Emergency care of the sick and wounded in the field has deep historical roots as far back as the ancient times when Roman soldiers were carried off the field of battle on their own shields or by chariots and wooden carts. Homer describes medical care being provided in the field by surgeons for those who were too badly injured to be moved. The Brothers of the Benedictine Monastery of Saint Mary Latina began providing care in ad 1080, and later as the Knights Hospitaller1 of the order of St John began rendering emergency medical care on the battlefield and evacuating the victims to a hospital for continued care. Historical references demonstrate stretcher movements of nonambulatory injured or sick persons in Native American North America, India, Egypt, and Europe throughout early history and into the more modern times.2 In the 15th century, King Ferdinand and Queen Isabella of Spain established deployable field hospitals called ambulancia. George Washington’s Continental Army possessed mobile field hospitals with organized systems for retrieving the wounded and delivering them to the field hospital for care. However, Napoleon’s surgeon, Dominique-Jean Larrey, is credited with creating one of the first most recognizable EMS systems, centered on his ambulance volante (or flying ambulance) that had been inspired by his observation that the injured waited long time periods without care and that the same basic cart design was a proven mode for rapidly moving artillery.
The American Civil War offered more experience with triage, field care, and movement to field hospitals for damage control medicine before movement to a hospital. Due to the success of this concept the US Congress passed “an act to establish a uniform system of ambulances in the United States” (also known as the Ambulance Corps Act) in 1864. During this time American hospitals began to develop their own ambulance services. World War I saw the use of motorized ambulances as a regular part of military operations. Despite the existence of ambulance services, and even rescue squads (like the Roanoke Life Saving Crew, Roanoke, VA, est. 1928), modern EMS in the United States did not take form until the late 1960s and early1970s. This chapter will focus on key events and developments in the evolution of modern EMS in the United States.
In 1864, President Abraham Lincoln signed into law “an act to establish a uniform system of ambulances in the United States.” Around the same time in Europe (1863) the Red Cross of Europe was founded. The 1860s would also see the first hospital-based ambulance services. The first civilian hospital-based ambulance service in the United States was founded at the Commercial Hospital (now Cincinnati General) in Cincinnati, Ohio, in 1865. Four years later, Bellevue Hospital began ambulance service in 1869 under the direction of Dr Dalton. These services provided transportation of patients to the hospital, however, little care was provided until they arrived. Although paramedics would not exist until the 1970s, the first civilian prehospital care system staffed by nonphysicians (who provided care) began operation in 1872 in England under the direction of a surgeon by the name of Major Peter Shepard. In 1877, this service became St Johns Ambulance Association. Boston City Hospital began operation of its own ambulance service in 1892 and the first automobile ambulance began operation out of Michael Reese Hospital in Chicago in 1899.
The 1900s saw the birth of air medical transport with one of the first air medical flights in1910 which took off from Fort Barrancas and unfortunately crashed after takeoff after about 500 yards of travel.3 In 1917, an injured English soldier was airlifted successfully in Turkey, and in 1918 two American officers successfully demonstrated the use of a modified Curtis JN-4 biplane for air medical evacuation.3 The US Army Air Corps designed and placed into service three air medical transport planes in 1929. These aircraft were designed to carry two patients and an attendant. Helicopters were placed in use in the Korean War for medical evacuation in 1951 and the value of this concept became apparent in both the military and civilian realms.
On the ground things had also been developing. During World War I (1914-1918), the US Army had assembled a fleet of motorized ambulances and in the civilian world, the first Rescue Squad known to have been formed in the United States was founded in Roanoke, Virginia. The Roanoke Life Saving Crew was formed in 1928. By 1939, the American Red Cross had nearly 5000 units and incorporated mobile aid units and training posts. These were typically manned by trained volunteers and had the ability to call upon local medical assets such as physicians and ambulances. By 1948 around 40,000 citizens were trained in First Aid by the American Red Cross.
In 1952, Dr Paul Zoll performed the first successful external electrical defibrillation at Beth Israel Hospital in Boston. This raised interest in the potential for improved responses to cardiac emergencies. In 1956, Drs Elan and Peter Zafar develop mouth-to-mouth resuscitation which further contributed to the interest in advancing emergency care. In 1959, Johns Hopkins developed the first portable defibrillator on record. These were some of the prerequisite elements needed to drive forward the early concept of prehospital medical care.
In 1960, Dr Zoll further developed the use of defibrillation when he demonstrated external electrical countershock and showed it could successfully terminate supraventricular tachycardia (SVT) and ventricular tachycardia (VTach). In that same year (1960), Drs Kouwenhoven, Knickerbocker, and Jude published their report on the use of cardiopulmonary resuscitation (CPR). Los Angeles County Fire Department, in an effort to advance care in the prehospital setting, equipped every fire engine, ladder truck, and rescue truck with a resuscitator in 1960, signifying a significant commitment to the idea of prehospital emergency care. The year 1965 marked a dubious epidemiological point in American history when it was found that more people died in automobile accidents (50,000) than in 8 years of armed conflict during the Vietnam War. In response to this fact, and due to growing concern for public safety, President Lyndon Johnson signed into law the National Highway Safety Act of 1965. In an interesting turn of events, just 5 years later (1970) President Johnson was, himself, a patient of a newly formed rescue squad while visiting his son-in-law in Charlottesville, Virginia. The Charlottesville-Albemarle Rescue Squad, under the medical direction of Dr Richard Crampton, was the first volunteer paramedic agency in the county. The now famous white paper on trauma and motor vehicle related deaths entitled “Accidental Death & Disability—The Neglected Disease of Modern Society” was published by the National Research Council in 1966 and sparked continued interest and political efforts to address the need for improved emergency care in the United States. The following government acts, including the EMS Systems Act of 1973, were intended to create research, funding, and regulatory structure for EMS systems in America and in many ways have helped shape the development of modern EMS since the 1970s.
In 1966, Dr Pantridge developed coronary care ambulances and showed improved survival in out-of-hospital cardiac arrest in Belfast, Ireland. He had developed a portable defibrillator and much of his published work focused on the acute management of cardiac injury and arrest (Figure 2-1). One paper in 1977 describing the energy needed to successfully defibrillate patients in ventricular fibrillation reported data including shocks delivered by a Pantridge portable defibrillator.
In 1967, the American Ambulance Association published an article that claimed that around 25,000 Americans had been left permanently disabled due to the improper care that they had received from undertrained prehospital providers. That same year the City of Miami (Miami, Florida) Fire Department began training paramedics in what would be the first of such programs in the United States. Dr Eugene Nagal championed the development of prehospital cardiac care advocating for CPR and developing first radio ECG telemetry program with the help of a colleague, Dr Jim Hirschmann. These transmitted ECGs demonstrated the presence of cardiac rhythms in the victims likely responsible for their death, further illustrating the need to bring defibrillation to the prehospital arena.
In 1968, just 2 years after Dr Pantridge introduced a similar concept, Dr Grace of St Vincent’s Hospital in New York City launched the United States’ first mobile coronary care units. The program was originally designed with ambulances staffed by physicians. The year 1968 also saw three other important events in the development of American EMS. The same year as St Vincent’s Hospital launched its new program, the American Telephone & Telegram Company (AT&T) began an initiative to systematically reserve the telephone digits 9-1-1 for planned use as a universal emergency number. At the same time, the state of Virginia made an important distinction recognizing ambulances and their unique role by establishing legislation regulating ambulances, required training, and providing permits for their use. And possibly what would prove to be the most significant pro-EMS event of 1968 and one that would help aid in the professional development of prehospital medicine was the establishment of the American College of Emergency Physicians.
In 1969, several other notable events related to the development of prehospital cardiac care were recorded. Dr Leonard Cobb from Harbor View Hospital in Seattle, Washington, formed a relationship with the Seattle Fire Department and together they developed the “Medic 1” program. They utilized firefighters with special training in a converted recreational vehicle that was equipped and dispatched from the hospital in response to calls for cardiac events. In Toronto, Canada, a program known as “Cardiac One” was established to provide advanced cardiac life support measures utilizing a hospital physician and a portable cardiac monitor. That same year, the Ohio State University Medical Center (Columbus, Ohio) placed a unit in service, staffed by three firemen and one physician, designed to respond to prehospital coronary events. The program was dubbed “The Heartmobile” and was later absorbed by the Columbus Division of Fire, then removing the physician from the standard crew (Figure 2-2). The Miami Fire Department (Miami, Florida) documented the first successful prehospital cardiac defibrillation in June 1969, resulting in the patient experiencing full recovery with normal neurological outcome at the time of hospital discharge. Notably, the Florida legislature passed 10-D-66 that same year, making the provision of prehospital emergency care legal under the laws of the State of Florida.
In 1972, the American public began to have some additional exposure to the concept of advanced prehospital care and the relationship with emergency “room” physicians through the popularization of the concept by the television program “Emergency!” featuring two Los Angeles County Fire Department paramedics and their prehospital exploits. The characters of Johnny Gage (Randolph Mantooth) and Roy DeSoto (Kevin Tighe), and their now famous Squad 51, graced the screens of American televisions from January 1972 until 1979 with 5 years of regular broadcasts and six 2-hour specials and introduced the “paramedic” to most Americans who had never heard the term. The show introduced some basic concepts surrounding the relatively new concept of paramedicine, including emergency medical dispatching, advanced life support, and on-line medical control as well as introducing some to the concepts of CPR and first aid, that many Americans had never seen much less had received training. At the start of broadcast there were only six paramedic-level units in the country and by the end of production there was one in every state.4
The first air medical evacuation in recorded history is that of a Serbian officer that was airlifted by the French Air Service during World War I. The French noted a reduction in battlefield mortality from 60% down to 10% using their fixed wing medical evacuation strategy. In 1917, a British soldier with a gunshot wound on his ankle made the trip to hospital in 45 minutes, when by ground the trip would have taken 3 days. In the 1920s, the French and English continued to experiment with military air medical evacuation. The French documented over 7000 air evacuations.5 The concept spread and became more widely adopted into the 1930s and World War II saw the first use of helicopters for the purpose, with the evacuation of three wounded British pilots by a US Army Sikorsky in Burma. The US Army continued use of helicopters in the Korean War and the French did as well in the First Indochina War. By the time the United States entered into the Vietnam War, medical corpsmen were incorporated into the air medical evacuation operation. This practice sparked the concept of civilian helicopter air medical programs and is a vital component of the military medical operation to this day.
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