third edition of Emergency Medical Services: Clinical Practice and Systems Oversight builds on the foundations of its predecessors: EMS Medical Directors Handbook (1989), Prehospital Systems and Medical Oversight (1994, 2002), and the first two editions of this book (2009 and 2015). As with the 2015 edition, this text is intended to be the primary textbook for EMS fellowship programs, structured around the 2019 version of the core content of EMS medicine [1], which forms the basis for the ABEM certification examination. The Appendix maps the current EMS fellowship core content to specific chapters for easy reference. Noting that the ABEM certification exam is written to help assure the qualifications of the minimally qualified EMS physician who has attained “proficiency in managing the breadth of clinical conditions and operational aspects encountered by EMS systems in non‐traditional healthcare settings [2]”, this text is written at the “essentials‐plus” level. The intent is to cover the essential material that the exam candidate needs to know, with additional detail in key areas.
We thank the dozens of authors who have generously donated their time and effort to this new edition, and the hundreds of authors and editors of the past editions, upon whose efforts this latest edition are built.
D Cone
J Brice
T Delbridge
B Myers
April 2021
References
1 1 Delbridge TR, Dyer S, Goodloe JM, et al. The 2019 core content of emergency medical services medicine. Prehosp Emerg Care. 2020; 24:32–45.
2 2 American Board of Emergency Medicine. Emergency medical services. Available at: https://www.abem.org/public/become‐certified/subspecialties/emergency‐medical‐services. Accessed February 22, 2021.
About the Companion Site
This series is accompanied by a companion website:
https://naemsp.org/career‐development/textbooks/textbook‐support‐3rd‐edition/
The website includes:
Videos
Note: The videos are clearly signposted throughout the book. Look out for
CHAPTER 1 History of emergency medical services
Jon R. Krohmer
Before 1966: Historical Perspectives
The true origins of the concept of prehospital emergency care may not be clear, but there is no doubt that this philosophy has existed for centuries. Early hunters and warriors provided care for the injured. Although the methods used to staunch bleeding, stabilize fractures, and provide nourishment were primitive, the need for treatment was undoubtedly recognized. The basic elements of prehistoric response to injury still guide contemporary emergency medical services (EMS) activities. Recognition of the need for action led to the development of medical and surgical emergency treatment techniques. These techniques in turn made way for systems of communication, treatment, and transport, all geared toward reducing morbidity and mortality.
The Edwin Smith Papyrus, written in 1500 BC, vividly describes triage and treatment protocols [1]. Reference to emergency care is also found in the Babylonian Code of Hammurabi, where a detailed protocol for treatment of the injured is described [2]. In the Old Testament, Elisha breathed into the mouth of a dead child and brought the child back to life [3]. The Good Samaritan not only treated the injured traveler but also instructed others to do likewise [4]. Greeks and Romans had surgeons present during battle to treat the wounded.
The most direct evidence of modern prehospital systems is found in the efforts of Jean Dominique Larrey, Napoleon’s chief military physician. Larrey developed a prehospital system in which the injured were treated on the battlefield before using horse‐drawn wagons to carry them away [5]. In 1797, Larrey built “ambulance volantes” of two or four wheels to rescue the wounded. He introduced a new concept in military surgery: early transport from the battlefield to aid stations and then to the frontline hospital. This method is comparable to the way that modern physicians modified the military use of helicopters in the Korean and Vietnam wars. Larrey also initiated detailed treatment protocols, such as the early amputation of shattered limbs to prevent gangrene.
The Civil War is the starting point for what we know as EMS systems in the United States [6]. Learning from the lessons of the Napoleonic and Crimean wars, military physicians led by Joseph Barnes and Jonathan Letterman established an extensive system of prehospital care. The Union army trained medical corpsmen to provide treatment in the field. A transportation system, which included railroads, was developed to bring the wounded to medical facilities. However, the wounded received suboptimal treatment in these facilities, stirring Clara Barton’s crusade for better care [7].
The medical experiences of the Civil War stimulated the beginning of civilian urban ambulance services. The first were established in cities such as Cincinnati, New York, London, and Paris. Edward Dalton, Sanitary Superintendent of the Board of Health in New York City, established a city ambulance program in 1869. Dalton, a former surgeon in the Union Army, spearheaded the development of urban civilian ambulances to permit greater speed, enhance comfort, and increase maneuverability on city streets [8]. His ambulances carried medical equipment such as splints, bandages, straitjackets, and a stomach pump, as well as a medicine chest of antidotes, anesthetics, brandy, and morphine. By the turn of the century, physician interns accompanied the ambulances. Care was rendered and often the patient was left at home. Ambulance drivers had virtually no medical training. Our knowledge of turn‐of‐the‐century urban ambulance service comes from the writings of Emily Barringer, the first woman ambulance surgeon in New York City [9].
Further development of urban ambulance services continued in the years before World War I. Electric, steam, and gasoline‐powered carriages were used as ambulances. Calls for service were generally processed and dispatched by individual hospitals, although improved telegraph and telephone systems with signal boxes throughout New York City were developed to connect the police department and the hospitals. In some cities, the first ambulances and hospitals, in fact, were developed as part of the police department [10]. During World War I, the introduction of the Thomas traction splint for the stabilization of patients with leg fractures led to a decrease in morbidity and mortality.
Between the two World Wars, ambulances began to be dispatched by mobile radios. In the 1920s, in Roanoke, Virginia, the first volunteer rescue squad was started. In many areas, volunteer rescue or ambulance squads gradually developed and provided an alternative to the local police department, fire department, or undertaker. In areas where medical resources were available, those ambulances were staffed with physicians, often interns. After the entry of America into World War II, the military demand for physicians pulled the interns from American ambulances, never to return, resulting in poorly trained staff and non‐standardized prehospital care. Postwar ambulances were underequipped hearses and similar vehicles staffed by untrained personnel. Half of the ambulances were operated by mortuary attendants, most of whom had never taken even a first aid course [11].
Throughout the 1950s and 1960s, two geographic patterns of ambulance service evolved. In cities, hospital‐based ambulances gradually coalesced into more centrally coordinated citywide programs, usually administered and staffed by the municipal hospital or fire department. In rural areas, funeral home hearses were sporadically replaced