In 1956, Jim Green was doing some yard work when he suddenly was gripped with crushing chest tightness. Within minutes he was on the ground, pale, sweaty and having trouble breathing. His wife happened to see him fall down, so she ran out to him and yelled to a neighbor for help.

The neighbor realized that Jim needed to get to the hospital. He searched for the number for Alan Williams, the local undertaker who took the sick and injured to the hospital. After a few minutes, he found the seven-digit number and placed the call. Alan's wife answered and said that they were out of the ambulance business. However, the fire department had recently purchased a Cadillac ambulance, so she offered another seven-digit number to call. The dispatcher for the fire department took the call and sent the new ambulance with two firefighters who had just recently completed 20 hours of first-aid training.

It took 14 minutes to get to the Greens' house — the call-taker had reversed the house numbers, and firefighters initially went to the wrong address. They found Jim unresponsive, very blue and clammy, and barely breathing. They put an oxygen mask on him and loaded him in the ambulance for the ride to the hospital. En route it appeared that Jim had stopped breathing. He was pronounced dead at the hospital.

Today, Jim Green Jr. collapses at his desk at work. A fellow employee checks to see if he's breathing and has a pulse. He is pulseless, so the employee shouts for someone to bring the automatic external defibrillator while she starts cardiopulmonary resuscitation. Another employee calls 911 and reports the situation to a dispatcher, who takes the information and asks if they need CPR instruction. The dispatcher sends the closest Advanced Life Support unit staffed with Emergency Medical Technicians — Paramedic. An engine company, which is the closest emergency vehicle to the office, is also dispatched because the firefighters are all trained as EMTs and can render care until the paramedics arrive.

Within a matter of seconds after Jim collapsed, another employee arrives with the AED and applies it to Jim. The unit detects ventricular fibrillation and shocks Jim. It takes the unit two shocks, but Jim's heart finally converts to a life-sustaining rhythm just as the engine company arrives, less than four minutes after dispatch. The firefighters bring in oxygen and their AED and take over care from the workers. Within another minute the paramedics arrive with their monitor and other ALS equipment and supplies. While they initiate care and prepare the patient for transport, the firefighters get their stretcher and help transfer the patient to the medic unit.

The patient is stabilized with intravenous fluid and medications and monitored en route to the receiving hospital, which specializes in managing heart conditions. The hospital staff, which has already received the patient report and 12-lead EKG, is ready to begin cardiac protocol for diagnosis and treatment. Jim Green Jr. survives the cardiac arrest and is discharged five days later after coronary bypass surgery.

Modern EMS began in the 1960s. The first major advancement was the development of CPR by physicians in Baltimore. The technique was formally endorsed by the American Heart Association in 1963. It was also during the 1960s that the portable external defibrillator was developed. Both of these breakthroughs laid the foundation for Advanced Life Support.

The other significant event of the 1960s was the release of the National Academy of Sciences and National Research Council's Accidental Death and Disability: The Neglected Disease of Modern Society. The report listed 29 recommendations to improve survivability of trauma patients; 11 related to prehospital EMS. The report called for developing training programs for prehospital providers, establishing standards for ambulances and equipment, creating a single nationwide telephone number for emergencies, and developing a systems approach to the care of injured people. These recommendations set in motion numerous advancements, including the first EMT training programs and the first ambulance design standards.

To support the development of a systems approach, Congress passed the EMS Systems Act in 1973. The grant program created by this legislation led to the development of regional EMS systems by identifying 15 essential components of an EMS system and providing funds for these components and system development. State governments took the lead in developing systems within their borders. The configurations varied, as did the state designation of authority and funding of programs. Over the years, the practices of emergency medicine, training, technology, equipment and vehicles have improved tremendously from where they were in the 1950s. The systems approach, considered so important to providing all citizens with equal access and standard levels of care nationally, has never fully been achieved.

EMS has come a long way in 50 years, yet according to a recent study by the Institute of Medicine, “prehospital EMS faces a number of special challenges.” While advancements are noted, the study cites that systems are still “fragmented” and coordination is lacking in many areas. The IOM's current Future of Emergency Care series lays the foundation for continued improvement and advancement into the next decades.