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Emergency Medical Services (EMS) have evolved dramatically over time, transforming from rudimentary systems of transport to sophisticated, life-saving networks of prehospital care. This article explores the general history of EMS, followed by a focused examination of its development in Iowa, highlighting key milestones, legislative changes, the push for essential service designation, and the unique challenges and innovations in the state.

The general history of EMS

Early Beginnings: From Battlefields to Urban Centers

The concept of EMS can be traced back to ancient times, but its modern form began to take shape during wartime. In the late 18th century, Dominique Jean Larrey, a surgeon in Napoleon’s army, introduced the concept of “flying ambulances” – horse-drawn carts designed to quickly remove wounded soldiers from battlefields and provide immediate care. This marked one of the earliest organized efforts to provide rapid medical intervention outside a hospital setting.

In the United States, the Civil War (1861-1865) saw further advancements. Union and Confederate armies used ambulance corps to transport injured soldiers, with trained personnel providing basic first aid. However, civilian EMS remained rudimentary. In the late 19th and early 20th centuries, urban areas relied on hearses, police wagons, or fire departments to transport the sick and injured, often with little to no medical training for those involved.

The 20th Century: Formalizing EMS

The modern EMS system began to take shape in the mid-20th century, driven by medical advancements and societal needs. World War II and the Korean War introduced innovations like triage, rapid evacuation, and mobile army surgical hospitals (MASH units), which influenced civilian practices. By the 1960s, the need for standardized prehospital care became evident, particularly as automobile accidents surged, contributing to high mortality rates.

A pivotal moment came in 1966 with the publication of Accidental Death and Disability: The Neglected Disease of Modern Society by the National Academy of Sciences. This report highlighted the inadequacies of prehospital care, noting that many preventable deaths occurred due to untrained responders and lack of coordination. It spurred federal action, including the Highway Safety Act of 1966, which established the U.S. Department of Transportation’s authority to fund and regulate EMS systems. This legislation also led to the development of the first national standards for ambulance design and equipment.

In the late 1960s and 1970s, paramedic programs emerged, inspired by military medics. Cities like Los Angeles, Seattle, and Pittsburgh pioneered paramedic training, equipping responders with skills like defibrillation, intubation, and medication administration. The 1973 Emergency Medical Services Systems Act provided federal funding to develop regional EMS systems, standardizing training and equipment across states. The introduction of the Emergency Medical Technician (EMT) certification and advanced life support (ALS) protocols further professionalized the field.

Modern EMS: Technology and Integration

By the late 20th and early 21st centuries, EMS had become a critical component of public health. Technological advancements, such as portable defibrillators, GPS navigation, and telemedicine, enhanced response times and care quality. The integration of EMS with hospital systems improved patient outcomes through seamless communication and data sharing. Today, EMS encompasses a range of services, from basic life support (BLS) to advanced paramedic care, with an emphasis on community-based programs like mobile integrated healthcare and community paramedicine.

Despite progress, challenges remain, including workforce shortages, funding disparities, and varying standards across regions. EMS continues to evolve, with ongoing efforts to improve training, equity, and access to care in both urban and rural settings.

The History of EMS in Iowa

Early EMS in Iowa: A Patchwork System

In Iowa, as in much of the U.S., early EMS was informal and varied by community. In the late 19th and early 20th centuries, Iowa’s largely rural population relied on local doctors, midwives, or volunteers to respond to emergencies. In small towns, undertakers often provided ambulance services using hearses, while larger cities like Des Moines and Cedar Rapids saw fire departments or police taking on transport roles. These services lacked standardized training or equipment, and response times in rural areas were often slow due to vast distances and limited infrastructure.

The post-World War II era brought gradual changes. The rise in car ownership and highway accidents in Iowa underscored the need for better emergency response. By the 1950s and 1960s, volunteer fire departments and community-based ambulance services began to form, particularly in rural areas. However, these services were inconsistent, with many responders having only basic first aid training.

The 1970s: Formalizing EMS in Iowa

The national push for EMS reform in the 1960s and 1970s had a significant impact on Iowa. The federal Emergency Medical Services Systems Act of 1973 provided funding to states, including Iowa, to develop regional EMS systems. Iowa began to establish training programs for EMTs, aligning with national standards. In 1978, the Iowa Department of Public Health created the Bureau of Emergency Medical Services to oversee training, certification, and coordination of EMS across the state.

During this period, Iowa’s EMS system began to address the state’s unique challenges, particularly its rural geography. With 99 counties and a dispersed population, ensuring timely access to care was difficult. Volunteer EMS agencies became a cornerstone of Iowa’s system, with many small towns relying on trained volunteers to staff ambulances. By the late 1970s, Iowa had established EMT-Basic and EMT-Intermediate certifications, with paramedic training following in the 1980s.

Legislative Milestones and Growth

Iowa’s EMS system saw significant legislative and organizational advancements in the following decades. In 1996, the Iowa Legislature passed the Emergency Medical Care Provider Act (Iowa Code Chapter 147A), which formalized EMS provider certification and established standards for ambulance services. This law also created the Iowa EMS Advisory Council to guide policy and ensure quality care.

The 1990s and 2000s saw increased professionalization. Iowa adopted national EMS education standards and expanded paramedic programs, particularly in urban centers like Des Moines, Cedar Rapids, and Iowa City. The University of Iowa Hospitals and Clinics developed one of the state’s first advanced life support programs, integrating EMS with trauma care. Rural areas, however, continued to face challenges, including limited funding and difficulty recruiting and retaining volunteers.

In response, Iowa implemented innovative solutions. The state expanded training programs through community colleges, such as Kirkwood Community College and Des Moines Area Community College, making EMT and paramedic education more accessible. Additionally, Iowa introduced the Critical Access Hospital program in the late 1990s, which supported rural hospitals in coordinating with EMS to stabilize patients before transfer to larger facilities.

Modern EMS in Iowa: Challenges and Innovations

Today, Iowa’s EMS system is a mix of volunteer and paid services, with approximately 700 EMS agencies statewide, the majority of which are volunteer-based in rural areas. The state has made strides in improving care through technology, such as electronic patient care reporting (ePCR) systems and telemedicine, which allow rural EMS providers to consult with physicians in real time. Iowa’s EMS system is also integrated with the state’s trauma system, established in 2001, which categorizes hospitals by trauma level and ensures patients are transported to appropriate facilities.

Despite these advancements, Iowa faces ongoing challenges. Rural EMS agencies struggle with funding, as many rely on local taxes and donations. Volunteer shortages are a persistent issue, with many communities reporting declining numbers of younger volunteers. In response, Iowa has invested in community paramedicine programs, which train EMS providers to offer preventive care and chronic disease management, reducing the burden on emergency services.

Recent legislative efforts have aimed to address these issues. In 2023, the Iowa Legislature passed House File 2680, which increased funding for EMS training and equipment and established a task force to study sustainable funding models for rural EMS. Additionally, Iowa has expanded its use of mobile integrated healthcare, allowing EMS providers to deliver care in patients’ homes, particularly in underserved areas.

Unique Aspects of Iowa’s EMS

Iowa’s EMS system is notable for its reliance on volunteers, a reflection of the state’s rural character and community spirit. The Iowa EMS Association, founded in 1987, has played a key role in advocating for providers and promoting training and recruitment. Iowa’s emphasis on community paramedicine and telemedicine also sets it apart, addressing the challenges of serving a geographically dispersed population.

Iowa EMS Essential Service Legislation

The Push for Essential Service Designation

In recent years, Iowa has grappled with the question of whether to designate EMS as an essential service, a move that would place it on par with fire and police services, ensuring more stable funding and resources. Unlike some states where EMS is already classified as an essential service, Iowa’s EMS system has historically relied on a patchwork of local funding, grants, and volunteer support, particularly in rural areas. This has led to disparities in service quality and availability, prompting advocacy from the Iowa EMS Association, EMS providers, and local governments.

The push for essential service designation gained momentum in the early 2020s as rural EMS agencies faced increasing financial strain and volunteer shortages. Designating EMS as an essential service would allow counties and municipalities to levy taxes specifically for EMS, similar to funding mechanisms for fire and police departments. This could stabilize budgets, support paid staff, and ensure consistent service levels across Iowa’s 99 counties.

Legislative Efforts

In June 2021 Senate File 615 was signed into law allowing individual counties to offer a referendum to the voters on whether or not EMS should be offered an essential service and whether to fund the service by approving a tax levy. The law allows EMS to be funded by an income surtax of 1% or up to 75-cents per $1000 property tax levy. Voters must approve the referendum by 60%. 19 Iowa counties have passed the referendum to include: Benton, Cedar, Ida, Iowa, Jones, Kossuth, Lee, Osceola, Pocahontas, Shelby, Winnebago, Butler, Cass, Hamilton, Jefferson, Sac, and Tama.

Implications and Challenges

Designating EMS as an essential service could transform Iowa’s EMS landscape by providing reliable funding, reducing reliance on volunteers, and ensuring equitable access to care. However, challenges remain. Rural counties with lower tax bases worry about the financial burden of a new levy, while urban areas with paid EMS services argue that the designation may have less impact on their already-funded systems. Additionally, some lawmakers and local officials question how to balance EMS funding with other essential services like fire and police.

The Iowa EMS Association has emphasized that essential service status would not only secure funding but also elevate the profession’s status, attracting more providers through better compensation and resources. The association has also advocated for a phased implementation, allowing counties to opt in based on local needs and resources.

Current Status

As of July 2025, EMS is not yet classified statewide as an essential service in Iowa, but could be on a county-by-county basis. The EMS Funding and Sustainability Task Force continues to meet, gathering data on pilot programs in counties that have voluntarily increased EMS funding. Public support for the designation is growing, driven by stories of delayed response times and service gaps in rural areas. The outcome of the 2026 legislative session will likely determine whether Iowa joins states like Illinois and Colorado in recognizing EMS as an essential service.

Conclusion

The history of EMS reflects a broader trend in healthcare: the shift from ad hoc, community-based responses to professional, coordinated systems. Globally, EMS has grown from battlefield innovations to a cornerstone of public health, driven by technological and legislative advancements. In Iowa, the evolution of EMS mirrors these trends but is shaped by the state’s rural landscape and reliance on volunteers. The ongoing push for essential service designation represents a critical step toward addressing funding and access challenges, ensuring that Iowa’s EMS system can meet the needs of all its residents.

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Christopher Cross is the chief of the Marshalltown Fire Department.