FDNY*EMS (Still the best despite FDNY's gross incompetence)

THE HISTORY OF EMS

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 en

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), was dveloped 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

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 transportation.

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.