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An illustrated history of paramedics in their first decade in the U.S.A.
By James O. Page, 1979
More than a title, the world of the paramedic is recognition that traditional forms of emergency care were not adequate. That reality had been demonstrated abroad many years before paramedics were prepared for advanced prehospital care in the United States.
Before the mid-sixties, American emergency care was presumed to commence when the patient arrived at a hospital. Thus, prehospital activities concentrated on speedy transportation. The ambulance vehicles of that era were long, low, streamlined and powered for rapid transit. This and other traditional concepts in emergency care and transportation came under strong attack from many quarters.
For example, between 1963 and 1966, committees on trauma, shock and anesthesia and special task forces of the Division of Medical Sciences, National Academy of Sciences-National Research Council (NAS-NRC) reviewed the then current status of initial care and emergency medical services afforded to victims of accidental injury. The product of their combined studies was the classic document, Accidental Death and Disability: The Neglected Disease of Modern Society.5
The NAS-NRC report, released in September 1966 presented a sordid picture of emergency care in the United States generally, but gave special critical attention to the topic of ambulances and ambulance attendants. "There are no generally accepted standards for the competence or training of ambulance attendants," the report said. "Attendants range from unschooled apprentices lacking training even in elementary first aid to poorly paid employees, public-spirited volunteers and specially trained full-time personnel of fire, police or commercial ambulance companies."
Reflecting the thinking and experience of the time, the report neither foresaw the usefulness nor recommended the establishment of paramedic-operated mobile intensive care units (MICUs). "Calls for ambulance services should be screened by a responsible agent under medical supervision so that when medical attendance is required, a physician can be dispatched and an ambulance properly equipped to his needs made available immediately," stated the report. Among the recommendations of the NAS-NRC report was the following: "Pilot programs [are needed] to determine the efficacy of providing physician-staffed ambulances for care at the site of injury and during transportation."
Several months later, in April 1967, the American Medical Association (AMA) conducted the National Conference on Emergency Medical Services at Chicago. In his keynote address, Dr. Wesley Hall quoted heavily from the NAS-NRC report and said that it "superbly summarizes the current status of the various levels of emergency care."
At the AMA conference, speakers represented both the American National Red Cross and the private ambulance industry. Although each made passing references to "paramedical" personnel, there is nothing in their presentations to indicate that either of them perceived the paramedic as we now understand this role in advanced life support (ALS). Workshops at the conference produced a series of recommendations that also reflected the state of the art in 1967.
With regard to first aid and rescue, for example, the workshop recommendation was that "All ambulance attendants should be given a minimum of advanced first aid training and additional training in specific emergency medical care. Annual refresher courses should be given ambulance attendants." Another Workshop recommendation: "In advanced courses, training in cardiopulmonary resuscitation should be given to police, fire, ambulance and allied health professionals."6
Thus, despite a major flurry of meeting and conferring over the relative poor quality of emergency care in the United States, the dialog and recommendations evidenced little foresight of the prehospital care revolution on the horizon. In retrospect, it can be seen that more than any other factor, the paramedic phenomena in the United States can be credited to the European experience.
In Russia, for example, the concept of prehospital patient care may have begun as early as 1918. 7 It is believed that the Russians began dispatching ambulance crews consisting of a doctor, a nurse and a special physician's assistant sometime prior to 1960. 8 Dr. Rudolph Frey, in Mainz, Germany, began placing doctors in ambulance vehicles as early as 1961. At about the same time, doctors began serving in prehospital care roles in Toulouse, France.9
The foreigner who had the greatest influence on EMS in America, however, was J. Frank Pantridge, physician in charge of the Department of Cardiology at Belfast’s Royal Victoria Hospital (Ireland) and professor of cardiology at that city's Queens University. Pantridge was influenced by the factor of time in treating prehospital episodes of acute myocardial infarction.
"I was first alerted to this situation when I stumbled on some epidemiology data," said Dr. Pantridge in 1963. Pantridge noted that more than 60% of the young and middle-age males who had died from this form of heart attack, did so within one hour of the onset of symptoms. In addition, he noted that more than 90% of the early deaths resulted from ventricular fibrillation and that patients with mild infarction incur the same risk of ventricular fibrillation as those in whom the infarct is larger.
Pantridge saw the solution in simple terms. It was to get the right treatment started quickly. From this, he concluded that treatment must commence before the patient is admitted to the hospital.
Despite the war-like conditions of Belfast, Dr. Pantridge converted one of Royal Victoria Hospital's ambulances to a mobile coronary care unit (MCCU). The vehicle was equipped with coronary care equipment and supplies and staffed by personnel from the hospital's coronary care unit, including a physician. Thus, although the Belfast experiment was the first well-known system of prehospital care in the free world, it did not rely on non-physician paramedics as its staff.
In the first 15 months of mobile coronary care experience in Belfast, the success of the concept became evident. Although response times for the Royal Victoria team (from their hospital base to the scene of cardiac emergencies throughout the city of Belfast) were as much as 20 minutes, ten examples of prehospital resuscitation were recorded with a 50% long-term survival rate.
It is often said that academic physicians and other scientists must publish or perish. Pantridge published. He wrote about his successful experiment in a 1967 edition of the British medical journal, Lancet. 10 Joined by his associate, Dr. J.S. Geddes, Pantridge entitled his article, "A Mobile Intensive-Care Unit in the Management of Myocardial Infarction." His article was quoted many hundreds of times in support of the theory and practice of prehospital emergency care.
The late Dr. William J. Grace, who was director of Medicine at St. Vincent's Hospital and Medical Center in New York City, is generally credited with establishing the first MCCU in the United States. That unit served a limited area of New York's Manhattan and responded from St. Vincent's with a crew that included at least one resident physician.
Although his MCCU project did not rely on paramedics for emergency staffing, Dr. Grace acknowledged the value of such non-physician personnel. As author of a 1973 Heart Association booklet, he referred to prehospital-based MCCUs staffed by paramedics with physician contact. "This type of project requires extensive education of paramedics and a terrain suitable for telemetry," said Dr. Grace. "Given these requirements it is practical and feasible and is widely copied." 11 In 1975, two years prior to his death, Dr. Grace was interviewed by a health-related publication. "Carefully trained nurses, firemen and other non-physician personnel who respond quickly to calls and defibrillate on the spot have had good success in this country," he acknowledged.12
In studies of St. Vincent's MCCU, Dr. Grace and his associate, Dr. John Chadbourne, found that patients seen and treated by a prehospital team within one hour of onset of acute symptoms had a lower mortality than those patients for whom treatment was delayed for more than an hour (8% versus 21%). "Mobile coronary care is effective in saving lives by resuscitation of the unconscious patient and in lowering the death rate from myocardial infarction," said Grace and Chadbourne. "Hence, an out-of-hospital coronary care system is necessary," they concluded.
Although Grace is properly credited with the first MCCU in the United States, other physicians had concentrated on improved emergency care prior to import of the Belfast concept. Dr. Peter Safar, for example, had challenged widely accepted resuscitation techniques during the 1950s. During those years, Dr. Safar experimented with the technique of mouth-to-mouth rescue breathing.
Last Revision Date: 5/15/07 - 7:16 AM