Carl Post, in his book Omaha Orange – A Popular History of EMS in America, explains how NHTSA, under the Department of Transportation, was tasked with overseeing a program that authorized planning for ambulances and equipment to go in them, after Public Law 89-56 was passed in 1966. To easily recognize these emergency care individuals and vehicles, a symbol needed to be designed. It would become known as the “Star of Life.”
Arline Zatz wrote about the history of the Star of Life in an article for the July-August 1992 Rescue-EMS Magazine. In the article she indicated that at first, EMS used a red cross with four bars, which is a trademark of the American Red Cross (ARC) and the International Red Cross (ICRC). EMS organizations in the late ‘60’s and early ‘70’s used it or an orange version called Omaha Orange.
The Red Cross did not like EMS using the cross and the ARC stated it was a violation of an international treaty, backed up by federal law. The treaty and law states that the Red Cross in any form cannot be used by anyone not connected with the ICRC. Johnson & Johnson is the only corporation that can do this because it was grand fathered under the federal law.
Because the Red Cross symbol could not be used, Leo R. Schwartz, then Chief of the EMS Branch, NHTSA, took the red Medical Identification Symbol (Medic Alert) of the American Medical Association, changed it to blue, and placed it on a white square. This new Star of Life had six bars with a serpent entwined around a staff in the middle. It was registered as a certification mark on February 1, 1977 with the Commissioner of Patents and Trade Marks. The trademark remained in effect for twenty years. In an e-mail discussion, Howard Paul talked about whether a federal agency can obtain copyright protection on things they develop. There has been a lot of controversy over the years about whether anyone could use the Star of Life without DOT permission. However, with or without that protection, this star with the serpent and staff in the middle has become the symbol of emergency medical services.
The snake and staff in the center of the symbol portray the staff of Aesculapius who, according to Greek mythology, was the son of Apollo and the mortal maiden Coronis. Apollo was told to instruct his son in the ways of medicine and healing. Aesculapius became an excellent healer of the sick – too excellent. Zeus, the God of Gods, felt that Aesculapius’ powers were beyond the powers of mortal men and killed him where he stood with a bolt of lightning.
After Aesculapius death, he was worshipped and thought to be a God of healing. People would sleep in his temples. He would appear to them in their dreams offering cures and remedies. Drawings of Aesculapius usually show him in a standing position, dressed in a long cloak, holding a staff with a serpent coiled around it.
Another reason for using the serpent and staff may come from the Bible, in Numbers 21:8 and 9. It makes reference to a serpent on a staff.
And the Lord said unto Moses, Make thee a fiery serpent, and set it upon a pole: and it shall come to pass, that every one that is bitten, when he looketh upon it, shall live. And Moses made a serpent of brass, and put it upon a pole, and it came to pass, that if a serpent had bitten any man, when he beheld the serpent of brass, he lived.
The six bars of the Star of Life represent six distinct phases of an EMS response – detection, reporting, response, on scene care, care in transit, and transfer to definitive care. These phases are considered critical to producing a good outcome for the patient. The phases are:
- Detection: Citizens must first recognize that an emergency exists and must know how to contact the EMS system in their community. This can be by several different methods such as dialing 9-1-1, using a seven digit local emergency number, or using amateur radios, or highway call boxes.
- Reporting: Callers are asked specific information so that the proper resources can respond. In an ideal system, certified Emergency Medical Dispatchers (EMDs) ask a pre-defined set of questions. If someone were having a heart attack, then they would look under the heart attack algorithm for appropriate questions to ask and also give appropriate pre-arrival instructions (such as CPR). In this phase, dispatchers also become a link between the scene and the responding units and can provide additional information as it becomes available.
- Response: This is the response of the EMS resources to the scene. This may be a tiered response with First Responders and EMTs responding initially and backed up by paramedics shortly thereafter (EMS…A System To Save Lives). It may mean that a fire engine and crew are also dispatched to help with lifting and moving the patient or getting them out of a smashed automobile.
- On Scene Care: A lot of types of care can be provided on the scene, versus waiting until the patient arrives at the hospital. Standing orders and radio or cellular contact with the emergency physician has broadened the range of on-scene care that can be provided. A long algorithm of procedures and drugs may be used before the patient is removed from the scene. When the EMS system was just getting started, all patients were transported to a hospital. Today, in certain instances such as cardiac arrest, or when a patient is not seriously ill or injured, not all patients are transported from the scene to a hospital.
- Care in Transit: As stated earlier, patients were once transported in hearses or station wagons, with nobody taking care of them in the back. With the advent of federal regulations and the maturing of EMS, specially designed trucks now carry mobile oxygen, suction, patient monitoring and communications equipment, as well as special drugs for emergency care of patients (EMS…A System To Save Lives). Station wagons and hearses have been replaced with huge 15,000-pound trucks that our EMS personnel call “monster medics.”
- Transfer to Definitive Care: Up until the passage of the Trauma Care Systems Planning and Development Act of 1990, a patient might be seen in the emergency room (ER) by a physician trained in a certain kind of specialty, such as a cardiologist or a surgeon (NHTSA Leading The Way). They usually did not have the training necessary to address the many types of injuries and illnesses that present themselves in an ER. Today, there are board certified emergency medical care physicians waiting to help patients. Nurses now receive certification in emergency care and specialized training in trauma. Hospitals may hold special levels of designation in trauma care. This means they have additional specific equipment, rooms and physicians available for the most traumatically injured patients (NHTSA Leading the Way). There are specialized burn centers to handle burn patients and special children’s hospitals that handle only pediatric patients. Definitive care has come a long way, as has EMS, in a relatively short time.
Who may use the "Star of Life" symbol? NHTSA has exclusive rights to monitor its use throughout the United States. Its use on emergency medical vehicles certifies that such vehicles meet the U.S. Department of Transportation standards and certify that the emergency medical care personnel who use it have been trained to meet these standards. Its use on road maps and highway signs indicates the location or access to qualified emergency care services. No other use of the symbol is allowed, except as listed below:
States and Federal agencies that have emergency medical services involvement are authorized to permit use of the "Star of Life" symbol summarized as follows:
As a means of identification for medical equipment and supplies for installation and use in the Emergency Medical Care Vehicle-Ambulance.
To point to the location of qualified medical care services and access to such facilities.
For use on shoulder patches worn only by personnel who have satisfactorily completed DOT training courses or approved equivalents, and for persons who by title and function administer, directly supervise, or participate in all or part of National, State, or community EMS programs.
On EMS personnel items - badges, plaques, buckles, etc.
Books, pamphlets, manuals, reports or other printed material having direct EMS application.
Administrative personnel, project directors and staff, councils and advisory groups may wear the “Star of Life” symbol. If shoulder patches are worn, they should be plain blue "Star of Life" on a white square or round background. The function, identifying letters or words should be printed on bars and attached across the bottom separately. The edges of the basic patch and functional bars are to be embroidered.
Special function identification and physical characteristics must be adhered to when applying the "Star of Life" to personal items, as follows:
- Administrative and dispatcher personnel must use a silver colored edge, and the staff of Asclepias should be with a silver colored serpent. These items do not need a white background.
- The shoulder patches and other EMS patches may be displayed on uniform pockets and the symbol can also be placed on collars and headgear.
Post, Carl J., PhD, EMT. Omaha Orange, A Popular History of EMS In America. Boston: Jones & Bartlett, 1992.
United States. Department of Transportation. National Highway Traffic Safety Administration, EMS Division. NHTSA Leading the Way. Washington, D.C., 1995.
Zatz, Arline. “The Blue ‘Star of Life’ – The Emergency Medical Care Symbol.” Rescue-EMS Magazine July-August 1992.
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