Monthly Archives: December 2012

Birth by fire: a look at how military emergency care influenced civilian care

Note: This entry was originally posted on a blog I created for my History of Medicine class final project during December 2012.

US Army Manual

When the National Academy of Sciences published its White Paper in 1966, it found civilian EMS services woefully inadequate, yet praised the military, stating: "Excellence of initial first aid, efficiency of transportation, and energetic treatment of military casualties have proved to be major factors in the progressive decrease in death rates of battle casualties reaching medical facilities, from 8 percent in World War I, to 4.5 percent in World War II, to 2.5 percent in Korea, and to less than 2 percent in Vietnam."

Unsurprisingly, the NAS recommended emulating military techniques. I was curious what the military was doing that worked so well, beyond simply removing injured soldiers from the battlefield with great speed (I've already covered some of its transportation techniques in my Hemingway post). To answer my question, I happened to find a 1950 edition of US Army Manual TM8-230, Medical and Surgical Technicians (search the text here). That this manual was written in 1950 means its authors had the benefit of discovering what worked well and what didn't work well for emergency medicine in the World Wars. Its age also means that these were military standards that would have been implemented over a decade before the NAS began evaluating EMS in the states. (A 1930 edition is available; a brief preview offered by Google suggests it had similar, if not as advanced or thorough, contents, but I haven't been able to find a copy of the whole book for a proper comparison. No doubt many other year editions exist. I'd love to see what the current issue looks like.)

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Just how old is EMS? A brief overview of interesting points

Note: This entry was originally posted on a blog I created for my History of Medicine class final project during December 2012.

490 B.C.

Due to its relatively late emergence as a defined field in the United States, emergency medicine is often described as "new". This foundling status is sometimes used as a reason why professionals in that field perceive discriminatory pay and status compared to other medical fields that have apparently existed for much longer. However, truth be told, emergency medicine reaches much back farther than the 1960's paper credited with establishing EMS in the United States. This history is so lengthy, in fact, that it would be impossible to reasonably cover it in one blog post.

After all, as long as there have been wars, there has been a need for emergency medicine in one form or another; what's more, one could divide emergency medicine into the two components of transportation and treatment. Therefore, one could reasonably classify all wound treatments as EMS; then EMS might be considered the oldest of all the medical specialties, laying claim to figures like Galen. However, modern EMS is connotatively inseparable from its transportation aspect, so I'm going to mainly consider this. To that end, I'll go over a few interesting cases that should prove that even with strict application of this designation, EMS has roots far back in time. (This two-edged definition is perhaps what makes the history of EMS so difficult to trace. Should both emergency treatment and transportation be required of an event in order to link it to the background of EMS, or is it okay to focus on only one of those factors? The first approach is too narrow, yet the latter ends up being too comprehensive. Where do we draw the line?)

Greek & Roman. As early as Roman times, chariots and carts were used to remove injured soldiers from the battlefield. Nobody knows if these carts were specially equipped or if there were individuals assigned to provide rudimentary treatment. Initially, these soldiers were probably simply deposited out of harm's way; by 100 AD, they would be taken to valentudinaria, or Roman military field hospitals. Sometimes, however, before or instead of transporting a fallen soldier, care was simply administered on site, occasionally even while the battle raged on. One ancient Greek vase depicts the story of Achilles bandaging the arm of his wounded cousin (Robbins).

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Why is EMS a part of the DOT? A look at The White Paper

Note: This entry was originally posted on a blog I created for my History of Medicine class final project during December 2012.

National Academy of Sciences

If you had to guess, what federal body would you think EMS falls under: the Department of Transportation, or the US Public Health Service? If you guessed the US Public Health Service, you'd be wrong. Read on to find out why. This story is crucial to understanding the evolution of EMS in the United States and the problems the system currently faces, problems that should concern every person who could ever need to call an ambulance.

The Nouveau plan de constitution pour la médecine en France published in the 1790's laid down new standards for medical education and practice in France, becoming a charter of sorts. It's true that educational models had existed long before this point, but the Nouveau plan illustrates that in medicine, a single document can serve to bring together many circulating ideas into one coherent system, thereby facilitating its implementation. In 1966, the National Academy of Sciences released its seminal paper, Accidental Death and Disability: The Neglected Disease of Modern Society -- known in the EMS trade as simply "The White Paper" -- which had the same effect of rallying EMS in the United States (you can download the paper here).

The modern EMS system in America owes its roots directly to this White Paper, and had it never been published, EMS might have evolved in a very different way. Particularly, to the modern audience, it makes sense that EMS -- emergency medical services -- might fall under the purview of some federal medical regulatory body, and yet it belongs to the Department of Transportation. Understanding the White Paper can explain this apparently awkward ordering. The White Paper, after all, was written largely in response to the growing problem of car wrecks, as motorized vehicles not only increased the incident of trauma in the US but also provided dramatic examples of just how bad trauma could be. Cars made trauma very visible.

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Hemingway, the ambulance driver

Note: This entry was originally posted on a blog I created for my History of Medicine class final project during December 2012.

Hemingway in his WWI Ambulance

Doctors and nurses have lofty figures like Hippocrates and Florence Nightingale that they can point to as bastions of their fields, but as many medics lament, their field largely seems to lack famous names; instead, the field has as its media representation raunchy films like Mother, Jugs & Speed in the seventies and Paramedics in the eighties. Therefore, while visiting the Ernest Hemingway House in the Keys over Thanksgiving break this year, I was pleasantly surprised to learn on the guided tour that famous author served as an ambulance driver during World War I. You just don't get any better than Hemingway if you're wanting a culturally-respectable name to drop! (Although I'll admit that Hemingway's father was a physician.) Actually, I soon discovered that several literary figures served in that role during the war, including EE. Cummings.

The American Field Service and American Red Cross both ran volunteer ambulance services in Europe in World War I, although when the US entered the war in 1917, the former was rolled into the US Army Ambulance Corps.

Volunteering as an ambulance driver was actually a popular choice for upper class young men who wanted to take a part in the war, but either did not want to join the Army (which was beneath them or too dangerous) or who wanted to but were precluded due to health issues. In Hemingway's case, a poor left eye caused him problems. "I'll make it to Europe some way in spite of this optic. I can't let a show like this go on without getting into it," Hemingway explained to his sister.

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Somebody call a hearse!: the evolution of motorized emergency medical vehicles in the civilian US

Note: This entry was originally posted on a blog I created for my History of Medicine class final project during December 2012.

1958 Cadillac Combination Car © That Hardford Guy

The year is 1953 and a bad wreck has just occurred. One of the passengers involved seems to have broken his femur. A bystander who has pulled over to help yells, "Quick, call the funeral home! We need a hearse, stat!"

For many members of the public, the medic is synonymous with the ambulance, and understandably so, since a good deal of of the medic's work occurs within its walls. This vehicle, stereotypically a large box-like one replete with lights and the Star of Life plastered on every side (and sometimes even the roof so that critical care helicopters can quickly identify it!), represents hope. I've been on both sides of the ambulance story -- as an EMT rendering care and as a 16-year-old watching my father suffer a heart attack -- and I think it goes without saying that when you or your loved one is in the middle of a medical crisis, it is reassuring when somebody arrives on scene -- dressed in a uniform and wielding fancy equipment -- who can take the situation out of your hands and form a plan of action. However, once upon a time, the vehicle that responded to emergencies was perhaps the anti-thesis of hope and in fact represented, if anything, death: that vehicle was the hearse.

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