In our last episode, we heard Chapter 6 from Donnie Woodyard's book, The Dark Ages of Emergency Medical Services — the chapter that reframes the entire CMS debate by asking whether the profession has spent decades fighting the wrong fight.

In this discussion episode, two colleagues sit down to work through an argument that, if it's right, changes everything about how EMS advocates for itself.

The conversation starts with the number that stops you cold: eighty-five percent. That's the share of EMS costs committed to readiness — personnel, vehicles, equipment, dispatch, training, insurance — before the first call of the day is ever dispatched. Only 15 to 20 percent of the total cost is the variable cost of the actual patient encounter. And Medicare's per-transport reimbursement may already approach that variable cost. The profession has spent decades fighting for a higher rate on the fifteen percent while no one funds the eighty-five.

They talk through the hospital comparison and why it's so damaging. Hill-Burton built a third of America's hospitals with federal grants. Tax-exempt bonds finance the majority of hospital construction. Facility fees exist specifically to cover twenty-four-hour readiness. Philanthropy adds billions. And even with all five mechanisms, hospitals still can't fund readiness through patient billing alone. EMS has zero of those mechanisms — and the profession's primary strategy has been to demand that CMS somehow cover everything.

The conversation gets into the police analogy — no one bills a crime victim for the responding officer — and why that framing makes the argument accessible to legislators who've never thought about EMS funding before. They wrestle with what it means for the profession's lobbying strategy if the real fight isn't in Baltimore but in state capitols and county courthouses. And they explore the uncomfortable flip side: if CMS isn't the villain, then who is?

The chapter's answer — the absence of a readiness funding architecture — is simple to state and enormously difficult to build. That's what makes this conversation worth having.

Why is EMS the only major emergency service in America that bills the people it rescues? In this episode of EMS Evolution, we continue our series featuring chapters from Donnie Woodyard's book, *The Dark Ages of Emergency Medical Services: How America Created, then Forgot, Its Early Emergency Medical Legacy.*

Chapter 6 tackles what may be the most uncomfortable question in the profession: Is EMS fighting the wrong fight?

For decades, the profession has campaigned for higher reimbursement from CMS — and the grievance is real. But what if the reimbursement rate isn't the actual problem? What if Medicare is already paying close to what an insurance payer should pay for a clinical encounter — and the real crisis is that no one is funding the 85% of EMS costs that exist before the first call of the day is ever dispatched?

Police departments don't bill crime victims. Fire departments don't invoice homeowners. Yet EMS loads the full cost of 24/7 readiness onto the patients who happen to need help on any given day — disproportionately the elderly, the uninsured, and the chronically ill — and then wonders why the model is broken.

This episode traces how we got here: a jurisdictional contest between federal agencies in the 1960s, a self-sufficiency mandate in the 1973 EMS Systems Act, and the collapse of federal EMS funding in 1981. It compares how hospitals fund readiness — Hill-Burton grants, tax-exempt bonds, facility fees, philanthropy, and tax exemptions — against the zero equivalent mechanisms available to EMS. And it asks whether the profession has spent decades sending its lobbyists to the wrong address.

Some of what you hear may challenge long-held assumptions. Good. That's the point.

In our last episode, we heard two chapters from Donnie Woodyard's book, The Dark Ages of Emergency Medical Services— one tracing the rebuilding of EMS in the 1960s and 70s, and the other asking whether we ever actually left the Dark Ages at all.

In this discussion episode, two colleagues sit down to talk through the pieces that are hardest to reconcile — starting with the Freedom House story.

A program in Pittsburgh's Hill District that trained chronically unemployed residents and Vietnam veterans to perform intubations, cardiac care, and IV drug administration in the field. Two hundred lives saved in the first year. Its curriculum became the national paramedic standard. Its ambulance design became the federal standard. And then it was defunded, its Black paramedics largely shut out of the replacement system, and the nation moved on with everything Freedom House created except Freedom House itself. The conversation wrestles with what that pattern says about a profession that keeps adopting innovations while abandoning the people and programs that produced them.

They talk through the 1966 White Paper — and how it reads completely differently after the earlier chapters. Not as a discovery, but as a rediscovery by people who didn't know there was anything to rediscover. The 140-hour EMT standard that was supposed to be a floor. The federal fragmentation between DOT and HHS that created competing mandates instead of a unified system. And the 1981 collapse that defunded everything mid-construction.

Then the conversation turns to Chapter 5 and the numbers that won't go away. South Dakota's EMTs in their eighties. Medicare reimbursement below cost. Fifty years of independent state analyses all arriving at the same conclusion — and the realization that volunteer labor was never a solution. It was a subsidy that masked the fact no one was paying for EMS at all.

The question they keep circling back to: if the compromises were supposed to be temporary, at what point does accepting them become the real failure?

The reformers who rebuilt American EMS in the 1960s and 1970s are rightly honored as visionaries. But what if the conventional narrative gives them credit for the wrong thing? They didn't invent emergency medical services in America. They recovered it — imperfectly, and from a lower baseline than what had existed nearly a century before.

In this episode of EMS Evolution, we continue our series from Donnie Woodyard's book, *The Dark Ages of Emergency Medical Services,* with two chapters that trace the rebuilding — and ask whether it was ever actually finished.

Chapter 4 reexamines the landmark 1966 White Paper not as a bold discovery of something new, but as an anguished recognition of something lost. It follows the rapid expansion of EMT training — 140 hours designed as a floor, never intended as a ceiling — and the federal fragmentation that left EMS caught between the Department of Transportation and Health and Human Services with no unified architecture. It tells the story of Freedom House, the Pittsburgh program that proved advanced prehospital care could be delivered by rigorously trained non-physician providers, whose curriculum and ambulance design became the national standard — even as the program itself was defunded and its pioneering Black paramedics were largely excluded from what replaced it.

The nation adopted Freedom House's innovations and let the program die. The pattern, by this point in the book, is familiar.

Chapter 5 asks the uncomfortable question: Are we still in the Dark Ages? South Dakota's average EMT is 52 years old. The state has EMTs in their eighties. Medicare reimburses less than the cost of the response. Independent analyses spanning fifty years and multiple states all reach the same conclusion — the EMS financial model doesn't work, has never worked, and cannot be made to work through incremental adjustment. The only thing that's changed is that the decline in volunteerism is finally revealing what was always true: communities never knew what EMS actually cost because they were never paying for it.

The greatest failure wasn't in making the compromises. It was in never going back to finish the work.

In our last episode, we heard Chapter 3 from Donnie Woodyard's book, The Dark Ages of Emergency Medical Services — the chapter that documents the collapse. Physician-staffed ambulances replaced by funeral home hearses. Trained medical crews replaced by mortuary attendants with no first aid training. An entire generation growing up believing that's what ambulance service was supposed to look like.

In this discussion episode, two colleagues sit down to process what they just heard — because this one lingers.

The conversation starts with the detail that's hardest to shake: morticians racing each other to accident scenes not to provide care, but to secure the funeral business if the patient died. The emergency call as a sales lead. They talk about how something that grotesque became normalized for over twenty years — and what it says about how quickly a profession can lose its identity when the people who built it are pulled away.

They dig into the Rome parallel that runs through the chapter — the idea that the vehicles and buildings didn't immediately crumble, but the institutional knowledge and clinical mission simply evaporated. Within a generation, communities were left with infrastructure they could see but couldn't replicate. And they explore what it means that the Soviet Union maintained purpose-built ambulance systems throughout this same period while America was dispatching repurposed hearses.

The conversation also wrestles with the silence — the near-total void in the EMS development timeline between 1939 and 1956. Not a gap in the research, but the research finding itself. And the few who kept the flame alive: the American College of Surgeons publishing standards nobody followed, and Peter Safar rediscovering a lifesaving technique so thoroughly lost it had to be scientifically revalidated from scratch.

How does a nation forget something it built? And how much of what we accept as normal today is just the Dark Age's legacy that we stopped questioning?

In 1889, a Chicago police ambulance carried tourniquets, splints, disinfectant, and trained personnel dispatched by telegraph. By the 1950s, the same city's emergency calls were answered by undertakers driving combination hearse-ambulances equipped with little more than a stretcher and a blanket.

How did America go backward?

In this episode of EMS Evolution, we continue our series from Donnie Woodyard's book, *The Dark Ages of Emergency Medical Services: How America Created, then Forgot, Its Early Emergency Medical Legacy,* with Chapter 3: The EMS Dark Age.

This chapter documents the collapse — not a gradual decline, but an active regression. World War II didn't just pause the development of civilian EMS. It gutted it. Physicians and trained ambulance crews were pulled into military service, municipal budgets already weakened by the Great Depression couldn't absorb the loss, and what replaced them was the funeral industry. By the 1950s, funeral homes were the primary ambulance providers across much of America — not because they were qualified, but because they owned the only vehicles long enough to fit a stretcher.

The incentive structure was as perverse as it sounds. Morticians raced each other to accident scenes — not to provide care, but to secure the funeral business if the patient died. The emergency call was, functionally, a sales lead.

Meanwhile, the Soviet Union maintained purpose-built ambulance systems throughout this same period. America's Cold War rival preserved what America abandoned.

The chapter also explores the few who kept the flame alive: the American College of Surgeons publishing standards no one followed, Peter Safar rediscovering mouth-to-mouth resuscitation — a life-saving technique so thoroughly lost it had to be scientifically revalidated — and Dr. Deke Farrington asking the question that would eventually spark EMS reform: Why aren't battlefield lessons being applied to civilian emergencies?

The answer was simple. The civilian system that should have received those lessons no longer existed.

In our last episode, we heard the opening chapters of Donnie Woodyard's book, The Dark Ages of Emergency Medical Services — the Prologue, Chapter 1: Is EMS Essential?, and Chapter 2: The Illumination. The book opens with a bold claim: American cities built sophisticated, physician-staffed ambulance systems decades before the 1966 White Paper, and the profession we think started from nothing actually started from something extraordinary — then forgot it existed.

Now we put that argument to the test.

In this debate episode, one voice defends the book's position: that the pre-war ambulance systems were genuinely advanced, that the profession's origin story is fundamentally wrong, and that the forgetting matters because it shapes how EMS advocates for itself today. The other voice pushes back hard: Were those early systems really comparable to modern EMS, or is the book romanticizing horse-drawn ambulances staffed by police officers with minimal training? Does it matter what existed in 1889 if the clinical reality of the 1960s demanded a fresh start anyway? Is the "forgotten history" argument a compelling foundation for reform — or an intellectual exercise that distracts from the practical challenges the profession faces right now?

They debate whether the South Dakota testimony is evidence of a national structural failure or an outlier that unfairly represents a profession making real progress. They challenge whether the comparison between 1889 clinical capabilities and 2026 legislative proposals is fair — or whether it strips away context that matters. And they confront the book's central framing: does knowing this history actually change anything, or does EMS need to stop looking backward and focus entirely on what's ahead?

The evidence is on the table. You decide.

In our last episode, we launched a special series featuring chapters from Donnie Woodyard's book, The Dark Ages of Emergency Medical Services. The opening installment covered the Prologue, Chapter 1: Is EMS Essential?, and Chapter 2: The Illumination — spanning from 1869 Bellevue Hospital to a 2026 South Dakota hearing room where legislators proposed letting people trained only in CPR staff ambulances.

In this companion episode, two colleagues sit down to talk through what they just heard — and what hit hardest.

The conversation starts where most listeners probably did a double take: the realization that American cities had physician-staffed, telegraph-dispatched, hospital-integrated ambulance systems before the twentieth century even began. Cities competing to build the best ambulance services. A military surgeon hand-delivering the American model to London. Edinburgh physicians writing that their American counterparts were decades ahead. If that history is real — and it's meticulously sourced — then everything the profession has been told about starting from nothing in 1966 needs reexamination.

They dig into the South Dakota testimony and what it reveals about a profession that everyone calls essential but no one will fund. They talk about the emotional weight of hearing 1889 clinical capabilities compared side by side with 2026 legislative proposals — and what it means that the distance between those two moments isn't progress. It's regression.

And they explore the question the opening chapters leave you with: if America built all of this once before, how did it disappear so completely that the people who rebuilt it didn't even know it had existed?

This is the first in a series of discussion episodes released between chapter installments — a chance to slow down, react, and think critically about what the book is asking the profession to confront.

In 1889, a Chicago police officer climbed into the back of a horse-drawn ambulance carrying tourniquets, splints, wound disinfectant, and a protocol for poisoning cases. He had been trained to control hemorrhage, assess trauma, and deliver structured clinical interventions in the field.

In 2026, a South Dakota state legislature couldn't bring itself to call EMS essential — and proposed letting people trained only in CPR staff ambulances.

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

This is the first episode in a special series on EMS Evolution featuring chapters from Donnie Woodyard's *The Dark Ages of Emergency Medical Services: How America Created, then Forgot, Its Early Emergency Medical Legacy.* In this episode, we begin at the beginning — with the Prologue, Chapter 1: Is EMS Essential?, and Chapter 2: The Illumination.

What you'll hear may surprise you. Before the 1966 White Paper, before the modern paramedic, before everything we think of as the origin of EMS — American cities had already built sophisticated, physician-staffed, hospital-integrated ambulance systems that were the envy of the world. Bellevue Hospital dispatched surgeons by telegraph in 1869. Cities competed to build the best ambulance services the way they competed to build the best fire departments. A U.S. military surgeon hand-delivered the American ambulance model to London and built the equipment himself. By 1884, Edinburgh physicians were writing that their American cousins were decades ahead.

Then Chapter 1 brings us to the present — to a South Dakota hearing room in 2026, where aging volunteers, vanishing services, and legislators unwilling to fund what everyone acknowledges is necessary reveal just how far we've fallen from what was once built.

This isn't where EMS history starts. This is where the forgetting started.

In this special episode, we're thrilled to announce the release of Leadership in Action: The Wisdom and Stories of EMS Innovators! Edited and compiled by Donnie Woodyard, Jr., this groundbreaking book brings together the real-life experiences and leadership lessons of some of the most influential figures in Emergency Medical Services.

Join us as we dive into the inspiration behind the book, explore its powerful themes, and discuss why these stories matter for current and aspiring EMS leaders. You'll hear about the challenges, triumphs, and defining moments that have shaped EMS leadership—and how you can apply these lessons to your own career. Whether you're a veteran leader or just starting your journey, this episode is packed with insights that will inspire and empower you.

Learn more about the book:

https://www.ems-history.com/leadership-in-action

• Library of Congress Control Number: 2025901515

• ISBN: 979-8-9885254-5-5 (pbk. book)

• ISBN: 979-8-9885254-7-9 (hardback)

Contributing Authors: Zach Alvey; Alan Arguello; Jeanne-Marie Bakehouse; John Barrett; John Becknell; Maria Beermann-Foat; William J. Bullock, Daniel Burke; Sean Caffrey; Brandon Chambers; Gayan Chaturanga; Fred Claridge; John Clark; Bruce Evans; Leroy M. Garcia, Daniel Gerard; Shannon Gollnick; Kraig Kinney; Skip Kirkwood; Jon Krohmer; Douglas Kupas; Randy Lesher; Alex MacQuarrie; Gregg Margolis; Deb McDonald; Mike McEvoy; Asbel Montes; John Moon, Nitin Natarajan; Tad Rhodes; Justin Romanello; John Sammons; Joseph Schmider; Jay M. Scott; Randy Stair; Walt Stoy; Ryan Thorne; Joshua Tromp; Keith Wages; Moriah Washington; Roger White; Kenneth Williams; Doug Wolfberg; Dominique Wong; Donnie Woodyard, Jr.