History of EMS

During the late 1700's, Napoleon Bonaparte appointed Baron Dominique-Jean Larrey to develop the medical patient care system for the French army. One of findings was that leaving wounded soldiers on the field for several days increased the complications and suffering. He felt that 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 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 used today: 1) rapid access to the patient by trained personnel, 2) field treatment and stabilization, and 3) rapid transportation back to the medical facility, while 4) providing medical care en route. 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."

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 prevented the development of an effective system. During the Second Battle of Bull Run in August of 1862, on the Yankee side alone 3000 wounded lay in the field for 3 days and 600 wounded lay for 1 week. James Brady and Walt Whitman reported that facilities were primitive and many wounded died in agony. At that time the ambulance service was run by the Quartermaster Corps. It was transferred to surgeon general Jonathan Letterman, MD, to organize. He reinstated Larrey''s concepts.

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.

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.

The first ambulance service in the United States was created in Cincinnati in 1865 at Cincinnati General Hospital. This service still operated in the fire department. Other services followed at Grady Hospital in Atlanta, Charity Hospital in New Orleans, and several hospitals in New York City and other major cities. In December of 1869 the first month of operation of the ambulance service of the Free Hospital of New York (Bellevue) ran 74 calls. A total of 1466 calls were run in 1870. The dispatch system was different from that used today. The hospital ran a bess, 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 care was mostly limited to the larger cities.

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.

Until the concept arose that no 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 Orthopaedic 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 prehospital 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 prehospital 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 licensure.

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.

Author: Norman E. McSwain, Jr.