transported from the front lines to field hospitals in the rear After the Civil War, civilian systems of emergency care and transport were developed in the United States What is now University Hospital in Cincinnati, Ohio, developed the first civilian-run, hospital-based ambulance service in 1865 In 1928, volunteers organized to be trained to deliver assistance at the scene of injury or illness, establishing the first “EMS agency.” EMS in the United States underwent rapid growth and development in the 1960s and 1970s Two historic advances in medicine: the introduction of mouth-to-mouth ventilation in 1958, and closed cardiac massage in 1960, led to the realization that rapid response of trained personnel could help improve cardiac outcomes This provided a firm foundation on which the concepts of advanced life support (ALS) and emergency care systems could be further developed The current EMS system was established in part through the passage of the National Highway Safety Act of 1966 In response to traffic accidents being recognized as a major health problem of the time, The Highway Safety Act established the U.S Department of Transportation (DOT) and charged it with improving EMS in the United States States were required to develop regional EMS systems The DOT developed a 70-hour basic Emergency Medical Technician (EMT) curriculum In 1970, the Wedsworth-Townsend Act was signed, permitting paramedics to act as physician surrogates Prior to this, paramedics were required to have a physician or nurse present to administer medications During this period, federal grant funding for EMS demonstration programs led to the development of regional EMS systems As states became responsible for appropriating their own EMS funds, many of the regional EMS management entities established by federal funding dissolved Although the goal was a well-coordinated system of prehospital training and care, EMS development progressed in a disorganized manner, with organizational structure and scope of practice based on local needs and concerns The result of regional development is wide practice variation among EMS systems across the United States The EMS Systems Act of 1973 authorized responsibility of EMS programs to what is now the Department of Health and Human Services and identified the scope of practice of EMS personnel It led to the establishment of several hundred new EMS regional systems across the United States, albeit without a clear mandate for physician oversight initially Congress established a Federal Interagency Committee on Emergency Medical Services (FICEMS) in 2005, to ensure coordination among Federal agencies involved with State, local, tribal, and regional EMS and 9-1-1 systems and streamline the process through which federal agencies provide support to these systems Some foresee the possibility that one day the U.S EMS system could have a single lead federal agency for EMS, which would improve the quality of EMS care by standardizing training and treatment and by reducing the redundancies within state and regional systems Affected by the evolution of health care, EMS has been identified as being in a position to integrate into the community healthcare system A recently developed area of EMS called mobile-integrated health care, that has also been referred to as community paramedicine, offers the ability for patients to receive mobile healthcare services outside of medical facilities This care provided by EMS providers in a paradigm that differs from the typical transport to hospital can expand the reach of public health services to bridge healthcare gaps Epidemiology Over the past four decades, EMS capabilities have grown to provide emergency prehospital access to nearly every American There are more than 21,000 EMS systems in the United States utilizing approximately 800,000 EMS personnel Approximately 5% to 15% of calls for an ambulance in the United States will be for a patient younger than 18 years of age This subgroup of the population usually enjoys relatively good health; however, accidental trauma is the leading cause of death Similar to older patients, pediatric patients are also susceptible to acute medical illness and exacerbations of chronic conditions such as asthma, diabetes, or oncologic disease Infants may present with complications of congenital cardiac, respiratory, or metabolic disease or with perinatal complications during and after delivery out of the hospital Roughly half of EMS pediatric transports are for injury, and the other half are for medical complaints The vast majority of trauma is blunt injury, and common medical complaints include respiratory distress, seizures, and ingestions Data from multiple studies show a bimodal age distribution for pediatric EMS patients with infants and adolescents making up the majority of the patient population—teenagers with trauma and infants and preschoolers with illness Children with special healthcare needs (CWSHCN) are also more likely to use an