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 Historical references demonstrate stretcher movements of nonambulatory injured or sick persons in Native American North America, India, Egypt, and Europe throughout early history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.
Discuss key historical points in the evolution of EMS.
Name key leaders and their contributions.
Name key organizations and their contributions.
Discuss the evolution and changing role of the EMS physician.
Describe historical milestones for EMS physicians.
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.
DEVELOPMENT OF ADVANCED PREHOSPITAL CARE
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.
Pantridge defibrillator. (Reprinted with permission from National EMS Museum.)
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.
The Heartmobile. (Reprinted with permission from Central Ohio Fire Museum.)
PARAMEDICINE IN THE MEDIA
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.
Although civilian air medical evacuation had existed around the world since the 1920s, the United States did not see civilian air medical service until 1947. J Walter Schaefer started the program as an additional component of the Schaefer Ambulance Service in Los Angeles, California, and was the first FAA-certified air ambulance program. Prior to the point, air medical evacuation was typically based out of wilderness and remote locations and was done out of pure necessity. In the late 1960s, in response to the increasing interest in helicopter-based medical evacuation born of the military experience, the federal government funded two research programs to access the concept of civilian air medical helicopter programs.6 Project CARESOM was based in Mississippi in three separate communities (Figure 2-3). The project was found to be a success; however, only one of the sites chose to continue operation after completion of the project. In doing so, Hattiesburg, Mississippi, became the site of the first civilian medical helicopter program in the country.5 In 1969, the second demonstration project, based out of Fort Sam Houston in San Antonio, began operation by utilizing military aircraft to augment the civilian EMS system. The Military Assistance to Safety and Traffic (MAST) program was deemed a successful project and local governments recognized the value of employing helicopters in their EMS systems based on these results.
Mississippi State University CARE-SOM FH1100 helicopter. (Reprinted with permission from FH1100 Manufacturing Corp.)
Flight for Life Colorado was the first hospital-based air medical helicopter program in the United States, beginning operation in 1972 out of St Anthony Central Hospital in Denver, Colorado. In 1977, the Ontario Ministry of Health began operation of a helicopter service in Toronto with a predominantly paramedic-based staffing and has grown to a service of over 30 aircraft.5 Air medical programs are now a standard, yet many times debated, component of EMS systems in the United States.
LEGISLATING THE MODERN EMS SYSTEM
In 1960, John F. Kennedy stated that: “Traffic accidents constitute one of the greatest, perhaps the greatest, of the nation's public health problems.”2 This was one of the first public acknowledgments by the government for the need for improved organization, regulation, and funding of EMS from the federal government. In 1965, when Medicare was created by the Congress, funding for EMS as part of the reimbursement model was included. This was a key feature in the development of the system. In 1966, following the final report of the President's Commission of Highway Safety, President Lyndon Johnson's administration supported passage of what would become the National Highway Safety Act (Public Law 89-564) outlining the standards for the development of the EMS System in each state. Previously created by the National Traffic and Motor Vehicle Safety Act (Public Law 89-563), the National Traffic Safety Agency was merged with the National Highway Safety Advisory Committee (from Public Law 89-564) to form one body that was then moved under the newly formed Department of Transportation and was now overseen by Dr William J. Haddon, Jr.
President Richard Nixon's administration also contributed to the early development when in 1972 the Department of Health, Education and Welfare's (DHEW) EMS Division was focused on a more health care– oriented approach to the issues. Under the direction of Dr David R. Boyd, the Division of EMS provided funding to more than 300 demonstration projects across the United States.2 These programs and structure were the result of the EMS Systems Act of 1973 (Public Law 93-154) and were enacted under President Gerald Ford, who appointed Dr Boyd to his position.
PHYSICIANS IN RECENT EMS HISTORY
Throughout the recent history of EMS there are many important individuals who have contributed greatly to the development of this field. Many of these individuals are not noted here; however, this listing is meant to provide some prospective on the importance of the contributions of individual physicians. These individuals are listed in alphabetical order.
Dr Bledsoe was born in 1955 and became an EMT in 1974 and a paramedic in 1976. As an EMS physician he has contributed much to the literature and to provider education. He is the principal author of Paramedic Care: Principles & Practice, Essentials of Paramedic Care, Intermediate Emergency Care: Principles & Practice, Critical Care Paramedic, Anatomy & Physiology for Emergency Care, Prehospital Emergency Pharmacology, and Pocket Reference for ALS Providers. Dr Bledsoe stands out because of his place in modern EMS education, as well as his ability to communicate important EMS medicine concepts to physicians, EMS providers, other health care providers, and to lay people. He is an internationally recognized and cited EMS physician.7
Dr Boyd began his career as a resident in surgery at Cook County where he and his colleagues sought to improve the management of gunshot wounds and automobile trauma. He became the Illinois State EMS Medical Director and oversaw the development of a comprehensive trauma system that coordinated prehospital and hospital assets from 1970 to 1974. Under his leadership the program realized successful improvements in communication and utilization of more advanced staffing on ground and air ambulances. In 1974, Boyd was appointed to oversee the Department of Health Education and Welfare EMS Division by President Ford. Under his direction a “wall-to-wall” nation-wide EMS system began to take shape. In addition, Dr Boyd successfully advocated for EMS to President Ford, resulting in the White House conferences on EMS and the declaration of EMS Week. He served in the office until 1981 when the position was dissolved in favor of state-administered block grant programs.
NANCY CAROLINE, MD (1944-2002)
Dr Caroline started her career in EMS during her training in critical care medicine under Dr Peter Safar at the University of Pittsburg. Safar had begun work on the Freedom House Ambulance Service and much of the responsibility of organization and training of participants to become paramedics was delegated to Dr Caroline. She excelled at paramedic education and authored a textbook to suite the unique curriculum and scope of practice entitled Emergency Care in the Streets. She was a courageous field provider and innovator. In addition to her work in the United States, she had also been a bush doctor in Africa and after leaving in the States in 1976 became one of the most influential individuals in the development of EMS in Israel. She worked with prehospital programs, developed terrorism medical response tactics, and served as the medical director of Magen David Adom. Her textbook for paramedics was the only dedicated educational text on the topic for a decade and is still one of the most well known to this day.8
In many ways Seattle is considered one of the epicenters of EMS advancement in the United States. One of the key figures in the development of that reputation is Dr Leonard Cobb. In 1967, Dr Cobb was practicing cardiology in Seattle when he learned of the work of Dr Frank Pantridge at the Royal Victoria Hospital in Belfast, Ireland. In an effort to bring this new prehospital cardiac intensive care concept to Seattle, he worked with colleagues to bring about a paramedic training program based on the fire service that could provide similar advance cardiac care in the field. The resulting program developed by the University of Washington, Harborview Medical Center, and the Seattle Fire Department began serving King County under the name Medic One.9
Physicians practicing (and holding board certification in) EMS medicine have a number of key people to thank for the academic and political development of the subspecialty. One of the key concerns during the development of the subspecialty of EMS medicine was a lack of organized scientific productivity. In addition to his publications in peer-reviewed journals on EMS specific topics he also served to guide others in academic productivity in the field. Some of his notable positions from which he effectively served in this role have been as the editor-in-chief of the NAEMSP textbook, project leader for the development of the NAEMSP proposal that was used to petition the American Board of Emergency Medicine (ABEM) to pursue subspecialty board recognition, and also as the editor-in-chief of Academic Emergency Medicine. Dr Cone has provided significant mentorship to young EMS physicians in training and also served as the president of NAEMSP during a critical time in the development of the subspecialty. Dr Cone was the first chair of the Council of EMS Fellowship Directors.10
Dr Richard Crampton had worked with Dr William Grace who had founded the mobile coronary care unit at St Vincent's Hospital in Manhattan and he had taken the time to visit Dr Pentridge personally in order to better understand program developed there in Belfast, Ireland. He successfully implemented these concepts in Charlottesville, Virginia, and in doing so by 1971 the Charlottesville Rescue Squad was trained and certified in CPR and became the nation's second all-volunteer mobile coronary care unit. They operated in a rural environment. Dr Crampton's program did require a physician to respond in order to utilize the advanced coronary care concept.11
Dr Criley is credited with founding the Los Angeles County Paramedic Program in 1969 at the time he served as the Chief of the Division of Cardiology at Harbor—UCLA medical center. One of his chief accomplishments was convincing medical and public safety stakeholders as well as politicians that a well-designed prehospital coronary care program could be performed by paramedics. Recognizing legislative shortfalls he successfully petitioned state government, including the then governor Ronald Reagan, to approve legislation making it legal for paramedic personnel to provide advanced level coronary care in the prehospital environment.12
Dr Fletcher, along with Dr Ernie Goodwin, is credited with forming the nation's very first paramedic-level volunteer rescue squad. The Haywood County volunteer rescue squad became a paramedic-level service offering advanced coronary care and the prehospital setting in 1969.13,14
In addition to participating in the formation of the National Association of EMS physicians he also served as one of the early presidents of the organization. He has contributed as an author and as an editor for a number of textbooks. He has worked diligently to develop multidisciplinary training programs for providers and educators at all levels in the fields of EMS, disaster medicine, tactical medicine, and emergency medicine.15,16
WILLIAM GRACE, MD (-1974)
Dr William Grace is credited with founding the nation's first mobile coronary unit based on the program started in Belfast, Ireland, by Dr Pantridge. The program was based out of St Vincent's Hospital and Medical Center in New York. Dr Grace and his associate Dr John Chadbourn recognized the potential for improve survival if cardiac patients could be reached with advanced care in a more immediate fashion. In 1968, St Vincent's first mobile coronary care unit went into service in a van with a driver and attended, an attending physician, a resident physician, an emergency room nurse, an ECG technician, and a student nurse observer. The vehicle carried a portable battery power to defibrillator/ monitor, electrocardiograph, intravenous kit with drugs, and a resuscitation/oxygen kit. It was noted that it could take up to 25 to 30 minutes to reach the patient; however, the effect of the program's prehospital cardiac care was published with a reported reduction in mortality from 21% down to 8%.2 Many consider this first American version of the mobile coronary care unit concept to have directly inspired the development of such programs around the country.17,18
Dr Lewis is credited with participating in the development of the Heartmobile along with Dr James Warren. The City of Columbus Fire Services along with the Ohio State University Medical Center developed the Heartmobile paramedic program in 1969.13
Dr Mc Swain is best known for his work as a trauma surgeon. However, while on faculty at the University of Kansas he helped develop paramedic education and push for the development of the EMS system. At the time of his move to Tulane in New Orleans, he was credited with helping bring about the evolution of the Kansas EMS system to a point where 90% of citizens were covered by paramedic response in less than 10 minutes. While working with stakeholders in New Orleans he was selected to develop a comprehensive emergency medical services system for the city. This led to the introduction of BLS and ALS prehospital provider education and the development of a citywide EMS system. During his work with the American College of Surgeons Committee on Trauma (ACS-COT) he noted gaps in the education of prehospital providers as part of the trauma care team care team and was enlisted to help develop the Pre-Hospital Trauma Life-Support (PHTLS) program, a joint venture between the ACS-COT and the National Association of Emergency Medical Technicians (NAEMT).19
Dr Nagel is credited as being one of the first physicians to recognize that there was a potential impracticality to basing out of hospital coronary care on response of the physician to the field. Working with Miami-Dade fire officials and a cardiologist colleague, Dr Hirschman, to develop a system by which paramedics could transmit an ECG to the hospital and receive voice medical control by a physician. They enlisted the help of a little known company in developing their telemetry package with a defibrillator into a unit known as the Physio-Control LifePak 33. Although the LifePak device required redesign to allow for the rugged field environment, coupling this concept together with fire rescue personnel taught to defibrillate, provide intravenous medications, and advanced airway techniques proved to be a workable combination. At that time, however, there was no legal authority for them to implement their new paramedic skill set. It has been reported that Dr Nagel actually went to the city manager's office and allowed his newly trained paramedics to intubate him in the office to prove their skill set. Ultimately Dr Nagel was able to spearhead the creation of a law (10-D-66) in the state of Florida that made it illegal for paramedics perform the skills and is considered the cornerstone for EMS law in that state. Dr Nagel was also successful in advocacy at the national level and was one of the key individuals who petitioned successfully for the passage of the EMS Systems Act.20,21
FRANK PANTRIDGE, MD (1916-2004)
In one very important way it could be said that Dr Pantridge is in fact the father of prehospital advanced coronary care. Dr Pantridge was a cardiologist working at Royal Victoria Hospital in Belfast, Ireland, when he determined that it would be most appropriate to deliver electrical therapy and advanced coronary care in the prehospital setting rather than delaying care until arrival at the hospital. In order to accomplish this, he developed a portable mobile defibrillator 1965. This was integrated into a prehospital care team which Pantridge then studied and published in the Lancet in 1967. The first prehospital advanced coronary care units in the United States were based on Pantridge's program.22
Dr Pepe is an outspoken and prolific academic and lecturer in EMS medicine. He has held numerous prestigious positions, but is well known for his work to develop and popularize many of the clinical concepts focal to our understanding of modern prehospital care. Dr Pepe has been cited as authoring over 400 published papers and abstracts and has provided high-level medical direction in multiple major systems. He coordinates the Eagles Consortium, comprised of medical directors for the nation's major metropolitan areas. He has provided mentorship and leadership to numerous EMS and emergency medicine physicians and is considered by many to be the chief expert on EMS physician interaction with the media.23
Dr Perina is a notable EMS physician and educator who has served since 1999 as the EMS fellowship director at the University of Virginia. She has contributed greatly to the development of the subspecialty through her work at NAEMSP and as the president of the American Board of Emergency Medicine (ABEM). Her leadership was critical during the development of the application to the American Board of Medical Specialties (ABMS) to create the new subspecialty. Her mentorship and guidance (along with other key members of the EMS physician community) in the development of the subspecialty and training program certification process has led to the realization of ACGME-accredited fellowship training programs and board certification.24
PETER SAFAR, MD (1923-2003)
Dr Safar is credited with popularizing the important concepts of CPR and developing the “ABCs” of resuscitation. In 1956, he and Dr James Elan invented mouth-to-mouth resuscitation after demonstrating the effectiveness of mouth-to-mouth rescue breathing through a series of experiments on human volunteers who had been paralyzed. He also advocated for and effectively showed that laypeople could serve as the initial prehospital rescuers for CPR. He partnered with Asmund Laerdal, who at the time was a doll maker, in the development of the initial (and now internationally recognized) prehospital cardiac training tool, Resusci Anne. Dr Safar is also credited with the successful development of one of the first modern ambulances, which he identified as a required replacement for the hearses and station wagons that were being used at the time. While working in the Baltimore system he trained fire department rescuers to add intubation skills to their CPR technique. He developed standards for emergency medical technician education and initiated the Freedom House Enterprise Ambulance Service in Pittsburgh in 1967. In 1976, he cofounded the World Association for Disaster and Emergency Medicine and in 1979 founded the International Resuscitation Research Center. He was nominated three times the Nobel Prize in Medicine.25
Dr Stewart, although a now famous contributor to the development of emergency medicine and EMS medicine, began his career as a general practitioner in Neil's Harbour, Nova Scotia. After completing his training in emergency medicine he became the founding medical director of the Los Angeles County paramedic program and served that community until accepting a position in Pittsburgh, Pennsylvania, where he was the founding director of the Center for Emergency Medicine and the medical director of the Department of Public Safety of the City of Pittsburg. This program soon became one of the preeminent centers for the development of EMS medicine in the country. He eventually returned to Canada and continued to develop his role in the political landscape of health care after taking up a post at Dalhousie University. In 1993, Dr Stuart became a member of the Nova Scotia legislature and was eventually appointed as the Minister of Health and Registrar General for the province until 1996. Dr Stewart's influence on the development of EMS medicine is evidenced by many publications and the productivity of his former students and colleagues in various areas of emergency medicine and EMS.26,27
Like many of the former presidents of the National Association of EMS Physicians, Dr Swor has provided significant academic contributions to the field. He has been politically active in his advocacy for the development of EMS medicine and serves as an advisor to multiple key stakeholder organizations, including the National Highway Traffic Safety Administration and the American Heart Association.28 His book on quality improvement was one of the first publications to address this area of medical direction in an organized and detailed fashion. He remains one of the most prominent EMS educators in the country.
Dr Warren of Columbus Ohio participated in the early development of advanced out-of-hospital coronary care through collaboration with the Ohio State University and the Columbus Division of Fire. In 1969, the Heartmobile program was initiated. The program included three firefighters and the physician responding in the Heartmobile from the hospital.29 In 1971, it was apparently clear to Dr Warren that the firefighters could be trained to operate the Heartmobile without the on-scene presence of the physician. On July 1, 1971, the Columbus vision division of fire took over Heartmobile operations.
PAUL M. ZOLL, MD (1911-1999)
In 1952, Dr Zoll published his work on the use of “external electrical stimulation” (transcutaneous pacing). In 1956, he and his colleagues published the paper detailing the successful termination of ventricular fibrillation with “electric countershock” (transcutaneous defibrillation) and in the same year developed an oscilloscope-based cardiac monitor with built-in audible alerts. Dr Zoll is also credited with advancing the concept of using countershock (electrocardioversion) as a viable alternative to antidysrhythmic medications in the termination of dysrhythmias.
KEY PROFESSIONAL ORGANIZATIONS
A number of organizations have contributed to the evolution of modern emergency medical services in the United States and beyond. The International Association of Fire Chiefs (IAFC) was founded in 1873 as the National Association of Fire Engineers. The IAFC has a long history of advocacy and the development of standards and guidelines for fire and EMS operations and has supported the development of a number of other EMS organizations throughout the development of EMS systems and the evolution of the practice of prehospital emergency care. The National Registry of EMTs (NREMT) was formed in 1970 in response to President Lyndon Johnson's Committee on Highway Traffic Safety recommended the creation of a national certification agency. The NREMT focuses on the development and proliferation of national standards for education of EMS providers. The American Ambulance Association (AAA) was founded in 1979 and has contributed much to the early studies and more to ongoing political advocacy and the creation of industry guidelines. The American College of Emergency Physicians (ACEP), founded in 1968, was the primary voice of the new specialty of emergency medicine and spearheaded to creation of the specialty in 1979. Much of the unique nature of emergency medicine was tied directly to the developing prehospital emergency care in the nation.30 The National Association of Emergency Medical Technicians (NAEMT) was founded in 1975 and served to provide significant educational programs to prehospital providers, including Pre-Hospital Trauma Life Support (PHTLS) and Advanced Medical Life Support (AMLS).31 NAEMT has a strong advocacy mission and supports political and scientific advancement in the field. The National Association of State EMS Officials (NASEMSO) was formed in 1980 and focuses on formation and development of policy and standards relating to oversight of EMS systems across the country. The Society for Academic Emergency Medicine (SAEM) was formed from University Association for Emergency Medicine (UAEM) and the Society of Teachers of Emergency Medicine (STEM) in 1989 and was instrumental in development of EMS Medicine fellowship curricula and funding of EMS research.32 National Association of EMS Physicians (NAEMSP) was founded in 1984 to represent a peer group of EMS physicians and to devise key resources to serve the EMS community. This organization has developed research, education, and advocacy programs that have had major influence in the evolution of EMS in North America and beyond. NAEMSP was a lead organization in the development of the proposals that ultimately led to the EMS Medicine board certification under ABMS and the advent of ACGME accreditation for EMS Medicine fellowship programs. The National Association of EMS Educators (NAEMSE) was founded in 1995 and is dedicated to the development of resources and advocacy directed at support EMS educators.33
In 1864, President Abraham Lincoln signed into law “an act to establish a uniform system of ambulances in the United States.”
In 1966, Dr Pantridge developed coronary care ambulances and showed improved survival in out-of-hospital cardiac arrest in Belfast, Ireland.
In 1968, Dr Grace of St Vincent's Hospital in New York City launched the United States' first mobile coronary care units.
In 1965, funding for EMS as part of the reimbursement model was included in Medicare.
In 1966, following the final report of the President's Commission of Highway Safety, President Lyndon Johnson's administration supported passage of what would become the National Highway Safety Act (Public Law 89-564).
The American College of Emergency Physicians (ACEP) was founded in 1968.
In 1973, the EMS Systems Act (Public Law 93-154) was enacted under President Gerald Ford.
National Association of EMS Physicians (NAEMSP) was founded in 1984.
JA. The mobile coronary care unit. Dis Chest. June 1969;55(6):452-455.