Digging into the history of Emergency Medical Services reveals details that were not found in the narratives used to describe how we came to be. With the opportunity as a public policy doctoral student, let me share what I have learned.
Out-of-Hospital Cardiac Arrest Research
Dr. Peter Safar conducted a number of experiments at John Hopkins University using expired-air ventilation with closed chest massage on human volunteers in the late 1950’s. “Closed-chest massage should be preceded and accompanied by pulmonary ventilation,” noting that the Baltimore City Hospital’s technique involved one operator inflating the lungs every five seconds, followed by a second operator providing four sternal compressions at one second intervals.
Closed chest massage was endorsed as in the United States as a:
- medical procedure in 1962
- reclassified as an emergency procedure in 1965
- Committee of Cardiopulmonary Resuscitation emphasized the A-B-C-D formula for resuscitation in 1966.
Baltimore City Fire Department Battalion Chief Martin McMahon encouraged his “ambulance men” to volunteer to be sedated so lung air exchange volumes could be determined when looking at different artificial ventilation techniques at John Hopkins University – including expired-air ventilation.
Out-of-hospital cardiac arrest research + The Great Society + federal response to traffic trauma = United States Emergency Medical Services
City “emergency” hospitals often included ambulance service at the start of the 20th century. (Burgess) Public safety organizations – police/fire/ambulance – got more involved in ambulance service after World War II. There was uneven coverage and levels of service.
Vince Robbins writes in Management of Ambulance Services that Miami was the first “nonphysician, mobile, advanced medical treatment service in America.” This determination is based, in part, on articles published in medical scientific journals describing out-of-hospital cardiac arrest research results.
Doctor Eugene Nagel developed a 54-pound defibrillator in Miami that was as effective as John Hopkin’s original 1959, 200-pound, portable defibrillator. The first out-of-hospital resuscitation from ventricular fibrillation occurred in Miami in June 1969.
United States EMS is a child of the Great Society
The Great Society was an ambitious series of policy initiatives, legislation and programs spearheaded by President Lyndon B. Johnson (D) with the main goals of ending poverty, reducing crime, abolishing inequality and improving the environment.
The first federal funding for EMS was $16M from the newly formed Division of Emergency Medical Services within the Department of Health Education and Welfare (DHEW) in 1972 to create demonstration projects in five states.
Congress passes the 1973 EMS Systems Act that provided a 5-year $454M Great Society grant program that funded the creation of more than 300 regional EMS systems. Funding was also provided for EMS feasibility studies, planning, operations, expansion and improvement, and research. In 1974 there was also a $15M Robert Wood Johnson Foundation grant that supported development of 44 EMS systems. (Shah)
Traffic Trauma
The 1966 National Academy of Sciences report on “Accidental Death and Disability” results in federal funding to establish Emergency Medical Services (EMS) as a component of the National Highway Safety Act of 1966.
A component of the National Highway Safety Act of 1966 was the improvement of emergency ambulance and rescue service to traffic collisions. This was assigned to the mission of the National Highway Traffic Safety Administration (NHTSA) within the Department of Transportation. This component included the development of a national EMS education curriculum. (Institute of Medicine)
Pittsburgh’s Hill District
The Hill District is a Pittsburgh neighborhood that often would not get the police ambulance to respond to emergency calls.
- Freedom House Enterprises was a community non-profit using grants to create African-American owned businesses
- Reached out to create a commercial ambulance service to cover the Hill and Oakland Districts
- Partnered with Presbyterian-University Hospital
Dr. Peter Safar, now working at Presbyterian-University Hospital in Pittsburgh, accepted 44 residents of the Hill district through Freedom House Enterprises in 1967. They took a 9-month training program at Presbyterian-University Hospital that included classroom and clinical rotations.
Twenty six students completed the paramedic-level training (EMT II). Paramedic ambulance service started June 16, 1968. Miami and Los Angeles County Fire Department paramedics started responding to emergencies one year later. Seattle two years later
There is a different focus between the Freedom House paramedics and the Seattle, Miami and Los Angeles programs. As a grant-funded community development project, the Freedom House paramedics started running calls as the primary caregiver from the very first day. The paramedics in Seattle, Miami and Los Angeles, because they were in a clinical research project, responded to emergencies with a nurse or physician on the unit during the first year or so. All of the paramedic programs included physician review of calls, with feedback on their clinical performance and case management.
Freedom House is the source of the National Standard Curriculum for Paramedics
The National Highway Transportation Safety Administration (NHTSA) developed the National Standard Curricula outline using University of Pittsburgh/Freedom House 300 hour “EMT II” training program as template. I recall pages of concept and practice bullet-point lists for each of the 15 modules.
University of Pittsburgh Presbyterian-University Hospital contracted with the National Highway Traffic Safety Administration in 1975 to write a paramedic textbook based on the outline. Nancy Caroline, M.D., was the primary author and Walt Stoy, Ph.D./paramedic, was the principal investigator.
NHTSA projected that a textbook to be available by late August 1977. Something happened. Instead of getting 25 textbooks I was buying a “blue line” pre-publication manuscript from the Government Printing Office. I needed the manuscript to develop study guides for a paramedic course. Emergency Care In The Streets was eventually published in 1979 by Little Brown.
Freedom House Ambulance 1967-1975
Freedom House Ambulance staffed five ambulances to serve the Hill and Oakland Districts, averaging 6,000 responses a year. A 1971 University Hospital study compared “inappropriate care” delivered by the two ambulance services. The police ambulances, staffed with Advanced First Aid credentialed caregivers, delivered inappropriate care 62% of the time, Freedom House ambulances, staffed with University Hospital trained EMT and EMT II’s, delivered inappropriate care 11% of the time. (Edwards)
Matthew Edwards is a physician who researches the intersection of medical history, ethics and public policy. His look into the history of Freedom House includes identifying the situations that lead to its demise:
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In 1975 the Freedom House caregivers were paid at a much lower rate than the police, firefighters and “superambulance” personnel. Few of the Freedom House caregivers were able to thrive as employees in the city-operated EMS system. They were required to be “retrained” as city ambulance attendants.
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Safar P, Brown TC, Holtey WJ, Wilder RJ. (1961) Ventilation and circulation with closed-chest cardiac massage in man. Journal of the American Medical Association. 176:574-576.
Safar P, Escarraga LA, Elam JO. (1958) A comparison of the mouth-to-mouth and mouth-to-airway methods of artificial respiration with the chest pressure arm-lift methods. New England Journal of Medicine. 258:671–7
Rasmussen, FN. (2005 February 13) Chief Martin McMahon, 94, first-aid pioneer. The Baltimore Sun. Accessed September 8, 2020: https://www.baltimoresun.com/news/bs-xpm-2005-02-13-0502130054-story.html
Burgess, G. (2018, April 30) Early Days of the San Francisco Emergency Service: From the Police Infirmary to Mission Emergency. Brought to Light, UCSF Archives and Special Collections. Accessed January 30, 2021: https://blogs.library.ucsf.edu/broughttolight/2018/04/30/early-days-of-the-san-francisco-emergency-service/
Robbins, V. (2015) “The History of Ambulance Services and Medical Transportation Systems in the United States” in Kirkwood, S., ed. Management of Ambulance Services. Boston: Pearson/Brady. ISBN 978-0-13-503829-2
Zeitz, J. (2018) Building the Great Society: Inside Lyndon Johnson’s White House. New York: Penguin Books. ISBN 9780698191594
Committee on Trauma and Committee on Shock (1966) Accidental Death and Disability: The Neglected Disease of Modern Society. Washington DC: National Academy of Sciences/National Research Council.
Shah M. N. (2006). The formation of the emergency medical services system. American Journal of Public Health, 96(3), 414-23.
Committee of the Future of Emergency Care in the United States Health System, Board on Health Care Services (2007) Emergency Medical Services at the Crossroads. Washington DC: Institute of Medicine of the National Academies Press. ISBN 978-0-309-10174-5
Staresinic, C. (2004 February) Send Freedom House! Nobody has seen ambulance attendants like these before. PITTMED Vol 6, No 1. pp 32-34 Accessed September 14, 2020: https://www.pittmed.health.pitt.edu/Feb_2004/PittMed.pdf
Edwards, M. L. (2019) Pittsburgh’s Freedom House Ambulance Service: The Origins of Emergency Medical Services and the Politics of Race and Health. Journal of the History of Medicine and Allied Sciences 74(4) pp. 440-466. doe: 10.1093jhmas/jrz041