LEO R. SCHWARTZ: The Essence of EMS
The EMS goal is a simple one—that there be a national, cohesive program of emergency medical service, turning victims into patients as quickly as possible and delivering them safely and efficiently to definitive care. For the first time in our nation’s history, the general public has access to field intervention medicine.
Everything occurs on the roadways” of our nation—from conception to death. So emergency medical technicians (EMTs) have to be prepared for everything.”
Last month, Leo R. Schwartz retired as chief of the EMS Division of the National Highway Traffic Safety Administration (NHTSA), Washington, D.C., after 40 years accumulated federal service. He took with him more than just the good wishes of his fellow workers. He took a wisdom and an insight that can only be gained after 30 years in the pre-hospital emergency medical services field—even before EMS was a field.
Schwartz got his start in the emergency services when he joined the U.S. Marine Corps in March 1942. “I was in logistics, which involved field intervention medicine. Translated into the civilian section, this is a compilation of designed communications, transportation, medical equipment, training, public education, administration and ongoing evaluation.”
After World War II, Schwartz finished his education (A.B., M.A.) at the University of Nebraska, remaining in the active reserves. After recall to active duty in 1950, he remained in the regular corps until April 1968, when he retired as a lieutenant colonel.
Following retirement, Schwartz managed, through final report writing, an arthritis research project for the George Washington University Medical Center. In September 1969, he accepted an offer by the federal government to work in the EMS Division of the Highway Safety Bureau, now NHTSA.
“The highway safety program was just getting underway. I was brought on board for purposes of identifying, planning, developing and implementing an EMS system that, from the first, was designed to be field intervention medicine,” explained Schwartz.
As late as 1969, very limited, creditable ambulance service existed, said Schwartz. Emergency medical services systems or any organized effort toward EMS development had not existed. Although there were a few private ambulance operators w’ho tried to provide care at the scene of an accident and en route to the hospital, it was basically undertakers who furnished transportation in their hearses. “There was a definite conflict of interest,” said Schwartz.
“Whatever was being done had to be done better,” Schwartz added. “And since nothing was being done, the only way to go was up.”
The federal government first began looking into the subject of accidental death and disability in 1946, when President Harry S. Truman recognized that the auto was becoming a major contributor to an appalling loss of life, disability and property damage. It was killing over 40,000 people per year, and by 1968, it was killing more than 55,000 people each year. Truman appointed a committee for highway safety for the purpose of identifying and outlining solutions to the problem. The committee in its final (1965) report reported that many victims died at the accident scene or in transit to the hospital because they didn’t receive the care that could save them. Emergency care and transportation of the sick and injured was identified as an active program.
Although the committee went into demise in 1965, Schwartz said, it, along with the National Academy of Sciences’ book Accidental Death The Neglected Disease of Modern Society led to the passing of the Highway Safety Act in 1966. This act stated, among other things, that the term “safety” includes—emergency medical care and transportation of the sick and injured.
Schwartz helped to define the skills and knowledge needed to train EMTs; develop and publish basic and advanced EMS training courses; describe the duties of an EMT, hereby identifying a new allied health professional; develop ambulance specifications; establish vehicle operator training courses and a first responder course (originally a crash entry management course for law enforcement officers who were usually the first on the scene).
“If we didn’t develop standards, criteria, and training courses, nothing would have been changed,” said Schwartz. “It’s easy to perpetuate mediocrity as a standard of excellence.
“All this material we developed was to upgrade ambulance services and develop an EMS system,” said Schwartz. “Trained personnel, equipment, communications, and medical direction, support and involvement make up one cohesive operation.”
One of the first major obstacles EMS faced after it was officially implemented in 1969 was public acceptance of trained laymen providing emergency care in the field. “The attitude then was to get the doctor,” Schwartz said. “What are you going to do? Open the Yellow Pages while the victim is lying there dying?”
Today emergency medical personnel have gained national public acceptance and “the term EMS is now definable. In each state, EMS training coordinators, directors and staff can be identified. This didn’t exist in 1969. Today, we also have EMS publications, EMS organizations, a National Registry and the National Association of EMTs,” Schwartz stated with a well-deserved touch of pride.
Although EMS has made some healthy strides in the last 14 years, Schwartz says that there still has to be a lot of work done in the area of public awareness. “The public will make assumptions based on very shallow information. EMS personnel have to start illustrating with figures the number of cases they respond to the results of the cases, and the significance of the responses (did the care provided make the difference between life and death, between being disabled and not being disabled).
“There has to be an entirely different view of EMS. It is not just first aid. It is a professional service.”
Schwartz noted that without the involvement of the fire service, EMS would not be what it is today. The fire service is already a part of the emergency response system, says Schwartz, and the fire departments are a logical place to operate ambulances from, since they already have the buildings and the communication systems.
While much of EMS is provided by fire fighters, Schwartz feels that efficiency would greatly be increased by both groups being independent and separate, because both suffer when combined under one service. “The fire service and EMS are two different services involving two different types of training. Both services speak entirely different languages. It’s a schizophrenic existence for an individual to be a fire fighter one day and an EMT another day.
“Most fire chiefs will admit that the ambulance responds about 60 times to every 30 times for the fire trucks Still,” Schwartz continues, “there are a lot of fire fighters, and fire chiefs in particular, who need to reassess the relative position of the operation of prehospital care with relation to the operation of their pumpers.”
Whereas fire departments are divided into jurisdictions and response districts, Schwartz feels quite strongly against EMS being jurisdictional. Ambulances have to cross county and city lines all the time, and it’s a burden when EMTs have to be preoccupied with the differences in jurisdictional protocols and the level of patient care allowable in the different jurisdictions.
EMS should be regional, Schwartz said, so that no matter where you are, the same level of care will be given for the same level of injuries. “It’s amazing how people’s lives hang in the balance of economic and political idiosyncrasies.”
The federal government and its agencies (FCC, Department of Interior, Department of Transportation, Department of Agriculture, Department of Health and Human Services, Department of Labor) should continue to maintain a visibility, leadership and coordination in supporting the best quality EMS throughout the nation, says Schwartz, because it is for the benefit of the citizens—the citizens of the United States. National uniform standard and criteria for achievement should continue to be identified, supported and implemented.
Schwartz is a little concerned about the future of EMS because “I’m not sure it is so well and thoroughly established that it can perpetuate itself on an equal basis with fire and police service for every citizen across the nation.” According to Schwartz, “Despite its remarkable achievements to date, the EMS system has one Achilles’ heel: an apparent lack of strength, stability and recognition in much of the administrative structure. Too many EMS administrative and/or supervisory personnel, rather than being in a position of leadership with stature, find themselves subordinated and must function with ‘hat in hand’ and low profile. EMS lends itself well to lip service while being subjected to diminishing tangible support. Without strong leadership and support, EMS is very susceptible to regression and erosion of quality care.”
Schwartz would like to see a cohesion among all the emergency response elements “so we can talk to each other rather than about each other.
“The police force is an established structure, and the fire service has a certain clout, but the EMS and its people are very much subordinated. And when you have something so subordinated, it’s easy to neglect it and lose sight of its purposes, its contributions.”
Schwartz doesn’t feel EMS will ever go back to the hearses and carryalls, but it can regress if a constant viligance isn’t maintained by all people. “Providing EMS has been one of the most significant things done in our society …. It took a lot of hard work to bring EMS and ambulances where they are today.”
Star of Life: its meaning
The blue Star of Life, the standard symbol of the EMS system, was designed by Leo R. Schwartz.
The six-barred cross, adopted from the medical identification symbol of the American Medical Association, represents the six EMS functions: detection, reporting, response, on-scene care, care in transit and transfer to definitive care.
The coiled serpent on the staff represents the staff of Asclepius, the Greek god of medicine.
On February 1, 1977, the Star of Life was issued to the National Highway Traffic Safety Administration (NHTSA) by the Commissioner of Patents and Trademarks as a registered certification mark.
The Star of Life is used on emergency care vehicles to certify that they meet NHTSA standards; by emergency care personnel to show they have been trained to meet NHTSA standards; and on road maps and highway signs to indicate the location of or access to qualified emergency medical care services.
Schwartz feels he accomplished all he could under the present circumstances, and so opted for retirement, when asked if he found the EMS field challenging, frustrating, exciting, Schwartz smiled a smile that spanned some 40 years. “All of the above. I also found it stressful and sometimes downright nauseating. At times, I felt I was a full-time teacher with a student body so diverse that their own interests ran in direct conflict with the lesson plan.”
Before Schwartz retired, he sent a letter to the entire EMS community, thanking one and all for their cooperation, enthusiasm and dedication, and asking them to “. . . please continue to apply the concepts, principles and standards that you have worked so hard to help institute. Protect them from the provincial and parochial winds of compromise, opportunism and regression, because you make the difference between life and death, and can say that the victim is now a patient in the field.”