Before the Compact: The Atlantic EMS Council's 1980s Experiment in Interstate EMS

Every so often a document surfaces that quietly rewrites the story you thought you knew. A set of agreements adopted by the Atlantic Emergency Medical Services Council in the 1980s is one of those documents. It has now been added to the EMS-History.com archive, preserved from the Council's own records before the organization dissolved.

What strikes me most about it is the timing. Within just a few years of the 1977 formalization of the paramedic, state leadership already understood something it would take the field decades to fully operationalize: EMS is, by definition, mobile. Patients cross state lines. Clinicians cross state lines. Medical command crosses state lines. The states recognized that they needed a rapid mechanism to align standards, education, and accountability, and they reached for the only tools their offices controlled.

What the Council Built

The compilation gathers several instruments adopted across roughly a decade by the Atlantic Council (formerly the Mid-Atlantic Emergency Medical Services Council):

• Joint Resolution on Reciprocity of Services for Emergency Medical Care (1982). Eight jurisdictions — Virginia, West Virginia, Maryland, the District of Columbia, Pennsylvania, Delaware, New Jersey, and New York — agreed to recognize one another's certified Basic and Advanced Life Support personnel when they crossed a border to provide emergency care.
• Resolution on Reimbursement for Trauma Services. A recognition that if patients were going to be routed to the most appropriate facility regardless of state line, neighboring facilities had to be reimbursed equitably for the care they rendered.
• Joint Declaration of Interstate Medical Command (1985). A declaration that each jurisdiction's laws permitted physicians to give emergency instructions to certified paramedics across state lines, paired with Good Samaritan civil immunity for the physician giving that command via telecommunications.
• Memorandum of Agreement on a shared EMT examination. The Atlantic states pooled resources to build and maintain a common, validated written test bank, housed at Central Connecticut State University under Dr. Richard L. Judd.
• Statement of Clarification (1990). A conference-call-driven position statement reconciling the earlier resolutions as new technologies began pushing physician medical direction across state lines in unforeseen ways.

The signatures alone make it worth preserving. These were state health commissioners, secretaries, and EMS directors — among them R Adams Cowley of Maryland, whose name on a page still carries weight in this field.

Where the Fragility Shows

That is also where the fragility shows. These instruments were signed by health secretaries, commissioners, and EMS directors in their administrative capacities. They were not enacted by legislatures or executed by governors. The drafters clearly knew it, too.

The Joint Resolution effectively concedes the point by making itself effective “at the time of execution” rather than as law. The Interstate Medical Command declaration does not even purport to create a new obligation; it simply has each official assure that existing state law already provides the protection. And any state could walk away on ninety days' written notice.

In my opinion, if any of this had ever been seriously challenged, it would have faced real enforcement questions. Recognition that lasts only as long as the current director's signature, and that dissolves on ninety days' notice, is not durable interstate law. It is a handshake — a good-faith, well-intentioned, professionally sophisticated handshake — but a handshake nonetheless.

The Prehistory of What We Have Now

Which is exactly why I appreciate seeing it. This is the prehistory of the modern EMS Compact. Today we have a compact founded in constitutional law and enacted by legislatures as statute, which solves the structural problem these signatories were wrestling with. The privilege to practice is recognized across member states because the law of each member state says so, not because a single administrator's signature remains on file.

The men and women of the Atlantic Council got the policy goal right. They understood, forty years ago, that emergency care does not respect a state line and that the profession needed a mechanism for interstate recognition. They simply did not yet have the instrument to make it stick. It took the field another generation to reach for interstate compact law — the same constitutional tool that governs everything from driver licensing to nurse licensure — and build something durable on top of the goal they had already named.

A great relic to have in hand, and a reminder that the questions we are still answering are older than we think.

Read the Atlantic EMS Council Interstate Agreements (1982–1990) in the archive (PDF), or explore the era in context on the Interactive Timeline.