Ed's Note: Download your copy of the original White Paper here.
September marks the 50th anniversary of EMS’ landmark document, Accidental Death and Disability: The Neglected Disease of Modern Society, more commonly known as the “white paper.” While the white paper is sometimes viewed as a relic from the past, its findings and recommendations deserve a review to understand how they’ve influenced EMS. It may be a surprise how relevant the white paper still is today.
Death in a Ditch
Automobiles have always been dangerous. By the mid 1920s there were more than 22 million cars in America, and the market was saturated, at least by General Motors’ definition. As a marketing scheme, GM began releasing new models annually to increase sales and encourage upgrades. Style, speed and comfort were central to these changes, and safety took a backseat.1
With more cars on the road, the annual miles driven in the U.S. began to double every 15 years.2 Accordingly the 1950s and 1960s saw congested highways and increased accidents as more drivers enjoyed the independence automobiles provided.
Federal scrutiny ultimately came from the National Academy of Sciences (NAS), which was founded in 1863 to independently advise the president on scientific issues.3 It began work on the white paper in 1962. Four years later Accidental Death and Disability posed worrisome findings for legislators, but change took time. Motor vehicle death rates increased through the 1960s, and 1970 saw a record rate for highway fatalities, 26.9 deaths per 100,000, or, 1 out of every 3,717 people in the U.S.4,5
In light of the white paper’s recommendations, Congress ultimately passed the Emergency Medical Services Systems Act of 1973, providing funding for research and development, support for improved standards and rural systems, and much-needed administrative oversight that supported EMS systems into the early 1980s.6
While the NAS produced many other reports before the white paper, the white paper had far more influence on people’s lives than any other. It served as the impetus for what would become our modern emergency medical system.
The white paper outlined nine areas for improvement:7
Emergency first aid and medical care;
Development of trauma registries;
Hospital trauma committees;
Convalescence disability and rehabilitation;
Autopsy of the victim;
Care of casualties under conditions of natural disaster; and
Research in trauma.
For brevity, only the areas of significant contributions to EMS are listed.
Ambulance standards—The findings of the white paper prompted Congress to pass the Highway Safety Act of 1966, mandating standards for ambulance design, construction and inspection. Prior to 1966 ambulances—often vans and Cadillac ambulances—were retrofitted because of a lack of any design standard.
Accident prevention—Accident prevention was a significant element of the white paper that prompted legislators to require lap belts in all new vehicles by 1968. Though the belts weren’t immediately welcomed, their addition proved to be as important as those of safety glass and airbags. The period from 1970–2009 saw an almost threefold decrease in motor vehicle-related deaths because of safety advances that began with the seat belt. Moreover, in 1971 the government took a bold step to prevent accidents in the workplace by forming the Occupational Safety and Health Administration (OSHA). Prior to OSHA, there were approximately 14,000 job-related deaths in 1970; that dropped to 4,340 in 2009 (not adjusted for workplace population).8
Emergency first aid and medical care—In 1966 half of ambulances were staffed with morticians. The remaining half had volunteers (usually retirees and those not already working in a career), hospital techs and medical interns. As a result, the level of care from one ambulance to another was highly inconsistent.9 Moreover, ambulance crews commonly had minimal training and equipment. In light of these inconsistencies, the white paper recommended the adoption of national curricula, regulations and training.
Prior to EMT training, the 1970s saw the American Red Cross’ Advanced First Aid course become the de facto standard for prehospital education, even though the course materials frequently addressed what needed to be done prior to the ambulance’s arrival.10 During the same year the National Registry of Emergency Medical Technicians (NREMT) convened to produce the first standardized EMT-B test. The group would meet again to develop the first EMT-P curriculum, and that led to the first NREMT EMT-P test in 1978. More than 30 years later, the basic and advanced standard has stood the test of time and become the primarily military and civilian EMS curriculum.11
Hospital trauma committees—The white paper recommended the formation of trauma committees to oversee hospital protocols, efficacy of procedures and general efficiency of hospitals’ trauma-related issues. It wasn’t long until trauma committees became a primary element of trauma center governance.12
Recommendations That Never Took Hold
Autopsy of the victim—The white paper made a clear recommendation to increase the number of autopsies performed on accident victims to gain knowledge of their true causes of death. This recommendation appeared reasonable at the time in light of the valuable information autopsies may produce. Unfortunately, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) had different plans.
In 1971 JCAHO eliminated minimum autopsy requirements from hospital accreditation regulations. Except for teaching hospitals, the number of autopsies performed annually dropped precipitously. The change came about with the idea that modern-day (the 1970s) medical research was effective enough without data obtained from autopsies. Whether JCAHO’s decision was warranted or not, today autopsies are typically reserved for special circumstances.
Hospital overcrowding and the increase in nonemergencies—While many recommendations to improve emergency first aid and medical care were implemented, hospital overcrowding and frequent nonemergent use of emergency departments have not changed. In 1966 more than two-thirds of the nation’s 40 million emergency room visits were classified as nonemergent.13 Thus the white paper recommended a “provision for Emergency Department populations to double within a few decades,” with a mechanism to properly allocate resource for optimal patient care.14 Skipping forward a few decades, efficiencies of scale, electronic records and fast-track zones have helped, but EDs have not kept up with demand. One can only hope the push toward community paramedicine will help reduce hospital overcrowding.
Between 1993–2003, the Institute of Medicine reported emergency room visits in the U.S. grew by 26%, while the number of emergency departments declined by 425.15 In addition, a New York study showed 43% of patients who visited the emergency department were considered nonemergent. A larger 2003 multistate study found an avoidable, nonemergent patient rate of 56% of all ED visits.16
These are only some examples, but they depict the problem. Emergency departments around the nation are frequently treating patients who would be better cared for by a physician with whom they have an established relationship. As a result EDs are frequently overcrowded to the point of system failure, leading to new terms in the EMS vocabulary like “wall time” and “ambulance diversion”—not exactly the resource allocation the white paper had in mind.
For the most part EMS, despite all of its challenges, has kept up with the needs of its communities and adapted to its role as a de facto safety net. When the white paper was written, treatment for the injured varied radically from state to state and city to city. While some may feel the white paper was not the impetus for all the changes outlined, it’s difficult to argue these changes would have happened as quickly without such an influential document. We must keep its findings in mind to stay at the forefront of prehospital advancements, as opposed to reacting as a necessity of survival.
4. While this increase in deaths correlated with an increase in vehicle miles traveled, decreasing the total deaths per miles traveled, the number of deaths per 100,000 increased due to more people on the roads.