Before you can fully understand this webpage and all of the issues facing the EMS you need to understand the rich and
complex history of ambulances and the Emergency Medical Service. It doesn't matter if you know everything about EMS,
or nothing at all this information will prove enlightening to everyone. As I researched this material for my website I
learned quite a bit about the history of EMS and I think you will too.

The History of the ambulance service (a precursor to the modern Emergency Medical Service) was born as a result of
numerous milestones throughout history. The ambulance service can be traced all the way back to the middle ages.
During the Crusades of the 11th Century, the Knights of Saint John received instruction in first-aid treatment from Arab
and Greek doctors. The Knights of Saint John then acted as the first emergency workers, treating soldiers on both sides
of the war on the battlefield and bringing in the wounded to nearby tents for further medical treatment. During this time it
had become common practice for small rewards to be paid to soldiers who treated and carried the wounded bodies of
other soldiers in for medical treatment.

In the year 1487 during the siege of Malaga in Spain, the next recorded use of an ambulance (horse drawn cart with
attendant) was used by the military. They were used to help remove wounded solders and civilians from the fields of
battle. However the first big leap in EMS came during the late 1700's. Napoleon Bonaparte appointed Baron
Dominique-Jean Larrey to develop the first medical patient care system for the French army. One of his findings was
that leaving wounded soldiers on the battlefield for several days increased the complications and suffering. This delay in
treatment resulted in needless deaths. "The remoteness of our ambulances deprived the wounded of the requisite
attention," he wrote. In 1797. Larrey then developed a method to send trained medical personnel into the field to
provide medical care to the wounded soldiers and to provide medical care en route to the field hospital. This action
increased their chances of survival and benefited Napoleon's conquest efforts. He designed a special carriage staffed
with medical personnel to access all parts of the battlefield. The carriage became known as the ambulance volante, or
flying ambulance.

Baron Larrey developed all of the precepts of emergency medical care that is used today by all modern EMS systems:

1) Rapid access to the patient by trained personnel.

2) Field treatment and stabilization.

3) Rapid transportation back to the medical facility, while providing medical care en
route.

Although removal of the wounded and dead from the battlefields has existed in some form since early Greek and Roman
times, Larrey can still be considered the "Father of Emergency Medical Services."

At the beginning of the 1860's the United States created the first field ambulance and attendant. The first recorded use
of a field ambulance and attendant was during the Civil War. During the U.S. Civil War, both sides attempted to emulate
the medical practices of the Napoleonic wars with little success. Lack of funding, government support, and dedicated
personnel initially prevented the development of an effective ambulance system. During the Second Battle of Bull Run in
August of 1862, on the Union side alone over 3000 wounded solders lay in the field for 3 days and 600 wounded
solders lay in the fields for over a week. James Brady and Walt Whitman reported that emergency medical facilities were
primitive and many wounded solders died in agony. At that time the ambulance service was being run by the
Quartermaster Corps. It was transferred to surgeon general Jonathan Letterman, MD, to organize and he reinstated all
of Larrey's concepts greatly increasing the survival rate of the wounded.

At the Geneva Convention of 1864 an agreement was developed among the European countries to recognize the
neutrality of hospitals, the sick and wounded, all persons involved in medical care, and ambulances. It provided safe
passage across battle lines for all medical and injured personnel. On August 22, 1864, the organization adopted for its
logo the reverse of the Swiss flag. The logo was a red cross on a white background. The name that they adopted was
the International Red Cross. By late 1865 the first civilian ambulance service in the nation was being run by The
Commercial Hospital of Cincinnati. Other ambulance services followed at Grady Hospital in Atlanta, and Charity Hospital
in New Orleans. In 1867 Major General Rucker won the"best of kind" for an ambulance that was adopted as the
regulation ambulance. It had extra springs on the floor, more elasticity to the stretchers, and improved ventilation.

By the late 1860's there was a major proliferation of ambulances throughout the United States. In late 1869 the first New
York City hospital-based ambulance service was established at Bellevue Hospital by Dr. Edward L. Dalton. In December
of 1869 the first month of operation of the ambulance service of the Free Hospital of New York (Bellevue) they ran a
total of 74 calls. In 1870 1466 calls were run. The Bellevue dispatch system was different from the dispatch used today.
A hospital worker rang a bell, which triggered a weight to fall, lighting the gas lamp to wake the physician and the driver.
It also caused the harness, saddle, and collar to drop on the horse and opened the stable doors. However, this
improved response and care was mostly limited to the larger cities in America.

During World War I and especially during World War II, the military medical corps proved their worth in field assessment
and early management of injured personnel. Although the military system of emergency care became well developed,
the development of a civilian system lagged far behind. In the mid 1950's, J.D. "Deke" Farrington, MD, FACS (the Father
of modern EMS), and others, questioned why the lessons learned by the military medical corps during World War II and
the Korean War could not be brought into the civilian community to improve the standard of civilian care. At that time,
emergency medicine and EMS were not what we know today.

In San Francisco, New York, New Orleans, and other American cities, interns were assigned to ambulances to provide
care for the victims of trauma and other conditions outside of the hospital. Most hospitals did not have a place to
manage emergencies. Some hospitals had set up an unstaffed "emergency room" at the back of the hospital. The
"ambulance driver" had to ring the doorbell beside the emergency room door so that the nurse could come down from
the ward to unlock the door. The nurse then checked the patient and called a physician from home if she thought that
the patient was really sick. (Did you ever wonder why modern emergency departments are in the rear of the hospital and
not out front? Tradition.) All the physicians on staff had to take turns "covering the Emergency Room." A patient
involved in a major wreck with multiple fractures, and perhaps a ruptured spleen or a head injury, might be seen by an
ophthalmologist or a dermatologist. Many physicians knew that they were ill prepared to handle trauma or a major
myocardial infarction, but there was no alternative at the time.

Until the concept arose that  non physicians could be trained to provide this kind of emergency care, the majority of the
pre-hospital care was merely transportation provided by the local mortuary. The victim was driven to the hospital in a
hearse with no one in the "patient compartment" except the patient and perhaps a family member. Many people began
to question the efficacy and even ethics of this transportation. When the paper titled "Accidental Death and Disability:
The Neglected Disease of Modern Society" was written by the National Academy of Sciences and the National Research
Council in 1966, it became apparent that much improvement could be made by changing the emergency vehicles
themselves and improving the training of EMT's, communications, record keeping, and the care provided upon arrival to
the facility.

At the Airlie House conference (May 1969) sponsored by the Committee on Trauma, American College of Surgeons and
Committee on Injuries, American Academy of Orthopedic Surgeons, "Recommendations for an Approach to an Urgent
National Problem" was written. This conference indicated that immediate attention and control were needed in the areas
of transportation and communication. Developing standards for ambulance design and equipment was recognized as
"painfully slow." Dr. Farrington and Dr. Sam Banks developed a trauma training school for the Chicago Fire Department
that served as the prototype of what later became the first EMT-Ambulance (EMT-A) training program. The task force
involved in the design of the program for the United States Department of Transportation (USDOT) included Deke
Farrington, Rocco Morando, Oscar Hampton, Walter Hoyt, Walter Hunt, Robert Oswald, Peter Safar, and Joseph Territo.

At the same time that the EMT-A training program was evolving, Eugene Nagle in Miami; Ron Stewart and Jim Page in
Los Angeles; John Waters in Jacksonville, Florida; Costas Lambrew in New York; Mark Vasu in Grand Rapids, Michigan;
Jim Warren in Columbus, Ohio; and others began to provide "paramedic care." Originally designed for cardiac patients,
all types of patients soon received the type of pre-hospital cardiac care developed by Pantridge and Geddes in Belfast,
Ireland. Small communities, such as Newton, Kansas, under the direction of Jim Werries, had developed a cardiac care
EMS service by the early 1970's, but these were isolated situations. Kansas was like many of the states during the
period that worked in isolation to develop a method of providing pre-hospital care for its citizens.

It was not until 1974 to 1975 that Kansas had the statewide program going at the basic level and partially evolved at the
EMT-Paramedic (EMT-P) level. The initial training program was called the Advanced Training Program of EMT. The
USDOT organized a subcommittee on ambulance services, which developed the standards on which this course was
based. Many of those leaders who have been identified were active in the development of this curriculum. Nancy
Caroline and her team at the University of Pittsburgh was awarded the contract from the USDOT to write the National
Standard Curriculum for the EMT-P. This modular training program included sections that then became the basis for the
EMT-Intermediate (EMT-I). Up until the late 1970's, most of the federal involvement came through the USDOT under the
leadership of Leo Schwartz and Robert Motley. A new EMS act was passed in 1976 that gave money and responsibility
to the U.S. Department of Health, Education, and Welfare. Chicago trauma surgeon David Boyd led this enactment,
which resulted in the development of state and local EMS regions throughout the United States.

The National Registry of EMT's (NREMT) was created shortly after the Airlie Conference. This organization was
responsible for registering EMT's based on completion of the USDOT standard EMT-A curriculum (and later the EMT-I
and EMT-P training). The NREMT developed written and practical examinations based on the objectives of these
courses to examine and register those who satisfactorily completed the examination process. Most states use the
NREMT's process in whole or in part as the basis for licenser. The "Star of Life" is a logo patented by the American
Medical Association in 1967. It represents the three rivers of life and the staff of Aesculapius. It was given to the NREMT
as the EMT logo. When Dawson Mills of the USDOT asked the American Red Cross to use the red cross as the EMS
logo for ambulances and was refused, he asked "Deke" Farrington if the USDOT could use the Star of Life on all
ambulances in the United States, and Farrington approved it. The six points of the star were named by Leo Schwartz.

The National Association of EMT's (NAEMT), was developed to represent EMT's at all levels. The state EMS directors
formed the National Association of State EMS Directors (NASEMSD) to share ideas and develop strategies for EMS
development across state lines. Another organization, the National Council of EMS Training Coordinators (NASEMSTC),
is also charged with sharing educational ideas across state lines. The National Association of EMS Physicians
(NAEMSP) was formed to provide leadership in medical direction of EMS services. This association is the focus of
activities, discussion, and meetings for physicians involved either full-or part-time in EMS. This very brief overview can
only mention a few of the highlights in the development of EMS in the United States. However, even this history
underscores how far EMS has evolved from its roots in European battlefields. On the next page you can see a timetable
of the History of EMS.