Before you can fully understand this webpage and all of the issues facing the EMS you need to understand the rich and complex history of ambulances and the Emergency Medical Service. It doesn't matter if you know everything about EMS, or nothing at all this information will prove enlightening to everyone. As I researched this material for my website I learned quite a bit about the history of EMS and I think you will too.
The History of the ambulance service (a precursor to the modern Emergency Medical Service) was born as a result of numerous milestones throughout history. The ambulance service can be traced all the way back to the middle ages. During the Crusades of the 11th Century, the Knights of Saint John received instruction in first-aid treatment from Arab and Greek doctors. The Knights of Saint John then acted as the first emergency workers, treating soldiers on both sides of the war on the battlefield and bringing in the wounded to nearby tents for further medical treatment. During this time it had become common practice for small rewards to be paid to soldiers who treated and carried the wounded bodies of other soldiers in for medical treatment.
In the year 1487 during the siege of Malaga in Spain, the next recorded use of an ambulance (horse drawn cart with attendant) was used by the military. They were used to help remove wounded solders and civilians from the fields of battle.
However the first big leap in EMS came during the late 1700s. Napoleon Bonaparte appointed Baron Dominique-Jean Larrey to develop the first medical patient care system for the French army. One of his findings was that leaving wounded soldiers on the battlefield for several days increased the complications and suffering. This delay in treatment resulted in needless deaths. "The remoteness of our ambulances deprived the wounded of the requisite attention," he wrote. In 1797. Larrey then developed a method to send trained medical personnel into the field to provide medical care to the wounded soldiers and to provide medical care en route to the field hospital. This action increased their chances of survival and benefited Napoleon's conquest efforts. He designed a special carriage staffed with medical personnel to access all parts of the battlefield. The carriage became known as the ambulance volante, or flying ambulance.
Baron Larrey developed all of the precepts of emergency medical care that are used today by all modern EMS systems:
1) Rapid access to the patient by trained personnel.
2) Field treatment and stabilization.
3) Rapid transportation back to the medical facility, while providing medical care enroute.
Although removal of the wounded and dead from the battlefields has existed in some form since early Greek and Roman times, Larrey can still be considered the "father of emergency medical services."
At the beginning of the 1860s the United States created the first field ambulance and attendant. The first recorded use of a field ambulance and attendant was during the Civil War. During the U.S. Civil War, both sides attempted to emulate the medical practices of the Napoleonic wars with little success. Lack of funding, government support, and dedicated personnel initially prevented the development of an effective ambulance system. During the Second Battle of Bull Run in August of 1862, on the Union side alone over 3000 wounded solders lay in the field for 3 days and 600 wounded solders lay in the fields for over a week. James Brady and Walt Whitman reported that emergency medical facilities were primitive and many wounded solders died in agony. At that time the ambulance service was being run by the QuartermasterCorps. It was transferred to surgeon general Jonathan Letterman, MD, to organize and he reinstated all of Larrey's concepts greatly increasing the survival rate of the wounded.
At the Geneva Convention of 1864 an agreement was developed among the European countries to recognize the neutrality of hospitals, the sick and wounded, all persons involved in medical care, and ambulances. It provided safe passage across battle lines for all medical and injured personnel. On August 22, 1864, the organization adopted for its logo the reverse of the Swiss flag. The logo was a red cross on a white background. The name that they adopted was the International Red Cross.
By late 1865 the first civilian ambulance service in the nation was being run by The Commercial Hospital of Cincinnati. Other ambulance services followed at Grady Hospital in Atlanta, and Charity Hospital in New Orleans.
In 1867 Major General Rucker won the "best of kind" for an ambulance that was adopted as the regulation ambulance. It had extra springs on the floor, more elasticity to the stretchers, and improved ventilation.
By the late 1860s there was a major proliferation of ambulances throughout the United States. In late 1869 the first New York City hospital-based ambulance service was established at Bellevue Hospital by Dr. Edward L. Dalton. In December of 1869 the first month of operation of the ambulance service of the Free Hospital of New York (Bellevue) they ran a total of 74 calls. In 1870 1466 calls were run. The Bellevue dispatch system was different from the dispatch used today. A hospital worker rang a bell, which triggered a weight to fall, lighting the gas lamp to wake the physician and the driver. It also caused the harness, saddle, and collar to drop on the horse and opened the stable doors. However, this improved response and care was mostly limited to the larger cities in America.
During World War I and especially during World War II, the military medical corps proved their worth in field assessment and early management of injured personnel. Although the military system of emergency care became well developed, the development of a civilian system lagged far behind. In the mid 1950s, J.D. "Deke" Farrington, MD, FACS (the Father of modern EMS), and others, questioned why the lessons learned by the military medical corps during World War II and the Korean War could not be brought into the civilian community to improve the standard of civilian care. At that time, emergency medicine and EMS were not what we know today. In San Francisco, New York, New Orleans, and other American cities, interns were assigned to ambulances to provide care for the victims of trauma and other conditions outside of the hospital. Most hospitals did not have a place to manage emergencies.
Some hospitals had set up an unstaffed "emergency room" at the back of the hospital. The "ambulance driver" had to ring the doorbell beside the emergency room door so that the nurse could come down from the ward to unlock the door. The nurse then checked the patient and called a physician from home if she thought that the patient was really sick. (Did you ever wonder why modern emergency departments are in the rear of the hospital and not out front? Tradition.) All the physicians on staff had to take turns "covering the Emergency Room." A patient involved in a major wreck with multiple fractures, and perhaps a ruptured spleen or a head injury, might be seen by an ophthalmologist or a dermatologist. Many physicians knew that they were ill prepared to handle trauma or a major myocardial infarction, but there was no alternative at the time.
Until the concept arose that non physicians could be trained to provide this kind of emergency care, the majority of the pre-hospital care was merely transportation provided by the local mortuary. The victim was driven to the hospital in a hearse with no one in the "patient compartment" except the patient and perhaps a family member. Many people began to question the efficacy and even ethics of this transportation. When the paper titled "Accidental Death and Disability: The Neglected Disease of Modern Society" was written by the National Academy of Sciences and the National Research Council in 1966, it became apparent that much improvement could be made by changing the emergency vehicles themselves and improving the training of EMTs, communications, record keeping, and the care provided upon arrival to the facility.
At the Airlie House conference (May 1969) sponsored by the Committee on Trauma, American College of Surgeons and Committee on Injuries, American Academy of Orthopedic Surgeons, "Recommendations for an Approach to an Urgent National Problem" was written. This conference indicated that immediate attention and control were needed in the areas of transportation and communication. Developing standards for ambulance design and equipment was recognized as "painfully slow." Dr. Farrington and Dr. Sam Banks developed a trauma training school for the Chicago Fire Department that served as the prototype of what later became the first EMT-Ambulance (EMT-A) training program. The task force involved in the design of the program for the United States Department of Transportation (USDOT) included Deke Farrington, Rocco Morando, Oscar Hampton, Walter Hoyt, Walter Hunt, Robert Oswald, Peter Safar, and Joseph Territo.
At the same time that the EMT-A training program was evolving, Eugene Nagle in Miami; Ron Stewart and Jim Page in Los Angeles; John Waters in Jacksonville, Florida; Costas Lambrew in New York; Mark Vasu in Grand Rapids, Michigan; Jim Warren in Columbus, Ohio; and others began to provide "paramedic care." Originally designed for cardiac patients, all types of patients soon received the type of pre-hospital cardiac care developed by Pantridge and Geddes in Belfast, Ireland. Small communities, such as Newton, Kansas, under the direction of Jim Werries, had developed a cardiac care EMS service by the early 1970s, but these were isolated situations. Kansas was like many of the states during the period that worked in isolation to develop a method of providing pre-hospital care for its citizens. It was not until 1974 to 1975 that Kansas had the statewide program going at the basic level and partially evolved at the EMT-Paramedic (EMT-P) level.
The initial training program was called the Advanced Training Program of EMT. The USDOT organized a subcommittee on ambulance services, which developed the standards on which this course was based. Many of those leaders who have been identified were active in the development of this curriculum. Nancy Caroline and her team at the University of Pittsburgh was awarded the contract from the USDOT to write the National Standard Curriculum for the EMT-P. This modular training program included sections that then became the basis for the EMT-Intermediate (EMT-I). Up until the late 1970s, most of the federal involvement came through the USDOT under the leadership of Leo Schwartz and Robert Motley. A new EMS act was passed in 1976 that gave money and responsibility to the U.S. Department of Health, Education, and Welfare. Chicago trauma surgeon David Boyd led this enactment, which resulted in the development of state and local EMS regions throughout the United States.
The National Registry of EMTs (NREMT) was created shortly after the Airlie Conference. This organization was responsible for registering and reregistering EMTs based on completion of the USDOT standard EMT-A curriculum (and later the EMT-I and EMT-P training). The NREMT developed written and practical examinations based on the objectives of these courses to examine and register those who satisfactorily completed the examination process. Most states use the NREMT's process in whole or in part as the basis for licenser. The "Star of Life" is a logo patented by the American Medical Association in 1967. It represents the three rivers of life and the staff of Aesculapius. It was given to the NREMT as the EMT logo. When Dawson Mills of the USDOT asked the American Red Cross to use the red cross as the EMS logo for ambulances and was refused, he asked "Deke" Farrington if the USDOT could use the Star of Life on all ambulances in the United States, and Farrington approved it. The six points of the star were named by Leo Schwartz.
The National Association of EMTs (NAEMT), founded in 1975, was developed to represent EMTs at all levels. The state EMS directors formed the National Association of State EMS Directors (NASEMSD) to share ideas and develop strategies for EMS development across state lines. Another organization, the National Council of EMS Training Coordinators (NASEMSTC), is also charged with sharing educational ideas across state lines. The National Association of EMS Physicians (NAEMSP) was formed to provide leadership in medical direction of EMS services. This association is the focus of activities, discussion, and meetings for physicians involved either full-or part-time in EMS.
This very brief overview can only mention a few of the highlights in the development of EMS in the United States. However, even this history underscores how far EMS has evolved from its roots in European battlefields. Below is a table of some of the important events in the history of EMS.
1865 America's first ambulance service is instituted by the U.S. Army.
1865 The first civilian ambulance service in the nation was being run by The Commercial Hospital of Cincinnati.
1869 America's first city ambulance service (utilizing horse drawn carriages) is instituted in New York City by Bellevue Hospital.
1870 Prussian siege of Paris used hot air balloons to transported wounded soldiers. This was the first documented case of aeromedical
1899 First motorized ambulance operated out of the Michael Reese Hospital in Chicago; reached a speed of 16 miles per hour
1901 President McKinley shot in Buffalo and transported in a motorized ambulance
1910 First known air ambulance aircraft was built in North Carolina and tested in Florida. The aircraft failed after flying only 400 yards and crashing.
1922 Committee on Treatment of Fractures formed
1926 Phoenix Fire Department begins "inhalator" calls.
1928 Julien Stanley Wise implemented the first rescue squad (Roanoke Life Saving Crew) in the nation in Roanoke, VA.
1931 Outline of Treatment of Injuries
1939 Committee on Fractures and Other Injures formed
1940 Prior to World War II, hospitals provided ambulance service in many large cities. With the severe manpower shortages imposed by the war effort, it became difficult for many hospitals to maintain their ambulance operations. City governments in many cases turned ambulance service over to the police or fire department. No laws required minimal training for ambulance personnel and no training programs existed beyond basic first aid existed. In many fire departments, assignment to ambulance duty became an unofficial form of punishment.
1951 Helicopters began to be used for medical evacuations during the Korea war.
1954 Survey of EMS systems performed by ACS/COT chairman Alan Dimick, MD; 64 cities, 5 years of data (1/4 excellent, 1/3 unacceptable)
1955 Saturday Evening Post article, "Let Those Crash Victims Lie-Ambulance Attendants are Trained to Handle Them," published
1956 Dr. Elan & Dr. Safar developed mouth-to-mouth resuscitation.
1957 Chicago Fire Department training program developed by "Deke" Farrington, MD
1959 Symposium on Medical Aspects of Traffic Safety formed
1959 Researchers at John's Hopkins Hospital in Baltimore, MD developed the first portable defibrillator as well as perfected CPR.
1960 "Management of Fractures and Soft Tissue" published by Committee on Trauma, American College of Surgeons
1960 Cardiopulmonary resuscitation (CPR) successful (Kouwenhoven)
1960 "CPR"-Journal of the American Medical Association article published by Jude
1960 - Martin McMahon experimented with various types of artificial respiration by paralyzing Baltimore City firefighters and seeing which method worked best.
1962 AMBU bag developed
1962 "Thumper," developed by Michigan Instruments
1962 "Resusci-Anne," developed by Laerdal
1965 Life Pack 33 developed
1966 "Accidental Death and Disability-The Neglected Disease of Modern Society" published by NRC-NAS
1966 Presidents Commission on Highway Safety formed
1966 Highway Safety Act enacted
1966 Dr. Pantridge in Belfast, Ireland, started to deliver pre-hospital coronary care using ambulances. His research showed that his program significantly improved patient survivability in out-of-hospital cardiac events.
1966 In Pittsburgh, citizens demand an ambulance service to transport minority citizens. Freedom House Enterprises took 44 unemployed 18-60 year old men and gave then 3,000 hours of medical training. The program was deemed a success.
1967 "Death in a Ditch" published by "Deke" Farrington, MD
1967 Mobile Coronary Care Units developed by Pantridge
1967 Traction splint developed by Glenn Hare
1967 "Star of Life" patented by American Medical Association
1967 Jaws of Life developed by George Hurst
1968 On January 12, 1968 AT&T announces their designation of 911 as a universal emergency number at a press conference in the Washington (DC) office of Indiana Rep. Ed Roush, who had championed for Congressional support for "one number." AT&T's plan affected only the Bell companies, and not any of the independent telephone companies. Up to this point, the number "911" wasn't mentioned in any literature, and apparently wasn't identified until the press conference. In fact, a Wall Street Journal article written the day before the press conference didn't mention "911" as the number that AT&T selected.
1969 Ohio Heart mobile developed
1969 Arlie House Conference formed
1969 American Medical Association Commission on EMS formed
1969 Helicopter used for civilian medical transportation
1969 EMT-A published by Dunlap and Associates
1969 The Miami FL Fire Department started the nation's first paramedic program under Dr. Eugene Nagel. The very first out-of-hospital defibrillation occurred shortly thereafter (the patient survived and left the hospital neurologically intact). In Seattle, Dr. Leonard Cobb at Harbor View Medical Center teams up with the Seattle Fire Department and creates Medic I. Medic I is a Winnebago, (called "Mobi Pig" by the firefighters manning it), based at the hospital and is dispatched only on cardiac related calls.
1970 National Registry of EMTs (NREMT) founded
1970 "Emergency!" with Johnny and Roy airs on TV
1972 The Department of Transportation and Department of Defense team up to form a helicopter evacuation service. In Seattle, Medic II is instituted. Medic II is a program to train 100,000 citizens in CPR. Harbor View Medical Center starts up the nation's most intensive training program for paramedics. The course is 5,000 hours long, compared to 3,600 hours a medical student endures to become a doctor.
1973 Emergency Medical Services Act enacted
1975 National Association of EMTs (NAEMT) founded
1975 ACLS developed by American Heart Association
1978 ATLS pilot course developed in Auburn, Nebraska
1979 ATLS approved by ACS/COT
1979 Joint Review Committee for EMT-Paramedic accreditation formed
1981 Pre-hospital Trauma Life Support (PHTLS) approved by NAEMT and ACS/COT
1981 BTLS developed by Alabama Chapter of ACEP
1983 PHTLS pilot courses run in Iowa, Connecticut, and Louisiana
EMS grew exponentially after the early 1980s. So many people contributed so much that an attempt to list all of these contributions would leave out many of the major players. This does not detract from all of the work done by each of them. It only points out the growth of EMS in the United States and the world. A small example is all of those who made possible the spread of PHTLS to 25 countries and greater than 300,000 providers trained by the year 2000 and a similar spread of BTLS by its contributors.
1986 The Comprehensive Omnibus Budget Reconciliation Act (COBRA) is passed by Congress. This affected transfers of patients from ED to ED and prevented "dumping" (financially motivated transfers of patients).
1992 A public opinion survey conducted for the American College of Emergency Physicians found that nearly half of adult Americans could not identify 9-1-1 as the emergency number, or confused it with 4-1-1, the directory assistance number.
1995 Los Angeles City Fire Department institutes EMT Assessment & Paramedic Engine companies.
1996 New York City EMS is absorbed by FDNY.
1997 San Francisco and Chicago institute paramedic engine companies.
1999 President Clinton signs Senate Bill 800, which designates 911 as the nationwide emergency telephone number.
09-11-01 Terrorist attacks on the World Trade Center, and Pentagon result in the largest peacetime EMS response in history. Over 3000 people are killed in the attacks.
04-2013 Terrorist attack the Boston Marathon using "Pressure Cooker Bombs," injuring hundreds and killing three (3). Despite the Dangers of more explosive devices, Medics, Nurse's, Doctor's rushed to the area and began treating those injured. Their efforts are credited for preventing further loss of life.
This section will be Updated from 2001 thru 2012
When the police are called for a fight, a family fight turned abusive, or a child struck, Police Officers are sent to the scene, they begin their investigation, while two medics, a highly trained team, which may consist of an Emergency Medical Technician (EMT) and a Paramedic, arrive on scene in an ambulance which is equipped with highly sophisticated equipment and serves as a pre-hospital mobile emergency room. This EMS crew begins treating the injured. While the medics work on the injured, law enforcement continues to carry out their responsibilities of investigation and possibly arresting a suspect who was involved.
When firefighters are called to a burning home, it is the firefighters who arrive on scene they take risks entering burning buildings and rescue those who have become incapacitated from smoke inhalation, or suffer burns that can range from minor, to severe. However it is the EMS Crew who is sent to the same scene who takes over care of the patient. Providing pre-hospital care, on the scene and while enroute hospital. That care may make the difference between life and death. Similar to a crime scene medics treat the injured, as Firefighters continue to work at putting out the fire.
When a Police Officer is injured in the performance of his or her duty whether it is by a bullet wound, assault, or an accident, it is the EMS Medics who respond and treat the injured officer on scene, utilizing all of their skills, equipment, and respect as if they would treating one of their own co-workers.
The same care and commitment is provided to Firefighters, as they battle to save your home or business. EMS crews respond to provide treatment for the dehydrated firefighter, taking of vitals, providing intravenous therapy, (IV’s) and when the worst occurs medics provide the firefighter with the most advanced life support, pre-hospital care available.
Emergency Medical Technicians, (EMT’S) Emergency Medical Specialist, (EMT-S) and Emergency Medical Paramedics, (EMT-P) have obtained extensive didactic and practical training, and are State and Nationally Certified. The men and women in the Field of Emergency Medical Services truly are dedicated to the preservation of Life.
Medics are professional, caring, and highly trained. They are part of the three tiered Emergency Services System; they are also sadly the least known of the three Emergency Services until you need them. They face many dangers and have to take many risks in the performance of their duties. EMS Personnel sufferer many types of injuries ranging from minor to critical in the performance of their jobs. Also EMS Personnel have made the ultimate sacrifice while in the performance of their jobs; their life. Medics have been attacked, assaulted, ambushed, or killed; either while on scene when a motorist fails to slow down striking the medic while he/she treats a sick or injured patient, causing the loss of a medic’s life.
An Emergency response to either a scene or transporting a critical patient to the hospital is one of the most dangerous situations for EMS Personnel, who face drivers oblivious to their lights and sirens, drivers who fail to yield, and blaring car stereos that can and have resulted in horrific accidents, that cost medics career ending disabilities, or cause a medics life.
Emergency Medical Service (EMS) is provided by Local Volunteer agencies, Private EMS Agencies, County operated EMS Systems, and Fire Departments who provide EMS divisions. (Primarily in major cities, such as; New York Detroit etc.)
The next time you see an EMT or Paramedic please simply take a moment to say hello, or a simple “thank you for their service to our community.” Did you know that EMS Personnel are the lowest paid of the three emergency service’s Police, Fire, and EMS? As Police Officers are dedicated to protecting the public and Firefighters are dedicated to fire suppression. EMS Personnel are dedicated to providing pre-hospital care to sick and injured.
EMS Personnel are color blind in treating any patient, they respond to low, middle, and high income neighborhoods, and they provide the same compassion to the homeless alcoholic as they would show to a new born child. EMT’s and Paramedics work eight, twelve, and twenty-four hour shifts. Over the course of any of these shifts they may deliver a child, hold then hand of an elderly patient fallen ill, or may have just left a scene of a tragic accident that has killed several teenagers on their prom night. They treat the patient whose heart has stopped, a baby, the victim of sudden infant death; and even though they have not forgotten about their last patient, they must now and do focus on your call for medical help.
Emergency Medical Technicians of all levels of training are your community’s unsung heroes.
Written by: David D.
Dave’s EMS Headquarters
Written: May 22, 2012