The History of EMS

from the battlefield to the inner city Steve Davis, MD April 15, 2003

Early history
Around

the 1st century BC, Romans trained combat medics (armed with bandages) and dedicated transport for the wounded 900 A.D.: first recorded use of a wagon for transporting invalids
Anglo-Saxon hammock pulled by horses
1100:

Norman horse-litter 1300: English long wagon (whirlicote), pulled by a team of horses

Early ambulances
1487:

Queen Isabella of Spain at the siege of Malaga used ambulancias, bringing together surgical and medical supplies in a special tent for the wounded Charles V (her grandson) at the siege of Metz not battle wounds, killed most

1553:

Infection,

soldiers

Eighteenth Century
1718:

Jean Louis Petit invents the screw tourniquet, allowing amputations in the field 1740: John Pringle identifies typhus as the cause of jail fever, ship fever, and hospital fever (though he didnt know the organism) Few militaries had dedicated transport of wounded
Often several days to reach a hospital 1/3 of patients died in transit

th 18
Seriously

c. French Military

wounded were evacuated to a collection point outside the battlefield; hospital usually about 3 miles behind the front lines
Required lots of healthy manpower One ambulance (wagon) per 20,000 soldiers 24-36 hours for wounded soldiers to reach treatment

Percy
Surgeon-in-chief In

who organized litter bearers

retreat before the enemy there is no more frightful a spectacle than the evacuation of mutilated soldiers on big wagons; each jolt brings the most piercing cries. They have to suffer from rain, from suffocating heat or freezing cold and often do not have aid of food of any sort. Death would be a favor and we have often heard them begging it as a gift from heaven. 1792

Dominique-Jean Larrey
French naval surgeon who joined in 1792 Developed horse-drawn light carriage to bring wounded back from the front lines immediately (during battle) during Napoleonic Wars flying ambulances since they were placed with flying artillery Surgeons worked on the battlefield as well as field hospitals

Dominique-Jean Larrey
Performed

hip (1803)

first two field amputations at the

1 minute for a leg; 17 seconds for an arm

Larreys

amputation: a method of disarticulating the humerus at the shoulder joint Discovered that maggots helped clear up infections, and that a clean surgical wound was preferable to a dirty battle wound prior to transport

Dominique-Jean Larrey
First

to come up with triage system

Injury, not rank, decided who was transported first

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

Carriage for Cholera

George

Glover created it in 1832 Patient would lie on a moveable couch, which was kept warm by a mattress of heated salt (kept warm by a sand-bath)

Carriage for Cholera

The

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

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

Civil War
June

13, 1861: Lincoln approved an order creating the United States Sanitary Commission, which later became the Red Cross of the Civil War Bull Run: used two-wheeled ambulances nicknamed the avalanche
Driven by civilian drunkards and thieves

Jonathan Letterman
Jefferson

Medical College 1849 1862: medical director of the Army of the Potomac under Major General McClellan
Completely reorganized the field medical service Created effective mobile hospital organization Provided ambulance service for evacuation of casualties
After

Chancellorsville, Antietam, and Gettysburg, changes made throughout Union Army Fredericksburg 1862: 9,000 wounded transported, treated and hospitalized in 24 hours

Rucker Ambulance
Handled

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

1864
An

Act to Establish a Uniform System of Ambulances in the Armies of the United States
Separated Ambulance Transport from all other transport services Personnel and wagons should be specially marked

Geneva Convention -- 1864

Guarantees

the neutrality of hospitals, the sick and wounded, and those caring for them Also created the symbol of the Red Cross Ratified by the US in 1882, largely due to the efforts of Clara Barton

Paris Exhibition -- 1867

Large

collection of ambulances used by armies worldwide, with hands-on demos Dr. Thomas Evans, an American dentist, won the Grand Prix dHonneur for his display of tents, instruments, and railroad cars

First hospital ambulance service in the U.S.

Commercial

Hospital (now University of Cincinnati Hospital) started sometime before 1865 driver in 1866 made $360

Ambulance

Cincinnati paramedics now: ~$40,000

New York City

Bellevue Hospital started the first service in NYC in 1869

1870: 1401 ambulance calls (Manhattan 2002: 296,124 calls) 1891: 4392 calls (NYC 2002: 1,268,881 calls)

Supplies: 1 quart of brandy, 2 tourniquets, 6 bandages, 6 sponges, splints, blankets, and 2oz vial of persulphate of iron Stretcher, handcuffs and straight jacket for the insane

First motorized ambulance

Chicago

1899, for Michael Reese Hospital 1600 pounds, 16 mph, 2 hp electric motor

Oh, Canada!
Pallisers

Three Wheeled Ambulance

18 hp gasoline powered motor; 3-6mph Fully armored Motor could be disengaged and used to provide light for the passenger compartment

World War I
Transition

from horse-drawn to motorized ambulances

Model T

British Commer ambulance

World War I organization

Buddy-aid

treatment & field medics First aid stations 500-1000 yards behind regimental reserves (anti-tetanus serum) Field hospitals (via dedicated ambulance squads)
Urgent / emergent operations
Hospital

trains Larger hospitals in the rear

World War I advances

Traction

splint for femur fractures (Thomas, Blake, and Buck splints)

Mortality from 80% in 1914 to 7.3% in 1918

Buddy

aid (first aid on the front lines) Field medics

Big focus on prevention of shock
Tourniquets

and compression bandages

Germ

theory of disease helps support cleanliness efforts

WWI to WWII
No

organized EMS care in the country Great Depression halted any major civic initiatives

World War II
The

US Army formally organizes the ambulance company

World War II organization

Combat medics Aid stations 300-500

Clearing stations (morphine, Evacuation hospitals for less

Litter bearer to take patients further back

yards behind the front

plasma IV) seriously wounded

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

End of WWII saw the use of Portable Surgical Hospital in the Pacific Theater

hospitals (well in the rear)

World War II advances

Combat

medics

Care usually within first half-hour after wounding Included sulfa tablets and powder for immediate antibiotics
Litter

bearers dedicated to task Field hospitals Colonel Edward Churchill: shock related not only to fluid loss but also electrolyte loss

Korea
MASH

hospitals: take the care to the wounded (developed from PSH of WWII)
"You've gotta understand I'm not working on sick people here. I'm working on hurt young people, with essentially healthy bodies that have been insulted by ammunition." -- BJ Hunnicut, M*A*S*H (Mike Farrell)

Helicopter

evacuation

17,000 injured transported by helicopter

Vietnam

Vietnam
Further

development of field medics to reduce battlefield casualties

Necessary due to difficult terrain for evacuation More highly skilled than paramedics today

Helicopter

success

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

Post-Vietnam
Better

care as a victim of Viet Cong than if injured on a highway in the USA

White Paper establishes National Highway Traffic Safety Administration, which oversees creation of early EMS systems

Denver

becomes first city with air ambulance in 1972 (St. Anthonys Hospital)

EMS in L.A.
July

1969: First firefighter response to a medical call (in a rescue squad car)
Had to bring a nurse along Wedworth-Townsend Paramedic Act (signed by Gov. Ronald Regan in 1970) gave paramedics authority to practice under medical license of hospital MD Initially created to respond to cardiac arrest / heart attack calls
First

portable defibrillator weighed approximately 100 pounds

By

1974, paramedics trained to respond to multiple types of calls

Free 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 Life

Created

by NHTSA in 1977 after Red Cross complained about the widespread use of its symbol 6 points
Detection Reporting Response On Scene Care Care in Transit Transfer to Definitive Care

EMS today
Aggressive Evolution

golden hour philosophy

from as much care as possible in the field to quick interventions

Aspirin,

nitro, oxygen, lights (& sirens, maybe)

Military

surgeons training with civilian innercity trauma centers

Military Medicine in Iraq

Very

aggressive push to bring high levels of care to the front lines

Pressure dressings in all first aid kits, impregnated with fibrin and thrombin New anti-clotting compounds put directly on wounds (Marines doing research) Damage control surgery at the front lines
Operating

room set up in one hour

PDA-sized devices to do BMPs, handheld ultrasound

Civilian EMS future

Joint

military-civilian project testing videophone / headset cameras between treating paramedics and base station MDs (San Antonio) Blood analysis started in the field, with results on arrival to ED X-rays done prior to arrival

Other things to consider

EMS

has changed significantly, especially over the past 20 years

By far more sick calls than injured EMS and ERs being used for primary care

So,

can primary care be moved to EMS?

Paramedics as physician extenders Social services tied directly to EMS encounters

The End

Sources

Course Syllabus, Correspondence Course of the US Army Medical Department Center and School.
Downloaded from: http://www.au.af.mil/au/awc/awcgate/milmedhist/acv.htm

Barkley, Katherine Traver. The ambulance: the story of emergency transportation of sick and wounded through the centuries. Hicksville, N.Y.: Exposition Press, 1978. Kolata, G. (2003, March 30). Armed with New Tools and Tactics, Doctors Head to Battlefield. New York Times, p. B2.