1940s–1960s: The beginning of the modern emergency
care system
care system
The modern emergency room developed at a time when
the specialization of medical practice swept the nation after World War II. As
the number of house calls from general physicians declined, patients
increasingly turned to the local hospital for treatment. This trend was
reinforced by the development of private insurance plans, which geared payments
toward hospitals and away from home visits (Rosen, 1995). The development of
the emergency room also reflects the passage of the Hill-Burton Act of 1946,
which gave states federal grants to build hospitals provided that the states
met a variety of conditions, including a community service obligation. Among
other things, the community service obligation required hospitals that received
the federal funding to maintain an emergency room. This requirement applies to
the vast majority of nonprofit U.S. hospitals in operation today (Rosenblatt et
al., 2001).
the specialization of medical practice swept the nation after World War II. As
the number of house calls from general physicians declined, patients
increasingly turned to the local hospital for treatment. This trend was
reinforced by the development of private insurance plans, which geared payments
toward hospitals and away from home visits (Rosen, 1995). The development of
the emergency room also reflects the passage of the Hill-Burton Act of 1946,
which gave states federal grants to build hospitals provided that the states
met a variety of conditions, including a community service obligation. Among
other things, the community service obligation required hospitals that received
the federal funding to maintain an emergency room. This requirement applies to
the vast majority of nonprofit U.S. hospitals in operation today (Rosenblatt et
al., 2001).
Emergency care as a field advanced as the result of
several forces that drew attention to emergency care in the 1950s and 1960s.
One was new knowledge about the value of prompt prehospital treatment and
transport derived from military experience in Korea. During that conflict,
technical innovations such as the creation of battalion aid stations and rapid
transport by helicopter to mobile field hospitals were introduced and resulted
in dramatically improved survival rates for battle-wounded soldiers. Experience
in Vietnam led to advances in trauma care. Surgeons returning to the United
States from Korea and Vietnam recognized that the systems developed by the Army
for triage, transport, and field surgery could surpass anything available to
civilians at home (Rosen, 1995), and they believed that similar innovations
could and should be applied to civilian care. Around the same time, advances in
cardiac care, such as the creation of “mobile coronary care units,” improved
the survival rate of patients prior to reaching the hospital (Pantridge and
Geddes, 1967).
several forces that drew attention to emergency care in the 1950s and 1960s.
One was new knowledge about the value of prompt prehospital treatment and
transport derived from military experience in Korea. During that conflict,
technical innovations such as the creation of battalion aid stations and rapid
transport by helicopter to mobile field hospitals were introduced and resulted
in dramatically improved survival rates for battle-wounded soldiers. Experience
in Vietnam led to advances in trauma care. Surgeons returning to the United
States from Korea and Vietnam recognized that the systems developed by the Army
for triage, transport, and field surgery could surpass anything available to
civilians at home (Rosen, 1995), and they believed that similar innovations
could and should be applied to civilian care. Around the same time, advances in
cardiac care, such as the creation of “mobile coronary care units,” improved
the survival rate of patients prior to reaching the hospital (Pantridge and
Geddes, 1967).
Another major turning point was the publication of
the landmark National Academy of Sciences (NAS)/National Research Council (NRC)
report Accidental Death and Disability: The Neglected Disease of Modern
Society in 1966 (NAS and NRC, 1966). The report described the epidemic of
injuries and deaths from automobile crashes and other causes in the United
States and lamented the deplorable system for treating those injuries
nationwide. In 1966, prehospital and hospital services were largely
inadequate or nonexistent. Although a few communities were providing
ambulance services through their fire or police departments, it is estimated
that morticians provided about half of such services. No specific training was
required for ambulance attendants. Most emergency rooms could offer only
advanced first aid, and only a few hospitals appeared to have the infrastructure
necessary to provide complete care for the critically ill and injured.
the landmark National Academy of Sciences (NAS)/National Research Council (NRC)
report Accidental Death and Disability: The Neglected Disease of Modern
Society in 1966 (NAS and NRC, 1966). The report described the epidemic of
injuries and deaths from automobile crashes and other causes in the United
States and lamented the deplorable system for treating those injuries
nationwide. In 1966, prehospital and hospital services were largely
inadequate or nonexistent. Although a few communities were providing
ambulance services through their fire or police departments, it is estimated
that morticians provided about half of such services. No specific training was
required for ambulance attendants. Most emergency rooms could offer only
advanced first aid, and only a few hospitals appeared to have the infrastructure
necessary to provide complete care for the critically ill and injured.
The
1980s: Pediatric emergency care in its infancy
1980s: Pediatric emergency care in its infancy
The burgeoning EMS system suffered a setback in
1981 when Congress passed legislation that indirectly resulted in a sharp loss
of funding for state EMS activities. Categorical federal funding that had been
dedicated to EMS was replaced by the Preventive Health and Health Services
Block Grant, which essentially shifted responsibility for EMS from the federal
to the state level. Because the states were given greater discretion regarding
the use of funds and EMS was a relative newcomer without a significant
political constituency, most states chose to spend the money in other areas of
need. The immediate impact of the shift to block grants was a considerable
reduction in total funding allocated to EMS (Office of Technology Assessment,
1989).
1981 when Congress passed legislation that indirectly resulted in a sharp loss
of funding for state EMS activities. Categorical federal funding that had been
dedicated to EMS was replaced by the Preventive Health and Health Services
Block Grant, which essentially shifted responsibility for EMS from the federal
to the state level. Because the states were given greater discretion regarding
the use of funds and EMS was a relative newcomer without a significant
political constituency, most states chose to spend the money in other areas of
need. The immediate impact of the shift to block grants was a considerable
reduction in total funding allocated to EMS (Office of Technology Assessment,
1989).
Conversely, attention to pediatric emergency care
grew dramatically throughout the 1980s as initial data on this domain of care
became available. For example, studies indicated that children represented
about 10 percent of all ambulance runs (Seidel et al., 1984); that young
children were likely to suffer from respiratory distress, whereas older
children were likely to need trauma care (Fifield et al., 1984); and that up to
half of pediatric deaths due to trauma might be preventable (Ramenofsky et al.,
1984). Studies also indicated that children’s outcomes, given the same severity
of injury, tended to be worse than those of adults (Seidel et al., 1984;
Seidel, 1986a). For example, a study of 88 general acute care hospitals in Los
Angeles County found nearly twice as many deaths among children with serious
traumatic injuries as among adults with similar injuries (Seidel et al., 1984).
Most of the deaths occurred in areas lacking pediatric tertiary care centers.
The studies also revealed that prehospital personnel generally had little
training in pediatric care. Also, most lacked the equipment needed to treat
children (Seidel, 1986b).
grew dramatically throughout the 1980s as initial data on this domain of care
became available. For example, studies indicated that children represented
about 10 percent of all ambulance runs (Seidel et al., 1984); that young
children were likely to suffer from respiratory distress, whereas older
children were likely to need trauma care (Fifield et al., 1984); and that up to
half of pediatric deaths due to trauma might be preventable (Ramenofsky et al.,
1984). Studies also indicated that children’s outcomes, given the same severity
of injury, tended to be worse than those of adults (Seidel et al., 1984;
Seidel, 1986a). For example, a study of 88 general acute care hospitals in Los
Angeles County found nearly twice as many deaths among children with serious
traumatic injuries as among adults with similar injuries (Seidel et al., 1984).
Most of the deaths occurred in areas lacking pediatric tertiary care centers.
The studies also revealed that prehospital personnel generally had little
training in pediatric care. Also, most lacked the equipment needed to treat
children (Seidel, 1986b).
Findings of these early studies led to recognition
of the need to address pediatric emergency care and of the existence of a
distinct body of knowledge that should be applied in so doing. This recognition
stimulated action on several fronts. First, there were advances in resources
for care. In the 1980s, several cities designated pediatric trauma centers.
Advocates for pediatric emergency care in Los Angeles developed a new
two-tiered approach for organizing such care. Under this system, seriously ill
or injured children were to be treated only at hospitals that had been
certified as meeting a certain set of requirements and capabilities for
pediatric care. Perhaps the most significant development for pediatric
emergency care was the establishment in 1984 of the federal EMS C program, a
grant program that assists states in addressing pediatric deficiencies within
their emergency care systems. The first federal funding for EMS-C was made
available in 1985, and later appropriation acts continued to increase funding
for the program.
of the need to address pediatric emergency care and of the existence of a
distinct body of knowledge that should be applied in so doing. This recognition
stimulated action on several fronts. First, there were advances in resources
for care. In the 1980s, several cities designated pediatric trauma centers.
Advocates for pediatric emergency care in Los Angeles developed a new
two-tiered approach for organizing such care. Under this system, seriously ill
or injured children were to be treated only at hospitals that had been
certified as meeting a certain set of requirements and capabilities for
pediatric care. Perhaps the most significant development for pediatric
emergency care was the establishment in 1984 of the federal EMS C program, a
grant program that assists states in addressing pediatric deficiencies within
their emergency care systems. The first federal funding for EMS-C was made
available in 1985, and later appropriation acts continued to increase funding
for the program.