EMS stands for emergency medical services. It is a branch of government or hospital services that responds to medical emergencies at home and in public to provide immediate stabilizing care, assessment, and transport to an appropriate hospital for long-term or further care.

While it classically involves big box ambulances and flashing lights, EMS has evolved a lot from its start in the 1970s. Founded primarily for the purpose of reducing highway trauma deaths, EMS has grown to encompass all sorts of different care systems. Modern EMS systems today use ambulance transports, “chase” cars to provide initial care on scene, flight and helicopter transport, and even community health initiatives through the form of community paramedicine.

A variety of EMS models are used across the country, with the most common being fire-department ran. Other types of EMS agencies include 3rd service government branches, private companies contracted to provide EMS services to a locality, or hospital-based EMS services. Agencies can also be transporting or non-transporting, meaning that they either transport patients to the hospital from the scene or only provide initial stabilizing care while another service or department provides the transport to the hospital.

EMS in its current form was started following the publishing of the 1966 paper, Accidental Death & Disability: The Neglected Disease of Modern Society. This paper will be referred to as the “White Paper” for the rest of this article. This paper was the spark that kicked off the development of modern EMS and led us to where we are today. As the paper itself states, trauma deaths on the roadway were nearing an all-time high in 1965, with over 107k deaths and 10 million more life-altering disabilities as a result of motor vehicle accidents. For young adults, motor vehicle accidents responsible for up to half of all deaths in the United States. Something had to change.

Prior to the development of EMS systems, a variety of means were used to transport the sick and injured to the hospital. Funeral homes, police departments, and private citizens all used their vehicles to throw the injured in the back and drive as fast as possible to the hospital. The prevailing idea of trauma care at the time was that the only thing that could save patients was the hospital, and all efforts were focused towards reducing the transport time as a result.

However, the White Paper argued that there was a missing piece between the scene and the hospital. The White Paper argued that a large portion of trauma deaths could be prevented by a trained crew providing immediate life-saving measures and keeping a patient stable during the transport. Patients were still going to be transported to the hospital for their full treatment, but a crew of people could respond and ensure that they made it there in the first place. A trauma hospital is little use if a patient never makes it there from the scene.

The White Paper advocated for further first aid training in schools, implementing further traffic and vehicle safety legislation, upgrading existing and adding additional emergency departments in hospitals, and creating a system of trained ambulance providers to provide emergency care and transport. From this, the modern EMS system was born. America moved fast to implement these recommendations - by 1969, trained Maryland State Police troopers were providing helicopter transport to Shock Trauma, a pioneer trauma hospital in Maryland.

EMS today has grown far beyond its initial roots in trauma care. Today, EMS providers respond to a range of emergencies ranging from cardiac arrests, burns, and heart attacks to roadway trauma, general illnesses, and trapped persons in vehicles. With the increase in responsibility, EMS providers have increased their training to meet the needs of a growing and increasingly complex population.

EMS educational standards are regulated by the United States Department of Transport. In addition, the National Registry of Emergency Medical Technicians (NREMT) provides initial certification, examination, and educational resources - similar to a state board of nursing. Each state runs their own office of emergency medical services, which handles licensing for EMS providers in their own state.

There are two main levels of EMS education in the United States, but several other levels exist under the NREMT standards.

Emergency Medical Responder (EMR): This level of training is common for immediate first responders - firefighters, police officers, security guards, etc. EMRs are trained to provide initial lifesaving care to patients in public places. Their skills include applying pressure and tourniqueting to bleeding wounds, providing CPR in the case of cardiac arrest, and breathing for someone when they cannot do so on their own. This level is meant to be the link from the scene to the ambulance. EMRs do not typically serve on ambulances transporting to the hospital. These courses are typically several weeks.

Emergency Medical Technician (EMT-B): This is the standard for entry into professional EMS. This level of training allows for everything that an EMR can do, but also adds splinting, providing oxygen to those that need it, providing a limited range of medications including aspirin and charcoal, and a bit more knowledge on the pathophysiology behind diseases. Training for this is typically several months, and often includes ride-along time on an ambulance and clinical time in hospitals.

Paramedic (NRP): This is the top level of licensure for prehospital providers. Paramedics are allied health professionals that are trained to not only perform skills and life-saving treatments in the field, but also understand the pathophysiology behind disease processes and how their interventions affect them. Their skills include starting IVs for providing medications and fluids into the body, providing a large amount of medications to correct a variety of illnesses, providing pain management for the injured, placing breathing tubes (intubation), and understanding EKG findings to find heart attacks and other cardiac conditions. The training for these providers is 2 years on average, and is usually done by a college or university. Degree programs exist for this level of licensure. These are usually the lead providers if on scene, and are charged with directing patient care during transport to the hospital.

Other levels of licensure exist. More information can be found through the NREMT.

BLS, in the United States, stands for basic life support. Both the terms ALS and BLS refer to different tiered levels of medical care that each type of licensure can provide. BLS is most commonly provided by EMT-Basics in the United States. BLS is basic at its core - it involves mostly addressing immediate life threats, packaging patients for transport, and determining the proper location for the patient. Examples of BLS care include providing manual ventilations through a bag-valve mask device, providing oxygen for those in respiratory distress, providing CPR for those in cardiac arrest, bandaging and trauma care, and providing a limited range of medications. Most EMS services at the BLS level allow for EMTs to administer glucose (for diabetics), aspirin, activated charcoal, albuterol (for asthmatics), oxygen, and Tylenol. Some other services go a bit further, allowing medications like Nitroglycerin under certain conditions. BLS is the core of all EMS medical care - if something can be managed with BLS measures, it will be.

ALS, in the United States, refers to advanced life support. The most common provider for this level of care is Paramedics. ALS is a tier above BLS and focuses on providing advanced, invasive care. Paramedics are expected to provide high level critical thinking to understand the pathophysiology behind health conditions and tailor their treatment to the individual patient. ALS is largely evidence based and includes a multitude of medications. Examples of ALS care include providing intravenous access for providing medications and fluids, providing fluids to bring up blood pressure, providing cardiac medications for certain conditions, and taking over someone’s airway when they need it (called RSI in many places). Paramedics have heavy cardiac training and are able to read EKGs, provide defibrillation, and control electricity to provide various therapies to sick patients.

Most states and localities use a variety of different EMS systems to provide care to their populace. It often differs between counties. To find out more about your own state, you will have to look at the website for your EMS office. Some of the most common systems are hospital based, fire based, and third service EMS. Some private companies also offer EMS when contracted by localities. For instance, New Jersey uses all hospital-based Paramedics, with local EMTs from fire departments providing BLS services.