The History of EMSThe History of EMS

from the battlefield to from the battlefield to the inner citythe inner city

Steve Davis, MDSteve Davis, MDApril 15, 2003April 15, 2003

Early historyEarly history

►Around the 1Around the 1stst century BC, Romans century BC, Romans trained combat medics (armed with trained combat medics (armed with bandages) and dedicated transport for bandages) and dedicated transport for the woundedthe wounded

►900 A.D.: first recorded use of a wagon 900 A.D.: first recorded use of a wagon for transporting “invalids”for transporting “invalids” Anglo-Saxon hammock pulled by horsesAnglo-Saxon hammock pulled by horses

►1100: Norman horse-litter1100: Norman horse-litter►1300: English long wagon (whirlicote), 1300: English long wagon (whirlicote),

pulled by a team of horsespulled by a team of horses

Early ambulancesEarly ambulances►1487: Queen Isabella of Spain at the 1487: Queen Isabella of Spain at the

siege of Malaga used siege of Malaga used ambulanciasambulancias, , bringing together surgical and medical bringing together surgical and medical supplies in a special tent for the supplies in a special tent for the woundedwounded

►1553: Charles V (her grandson) at the 1553: Charles V (her grandson) at the siege of Metzsiege of Metz

► Infection, not battle wounds, killed most Infection, not battle wounds, killed most soldierssoldiers

Eighteenth CenturyEighteenth Century

►1718: Jean Louis Petit invents the screw 1718: Jean Louis Petit invents the screw tourniquet, allowing amputations in the tourniquet, allowing amputations in the fieldfield

►1740: John Pringle identifies typhus as the 1740: John Pringle identifies typhus as the cause of jail fever, ship fever, and hospital cause of jail fever, ship fever, and hospital fever (though he didn’t know the organism)fever (though he didn’t know the organism)

►Few militaries had dedicated transport of Few militaries had dedicated transport of woundedwounded Often several days to reach a hospitalOften several days to reach a hospital 1/3 of patients died in transit1/3 of patients died in transit

1818thth c. French Military c. French Military

►Seriously wounded were evacuated to Seriously wounded were evacuated to a collection point outside the a collection point outside the battlefield; hospital usually about 3 battlefield; hospital usually about 3 miles behind the front linesmiles behind the front lines Required lots of healthy manpowerRequired lots of healthy manpower One ambulance (wagon) per 20,000 One ambulance (wagon) per 20,000

soldierssoldiers 24-36 hours for wounded soldiers to reach 24-36 hours for wounded soldiers to reach

treatmenttreatment

PercyPercy► Surgeon-in-chief who organized litter Surgeon-in-chief who organized litter

bearersbearers

► ““In retreat before the enemy there is no In retreat before the enemy there is no more frightful a spectacle than the more frightful a spectacle than the evacuation of mutilated soldiers on big evacuation of mutilated soldiers on big wagons; each jolt brings the most piercing wagons; each jolt brings the most piercing cries. They have to suffer from rain, from cries. They have to suffer from rain, from suffocating heat or freezing cold and often suffocating heat or freezing cold and often do not have aid of food of any sort. Death do not have aid of food of any sort. Death would be a favor and we have often heard would be a favor and we have often heard them begging it as a gift from heaven.” them begging it as a gift from heaven.” 17921792

Dominique-Jean LarreyDominique-Jean Larrey

► French naval surgeon French naval surgeon who joined in 1792who joined in 1792

► Developed horse-drawn Developed horse-drawn light carriage to bring light carriage to bring wounded back from the wounded back from the front lines immediately front lines immediately (during battle) during (during battle) during Napoleonic WarsNapoleonic Wars

► ““flying ambulances” flying ambulances” since they were placed since they were placed with “flying artillery”with “flying artillery”

► Surgeons worked on Surgeons worked on the battlefield as well the battlefield as well as field hospitalsas field hospitals

Dominique-Jean LarreyDominique-Jean Larrey►Performed first two field amputations Performed first two field amputations

at the hip (1803)at the hip (1803) 1 minute for a leg; 17 seconds for an arm1 minute for a leg; 17 seconds for an arm

►Larrey’s amputation: a method of Larrey’s amputation: a method of disarticulating the humerus at the disarticulating the humerus at the shoulder jointshoulder joint

►Discovered that maggots helped clear Discovered that maggots helped clear up infections, and that a clean surgical up infections, and that a clean surgical wound was preferable to a dirty battle wound was preferable to a dirty battle wound prior to transportwound prior to transport

Dominique-Jean LarreyDominique-Jean Larrey

► First to come up with triage systemFirst to come up with triage system Injury, not rank, decided who was transported firstInjury, not rank, decided who was transported first

"To prevent the evil consequences of leaving "To prevent the evil consequences of leaving soldiers who are severely wounded without soldiers who are severely wounded without assistance, we placed the ambulances as near assistance, we placed the ambulances as near as possible to the line of battle, and establish as possible to the line of battle, and establish headquarters to which all the wounded who headquarters to which all the wounded who require delicate operations are collected to be require delicate operations are collected to be operated on by expert surgeons." operated on by expert surgeons."

Carriage for CholeraCarriage for Cholera

►George Glover created it in 1832George Glover created it in 1832►Patient would lie on a moveable couch, Patient would lie on a moveable couch,

which was kept warm by a mattress of which was kept warm by a mattress of heated salt (kept warm by a sand-heated salt (kept warm by a sand-bath)bath)

Carriage for CholeraCarriage for Cholera

► ““The curative process commences the instant The curative process commences the instant the patient is put in the carriage; time is saved the patient is put in the carriage; time is saved which can be given to the care of the patient; which can be given to the care of the patient; the patient may be driven to the hospital so the patient may be driven to the hospital so speedily that the hospitals may be less speedily that the hospitals may be less numerous and located at greater distances numerous and located at greater distances from each other, and removed from a crowded from each other, and removed from a crowded part of the town to a more wholesome locality part of the town to a more wholesome locality so that the medical attendants will be less so that the medical attendants will be less exposed to contagion.”exposed to contagion.”

--J. Knapp in a letter to the editor of the --J. Knapp in a letter to the editor of the London London Medical GazetteMedical Gazette (1832) (1832)

Civil WarCivil War

► June 13, 1861: Lincoln June 13, 1861: Lincoln approved an order approved an order creating the United States creating the United States Sanitary Commission, Sanitary Commission, which later became the which later became the Red Cross of the Civil WarRed Cross of the Civil War

► Bull Run: used two-Bull Run: used two-wheeled ambulances wheeled ambulances nicknamed “the nicknamed “the avalanche”avalanche” Driven by civilian drunkards Driven by civilian drunkards

and thievesand thieves

Jonathan LettermanJonathan Letterman

► Jefferson Medical College 1849Jefferson Medical College 1849► 1862: medical director of the Army of the 1862: medical director of the Army of the

Potomac under Major General McClellanPotomac under Major General McClellan Completely reorganized the field medical serviceCompletely reorganized the field medical service Created effective mobile hospital organizationCreated effective mobile hospital organization Provided ambulance service for evacuation of Provided ambulance service for evacuation of

casualtiescasualties

► After Chancellorsville, Antietam, and Gettysburg, After Chancellorsville, Antietam, and Gettysburg, changes made throughout Union Armychanges made throughout Union Army

► Fredericksburg 1862: 9,000 wounded Fredericksburg 1862: 9,000 wounded transported, treated and hospitalized in 24 hourstransported, treated and hospitalized in 24 hours

Rucker AmbulanceRucker Ambulance

►Handled both Handled both recumbent (4) and recumbent (4) and ambulatory patients ambulatory patients (8-10)(8-10)

18641864

►““An Act to Establish a Uniform System An Act to Establish a Uniform System of Ambulances in the Armies of the of Ambulances in the Armies of the United States”United States” Separated Ambulance Transport from all Separated Ambulance Transport from all

other transport servicesother transport services Personnel and wagons should be specially Personnel and wagons should be specially

marked marked

Geneva Convention -- 1864Geneva Convention -- 1864

► Guarantees the Guarantees the neutrality of neutrality of hospitals, the sick hospitals, the sick and wounded, and and wounded, and those caring for those caring for themthem

► Also created the Also created the symbol of the Red symbol of the Red CrossCross

► Ratified by the US in Ratified by the US in 1882, largely due to 1882, largely due to the efforts of Clara the efforts of Clara BartonBarton

Paris Exhibition -- 1867Paris Exhibition -- 1867

► Large collection of Large collection of ambulances used by ambulances used by armies worldwide, armies worldwide, with hands-on demoswith hands-on demos

► Dr. Thomas Evans, Dr. Thomas Evans, an American dentist, an American dentist, won the won the Grand Prix Grand Prix d’Honneurd’Honneur for his for his display of tents, display of tents, instruments, and instruments, and railroad carsrailroad cars

First hospital ambulance service First hospital ambulance service in the U.S.in the U.S.

►Commercial Hospital (now University Commercial Hospital (now University of Cincinnati Hospital) started of Cincinnati Hospital) started sometime before 1865sometime before 1865

►Ambulance driver in 1866 made $360Ambulance driver in 1866 made $360 Cincinnati paramedics now: ~$40,000Cincinnati paramedics now: ~$40,000

New York CityNew York City► Bellevue Hospital Bellevue Hospital

started the first service started the first service in NYC in 1869in NYC in 1869 1870: 1401 ambulance 1870: 1401 ambulance

calls (Manhattan 2002: calls (Manhattan 2002: 296,124 calls)296,124 calls)

1891: 4392 calls (NYC 1891: 4392 calls (NYC 2002: 1,268,881 calls)2002: 1,268,881 calls)

► Supplies: 1 quart of Supplies: 1 quart of brandy, 2 tourniquets, brandy, 2 tourniquets, 6 bandages, 6 6 bandages, 6 sponges, splints, sponges, splints, blankets, and 2oz vial blankets, and 2oz vial of persulphate of ironof persulphate of iron

► Stretcher, handcuffs Stretcher, handcuffs and straight jacket for and straight jacket for the insanethe insane

First motorized ambulanceFirst motorized ambulance

► Chicago 1899, for Michael Reese HospitalChicago 1899, for Michael Reese Hospital► 1600 pounds, 16 mph, 2 hp electric motor1600 pounds, 16 mph, 2 hp electric motor

Oh, Canada!Oh, Canada!

►Palliser’s Three Wheeled AmbulancePalliser’s Three Wheeled Ambulance 18 hp gasoline powered motor; 3-6mph18 hp gasoline powered motor; 3-6mph Fully armoredFully armored Motor could be disengaged and used to Motor could be disengaged and used to

provide light for the passenger provide light for the passenger compartmentcompartment

World War IWorld War I► Transition from horse-drawn to motorized Transition from horse-drawn to motorized

ambulancesambulances

Model T British Commer ambulance

World War I organizationWorld War I organization

►Buddy-aid treatment & field medicsBuddy-aid treatment & field medics►First aid stations 500-1000 yards behind First aid stations 500-1000 yards behind

regimental reserves (anti-tetanus serum)regimental reserves (anti-tetanus serum)►Field hospitals (via dedicated ambulance Field hospitals (via dedicated ambulance

squads)squads) Urgent / emergent operationsUrgent / emergent operations

►Hospital trainsHospital trains►Larger hospitals in the rearLarger hospitals in the rear

World War I advancesWorld War I advances

►Traction splint for femur fractures Traction splint for femur fractures (Thomas, Blake, and Buck splints)(Thomas, Blake, and Buck splints) Mortality from 80% in 1914 to 7.3% in 1918Mortality from 80% in 1914 to 7.3% in 1918

►Buddy aid (first aid on the front lines)Buddy aid (first aid on the front lines)►Field medicsField medics

Big focus on prevention of shockBig focus on prevention of shock►Tourniquets and compression bandagesTourniquets and compression bandages

►Germ theory of disease helps support Germ theory of disease helps support cleanliness effortscleanliness efforts

WWI to WWIIWWI to WWII

►No organized EMS care in the countryNo organized EMS care in the country►Great Depression halted any major Great Depression halted any major

civic initiativescivic initiatives

World War IIWorld War II

► The US Army formally organizes the The US Army formally organizes the ambulance companyambulance company

World War II organizationWorld War II organization

► Combat medicsCombat medics► Aid stations 300-500 yards behind the frontAid stations 300-500 yards behind the front

Litter bearer to take patients further backLitter bearer to take patients further back► Clearing stations (morphine, plasma IV)Clearing stations (morphine, plasma IV)► Evacuation hospitals for less seriously Evacuation hospitals for less seriously

wounded (on rail, 15-30 miles back)wounded (on rail, 15-30 miles back)► Field hospitals for critical cases (around 10 Field hospitals for critical cases (around 10

miles back)miles back) End of WWII saw the use of Portable Surgical End of WWII saw the use of Portable Surgical

Hospital in the Pacific TheaterHospital in the Pacific Theater►General hospitals (well in the rear)General hospitals (well in the rear)

World War II advancesWorld War II advances

►Combat medicsCombat medics Care usually within first half-hour after Care usually within first half-hour after

woundingwounding Included sulfa tablets and powder for Included sulfa tablets and powder for

immediate antibioticsimmediate antibiotics►Litter bearers dedicated to taskLitter bearers dedicated to task►Field hospitalsField hospitals►Colonel Edward Churchill: shock related Colonel Edward Churchill: shock related

not only to fluid loss but also electrolyte not only to fluid loss but also electrolyte lossloss

KoreaKorea

►MASH hospitals: take the care to the MASH hospitals: take the care to the wounded (developed from PSH of WWII)wounded (developed from PSH of WWII) "You've gotta understand I'm not working on "You've gotta understand I'm not working on

sick people here. I'm working on hurt young sick people here. I'm working on hurt young people, with essentially healthy bodies that people, with essentially healthy bodies that have been insulted by ammunition." have been insulted by ammunition." -- BJ Hunnicut, M*A*S*H (Mike Farrell)-- BJ Hunnicut, M*A*S*H (Mike Farrell)

►Helicopter evacuationHelicopter evacuation 17,000 injured transported by helicopter17,000 injured transported by helicopter

VietnamVietnam

VietnamVietnam

►Further development of field medics to Further development of field medics to reduce battlefield casualtiesreduce battlefield casualties Necessary due to difficult terrain for Necessary due to difficult terrain for

evacuationevacuation More highly skilled than paramedics todayMore highly skilled than paramedics today

►Helicopter success Helicopter success Radio dispatching very effectiveRadio dispatching very effective Wound Wound treatment 35-40 minutes treatment 35-40 minutes 1969: >200,000 casualties transported by air1969: >200,000 casualties transported by air

Post-VietnamPost-Vietnam

►Better care as a victim of Viet Cong Better care as a victim of Viet Cong than if injured on a highway in the USAthan if injured on a highway in the USA ““White Paper” establishes National White Paper” establishes National

Highway Traffic Safety Administration, Highway Traffic Safety Administration, which oversees creation of early EMS which oversees creation of early EMS systemssystems

►Denver becomes first city with air Denver becomes first city with air ambulance in 1972 (St. Anthony’s ambulance in 1972 (St. Anthony’s Hospital)Hospital)

EMS in L.A.EMS in L.A.► July 1969: First firefighter response to a July 1969: First firefighter response to a

medical call (in a rescue squad car)medical call (in a rescue squad car) Had to bring a nurse alongHad to bring a nurse along Wedworth-Townsend Paramedic Act (signed by Wedworth-Townsend Paramedic Act (signed by

Gov. Ronald Regan in 1970) gave paramedics Gov. Ronald Regan in 1970) gave paramedics authority to practice under medical license of authority to practice under medical license of hospital MDhospital MD

Initially created to respond to cardiac arrest / Initially created to respond to cardiac arrest / heart attack callsheart attack calls►First “portable” defibrillator weighed approximately 100 First “portable” defibrillator weighed approximately 100

poundspounds

► By 1974, paramedics trained to respond to By 1974, paramedics trained to respond to multiple types of callsmultiple types of calls

Free AdvertisingFree Advertising

Emergency!1971-1976

At the start of the show, there were only 12 medic units in the entire country. Four years later at least 50% of the population of this country was within 10 minutes of a medic unit.

The Star of LifeThe Star of Life► Created by NHTSA Created by NHTSA

in 1977 after Red in 1977 after Red Cross complained Cross complained about the about the widespread use of widespread use of its symbolits symbol

► 6 points6 points DetectionDetection ReportingReporting ResponseResponse On Scene CareOn Scene Care Care in TransitCare in Transit Transfer to Transfer to

Definitive CareDefinitive Care

EMS todayEMS today

►Aggressive golden hour philosophyAggressive golden hour philosophy

►Evolution from as much care as possible Evolution from as much care as possible in the field to quick interventionsin the field to quick interventions

►Aspirin, nitro, oxygen, lights (& sirens, maybe)Aspirin, nitro, oxygen, lights (& sirens, maybe)

►Military surgeons training with civilian Military surgeons training with civilian inner-city trauma centersinner-city trauma centers

Military Medicine in IraqMilitary Medicine in Iraq

►Very aggressive push to bring high Very aggressive push to bring high levels of care to the front lineslevels of care to the front lines Pressure dressings in all first aid kits, Pressure dressings in all first aid kits,

impregnated with fibrin and thrombinimpregnated with fibrin and thrombin New anti-clotting compounds put directly New anti-clotting compounds put directly

on wounds (Marines doing research)on wounds (Marines doing research) ““Damage control” surgery at the front linesDamage control” surgery at the front lines

►Operating room set up in one hourOperating room set up in one hour PDA-sized devices to do BMPs, handheld PDA-sized devices to do BMPs, handheld

ultrasoundultrasound

Civilian EMS futureCivilian EMS future

► Joint military-civilian project testing Joint military-civilian project testing videophone / headset cameras videophone / headset cameras between treating paramedics and base between treating paramedics and base station MDs (San Antonio)station MDs (San Antonio)

►Blood analysis started in the field, with Blood analysis started in the field, with results on arrival to EDresults on arrival to ED

►X-rays done prior to arrivalX-rays done prior to arrival

Other things to considerOther things to consider

►EMS has changed significantly, EMS has changed significantly, especially over the past 20 yearsespecially over the past 20 years By far more “sick” calls than “injured”By far more “sick” calls than “injured” EMS and ERs being used for primary careEMS and ERs being used for primary care

►So, can primary care be moved to EMS?So, can primary care be moved to EMS? Paramedics as physician extendersParamedics as physician extenders Social services tied directly to EMS Social services tied directly to EMS

encountersencounters

The EndThe End

SourcesSources

► Course Syllabus, “Correspondence Course of the US Army Course Syllabus, “Correspondence Course of the US Army Medical Department Center and School.” Medical Department Center and School.” Downloaded from: Downloaded from:

http://www.au.af.mil/au/awc/awcgate/milmedhist/acv.htmhttp://www.au.af.mil/au/awc/awcgate/milmedhist/acv.htm

► Barkley, Katherine Traver. The ambulance: the story of Barkley, Katherine Traver. The ambulance: the story of emergency transportation of sick and wounded through the emergency transportation of sick and wounded through the centuries. Hicksville, N.Y.: Exposition Press, 1978.centuries. Hicksville, N.Y.: Exposition Press, 1978.

► Kolata, G. (2003, March 30). Armed with New Tools and Kolata, G. (2003, March 30). Armed with New Tools and Tactics, Doctors Head to Battlefield. Tactics, Doctors Head to Battlefield. New York Times, New York Times, p. B2.p. B2.