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Book excerpt: ‘EMS in the United States: Fragmented Past, Future of Opportunity’

Chapter 4 of this comprehensive desk reference about EMS in the U.S. untangles the origin and history of the EMS Star of Life

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Editor’s Note:EMS in the United States: Fragmented Past, Future of Opportunity” is a comprehensive desk reference that explores the evolution, current state, and future of EMS.

Woodyard explains service delivery models, financial challenges, and the significance of insurance and billing, as well as personnel management, recruitment, retention, mental health, and a professional code of conduct. The discusses state regulation and administration, providing an introduction to interstate compacts, investigations, enforcement, and public protection. It also outlines leadership lessons, stakeholder engagement, and change management in the EMS environment.

This excerpt is reprinted with permission from “EMS in the United States: Fragmented Past, Future of Opportunity,” by Donnie Woodyard Jr.

Chapter 4: A Guiding Star (Of Life)

The star of life is a powerful visual reminder of the critical role that EMS practitioners play in saving lives and promoting public health. By serving as a unifying symbol for EMS professionals since the late 1960s, the Star of Life highlights the essential nature of the work and the significant impact EMS practitioners have on the well-being of individuals and communities they serve. The symbol has six blue, interlocking bars with a white “serpent” coiled around a staff in the center, symbolizing the rod of Asclepius, the Greek god of medicine and healing. The six points of the star correspond to the six essential components of the EMS system: detection, reporting, response, on-scene care, care in transit, and transfer to definitive care. Each point of the star represents a specific function in the EMS system, underscoring the importance of a coordinated approach to emergency medical care. The Star of Life is prominently displayed on almost every ambulance in the United States, incorporated into EMS patches and uniforms, and often seen on road signs to indicate the presence of emergency medical care nearby.

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A page from the 1964 Journal of the American Medical Association.

EMS in the United States / Donnie Woodyard Jr.

Untangling the History

The Star of Life has a rich, yet often misrepresented history. The original Star of Life was designed by the American Medical Association (AMA) in the early 1960s as the “Universal Medical Identification Symbol”i (also known as the “Universal Emergency Medical Identification Symbol”). The original intent was for this symbol to be freely available and printed on cards carried by persons with any medical conditions such as diabetes or epilepsy. This universal symbol would be easily recognized by the public and medical professionals during an emergency. The AMA did not trademark or copyright the symbol, but freely provided it to manufacturers and the public for use. The AMA widely promoted the use of this “Universal Medical Identification Symbol” in its journal (as seen in the image on the previous page) and in governmental publications.ii

In 1964, the World Medical Association’s Assembly in Helsinki, Finland, adopted the “Universal Emergency Medical Identification Symbol” for worldwide use, sponsored by the AMA. Shortly after, in March (1966), the “Universal Emergency Medical Identification Symbol” was being referenced as the “Star of Life” by the Federal Bureau of Investigation and others. iii

In 1969, under the chairmanship of Irvin E. Henderson, MD, the AMA Commission on Emergency Medical Services encouraged the Department of Transportation to display the symbol on road signs to denote hospital Emergency Rooms. The next year, the AMA House of Delegates officially adopted the “Star of Life” design, which was the Universal Medical Identification Symbol without the surrounding hexagon.iv

Simultaneously, President Lyndon Johnson’s Committee on Highway Traffic Safety formed a Task Force tasked with establishing a national EMS certification agency.v The AMA led this Task Force, with many individuals who contributed to the creation and publication of the Universal Medical Identification symbol also appointed to the Task Force. The first meeting of this Task Force was on January 21, 1970, with additional representatives from the following organizations:

  • Ambulance Association of America
  • International Association of Fire Chiefs
  • International Rescue and First Aid Association
  • National Ambulance and Medical Services Association
  • National Forest Service
  • National Funeral Directors Association
  • National Park Service
  • National Safety Council
  • National Ski Patrol
  • American Heart Association
  • International Association of Chiefs of Police

The Task Force moved quickly, and on June 4, 1970, the first meeting of the Board of Directors of the Registry of Emergency Medical Technicians (later renamed as the National Registry of Emergency Medical Technicians) was convened. Roddy A. Brandes, of the Ambulance Association of America, was elected the Board’s first Chairman. However, this new national certification body for emergency medical services needed a logo, a unique symbol to unify the newest medical profession: a nationally standardized Emergency Medical Technician. Due to the close affiliation with the American Medical Association, the AMA transferred the Universal Medical Identification Symbol – a symbol already linked to emergency care - to the Registry of EMTs as a symbol to designate nationally certified EMS personnel. The symbol was incorporated into the Registry of EMTs branding and patches. In 1971, at 51 testing locations across the United States, 1,520 ambulance personnel took the first standardized national EMS certification examination. The successful candidates were presented with a patch that not only signified their newly demonstrated competence in Emergency Medical Services, but also indicated these personnel had a direct connection to the broader medical profession, the American Medical Association, and had met a unified national standard.

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The 1971 Registry of EMTs National EMT-Ambulance Patch, featuring the Star of Life.

EMS in the United States / Donnie Woodyard Jr.

On April 12, 1973, the Registry of EMTs trademarked the Registered Emergency Medical Technician symbol that clearly incorporated the Star of Life. Honoring the work of the visionary physicians of the American Medical Association - that fought for a new medical profession and gifted the profession a unique symbol – the Star of Life has been incorporated into every National EMS Certification card and patch earned for over fifty years.

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A Geneva Convention Violation?

It’s 1972 and ambulance services are being established at a record pace in communities across the nation. Thousands of personnel are being trained as EMTs, and the nation is being entertained and educated by the new hit show, “Emergency!”. However, there’s a growing two-fold problem that is rapidly getting out of control: NHTSA’s first attempt at a standardized symbol for the emerging profession was an Omaha Cross, which was an orange Greek Cross Ë on a white background, and secondly many community ambulance services were using the actual Red Cross logo on ambulances.

First, NHTSA encountered serious issues with the Omaha Cross (the orange Greek Cross). In a 1974 highway safety manual, NHTSA acknowledged the error noting that,

“a cross of reflectorized Omaha orange on a square background of reflectorized white might violate a Congressional grant to the Red Cross of ‘the right to have and to use ... as an emblem and badge, a Greek Red Cross on a white background, as the same has been treated in the treaties of Geneva’…the orange cross specified by the National Highway Traffic Safety Administration (NHTSA) clearly is a ‘colorable imitation’ of the Geneva Red Cross”.vii

Secondly, as previously noted, many of the local ambulance service volunteers were veterans of the Korean War, the Vietnam War, or World War II. From the perspective and experience of these personnel, combined with the public’s experience in the media, Red Cross logos were synonymous with ambulances. Recognizing this emerging concern that further use of the Omaha Cross or the Red Cross is restricted by both the U.S. Congress and the Geneva Convention, Dr. Dawson Mills, the Chief of the EMS Branch for the National Highway Traffic Safety Administration, had to find an alternative symbol for ambulances quickly.

Dr. Mills was very involved with the taskforce that formed the Registry of EMTs, so he raised this urgent concern to the organization’s multidisciplinary board. Recognizing the Universal Medical Identification Symbol was quickly gaining recognition and acceptance, he requested permission to extend the use of the Star of Life symbol as the “national identifier for Emergency Medical Services” that would be used on all ambulances. (Subsequently, the federal ambulance standard was later known as a “Star of Life Ambulance”.) The Registry’s board agreed and approved this request, and Dr. J.D. Farrington, as Chair of Board, memorialized this in a memo to Dr. Mills.

While the Registry of EMTs would continue to use the symbol, the Department of Transportation expanded the use of the blue ‘Star of Life’ and mandated it’s use on all ambulances purchased with federal funds. On September 26, 1972, the Office of the Secretary of Transportation issued a Memorandum adopting and recognizing the “Star of Life”. By 1975, Leo R. Schwartz, the new Chief of the EMS Branch at NHTSA, modified the Star of Life by adding the six main tasks associated with EMS.

In 1974, the Department of Transportation notedviii,

“It has been concluded by NHTSA that it is proper not to further interfere with the organizational identification provided by the Greek Red Cross. Rather, it is considered preferable to adopt a separate symbol which clearly and distinctively identifies the emergency care vehicle or ambulance within the total spectrum of the Emergency Medical Care system. The “Star of Life” has already been identified by the medical profession as a medical emergency symbol and its highway related use encouraged by the American Medical Association.”

On February 1, 1977, the “Star of Life” was issued Registration Number 1058022 by the United States Patent and Trademark Office in the name of the Department of Transportation’s National Highway Traffic Safety and Administration.

The Star of Life holds immense significance within the EMS profession, serving as a powerful reminder of both its unity and the potential for history to fade into oblivion. It emerged as a unifying symbol, aiming to bring together a fragmented profession and instill public confidence by signifying that every ambulance, EMT, or Paramedic adorned with the Star of Life had successfully met the unified national standard. However, in a mere span of 50 years, the EMS profession forgot its roots and several iterations of fragmentation occurred. As EMS again undergoes a process of reunification, the Star of Life will hopefully symbolize integration and a renewed linkage with the healthcare system.

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EMS in the United States / Donnie Woodyard Jr.

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EMS in the United States / Donnie Woodyard Jr.