KEY CONCEPTS:
Upon completion of this topic, it is expected that the reader will understand these following concepts:
• The paradigm in EMS has shifted from ambulance transport to advanced prehospital care
• Emergency Medical Services are incorporated into all levels of public life: local, state, and national
• The EMS Agenda for the Future has redefined both the scope of practice and educational standards
CASE STUDY:
The Paramedics were at the squad building and the group of them stared at the invitation. The local Emergency Physician’s Advocacy Group had invited a Paramedic to their next meeting to speak on the history of paramedicine, its scope of practice, its educational requirements, and its role in the local healthcare system. Who would go and represent them to their physician colleagues and what would they say, everyone asked. One thing was for sure, they wanted to put their best foot forward.
OVERVIEW
What started out as the simple idea of transporting the sick or wounded to medical care has evolved into an integral component of our healthcare system in the United States. Its development—one that originated out of necessity—now plays a vital role in an ever-expanding system of health care. This topic will not only outline the history and progression of EMS but also identify what defines EMS practices. The evolution of EMS in the healthcare system prompted the development of an EMS Agenda for the Future that establishes a clear vision for the future of EMS. This vision has been implemented by means of national core content, a defined scope of practice, and educational standards. With knowledge of how the EMS system is constructed and an understanding of the origin of its various components, a Paramedic can better appreciate the responsibility and function they have in the healthcare system.
The Evolution of EMS
While medicine has been in existence since the beginning of recorded time, Emergency Medical Services (EMS) is a relative newcomer to the field of medicine. Modern EMS, with its specially trained EMS providers and a systems approach, is generally considered to have started in the late 1960s and early 1970s.1-3 From these early beginnings EMS, and specifically Paramedics, have rapidly developed into one of the newest allied healthcare professions.
A constant throughout the development of EMS is the close working relationship of EMS with other parts of the healthcare system, particularly the emergency department. Therefore, to understand the evolution of EMS it is important to first review the history of American health care.
Historical Evolution of American Health Care
Before the 1800s, health care was largely delivered by physicians who traveled by mule to the homes of the sick and injured. In its day that level of health care was satisfactory for the fledgling republic.
As cities grew during the 1800s, largely due to a dramatic influx of European and Asian immigrants, the demand for more public healthcare facilities escalated. Forward thinking physicians helped develop large urban hospitals to meet that demand. These hospitals (e.g., Massachusetts General in Boston and Bellevue in New York City) could care for hundreds of patients, and allowed economies of scale (savings made from bulk purchases), which in turn made health care affordable to vast legions of poor and underserved persons.
The physician in the 1800s, armed with only limited experience and even more limited education—or no formal education at all—dealt largely with infectious diseases. Many of these infectious disease outbreaks occurred because of overcrowding in inadequate housing and almost nonexistent sanitation systems.4,5
Revolution in the Laboratory
During the early and mid-1900s, discoveries in the laboratories brought about a revolution in medicine. Scientists used microscopes to identify the sources of many infectious diseases and developed crude but effective treatments—using the scientific method—to treat these diseases. Word of these medical breakthroughs was widely disseminated via journals such as the New England Journal of Medicine. The field of medicine began to change.
Almost overnight, county and state medical societies were created and physicians gathered to discuss new developments in medicine in a climate of openness that fostered more medical research and established the beginning of modern medicine.
Public Health Care Emerges
As great strides were being made against infectious disease, the delivery of health care also changed. For example, in 1906 St. Luke’s Hospital in New York City opened its first private pavilion. This change marked the beginning of a healthcare system.
Prior to that time there was no perceived advantage to having patients cared for in the hospital setting rather than in the home where patients could receive equally good care. However, after the turn of the century—with the advent of hospital laboratories equipped with powerful microscopes as well as expansive pharmacies filled with new cures— the hospital setting provided distinct advantages. These resources empowered the physicians to encourage patients to be admitted into the hospital. Soon hospital admission for illness, predominantly infectious diseases, became a public expectation.
Evolution of Medicine
Following World War II and the successful introduction of modern antibiotics, the incidence of infectious diseases was waning. For example, smallpox was being eradicated due to the use of a new vaccine. Soon chronic diseases, such as cancer, stroke, and heart disease, were replacing infection as the leading killers. As a result, medicine began to concentrate less on infectious diseases and more on chronic diseases. Also during this time the development of medical sciences (biology, pharmacy, etc.) blossomed and the biotechnology industry—the marriage of medical science and technology— emerged in the health care industry.
At the same time, the growth of widespread employer-provided health insurance permitted an increasing segment of the U.S. population to afford medical care. With the widespread availability of health insurance the healthcare industry was then firmly established.
Also beginning in the 1980s, medicine began to integrate information technologies such as computers, and other bio-medical devices, into healthcare. The advancement of pharmaceutical research had also taken on revolutionary new directions, including the development of new bioengineered drugs.
Partially as a result of the significant advances in medical science, healthcare costs have skyrocketed. For this reason the federal government, in part because of Medicaid and Medicare health programs, has taken a greater role in healthcare policymaking in an effort to curb rising healthcare costs.
Public Health Movement
Paralleling the advances in medicine, and the development of healthcare systems, was the public health movement. The public health movement started in the early 1800s as a result of the smallpox, yellow fever, and cholera epidemics that ravaged the larger cities.
During that time, quarantines and in-house confinement were the only effective means of preventing the further spread of disease. As a result of widespread illness, business and the manufacturing industries suffered and productivity was affected.
In order to temper the effect of illness and sick call outs on business a few wealthy patrons hired graduate nurses to care for the sick and the poor in Boston, Cincinnati, and Washington, DC. These nurses, referred to as community nurses, worked tirelessly in the ghettos and tenements of major cities trying to improve sanitation and decrease morbidity and mortality as a result of infectious disease.
Similar to modern-day Paramedics, these public health nurses would leave the safety of the hospital to go to workers’ homes and worksites. Some community nurses established clinics to advance sanitary practices in the home and improve maternal-child health, as infant mortality was particularly high in the inner cities. Lillian Wald, RN (Figure 2-1), an early social work pioneer, is credited with starting the Henry Street Settlement in New York City, a social services shelter, in 1793 and coining the term "Public Health Nurse."
Figure 2-1 Lillian Wald, RN, a pioneer in public health.
Public Health Service
The federal Public Health Service actually evolved out of the need for health care for the maritime fleet. The Public Health Service roots can be traced to the creation of the Marine Hospital Service in 1798. At that time, sailors paid 20 cents a month to fund the Marine Hospital Service. The service provided them with medical care if they should get sick away from home and while in a distant port of call. As the public health movement grew, and pressure mounted on the federal government to provide service to the poor, the Marine Hospital Service became the federal Public Health Service.
The federal Public Health Service is a key portion of the Department of Health and Human Services today. With 5,700 commissioned health services officers and 51,000 civilian employees, all led by the Surgeon General, the current United States Public Health Service provides support to county and state Public Health Departments as well as health care to medically underserved areas.
The United States Public Health Service (PHS) consists of eight agencies, including the National Institute for Health (NIH), the Food and Drug Administration (FDA), the Agency for Toxic Substances and Disease Registry (ATSDR), and the Centers for Disease Control and Prevention (CDCP).
Current challenges to public health, including Lyme disease, West Nile virus, SARS, Avian flu, and swine flu, to name a few, have placed a renewed emphasis on public health medicine.
The mission of EMS is now seen as being more in step with the Public Health Service than previously thought. Relationships between Paramedics and the Public Health Service’s physicians, nurses, scientists, and sanitarians are growing and evolving; especially in light of the threats of pandemic flu and natural disasters.
The History of Emergency Medical Service
The transportation of the sick and injured has seen many developments over the past millennium. The earliest examples may be seen in the Roman Empire. Romans would use chariots to move battle-injured soldiers from the battle field in the time of Caesar (100 A.D.). This innovation was followed by the first hammock-wagon, a wagon designed specifically for transporting the sick and injured, and a forerunner of the modern ambulance, but the hammock-wagon was not created until about 900 A.D. In their day these crude carriages and horse litters would carry one invalid patient to medical care at a distant physician, at a monastery, for example, but the long transfer over rough roads often proved to be more dangerous to the wounded patient than the original battlefield wound.
During the Spanish crusade of Ferdinand and Isabella against the Moors in the late fifteenth century, the use of ambulancias, or mobile military hospitals, came into being. These facilities, which were located closer to the battlefront, helped provide more immediate care to the wounded. As a result, this more timely medical intervention improved the chances for a soldier’s survival from battle wounds.
However, credit for the concept of the modern ambulance is generally given to Dominique-Jean Larrey of Baudean, France. A surgeon, Larrey got a great deal of his training treating victims of the French Revolution during his stay at the Hotel Dieu, the premier French hospital in Paris. Larrey, pressed into military service by the Prussians, was disturbed by the then-common practice of waiting for the battle to end before rescuing the wounded. Larrey went about creating a light carriage that could swoop into a battle, scoop up the wounded, and then rapidly transport them to the waiting surgeons at the "ambulance." Those light two-wheeled carriages that carried an attendant as well as a driver were called les ambulance volantes, or flying ambulances.
The American Civil War utilized what could be described as weapons of mass destruction, such as rapid fire or repeating rifles and devastatingly accurate cannon fire. These improved weapons caused greater casualties and put greater demands on battle surgeons. While casualties were greater, medical attention to these combat casualties improved and resulted in many advances in field care of wounded soldiers. And to respond to the mass casualties sustained during these military engagements, army surgeon Major Jonathan Letterman completely reorganized the military field medical service, called the Letterman plan, into what was to be the forerunner of the modern trauma system.
The Letterman plan called for "an act to establish a uniform system of ambulances in the Armies of the United States," and was ratified by the United States Congress in 1864. The act declared that ambulances were a special corp. that needed personnel, in distinctive special uniforms, who drove specially marked wagons, and answered to the head of the medical department of the army, a physician, and not the battlefield commander (Figure 2-2).
Figure 2-2 Civil War ambulance accepting patients.
As a result of the shear number of casualties and the horrible carnage of war there was a public outcry to control warfare. In 1864, a convention was held in Geneva, Switzerland, to "civilize" warfare. The result was the Geneva Treaty. Among its many precepts, the Geneva Treaty established the neutrality of all ambulance workers who wore the "Red Cross"—an icon created by the reversed colors of the Swiss flag created in honor of the Swiss, who hosted the convention. In 1882 the United States Congress ratified the Geneva Convention accords.
In keeping with the accords of the Geneva Treaty, and with the help of Clara Barton (Figure 2-3), the American Red Cross was formed and chartered by the Congress in 1881 "to provide volunteer aid in time of war to the sick and wounded of the armed forces."11,12
The American Red Cross differs from its European counterparts because it was active during peacetime as well as during war, responding during peacetime with disaster relief and humanitarian aid. Since the American Red Cross is not a government agency, it offers neutral humanitarian service to victims of war.
Around the same time as the appearance of the American Red Cross, hospital-based civilian ambulance services started to appear in the United States. The first hospital-based ambulance, the ambulance of the Commercial Hospital of Cincinnati (later Cincinnati General), was started in 1865, followed by Bellevue Hospital ambulance in 1869. By 1891 Bellevue Hospital’s ambulance had responded to 4,392 calls. Shortly thereafter, hospitals throughout New York City provided ambulances staffed with an ambulance driver and a surgeon in accordance with a plan advanced by Dr. Dalton. These ambulances responded to medical emergencies throughout the City of New York.
Figure 2-3 Clara Barton, founder of the American Red Cross.
The practice of prehospital care rapidly advanced as new technologies were created to deal with the unique environment encountered in the civilian world as well as on the battlefield. For example, the outbreak of World War I and the invention of the motorized ambulance coincided, improving both the quality and the speed of ambulance transportation. Another example is the splint created by Sir Hugh Owen-Thomas. Dr. Thomas invented an external fixation and traction splint, called the Thomas half-ring, which reduced the number of fatalities resulting from a traumatic fractured femur from roughly 80% to less than 20%.
The combination of advances such as the Thomas half-ring splint, rudimentary first aid treatments to stop bleeding, and the introduction of motorized ambulances substantially reduced battlefield mortality during World War I. These battlefield advances, which were also adopted for the civilian population, led to improved survival from trauma in general during the same time.
Emergence of Civilian EMS
After World War I, citizens started to see the importance of an organized emergency medical service and subsequently the first volunteer rescue squad was formed in Roanoke, Virginia. The Roanoke Rescue Squad, lead by Stanley Wise (Figure 2-4), started to provide emergency medical service to the citizens of Roanoke in 1921.
After early successes with this model, community-based rescue squads began to spring up across the country. Many of these "independent" rescue squads (i.e., not hospital-based or commercial ambulance services) sprang from local volunteer fire departments and heralded an era of volunteer ambulances.
Changing Paradigms
Before World War II, the ambulance was chiefly seen as an expedient means to get a patient to a hospital. Following the successes of army "para-medical" personnel during World War II and the advent of a new treatment for cardiac arrest called "cardiopulmonary resuscitation" or CPR, it became apparent that the ambulance driver might be able to provide more than just a fast ride.
In 1958, Dr. Peter Safar demonstrated the safety and efficiency of mouth-to-mouth ventilation, using trained Baltimore firefighters, on anesthetized medical residents. This idea of non-medical personnel performing medical procedures was revolutionary in its day. The introduction of the lifesaving CPR technique quickly intrigued the public.13-16
The "can do" attitude in America led organizations such as the American Red Cross and the American Heart Association to conduct mass CPR and first aid training for the public in firehouses and rescue squad buildings across the country. By 1960, firefighters in major cities like Columbus, Los Angeles, Seattle, and Miami, to name a few, were trained to provide CPR.
Figure 2-4 Julian Stanley Wise, founder of the first volunteer rescue squad.
Also in 1960, Asmund S. Laerdal, a Norwegian dollmaker, created the first "resusci-annie," a manikin for CPR practice. With an acceptable simulator/manikin, the American Red Cross and the American Heart Association began to train the public in vast numbers. CPR training, along with American Red Cross advanced first aid training, became the standard for ambulance drivers.
