18th & 19th Centuries
First efforts of field care developed by
one of Napoleon’s surgeons.
Triage, a method of sorting patients by
•-Rule 4 - "To Excite Inspiration - During the
employment of the above method excite the
nostrils with snuff or smelling salts, tickle the
throat with a feather. Rub the chest and face
briskly, and dash cold and hot water alternately
Rule 5 - "To Induce Circulation and Warmth -
Wrap the patient in dry blankets and commence
rubbing the limbs upwards firmly and
energetically. The friction must be continued
under the blankets or over the dry clothing.
Promote the warmth of the body by the
application of hot flannels, bottles or bladders of
hot water, heated bricks etc., to the armpits, the
pit of the stomach, between the thighs and the
soles of the feet.”
•"On the restoration of life, when the power of
swallowing has returned, a teaspoon of warm
water, small quantities wine, warm brandy and
water, or coffee should be given. The patient
should be kept in bed and a disposition to sleep
encouraged. During reaction, large mustard
plasters to the chest and below the shoulders will
greatly relieve the distressed breathing."
Peter Shepherd, M.B. "Surgeon Major"
Army Medical Department
Associate of the Order of St. John of Jerusalem
Rule 1 - "To Maintain a Free Entrance of Air into the
Windpipe - Cleanse the mouth and nostrils; open the
mouth; draw forward the patient's tongue, and keep it
forward: an elastic band over the tongue and chin will
answer the purpose. Remove all tight clothing from
about the neck and chest."
Rule 2 - "To Adjust the Patient's Position - Place the
patient on his back on a flat surface, inclined a little
from the feet upwards; raise and support the head and
shoulders on a small firm cushion or folded article of
dress under the shoulder blades."
Rule 3: Dr. Shepherd goes on to describe the method
of manual artificial respiration developed by Dr. H.R.
Sylvester. To wit:
The procedure should be done "deliberately and
perserveringly, fifteen times a minute, until
spontaneous effort to respire is perceived, immediately
upon which, cease to imitate breathing and proceed to
INDUCE CIRCULATION AND WARMTH."
"Should a warm bath be procurable, the body may be
placed in it up to the neck, continued to imitate
breathing. Raise the body for twenty seconds in a
sitting position, dash cold water against the chest and
face, and pass ammonia under the nose. The patient
should not be kept in a warm bath for longer than five
to six minutes."
TREATMENT TO RESTORE
NATURAL BREATHING AND CIRCULATION
Ambulance as a specialized
First Know Hospital-Based
Soon Followed by other services
Bellevue Hospital- New York
Carrying equipment such as:
morphine, brandy, stomach
The first motorized ambulance is said to have been
provided by Michael Reese Hospital of Chicago in
Michael Reese Hospital Chicago
Followed in 1900 by New York City...
Both of these ambulances were electrically powered
with 2hp motors on the rear axle.
First official definition under the law, the Act
listed them as “Mobile Intensive Care
Funding came principally from two federal
agencies. The U.S. Department of Health,
Education and Welfare (DHEW) and the U.S.
Department of Transportation (DOT)... they
opted to use the word paramedic
4 Certification Levels
Emergency Medical Technician-Basic
Emergency Medical Technician-Intermediate
Emergency Medical Technician-Paramedic
The most advanced provider, includes all basic and
advanced life support techniques, plus numerous
medications and special skills such as intubation,
intraosseous infusions, needle decompression of
tension pneumothorax and surgical airway.
Advanced Life Support
…Refers to advanced life-saving
procedures such as intravenous therapy,
drug therapy, intubation, and defibrillation.
Some systems are tiered in which BLS
arrives first and then, if required, ALS
Online Medical Direction
The Medical Director /
MICN can provide on-
line guidance to EMS
personnel in the field.
This is known as on-
line medical direction.
Off-line medical direction refers
to medical policies, procedures,
and practices that medical
direction has set up in advance of
a call, such as standard protocols
or standing orders
1981 Block Grants by States to
administer EMS Funds
Did the Trauma System Success in
saving Regan’s Life change the funding
in EMS Development Program
Emergency Medical Dispatch-1981
Dr. Jeff Klauson- February 1981
Emergency Medical Dispatcher
Jack Stout- 1983
System Status Management
changed economics of working the streets
1982- Personal computers just starting
Emergency Medical Dispatcher
The activities of an EMD are
crucial to the efficient
operation of EMS. EMDs not
only send ambulances to
scenes, they also make sure
that system resources are in
constant readiness. EMDs
must be medically and
CLEAR- “Shocking at 360”
November 1983- a statement from a
group of esteemed cardiologists working
with the Physio Control Company
supporting the use of AED’s & SAED’s
in the prehospital setting.
National Association of EMS Physicians
Increased number of homeless stress EMS
1987- Electronic tracking of EMS
1989- Regulation of tools & Devices in
MAST Pants Challenged
High-quality CPR saves lives!!High-quality CPR saves lives!!
““PUSH IT HARD & PUSH IT FASTPUSH IT HARD & PUSH IT FAST””
in the words of the infamousin the words of the infamous
saltsalt ‘‘nn’’ pepapepa
The Trauma Care Systems planning
and development Act
Barely enough funding to support
Attempt at bombing the World Trade
One of the biggest challenges seen by an
EMS system up to that point
American Medical Response
August 1992- four private ambulance
company’s joined together and began to
sell stock through the NYSE...
This sparked a consolidation of the Nation’s
private ambulance company’s
Casino AED Programs
Very rapid response (< 3 mins)
Amazing survival rates : 53%
N=105 WITH V-FIB
Security with AEDs with BLS
90 were witnessed arrests
Valenzuela TD et al, NEJM Oct 2000
Airport PAD Programs
LAX, Chicago, others
3 airports in report from Chicago…
Prominently placed cabinets with automatic dispatch
alarm and public service announcement
2 year study: 26 AED uses by Good Samaritans
61% of non-traumatic arrests LIVED TO D/C
$7000 per life saved
Caffrey SL et al, NEJM 347 (16) : 1242 Oct 17, 2002
Patient Triage – START Triage
The START system is based upon three
• Respirations ( > or < 30 per minute)
• Perfusion (Capillary Refill > or < 2 seconds)
• Mental Status (Follow simple commands)
Inland Counties Emergency
Base Hospitals- San Bernardino County
Arrowhead Regional Medical Center
Chino Valley Medical Center
Hi-Desert Medical Center
Loma Linda University Medical Center
Redlands Community Hospital
San Antonio Community Hospital
STEMI Centers...We Have
Loma Linda Regional Medical Center
San Antonio Community Hospital (SACH)
St. Bernardines Hospital
Pomona Valley Hospital
ICEMA RegionInland Counties
Emergency Medical Agency
Emergency Medical Care
The EMCC is a platform for the
diverse groups and individuals which
form our Emergency Medical Services
System. They serve as an advisory
group for the Board of Supervisors.
Medical Care Committee
The MAC is made up of representatives
of our local health care system-
Including, base hospital physicians,
nurses, paramedics, medical educators.
The MAC committee helps set the
guidelines for field EMS operations and
acts as an advisory board to the EMCC.
As A Resident
During your EMS Rotation:
Public Fire Departments...SBCFD, Rialto, etc.
Private Ambulance Companies...AMR,etc.
Optional Flights with Mercy Air or Sheriffs Air
Ride Along with Sheriff’s Department Major Enforcement
Eight Hour orientation to the Base Station operations
One Lecture during your EMS rotation weeks
Review EMS pertinent Literature
Two other Assigned EMS Lectures Per
Larrey was present at the battle of Spires, between the French and Prussians, and was distressed by the fact that wounded soldiers were not picked up by the numerous ambulances (which Napoleon required to be stationed two and half miles back from the scene of battle) until after hostilities had ceased, and set about developing a new ambulance system. Having decided against using the Norman system of horse litters, he settled on two- or four-wheeled horse-drawn wagons, which were used to transport fallen soldiers from the (active) battlefield after they had received early treatment in the field. These &apos;flying ambulances&apos; were first used by Napoleon&apos;s Army of the Rhine is 1793. Larrey subsequently developed similar services for Napoleon&apos;s other armies, and adapted his ambulances to the conditions, including developing a litter which could be carried by a camel for a campaign in Egypt.
Hospital based services begin
The first known hospital based ambulance service was based out of Commercial Hospital, Cincinnati , Ohio (now the Cincinnati General) by 1865. This was soon followed by other services, notably the New York service provided out of Bellvue Hospital. Edward Dalton, a former surgeon in the Union Army , was charged with creating a hospital in lower New York, and his experiences from war lead him to start an ambulance service to bring the patients to the hospital faster and in more comfort, which started in 1869. He claimed the service was the first of its kind, being unaware of the work in Cincinnati four year earlier. (VM DIRECTORS NOTE: Bellevue was in fact the first MUNICIPAL Hospital based service in the U.S.) These ambulances carried medical equipment, such as splints, a stomach pump, morphine , and brandy , reflecting contemporary medicine. Dalton believed that speed was of the essence, and horses were left harnessed, being attached to the ambulance by a &apos;drop&apos; or &apos;snap&apos; harness , meaning they were ready to go within 30 seconds of being called. The scene was very popular, and it&apos;s fame spread – During the year 1870, the ambulances attended 1401 emergency calls, but twenty one years later, this had more than tripled to 4392. By the turn of the century, interns accompanied New York City ambulances, treated patients on scene, and often left them at home.
In 1867, the city of London &apos;s Metropolitan Asylums Board , in the United Kingdom , received six horse-drawn ambulances for the purpose of conveying smallpox and fever patients from their homes to a hospital. These ambulances were designed to resemble private carriages, but were equipped with rollers in their floors and large rear doors to allow for a patient, lying on a specially designed bed, to be easily loaded. Space was provided for an attendant to ride with the patient, and the entire patient compartment was designed to be easily cleaned and decontaminated. Anyone willing to pay the cost of horse hire could summon the ambulance by telegram or in person.
Dedicated services begin
In June 1887 the St John Ambulance Brigade was established to provide first aid and ambulance services at public events in London. It was modeled on a military-style command and discipline structure. The St John Ambulance Association had already been teaching first aid to the public for 10 years prior to that. National or state based branches of St John Ambulance now provides ambulance and first aid services in many countries around the world. 
In Queensland , a state in Australia , military medic Seymour Warrian called a public meeting in Brisbane and established an ambulance service after witnessing an event at the Brisbane showgrounds during Show Week in 1892. A fallen rider, suffering a broken leg was walked off the field by well meaning but misguided bystanders, worsening his injury. As a result of the meeting, the Queensland Ambulance Transport Brigade was formed on the 12th September. The first ambulance station in Queensland operated out of the Brisbane Newspaper Company and officers on night duty slept on rolls of newspaper on the floor. They had a stretcher, but no vehicle and transported patients on foot, although in time, they gained horse drawn stretchers and eventually vehicles. A year after the establishment of the Brisbane centre, another was established in Charters Towers in north Queensland, growing to over 90 community controlled ambulance centres. In 1991 the independent QATB centres amalgamated to form the Queensland Ambulance Service which is now the fourth largest ambulance service in the world.
19. Barkley, Katherine T. 1990. &quot;The Ambulance&quot;. Exposition Press. ISBN 0-682-48983-2
20. Kuehl, Alexander E. (Ed.). Prehospital Systems and Medical Oversight, 3rd edition. National Association of EMS Physicians. 2002 . @ ch. 1.
21. Higginbotham, Peter (October 2005). The MAB Land Ambulance Service . Retrieved on 2007 - 06-02 .
22. St John Ambulance in the Industrial Revolution . St John Ambulance UK. Retrieved on 2007 - 06-16 .
23. St John Ambulance First Aid Cover for Events . St John Ambulance UK. Retrieved on 2007 - 06-02 .
24. History of Queensland Ambulance Service. Retrieved on 2007-06-16.
Keywords: Bellevue, Dalton,Cincinnatti
Last Revision Date: 6/25/07 - 3:05 PM
However, the first motorized ambulance was brought into service in the last year of the 19th century, with the Michael Reese Hospital, Chicago, taking delivery of the first automobile ambulance, donated by 500 prominent local businessmen, in February 1899. This was followed in 1900 by New York city, who extolled its virtues of greater speed, more safety for the patient, faster stopping and a smoother ride. These first two automobile ambulances were electrically powered with 2hp motors on the rear axle.[24
ORIGINS OF THE NICKNAME &quot;BUS&quot; IN NEW YORK CITY EMS
Cross Posted: EMS History; Ambulances; Biographies; By Era; Public Sector ServicesSubmitter/Author: Mark Peck EMT-P, New York City EMS/FDNY EMS
In New York City, EMS responds with a Bus
BUS, AMBO, RESCUE, RA/RESCUE AMBULANCE, MEAT WAGON, ORANGE & WHITE BUS COMPANY, BIG WHITE TAXI- EVERY REGION HAS ITS OWN SLANG.
THE SLANG “BUS” IS A PROUD PART OF NEW YORK CITY AMBULANCE HERITAGE
When I came on the job (another NY term), I too asked why our ambulances were called buses. My partner, with some 30 years experience, told me to go stand in front of the bus and look at it. We were still in the ambulances we called “Bread Boxes” the step vans based on the Bread delivery trucks popular in the 60’s,with a single front door, and a split windshield that resembled the Transit Authority buses of the 40’s,50’s and 60’s. He was wrong.
New York City Department of Hospitals &quot;Bread Box&quot;- Built on an Olson Kurbmaster Jr. body 1958 New York City Transit Authority -General Motors
Past and present members of the FDNY/EMS continue to spread many incorrect myths of the terms origin. Another myth is they are called buses because of the first modular Grumman ambulances the service purchased in 1974. They are not. Most of the NYC buses in the 50’s and 60’s were General Motors. Grumman did not enter the transit bus business until 1978 when they purchased the Flxible Company , and NYC did not purchase a Grumman Flxible until 1980. The entire fleet was found to be defective and the city sued until the entire fleet purchase was returned.New York City Transit and MTA Bus Models
Retired Metropolitan Transportation Authority Bus Fleet
1980 Grumman Flxible- Metropolitan Transit Authority
The first reliable reference I can find for the use of Bus as an ambulance in NYC dates back to 1903…long before GM, or Grumman. The mode of ambulance propulsion was four legs. If you read the autobiography of Dr. Emily Dunning Barringer- “Bowery to Bellevue, The story of New York’s First Woman Ambulance Surgeon”, you will find it was a common reference to the horse drawn carriage ambulance of the day. How it came into existence is still a mystery, but it is thjought to come from the word omnibus. It is a tradition that has survived more than a century. Its use a celebration of tradition. It honor the ambulance men that came before.
(Random House Historical Dictionary of American Slang, Vol. I A-G) bus n. (...) 2. an automobile or other motor vehicle. 1914 T.A. Dorgan, in Zwilling TAD Lexicon 22: A friend of mine just bought a new car. A flivver...Thats like mine - some bus. 1916 W.J. Robinson At Front 121: The old &apos;bus made the most of what she had. 1917 Imbrie War Ambulance 115: A car was a &quot;buss.&quot; 1917 in Dos Passos 14th Chronicle 92: Our ambulance however is simply peppered with holes - how the old bus holds together is more than I can make out.
If you examine some of the terms for ambulance in use around the country, many exist out of tradition or common use. The use of RESCUE for an ambulance these days is often inaccurate. Most have nothing to do with physical rescue. They carry few if any rescue tools. The term is a holdover from the days when the Fire Department Rescue truck members were the only ones trained in even basic first aid, and carried a Pulmotor or a Reviv a Life or an E&J. They are Trucks or Rigs, because their ancestors were part of the fire service. In many parts of the country, the ambulances were double duty funeral cars, or station wagons. They earned the “Meat wagon” tag because most of their personnel had little medical training and even less equipment. Load and Go was the method of the day.
More information on Dr Dunning:
Dr. Emily Dunning Barringer Video- Dr. Dunning Riding the Bus( The Girl in White)
If you would like more information on the history of EMS in New York:
FDNY/New York City EMS History The Coney Island Ambulance Station
Keywords: NYC EMS, FDNY, Bus, Breadbox, Olson Kurbmaster, New York City EMS, nicknames, Emily Dunning, First Woman Ambulance Surgeon, The Girl in White, New York City Department of Hospitals
External Resource Link: www.ConeyIslandEMS.com
Last Revision Date: 5/5/11 - 0:49 AM
The White Steamers were a popular ambulances among the municipal hospitals operated by the Department of Public Charities serving Brooklyn, Queens and Staten island, as well as the Bellevue and Allied Hospitals serving Manhattan and the Bronx
New York Gas Light Company was founded in 1823 in New York City, providing a distribution system for both home and streetlight posts. In 1884, six other gas distribution companies joined to form Consolidated Gas Company of NY.
Thomas Alva Edison- The Wizard of Menlo Park- invented the first incandescent light bulb in 1879. Recognizing the benefit to mankind, as well as the commercial potential, he went on to design and patent an electrical distribution system. In 1878, Edison formed the Edison Electric Light Company in New York City, followed by the Edison Illuminating Company in 1880. On September 4, 1882, Edison switched on his Pearl Street generating station&apos;s electrical power distribution system, which provided 110 volts direct current to 59 customers in lower Manhattan.
By 1920, New York Edison became part of Consolidated Gas and then in 1936, as electrical use began to significantly replace gaslighting, the name was changed to Consolidated Edison Company of New York, Inc. Con Ed, as it is commonly known to New Yorkers, provides gas, electric, and high pressure steam service to Manhattan buildings.
With the widespresd use of early gas, and then elecric power, came the new life hazards of gas leaks, carbon monoxide poisoning, and electrocution. In an effort to respond to these emergencies, Consolidaed Gas began staffing emergency response units with the Pulmotor Resuscitator.
During World War One, further advances were made in providing care before and during transport – traction splints were introduced during World War I, and were found to have a positive effect on the morbidity and mortality of patients with leg fractures. Two-way radios became available shortly after World War I, enabling for more efficient radio dispatch of ambulances in some areas. Shortly before World War II, then, a modern ambulance carried advanced medical equipment, was staffed by a physician, and was dispatched by radio. In many locations, however, ambulances were hearses - the only available vehicle that could carry a recumbent patient - and were thus frequently run by funeral homes. These vehicles, which could serve either purpose, were known as combination cars.
Advances in the 1960s, especially the development of CPR & defibrillation as the standard form of care for out-of-hospital cardiac arrest, along with new pharmaceuticals, led to changes in the tasks of the ambulances. In Belfast, Northern Ireland the first experimental mobile coronary care ambulance successfully resuscitated patients using these technologies. One well-known report in the USA during that time was Accidental Death and Disability: The Neglected Disease of Modern Society. This report is commonly known as The White Paper. These studies, along with the White Paper report, placed pressure on governments to improve emergency care in general, including the care provided by ambulance services. Part of the result was the creation of standards in ambulance construction concerning the internal height of the patient care area (to allow for an attendant to continue to care for the patient during transport), in the equipment (and thus weight) that an ambulance had to carry, and several other factors.
Rather than treating all “shockable” rhythms with direct countershock, the current model of VF arrest suggests that the optimal treatment changes over time. While the treatment for VF in the first 4 minutes is still a shock, very few out of hospital cardiac arrest patients are reached in this phase. The notable exception is witnessed arrest patients, who should always be shocked immediately. The optimal therapy after 10+ minutes, when the metabolic phase is reached, is still unknown. It is worth pointing out that the morphology of VF appears to change over time, which is an observation that most EMS providers have made before.
The phrase &quot;chain of survival&quot; was first used as a slogan for the 1988 Conference on Citizen CPR. It then appeared in JEMS editorial in August 1989, and the first issue of Currents in Emergency Cardiac Care in 1990. The concept was elaborated in the American Heart Association&apos;s 1992 guidelines for cardiopulmonary resuscitation and emergency cardiac care, and then echoed by the International Liaison Committee on Resuscitation (ILCOR) in 1997.
Someone must witness the cardiac arrest and activate the EMS system with an immediate call to the emergency services.
In order to be most effective, bystander CPR should be provided immediately after collapse of the patient. Properly performed CPR can keep the heart in VF for 10-12 minutes longer.
Most adults who can be saved from cardiac arrest are in ventricular fibrillation or pulseless ventricular tachycardia. Early defibrillation is the link in the chain most likely to improve survival. Public access defibillation may be the key to improving survival rates in out-of-hospital cardiac arrest, but is of the greatest value when the other links in the chain do not fail.
Early advanced care
Early advanced cardiac life support by paramedics is another critical link in the chain of survival. In communities with survival rates &gt; 20%, a minimum of two of the rescuers are trained to the advanced level. In some countries, EMS delivery may be performed by ambulancemen, nurses, or doctors.
Cardiac Arrest Registry to Enhance Survival
^ a b c d e f g h i j &quot;Part 12: From Science to Survival - Strengthening the Chain of Survival in Every Community,&quot; Circulation 2000;102:I-358
^ a b c d e Bossaert LL (1997). &quot;Fibrillation and defibrillation of the heart&quot;. British journal of anaesthesia 79 (2): 203–13. PMID 9349131.
^ a b &quot;The Addition of the Fifth Link in the Chain of Survival to Include Myocardial Infarction,&quot; ChestPainCenters.org, Accessed July 11, 2007.
^ &quot;Chain of Survival: Converting a Nation,&quot; Citizen CPR Foundation, Accessed July 11, 2007.
^ Cummins RO, Ornato JP, Thies WH, Pepe PE (1991). &quot;Improving survival from sudden cardiac arrest: the &quot;chain of survival&quot; concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association&quot;. Circulation 83 (5): 1832–47. PMID 2022039.
^ , (1992). &quot;Guidelines for cardiopulmonary resuscitation and emergency cardiac care. Emergency Cardiac Care Committee and Subcommittees, American Heart Association. Part I. Introduction&quot;. JAMA 268 (16): 2171–83. doi:10.1001/jama.268.16.2171. PMID 1404767.
^ &quot;Strengthening Each Link in the Chain of Survival,&quot; American Heart Association, Accessed July 10, 2007.
^ Eisenberg MS, Bergner L, Hallstrom A (1979). &quot;Cardiac resuscitation in the community. Importance of rapid provision and implications for program planning&quot;. JAMA 241 (18): 1905–7. doi:10.1001/jama.241.18.1905. PMID 430772.
^ &quot;Early Defibrillation,&quot; Circulation 1997;95:2183-2184.
&quot;The Links in the Chain of Survival,&quot; American Heart Association
&quot;Chain of Survival: Converting a Nation,&quot; Citizen CPR Foundation
These VF tracings demonstrate the priming effect from an electrophysiological perspective. As pointed out with the 3-phase model schematic, the morphology of VF changes as time passed. The VF at 1 min is well within the electrical phase, with greater amplitude and median frequency. After 8 min, the morphology is very different; a shock at this point would likely be unsuccessful in producing return of spontaneous circulation (ROSC). However, after only 90 sec of chest compressions, the morphology looks similar to the “fresh” VF on the left.