The EMS White paper
That started it all

The EMS White paper was published in 1966 by the National Academy of Sciences as the paper "Accidental Death and Disability: The Neglected Disease of Modern Society" It was noted that the state of emergency care was rather poor in the early sixties. Many new EMTs wonder how our system evolved to where it is today. This page is going to go back in time to review the state of EMS in the early sixties. You can read the original paper here.


The EMS White Paper states that in 1965 there were 52,000,000 accidental injuries. Of these accidental injuries there were 107,000 killed, 10,000,000+ disabled and 400,000 permanently impaired. The estimated costs were $18 billion (this is $117 billion in 2008 dollars).


There were 49,000 motor vehicle crashes resulting in death or about 24.9 per 100,000 people in 1965. In 2006 there were 44,700 motor vehicle crashes resulting in death but since the population of the United States has increased from 1965 to 2006, the actual incidental rate has dropped to 14.2 per 100,000. Source (US Census) (warning, opens a new window)
The EMS White Paper identified that in 1965 there was a need to inform the public of these statistics. The Paper also identified that most people did not have basic first aid training. Those who do have some basic training had little to no training for cardio pulmonary resuscitation, childbirth and other life saving techniques. This includes police departments, fire departments and many ambulance services.


To address these problems the EMS White Paper said there was a need to create government and pseudo-government agencies such as community councils such as red cross to teach first aid, a National Council on Accident Prevention and a National institute of Trauma


The lay public did not understand the magnitude of the problem. Accidents were the leading cause of deaths between ages 1 and 37 and accidents were the 4th leading cause overall of death. 70% of motor vehicle crash deaths occurred in rural areas (with populations under 2500). There are more deaths per year from motor vehicle accidents than died in the entire Korean War.


What is the solution to this problem? The answer is "Accident prevention." Prevention is the long-term solution to this problem. Education is the key to prevention (as evidenced by reduced injury rates).


The state of emergency first aid and medical care in 1965 identified some additional problem areas. There was a general lack of on-scene medical care. Most medical care began at the emergency room. In fact, in 1965 a severely injured patient had a higher survival rate on the battle field than on a US highway because there were properly trained medical personal on the battlefield. Medical personal on the battle field were directly responsible for a dramatic reduction in battlefield deaths. In World War I 8% of battlefield injuries resulted in death. By World War II this had dropped to 4.5%. In the Korean War this was 2.5% and in Vietnam (as of 1965) this was 2%. The EMS White Paper recommended mandatory first aid training for all people beyond the 5th grade.


In 1965 ambulance services varied widely in capability. There was a lack of clinical data and no central reporting agency. What was found was that ambulance attendants had a wide variations in training. Many ambulance services used untested equipment that was too expensive. Ambulance services were not overseen by government agencies and volunteer agencies had almost no oversight.


50% of ambulance services in 1965 were provided by 12,000 morticians. The simple fact that hearses were better equipped to accommodate stretcher litters. Private ambulance services could not provide enroute care to the emergency room due to a lack of space in the transport vehicle and due to a lace of equipment an training.


In 1965 dispatching was poor and communications in some areas of the country did not exist. One notable exception was the city of Baltimore. To better use the limited resources available there should be a centralized facility to screen and route calls to units and to emergency rooms that can accept patients.


Medical training of ambulance attendants varied widely. Interns used to accompany ambulances but this practice was diminishing in 1965. There were no nationally accepted training standards for ambulance attendants. Currently there are nationally accepted standards for ambulance attendants. We call them emergency medical technicians. The National Highway Traffic and Safety Administration has developed a training curriculum for EMT's

The EMT White Paper identified that in 1965 there was no fixed definition of an ambulance. Most ambulances were based on a passenger vehicle (or a hearse) and were converted into an vehicle that could transport a patient. In 1966 the National Highway Traffic and Safety Administration set standards for ambulance construction.

Note: insert link to KKK spec when done.


Communications between the ambulance and the emergency room were very poor. It was easier to communicate with astronauts in orbit easier then with a responding ambulance. A better system of communication had to be developed. The EMS White Paper also identified a need for a nationally recognized and easy to remember phone number for civilians to call for services. In 1968 ATT announced that 9-1-1 would be the national emergency number The paper also indicated that more public phone were needed on the United States Highway system.

The EMS White Paper also addressed issues relating to hospitals and not to just accident prevention and ambulance response. In 1958 there were 18 million visits to emergency departments, in 1962 28.5 million and estimated to have 49.3 million in 1970. A 2008 report by the CDC shows that this trend has continued to increase.

In 2008 there were 119 million visits to emergency rooms. In 1965, emergency rooms were small. Often these "ER's" would only have a few beds. Only 7000 hospitals in 1965 reported to have dedicated emergency rooms in the United States.


Mass casualty events and natural disasters could overwhelm most emergency systems in 1965. This was due to poor planning on the part of local government.

The 1965 EMS White Paper made some specific recommendations to prevent accidental death. Accident prevention was on the top of the list. The paper recommended several prongs of attack on accident prevention. The first was to form a National Council on Accident Prevention. The second was to educate the lay public on basic first aid and to provide a nationally acceptable set of standard and a curriculum for training emergency responders.

The paper also recommended several items regarding ambulances. The first is that there should be a nationally acceptable standard for ambulance construction. In addition, ambulance services should have some sort of governmental oversight such as state wide certification. Local governments should be mandated to provide for emergency ambulance transport and have the funding made available to accomplish this feat.

Research was also recommended. Pilot studies for having doctors and more advanced medical personal on ambulances were to be conducted. To decrease response time, emergency transport by helicopter was to be studied.

Communications were a big issue in the paper and pilot studies were called for to designate emergency radio channels as well as to study centralized dispatching from central stations. Communication issues were so important that the paper called for the day-to-day use of voice communications.

Future research would be necessary to help reduce the risk of accidental death. Data needed to be collected to see if and where additional emergency departments were needed. Financial scoping studies should have been conducted to see if more studies were need. Centralized collection of trauma data was also to be established but by who and where was not discussed in the paper.

The EMS White Paper finally concludes that more research is required to establish legal medical oversight in death investigations and to increase the funding for trauma research.

How have we done since 1965?


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