, although a single link in
this chain, is a critical component. EMS providers are continually balancing the need for rapid transport to the

hospital with the ability to recognize and stabilize the sick or injured child in the field. This must all be done with
the patient’s best interest in mind, being mindful that prehospital care is only one portion of the patient’s medical
management.

FIGURE 134.1 EMS is at the intersection of health care, public health, and public safety.

History of EMS Systems
The first organized prehospital transport systems were developed and organized by the military. During the late
18th century, a system of field triage and transport provided that the most seriously wounded soldiers were


transported from the front lines to field hospitals in the rear. After the Civil War, civilian systems of emergency
care and transport were developed in the United States. What is now University Hospital in Cincinnati, Ohio,
developed the first civilian-run, hospital-based ambulance service in 1865. In 1928, volunteers organized to be
trained to deliver assistance at the scene of injury or illness, establishing the first “EMS agency.”
EMS in the United States underwent rapid growth and development in the 1960s and 1970s. Two historic
advances in medicine: the introduction of mouth-to-mouth ventilation in 1958, and closed cardiac massage in
1960, led to the realization that rapid response of trained personnel could help improve cardiac outcomes. This
provided a firm foundation on which the concepts of advanced life support (ALS) and emergency care systems
could be further developed.
The current EMS system was established in part through the passage of the National Highway Safety Act of
1966. In response to traffic accidents being recognized as a major health problem of the time, The Highway
Safety Act established the U.S. Department of Transportation (DOT) and charged it with improving EMS in the
United States. States were required to develop regional EMS systems. The DOT developed a 70-hour basic
Emergency Medical Technician (EMT) curriculum.
In 1970, the Wedsworth-Townsend Act was signed, permitting paramedics to act as physician surrogates. Prior
to this, paramedics were required to have a physician or nurse present to administer medications. During this
period, federal grant funding for EMS demonstration programs led to the development of regional EMS systems.
As states became responsible for appropriating their own EMS funds, many of the regional EMS management
entities established by federal funding dissolved. Although the goal was a well-coordinated system of prehospital

training and care, EMS development progressed in a disorganized manner, with organizational structure and
scope of practice based on local needs and concerns. The result of regional development is wide practice
variation among EMS systems across the United States.
The EMS Systems Act of 1973 authorized responsibility of EMS programs to what is now the Department of
Health and Human Services and identified the scope of practice of EMS personnel. It led to the establishment of
several hundred new EMS regional systems across the United States, albeit without a clear mandate for physician
oversight initially.
Congress established a Federal Interagency Committee on Emergency Medical Services (FICEMS) in 2005, to
ensure coordination among Federal agencies involved with State, local, tribal, and regional EMS and 9-1-1
systems and streamline the process through which federal agencies provide support to these systems. Some
foresee the possibility that one day the U.S. EMS system could have a single lead federal agency for EMS, which
would improve the quality of EMS care by standardizing training and treatment and by reducing the redundancies
within state and regional systems.
Affected by the evolution of health care, EMS has been identified as being in a position to integrate into the
community healthcare system. A recently developed area of EMS called mobile-integrated health care, that has
also been referred to as community paramedicine, offers the ability for patients to receive mobile healthcare
services outside of medical facilities. This care provided by EMS providers in a paradigm that differs from the
typical transport to hospital can expand the reach of public health services to bridge healthcare gaps.

Epidemiology
Over the past four decades, EMS capabilities have grown to provide emergency prehospital access to nearly
every American. There are more than 21,000 EMS systems in the United States utilizing approximately 800,000
EMS personnel. Approximately 5% to 15% of calls for an ambulance in the United States will be for a patient
younger than 18 years of age. This subgroup of the population usually enjoys relatively good health; however,
accidental trauma is the leading cause of death. Similar to older patients, pediatric patients are also susceptible to
acute medical illness and exacerbations of chronic conditions such as asthma, diabetes, or oncologic disease.
Infants may present with complications of congenital cardiac, respiratory, or metabolic disease or with perinatal
complications during and after delivery out of the hospital.
Roughly half of EMS pediatric transports are for injury, and the other half are for medical complaints. The vast
majority of trauma is blunt injury, and common medical complaints include respiratory distress, seizures, and

ingestions. Data from multiple studies show a bimodal age distribution for pediatric EMS patients with infants
and adolescents making up the majority of the patient population—teenagers with trauma and infants and
preschoolers with illness. Children with special healthcare needs (CWSHCN) are also more likely to use an