The Dark Ages
of EMS

In 1889, a Chicago police officer climbed into the back of a horse-drawn ambulance carrying tourniquets, splints, wound disinfectant, and an emetic protocol for poisoning cases. He had been trained to control hemorrhage, assess trauma patients, and apply structured clinical interventions by protocol. He was dispatched to emergencies through an integrated municipal system, funded by the city, and backed by the institutional authority of a major metropolitan government.

Today, state legislatures across the country are contemplating legislation lowering training standards, distancing EMS from the medical professions it was built to join, and drafting bills to let individuals trained in just CPR or basic first aid, staff ambulances. The systems that were supposed to provide emergency medical care have run out of people to send.

The distance between those two sentences is the subject of this book.

Most histories of emergency medical services in the United States begin in 1966, with the publication of Accidental Death and Disability: The Neglected Disease of Modern Society, the landmark National Academy of Sciences report known simply as the White Paper. The conventional narrative holds that organized emergency medical services essentially did not exist before that document sounded the alarm, and that everything recognizable as modern EMS was built in the decade that followed. It is a tidy origin story. It is also incomplete.

The reality is that American cities had built sophisticated, physician-staffed, hospital-integrated ambulance systems by the 1880s. These were not primitive forerunners of the real thing. They were funded municipal services with trained medical professionals, purpose-built vehicles, communications infrastructure, and clinical missions that would be recognizable to any EMS leader working today. That infrastructure expanded for half a century. Then the Great Depression hollowed it out, two world wars stripped it of personnel, and the funeral industry filled the vacuum with hearses driven by mortuary attendants who had never taken a first aid course. By the time the White Paper authors surveyed the wreckage in 1966, the earlier systems had been forgotten so thoroughly that the report read as a discovery of something new rather than a recognition of something lost.

The rebuilders of the 1960s and 1970s were genuine visionaries. They created the modern paramedic, a clinical role without historical precedent, and they saved countless lives in the process. But they built their new profession on a set of compromises that were supposed to be temporary: minimal training thresholds that were meant to be floors, not ceilings; a reimbursement structure that paid for transport rather than clinical care; a patchwork of fifty separate state regulatory systems with no unifying federal architecture. The nation was supposed to come back and finish the work. It never did.

This book traces that arc: from the illumination of the pre-war era, through the dark age of the mid-twentieth century, into the incomplete renaissance that followed, and finally into the present, where the profession confronts not only the external forces that have always constrained it but the internal resistance that now compounds them. It is a history, but it is not offered as an academic exercise. It is offered because the structural problems that define American EMS in 2026, the funding crises, the workforce shortages, the credentialing fragmentation, the professional marginalization, are not new problems. They are old problems, rooted in a collapse that happened nearly a century ago and a rebuilding that was never completed. Understanding where those problems came from is a prerequisite to solving them.

The framework for this book came not from an EMS conference or a policy paper, but from standing in the ruins of Rome and Corinth — cities that built aqueducts, surgical instruments, and public health infrastructure not matched for a thousand years after their collapse. The parallel to American EMS was not subtle. It was exact.

A word about tone. Some chapters of this book, "The Broken Promise" and "The Enemy Within," will make some readers uncomfortable. It is intended to. The chapters examine documented instances in which segments of the EMS profession itself have resisted the reforms necessary for its own advancement: opposing portable credentials, exempting practitioners from accountability standards applied to every other healthcare discipline, blocking educational requirements that comparable professions adopted decades ago. These are not accusations leveled from the outside. They are observations made by someone who has spent a career inside this profession, who cares deeply about its future, and who believes that intellectual honesty requires naming the problem even when the problem is us. The argument is not that every institutional actor within EMS is obstructing progress. It is that enough of them are, on enough fronts, that the pattern can no longer be ignored.

I wrote this book because I believe the EMS profession deserves to know its own history, including the parts that have been forgotten and the parts that are difficult to confront. The paramedics, EMTs, and emergency medical dispatchers who answer the call every day deserve a profession with the institutional standing, the financial architecture, and the political recognition that their work has always warranted. Building that profession requires understanding why it does not yet exist. That understanding begins here.

A note on the timeline. The conventional narrative places the origin of American EMS in 1966, with the publication of the White Paper. This book demonstrates that the history of organized ambulance medicine in the United States stretches back more than a hundred and sixty years — and that the century of development that preceded 1966, including what was built, what was destroyed, and what was incompletely rebuilt, is not background. It is the explanation. The structural crises that define EMS in 2026 cannot be understood without it, and they will not be resolved by a profession that does not know it happened.

— Donnie Woodyard, Jr.