emergency medical services in the united states emergency medical services in the united states in the united states, emergency medical services (ems) provide out-of-hospital acute medical care and/or transport to definitive care for those in need. they are regulated at the most basic level by the national highway traffic safety administration, which sets the minimum standards that all states' ems providers must meet, and regulated more strictly by individual state governments, which often require higher standards from the services they oversee. this medical services headquarters in darien, connecticut has an emergency vehicle outside ready to respond immediately in case of need. wide differences in population density, topography, and other conditions can call for different types of ems systems; consequently, there is often significant variation between the emergency medical services provided in one state and those provided in another. organization and funding land ambulance ems delivery in the us can be based on various models. while most services are, to some degree, publicly funded, the factor which often differentiates services is the manner in which they are operated. ems systems may be directly operated by the community, or they may fall to a third-party provider, such as a private company. the most common operating models in the u.s. include: publicly operated ems in one of the more common publicly operated models, an ems system is operated directly by the municipality it services. the services themselves may be provided by a local government, or may be the responsibility of the regional (or state) government. municipality-operated services may be funded by service fees and supplemented by property taxes. in many such cases, the ems system is considered to be too small to operate independently, and is organized as a branch of another municipal department, such as the public health department. in small communities that lack a large population or tax-base, such a service may not be able to operate unless it is staffed by community volunteers. in these cases, the volunteer squad may receive some funding from municipal taxes, but is generally heavily reliant on voluntary donations to cover operating expenses. this provides a significant challenge for volunteer groups, since the training standards for staff must be met, and the vehicle and equipment standards adhered to, while the group does all or most of its own fundraising. without the presence of dedicated volunteers, however, many small communities in america might be without local ems systems and would either have no service at all or be forced to rely on service from more distant communities. another operating model for publicly operated ems is what is generally referred to in the industry as the "third service" option. in this option, rather than being an integral part of (or in some cases, an "add-on" to) one of the traditional "emergency" services (fire and police), the service is organized as a separate, free-standing, municipal department, with organization that may be similar to, but operated independently from, either the fire or police departments. in a variant of this model, the ems system may be recognized as a legitimate third emergency service, but provided under a contractual agreement with another organization, such as a private company or a hospital, instead of direct operation. this model is sometimes referred to as the "public utility" model. this may be a cost-saving measure, or it may be because the community feels that they lack the resident expertise to deal with medical oversight and control issues, and the legal requirements that typically surround an emergency medical service. in yet another model for publicly operated ems, the system may be integrated into the operations of another municipal emergency service, such as the local fire department or police department. this integration may be partial or complete. in the case of partial integration, the ems staff may share quarters, administrative services, and even command and control with the other service. in the case of full integration, the ems staff may be fully cross-trained to perform the entry-level function of the other emergency service, whether firefighting or policing. many communities perceive this as providing "added value" to the community, since municipal workers are fulfilling more than one function, and are less likely to be idle. private/for profit ems ambulance services operating on a private/for profit basis have a long history in the u.s. often, particularly in smaller communities, ambulance service was seen by the community as a lower priority than police or fire services, and certainly nothing that should require public funding. until the professionalization of emergency medical services in the early 1970s, one of the most common providers of ambulance service in the united states was a community's local funeral home. this occurred essentially by default, as hearses were the only vehicles at the time capable of transporting a person lying down. funeral home ambulance operations were sometimes supplemented by "mom and pop" operations, which were not affiliated with funeral homes but rather operated on much the same basis as a taxi service. there were no national standards for ambulance services and staff generally had little, if any, medical training or equipment, leading to a high pre-hospital mortality rate. such companies continue to operate this way in some locations, providing non-emergency transport services, fee-for-service emergency service, or contracted emergency ambulance service to municipalities, as in the public utility model. during the late 1970s and early 1980s, more than 200 private ambulance companies in the u.s. were gradually merged into large regional companies, some of which continue to operate today. as this trend continued, the result was a few remaining private companies, a handful of regional companies, and two very large multinational companies which currently dominate the entire industry. these services continue to operate in some parts of the u.s., either on a fee-for-service basis to the patient, or by means of contracts with local municipalities. such contracts usually result in a fee-for-service operation which is funded by the municipality on a supplementary basis, in exchange for formal guarantees of adequate performance on such issues as staffing, skill sets, resources available, and response times. model of care the emergency medical service system in the united states typically follows the anglo-american service delivery model (bringing the patient to the hospital), as opposed to the franco-german model (bringing the hospital to the patient). apart from a handful of doctors who work on medevac aircraft or perform training or medical quality assurance, it is extremely uncommon to see a physician deliberately responding to the scene of an emergency. air ambulance air ambulance services in the united states can be operated by a variety of sources. some services are hospital-operated, while others may be operated by federal, state or local government; or through a variety of departments, including local or state police, the united states national park service, or fire departments. such services may be operated directly by any of these ems systems, or they may be contracted to a third-party provider, such as an aircraft charter company. in addition, it is not uncommon for u.s. military helicopters to be pressed into service providing air ambulance support. the vast distances covered by the u.s. mean that while helicopters may be the preferred form of service delivery for "on-scene" emergencies, fixed wing aircraft, including small jets, are often used for transfers from rural hospitals to tertiary care sites. these aircraft are typically staffed by a mix of personnel including physicians, nurses, and paramedics, and in some cases, by all three. publicly operated air ambulance service is supplemented by emergency and non-emergency air transport service, which may be provided by dedicated air ambulance companies, or by aircraft charter companies as a secondary business operation. 3 air ambulance in the united states training with lifeevac ii stat medevac phi airmedical aircare 2 history pre-modern grady ambulance service in the united states began in atlanta, georgia in 1869. grady memorial hospital staff rode in horse-drawn carriages designed specifically for transporting the sick and injured. the first volunteer rescue squads organized around 1920 in roanoke, virginia, palmyra, new jersey, and along the new jersey coast. gradually, especially during and after world war ii, hospitals and physicians faded from prehospital practice, yielding in urban areas to centrally coordinated programs. these were often controlled by the municipal hospital or fire department. sporadically, funeral home hearses, which had been the common mode of transport, were being replaced by fire department, rescue squad, and private ambulances. prior to the 1970s, ambulance service was largely unregulated. while some areas ambulances were staffed by advanced first-aid-level responders, in other areas, it was common for the local undertaker, having the only vehicles in town in which a person could lie down, to operate both the local furniture store (where he would make coffins as a sideline) and the local ambulance service. development of modern practices the 1966 release of the national highway traffic safety administration's study, "accidental death and disability: the neglected disease of modern society", (known in the ems trade as the white paper) prompted a concerted effort was undertaken to improve emergency medical care in the pre-hospital setting. the study found many unnecessary deaths could be prevented through a combination of community education, stricter safety standards, and better pre-hospital treatments. freedom house ambulance service was the first emergency medical service in the united states to be staffed by paramedics with medical training beyond basic first aid. in the late 1960s, dr. r adams cowley was instrumental in the creation of the country's first statewide ems program, in maryland. the system was called the division of emergency medical services (now known as the maryland institute for emergency medical services and systems). also in 1969, cowley obtained a military helicopter to assist in rapidly transporting patients to the center for the study of trauma (now known as the r adams cowley shock trauma center), a specialized hospital that he had started for the purpose of treating shock. this service was not only the first statewide ems program, but also the beginning of modern emergency medical helicopter transport in the united states. the first civilian hospital-based medical helicopter program in the u.s., flight for life colorado, began in 1972 with a single alouette iii helicopter, based at st. anthony central hospital in denver, colorado. national ems standards for the us are determined by the u.s. department of transportation and modified by each state's department of ems (usually under its department of health), and further altered by regional medical advisory committees (usually in rural areas) or by other committees, or even individual ems providers. in addition, the national registry of emergency medical technicians an independent body, was created in 1970 at the recommendation of president lyndon b. johnson in an effort to provide a nationally accepted certification for providers and a nationwide consensus on protocols. currently, national registry certification is accepted in some parts of the u.s., while other areas still maintain their own, separate protocols and training curricula. in particular, in the us state of california, in seattle, washington state (medic one), and in miami, projects began to include paramedics in the ems responses in the early 1970s. groups in pittsburgh, pennsylvania, charlottesville, virginia and portland, oregon were also early pioneers in pre-hospital emergency medical training. despite opposition from firefighters and doctors, the program eventually gained acceptance as its effectiveness became obvious. furthermore, such programs became widely popularized around north america in the 1970s with the nbc television series, emergency! which, in part, followed the adventures of two los angeles county fire department paramedics as they responded to various types of medical emergency. james o. page served as the series technical adviser and went on to become integral in the development of ems in the u.s. the popularity of this series encouraged other communities to establish their own equivalent services. shortages in the 21st century, rural communities with declining populations have had more problems finding ems volunteers, as the local population skews older and has more health problems. from 2005 to mid-2019, 160 rural hospitals closed, many in states that did not expand medicare as part of the affordable care act, leading to longer drive times for ems. the covid-19 pandemic in the united states caused a major increase in job danger, job stress, and employee turnover, causing a national shortage of ems workers. compounding the problem was a temporary shutdown of