CHAPTER 1 History of EMS Robert R. Bass University of Maryland School of Medicine and Maryland Institute for EMS Systems, Baltimore, USA Before 1966: historical perspectives care. The Union Army trained medical corpsmen to provide treatment in the field; a transportation system, which included Early hunters and warriors provided care for the injured. railroads, was developed to bring the wounded to medical facil- Although the methods used to staunch bleeding, stabilize ities. However, the wounded received suboptimal treatment in fractures, and provide nourishment were primitive, the need for these facilities, stirring Clara Barton’s crusade for better care [7]. treatment was undoubtedly recognized. The basic elements of The medical experiences of the Civil War stimulated the prehistoric response to injury still guide contemporary EMS beginning of civilian urban ambulance services. The first were programs. Recognition of the need for action led to the established in cities such as Cincinnati, New York, London, and development of medical and surgical emergency treatment Paris. Edward Dalton, Sanitary Superintendent of the Board of techniques. These techniques in turn made way for systems of Health in New York City, established a city ambulance program communication, treatment, and transport, all geared toward in 1869. Dalton, a former surgeon in the Union Army, spear- reducing morbidity and mortality. headed the development of urban civilian ambulances to permit The Edwin Smith Papyrus, written in 1500 BC, vividly describes greater speed, enhance comfort, and increase maneuverability triage and treatment protocols [1]. Reference to emergency care on city streets [8]. His ambulances carried medical equipment is also found in the Babylonian Code of Hammurabi, where a such as splints, bandages, straitjackets, and a stomach pump, as detailed protocol for treatment of the injured is described [2]. In well as a medicine chest of antidotes, anesthetics, brandy, and the Old Testament, Elisha breathed into the mouth of a dead child morphine. By the turn of the century, interns accompanied the and brought the child back to life [3]. The Good Samaritan not ambulances. Care was rendered and the patient left at home. only treated the injured traveler but also instructed others to do Ambulance drivers had virtually no medical training. Our likewise [4]. Greeks and Romans had surgeons present during knowledge of turn-of-the-century urban ambulance service battle to treat the wounded. comes from the writings of Emily Barringer, the first woman The most direct root of modern prehospital systems is found in ambulance surgeon in New York City [9]. the efforts of Jean Dominique Larrey, Napoleon’s chief military Further development of urban ambulance services continued physician. Larrey developed a prehospital system in which the in the years before World War I. Electric, steam, and gasoline- injured were treated on the battlefield and horse-drawn wagons powered carriages were used as ambulances. Calls for service were used to carry them away [5]. In 1797 Larrey built “ambulance were generally processed and dispatched by individual hospi- volantes” of two or four wheels to rescue the wounded. Larrey had tals, although improved telegraph and telephone systems with introduced a new concept in military surgery: early transport signal boxes throughout New York City were developed to from the battlefield to the aid stations and then to the frontline connect the police department and the hospitals. hospital. This method is comparable to the way that modern phy- During World War I, the introduction of the Thomas traction sicians modified the military use of helicopters in Korea and splint for the stabilization of patients with leg fractures led to a Vietnam. Larrey also initiated detailed treatment protocols, such decrease in morbidity and mortality. Between the two world as the early amputation of shattered limbs to prevent gangrene. wars, ambulances began to be dispatched by mobile radios. In The Civil War is the starting point for EMS systems in the the 1920s, in Roanoke, Virginia, the first volunteer rescue squad United States [6]. Learning from the lessons of the Napoleonic was started. In many areas, volunteer rescue or ambulance and Crimean Wars, military physicians led by Joseph Barnes and squads gradually developed and provided an alternative to the Jonathan Letterman established an extensive system of prehospital local fire department or undertaker. After the entry of America Emergency Medical Oversight: Clinical Practice and Systems Oversight, Second Edition. Edited by David C. Cone, Jane H. Brice, Theodore R. Delbridge and J. Brent Myers. © 2015 NAEMSP. Published 2015 by John Wiley & Sons, Inc. Companion website: www.wiley.com\go\cone\NAEMSP 1 0002166629.indd 1 8/18/2014 2:27:11 PM 2 Chapter 1 into World War II, the military demand for physicians pulled nationwide, was heralded by a report generated by the National the interns from ambulances, never to return, resulting in Academy of Sciences National Research Council (NAS-NRC), a poorly staffed units and non-standardized prehospital care. non-profit organization chartered by Congress to provide Postwar ambulances were underequipped hearses and similar scientific advice to the nation. Accidental Death and Disability: vehicles staffed by untrained personnel. Half of the ambulances The Neglected Disease of Modern Society documented the enor- were operated by mortuary attendants, most of whom had never mous failure of the United States health care system to provide taken even a first aid course [10]. even minimal care for the emergency patient. The NAS-NRC Throughout the 1950s and 1960s, two geographic patterns of report identified key issues and problems facing the United ambulance service evolved. In cities, hospital-based ambulances States in providing emergency care (Figure 1.1). Its summary gradually coalesced into more centrally coordinated city wide pro- report listed recommendations that would serve as a blueprint grams, usually administered and staffed by the municipal hospital for EMS development, including such things as first aid training or fire department. In rural areas, funeral home hearses were spo- for the lay public, state-level regulation of ambulance services, radically replaced by a variety of units operated by the local fire emergency department improvements, development of trauma department or a newly formed rescue squad. Additionally, in both registries, single nationwide phone number access for emer- urban and rural areas, a few profit-making providers delivered gencies, and disaster planning [15]. This document established transport services and occasionally contracted with local a benchmark against which to measure subsequent progress government to provide emergency prehospital services and trans- and change. port. Before 1966, very little legislation and regulation applicable The 1966 NAS-NRC document described both prehospital to ambulance services existed. Providers had relatively little formal services and hospital emergency departments as being woefully training, and physician involvement at all levels was minimal. inadequate. In the prehospital arena, treatment protocols, A number of factors combined in the mid-1960s to stimulate a trained medical personnel, rapid transportation, and modern revolution in prehospital care. Advances in medical treatments led communications concepts, such as two-way radios and to a perception that decreases in mortality and morbidity were emergency call numbers, were all identified as necessities that possible. Closed-chest cardiopulmonary resuscitation (CPR), were simply not available to civilians. Although there were more reported as successful in 1960 by W.B. Kouwenhoven [11] and than 7,000 accredited hospitals in the country at the time, very Peter Safar [12], was eventually adopted as the medical standard for few were prepared to meet the increased demand that developed cardiac arrest in the prehospital setting. New evidence that CPR, between 1945 and 1965. From 1958 to 1970, the annual number pharmaceuticals, and defibrillation could save lives immediately of emergency department visits increased from 18 million to created a demand for physician providers of those interventions in more than 49 million [15]. In addition, emergency departments both the hospital and prehospital environments. Throughout the were staffed by the least experienced personnel, who had little 1960s, fundamental understanding of the pathophysiology of education in the treatment of multiple injuries or critical med- potentially fatal dysrhythmias expanded significantly. The use of ical emergencies. Early efforts of the American College of rescue breathing and defibrillation was refined by Peter Safar, Surgeons (ACS) and the American Academy of Orthopedic Leonard Cobb, Herbert Loon, and Eugene Nagel [13]. Safar per- Surgeons (AAOS) to improve emergency care were largely suaded many others that defibrillation and resuscitation were unsuccessful because medical interest was essentially non-exis- viable areas of medical research and clinical intervention. tent [16,17,18,19]. In 1966 Pantridge and Geddes pioneered and documented The 1966 NAS-NRC document was the first to recommend the use of a mobile coronary care unit ambulance for prehospi- that emergency facilities be categorized. It also emphasized tal resuscitation of patients in Belfast, Ireland. Their treatment aggressive clinical management of trauma, suggesting that local protocols, originally