Significant Moments in U.S. Emergency Medicine, Pt. 1

In this first episode of a two-parter, we’ll be covering early emergency response services, a little bit of CPR history, and advent of the emergency care specialty for physicians. 

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Episode Transcript

Speaker 1 (00:01):
Welcome to Stuff You Missed in History Class, a production
of I Heart Radio. Hello, and welcome to the podcast.
I'm Holly Frying and I'm Tracy V. Wilson. Okay, Tracy.
There have always been situations where people have been in
need of immediate medical care. Yep, that's just part of

(00:23):
being a human. Uh. And we spoke recently in an
episode about how military needs during wartime have driven a
lot of innovation in emergency medicine, but of course civilians
need emergency care as well, and our current pandemic has
brought the focus onto the medical care providers who are
often doing far more than seems humanly possible to take

(00:44):
care of their patients. And as I continued to see
headlines specifically about how to know when to seek emergency
care during this time, it made me want to talk
about some of the really big moments in emergency medicine
as a developing field, because it's actually still a baby. Um,
it's a fairly new area in medicine. And also we

(01:07):
want to make sure that, in the interest of expectations management,
we let everybody know that this is primarily looking at
emergency care in the US. We briefly mentioned developments in
other countries just here and there, But that's about it,
And even narrowed down mostly to one country, it is
still a two parter and it is still nowhere near comprehensive. UH.

(01:28):
There are entire books written about the history of emergency
care just in the US, but I wanted to talk
about it and kind of honor the people that do it.
So what we're gonna do here is cover some of
the key areas and developments in its relatively short history.
So in this first episode, we're going to talk about
early emergency response services and a little bit of CPR

(01:48):
history and the advent of the emergency care specialty for physicians.
And then in the next episode we're going to cover
an important white paper that served as a turning point
for emergency met US in UH. We'll also talk about
the advent of the nine one one service and the
ambulance service that set the model for all of the others.
The first city ambulance in the United States started rolling

(02:12):
in eighteen sixty five, and we really don't know a
whole lot about it. Records are pretty sparse, but there
is a personnel record for an ambulance driver in Cincinnati
Ohio's Commercial Hospital. That person was listed in that year's
hospital records. That driver was a man named James R. Jackson,
and his annual salary was three d and sixty dollars

(02:33):
a year. That is all we know, uh And because
of the scarcity of documentation for whatever that program was
in Cincinnati. The ambulance that's more commonly cited as the
first City ambulance was in New York City and it
was a new initiative at Bellevue Hospital in eighteen sixty nine,
and it was the brainchild of Dr. Edward B. Dalton,

(02:55):
who had interned before the U. S Civil War as
a staff surgeon at the hospital. Dalton had served with
the Union during the Civil War, working as an inspector
of field hospitals for the Army of the Potomac. One
of his duties was establishing a system to get wounded
soldiers to field hospitals really quickly. He set up a
similar system to the one that French doctor and recent

(03:17):
show subject Dominique gen Lerey had done in Europe a
few decades earlier. And when the war ended, Dalton was
back in New York and then he applied his experience
in transporting soldiers to creating a similar service for the
civilian population there. Bellevue's new ambulance, which was a horse
drawn wagon, was equipped with a first aid kit that

(03:40):
included tourniquets, bandages, sponges, whiskey or brandy, depending on what
source you read, and a straight jacket in case a
patient was unruly or dangerous. It also had floor slats
that could be taken out of the wagon and used
as a stretcher. Bellevue's ambulance didn't have a siren. The
driver would bang a gong as he drove to alert

(04:02):
other people on the road. To get clear seems challenging
to me, Dalton's ambulance was called to scenes of medical
need one thousand, four hundred one times over the years
that number grew, and even as motorized ambulances were developed
and that happened first in Chicago, these horse drawn wagons
of Bellevue still covered their territory alongside their automated colleagues.

(04:26):
That went on for years. The last of the horse
drawn ambulances in the fleet was retired in nineteen four.
In ninety eight, Julian Stanley Wise of Roanoke, Virginia founded
the Roanoke Life Saving and First Aid crew, and this
was the first volunteer rescue unit in the country. It
was made up of ten men, including Wise, and each

(04:48):
man carried a fishing tackle box as his med kit.
Inside these kits were tannic acid compound, ammonia inhalent, tincture
of Merthia late, and poison ivy wash. When I first
looked over this, the idea that poison ivy wash was included.
It's obviously very useful to have the poison ivy washed

(05:09):
in there. Um, but as like an emergency thing that
that delighted me a little bit. Well, I suspect that
they were kind of a first aid crew. Yeah, and
this is out in Virginia. There was probably a likelihood
that people were getting into some poison ivy calling that
an emergency treat I also do know somebody who had

(05:31):
to go to the emergency room because of a poison
ivy exposure because it was um, it was dead vines
that they didn't recognize as poison ivy and they were
outside sweating and it's like they got the oil on
their face. It was a whole bad situation. Yeah, I
had a I didn't go to the emergency room. I
went to urgent kid. I had never been allergic to

(05:53):
poison IVY until I came into contact with it at
the same time that I had a tattoo that was
healing in my body. This is too much, and I
kind of dealt with the rash. And then one morning
we were actually on vacation, and I woke up and
my entire face was swollen, and I was like, goodness,
get in the car and let's start making Yeah. So

(06:14):
um so, why is this volunteer rescue plan? Had it start?
Almost twenty years before? When Julian was only nine, he
witnessed a canoeing accident that resulted in two people drowning
because the current was quickly carrying these canoeists away from
the small amount of help that bystanders were trying to offer.
They were basically trying to extend tree branches out there. Uh.

(06:35):
The event, he would later say, left an impression on
him that just gave him a determination that he carried
for the rest of his life. Quote right then I
resolved that I was going to become a lifesaver. Never
again would I watch a man die when he could
be saved. And as a young man, in his twenties,
Wise had taken a job at the Norfolk and Western Railroad.
He was working as a clerk, and he recruited his

(06:58):
fellow volunteer rescuers from his coworkers there at the railroad,
and they actually operated their little setup out of the
railroad offices, and they used the phone number of the
railroad's head clerk, Harry Avis, as their contact number. So
when Harry got an emergency call, he would then relay
that info to the rest of the crew and then
they would spring into action. This was not a huge success. Initially,

(07:21):
only six emergencies were called into the crew their first year,
and often they weren't speedy enough to do a lot
of help by the time they arrived on the scene.
But they kept at it. They kept improving, driven by
wise Is ethos of quote, save seconds and you have
a better chance of saving a life. The crew gained
national attention in ninety one when they revived a sixteen

(07:44):
year old boy after responding to a drowning call. Yeah,
they became headline news. And that brings us to the
topic of resuscitation. But before we get into that, which
we are going to do, let's take a little breather
of our own, and we will have a sponsor break.

(08:07):
So that last element that we talked about of a
sixteen year old boy being rescued after a drowning call
brings us to resuscitation in general. So the idea of
artificially restarting a patient's breathing and heartbeat has been part
of emergency medical care for hundreds of years. It goes back,
at least in the Western uh literature to Swiss physician

(08:30):
Paracelsus in the fifteen hundreds, and in those early days,
this whole thing was done by using a bellows to
pump air into the unconscious person's lungs. They would basically
put the end of the bellows in their mouth and
then carefully work the bellows. Before that, common but not
super effective approach was to whip an unconscious person in

(08:51):
the hopes that it would shock them awake. The earliest
Western record of mouth to mouth resuscitation being used dates
back to seventeen thirty two, when Scottish surgeon William Tassick
was able to revive a coal miner. Eight years later,
the French Academy de Seance issued a recommendation that mouth
to mouth resuscitation should be used for drowning victims. Four

(09:14):
years later, Scotland's Dr Tassick wrote a clinical description of
the mouth to mouth method that he had used in
seventeen thirty two. Yeah, when he initially did that, he
was kind of improvising and trying to figure out a
way to save this person, and it wasn't until quite
some time later that he actually wrote it up as
a way that other people could follow. There was enough

(09:35):
concern that people were not getting proper resuscitation attention in
the late eighteenth century that in seventeen seventy four the
Humane Society for the Recovery of Persons Apparently Drowned was formed.
This group was established in London at the Chapter Coffeehouse
in Saint Paul's Churchyard by Dr William Halles and Dr
Thomas Cogan. The pair had invited a number of friends

(09:58):
to help establish this Decide i D which was intended
to promote techniques of resuscitation, and they did this by
giving awards to people who performed life saving acts so
they could draw a little attention to it, and that
society actually continues to this day, although in seventeen seventy
six the name was changed simply to the Humane Society,
and then it changed again in seventeen seven to the

(10:20):
Royal Humane Society. In the eighteen fifties, two different doctors
in London came up with methodologies for resuscitation having to
do with repositioning the body. Dr Marshall Hall wrote up
his method in his book Asphyxia, It's Rationale and Its Remedy. Basically,
he was encouraging people to roll an unconscious person off
their back and onto their side, and an effort to

(10:43):
eliminate any airway obstructions and in some cases rolling farther
onto the stomach was recommended. Eventually, Hall refined his technique
to include the application of pressure to the chest. Two
years later, Dr Henry Sylvester developed an idea along a
similar line of thinking that repositioning the body could help
a person breathe. In Sylvester's method, the patient remained on

(11:06):
their back, but their arms were manipulated to try to
restart respiration. So first the arms were raised up over
the heads so the unconscious person's chest would naturally expand,
and then the arms were crossed and placed over the
chest to provide pressure to encourage excellation. In eighteen fifty nine,
Dr Sylvester published his method in the British Medical Journal.

(11:29):
He was met with some criticism, primarily that if a
patient remained on their back, their tongue could still obstruct
the airway just the same. This method was widely touted
for decades. It was published as a recommended resuscitation technique
in the handbook Describing Aids for Cases of Injuries or
Sudden Illness that was written by Surgeon Major Peter Shephard

(11:51):
of the training organization St. John Ambulance in eight seventy eight,
and it remained in every subsequent printing of that hand
until nineteen seventy two. There were other resuscitation methods being
tested during the late eighteen hundreds, including chest compression, which
was tested on cats in Germany in eighteen seventy eight.

(12:13):
By one, chest compression, used alongside ventilation, had saved the
lives of two human patients in Germany. Compression was also
seeing some success, first in dogs and then in human
cases in the early nineteen hundreds in Cleveland, Ohio, as
part of the work of doctor George Kryle. But compression
as a means of resuscitation kind of fizzled out until

(12:36):
it started to be used in tandem with defibrillation decades later.
The Hall and Sylvester methods were eventually replaced by the
Holder Nielsen method, developed by a Danish military physical fitness
instructor in the nineteen thirties. During a massage, Nielsen noticed
that when he was lying face down and the therapist
applied pressure between his shoulder blades while standing in his head,

(12:59):
he exhaled involuntarily. So he combined this idea with positioning
the patient's arms crossed above them with their head turned
sideways and resting on their arms. So yeah, he would
basically it's almost like you would lie down like in
the sun at the beach on your stomach. If you
did such things like with your head resting in your arms,
and then from above and in front of your head,

(13:20):
he would apply compressions in a regular period. In nineteen
fifty six, a big breakthrough an emergency medicine came when
Dr Peter Safar, an Austrian born physician, met Dr James
Elam at a convention of anthesiologists. Two years earlier, Elam
had published research proving that expired air that's the air

(13:40):
a person exhales ventilated in a mask or endotracheal tube
could enable adequate oxygenation to keep a patient's blood gases
in normal levels. This meeting led to the two of
them working together, and in nineteen fifty eight he published
a paper in the Journal of the American Medical Association
out finding experiments that had compared mouth to mouth ventilation

(14:03):
performed by lay people to the whole journeils and method
that was being performed by members of the Baltimore City
Fire Department. Mouth to mouth was by far more successful. Yeah,
that was like a big deal because it was like,
we have professionals doing it the old way, and we
have people we just trained off the street doing it
our way and they're having better success. Safar and Elam

(14:24):
continued to be at the epicenter of significant developments in
resuscitation because they went on to collaborate with other medical
scientists who were doing research in similar or related areas.
Through a connection to anesthesiologists Bjorn Lynde, Safar was introduced
to a Norwegian toymaker named Asmund Lairdahl, and in working together,

(14:44):
this team was able to develop the first recessa and
mannequin to train people in resuscitation techniques. RECESSA and or resuscitation. ANNIE,
as she is more commonly known here in the US,
is still produced today by the Layerdal Medical Company. A
separate team, engineers William Covenhoven and Guy Knickerbocker from Johns

(15:05):
Hopkins had been developing the first electrical cardiac defibrillator. Around
this same time, Dr Safar worked on refining the mouth
to mouth resuscitation technique that he and Elam had come
up with, and came up with the easy to remember
A BCS of cardio pulmonary resuscitation. There's abc s are
airway breathing and circulation, and the idea was that you

(15:27):
would first check to make sure the airway wasn't obstructed
and then administer rescue breaths followed by chess compression. And
that remained the standard and was probably what a lot
of us learned. If you're in my age group, I
definitely learned the A B c's when I had a
very basic CPR training in high school. We did it
until and at that point the order of operations recommended

(15:49):
was changed for the first time in forty years, and
then it became C A B training with chest compressions
beginning first and then doing the airway and rescue breaths.
And this is because it has been determined that a
patient's circulation can be supported through chest compressions enough to
keep oxygen aated blood flowing through the tissues. And if

(16:10):
that is already in place while the airway check and
rescue breathing is done, there is a better chance of
success for resuscitation. And we're gonna come back actually to
Dr Safar. In the second part of this two parter
coming up, we will find out how a general practitioner's
exhaustion led to the developments of the first full time
emergency jobs for physicians. First, we will take a quick

(16:32):
sponsor break. In nineteen one, the idea of doctors who
were specifically focused on emergency medicine as their job, rather
than it being a shift on a rotation for a
doctor who normally had other patients and duties manifested in

(16:54):
the work of doctor James Mills Jr. Mills was a
general practitioner and Alexander d of Virginia who was the
President elect of the Medical Staff at Alexandria Hospital and
the Alexandria Hospital's Emergency department was really in a state
of crisis, a crisis that Mills was tasked with fixing.
For one thing, patient visits to the emergency department had

(17:17):
increased by three hundred percent in the decades between nineteen
fifty and sixty. By the end of nineteen sixty, they
were seeing as many as eighteen thousand patients a year.
That averages out to a little more than forty nine
a day, and that was in an apartment that did
not have a dedicated medical staff. There had been a
plan in place to use medical students from nearby Georgetown

(17:41):
to cover shifts, but that didn't quite work out, and
Mills was one of several doctors on staff at the
hospital who did shifts in the emergency department. But there
were a lot of doctors who didn't. They either just
didn't want to or it couldn't fit into their schedule.
So wait times we're getting longer and longer, and the
hospital struggled to have an of medical staff on hand

(18:01):
to see to their growing emergency patient load. In the meantime,
Dr Mills was really having his own problems. He worked
incredibly long hours as a g P. In an interview
that he gave in nineteen sixty five, he said, quote,
one night, I came home after one am from working
a day that had started that morning at seven. I
remember thinking that as a chronically tired and overworked GP,

(18:25):
I wasn't being fair to myself, my family, or my patients.
It came to me that in emergency service, with regular hours,
I would be able to practice much better medicine. If
I could get three other good men to join me,
we'd have a team that could provide top notch treatment.
And his idea in that moment invented emergency medicine specialization.

(18:46):
He recruited three other doctors from the hospital to test
this novel idea with him, Dr John McDade, Dr C. A.
Low Ridge, and Dr William Weaver, and Mills and his
colleagues negotiated a deal with the hospital that would both
fill the needs of the emergency department and give these
doctors a much better work life balance. From a financial

(19:08):
point of view, it was a contract that would give
them the same or better income than they had already.
The hospital received a subsidy to cover the cost of
impoverished patients, and for other patients, they charged five dollars
a visit. But their shifts were really the big revolution here.
The emergency department was a small room essentially at this
point in this hospital. It was just four square feet

(19:30):
and it had four stretchers, and to cover that, each
doctor worked twelve hour shifts for five days straight, so
they would either work midnight to noon or noon to midnight.
And then after working five days on this schedule, they
would have five days off, which was a completely mind
blowing schedule for any doctor at the time, and it
gave them all much more downtime than they had as GPS.

(19:54):
But to be clear, although they were very glad to
have more time off, of course, the team that Mills
assembled was completely dedicated. They really wanted to make this
system work, not just for themselves, but for the hospital staff,
the hospital administration, and of course for the patients. Outside
of the economic and life balanced drivers, Mills was also

(20:15):
motivated by a desire to meet the healthcare needs of
Alexandria's impoverished and at risk population. Because he had taken
shifts in the emergency department and because he had done
volunteer outreach to provide care to the city's poor, he
was keenly aware of two things. First, there was a
gap in the system that made it hard for poor

(20:35):
and minority communities to get healthcare. Many of them were
turning to the emergency department to fill that gap. Second,
he recognized that not having healthcare contributed to ongoing poverty,
so he also wanted, with this move to full time
emergency care, to dedicate as much effort as he could
to seeing to the needs of communities that might not

(20:56):
ever have access to a regular GP. This for it
to make emergency care into its own fully staff department
came to be known as the Alexandria Plan, and the
Alexandria Plan got a lot of attention, and that attention
came not just from the hospital staff in the community,
but also the media and other hospitals who started to
wonder if similar organizational structures might work for them. Over

(21:21):
the next several years, the emergency department at Alexandria's patient
load doubled, and other hospitals soon started to emulate them.
Seven years after the beginning of the Alexandria Plan, the
idea of emergency medicine as a specialty was established enough
and demand for specialized training was high enough that the

(21:42):
American College of Emergency Physicians was founded. Dr Mills and
his trailblazing colleagues served in key positions within this organization,
but in the interim something else had happened which changed
the emergency landscape. On July, President Lyndon B. Johnson's find
a set of Social Security amendments into law, which included

(22:04):
provisions for the creation of two important programs, Medicare and Medicaid. So,
just in case you're not familiar with these two forms
of healthcare coverage, here is a very brief broad strokes rundown.
Medicare is federally funded and was initially created to offer
coverage to people sixty five and older who in the
nineteen sixties insurance market had a really hard time getting coverage.

(22:28):
That program has since expanded to include coverage for people
with disabilities and people meeting specific criteria related to end
stage renal disease. The program also added coverage for things
like prescription drugs over time. Medicaids function was and is
to provide medical insurance to low income families and individuals.

(22:48):
This is a federal and state program where the federal
government subsidizes at least half of the state's costs in
providing services to Medicaid beneficiaries, just has has been the
case with Medicare. The Medicaid program has evolved over time,
and it has expanded to include pregnant women, people with disabilities,
and those with long term care needs in their coverage guidelines.

(23:11):
Medicaid is not consistent state to state, though each state
has leeway to shape the program into what theoretically best
suits that states constituents, and it is also possible for
a person to qualify for both programs. So we mentioned
a moment ago that the Alexandria Hospitals patient load and
the emergency department doubled over the course of several years,

(23:33):
and those new programs were a significant driver of that
uptick in numbers because more people had insurance coverage, and
that meant that there were more cases where people were
using the emergency department instead of seeking out a GP
for their routine healthcare needs. In the five years following
the legislation that created Medicare and Medicaid, emergency department visits

(23:54):
in the US went from twenty nine million a year
to forty three million. And this also created an entirely
new problem in terms of poor communities, which was a
growing population in cities. In the nineteen sixties, most inner
cities had hospitals which were considered urban teaching hospitals. That
meant that their emergency departments were staffed by interns and residents,

(24:17):
and there were often few or no full time emergency
doctors working there to supervise or guide the department. Naturally,
this meant that the poor often received substandard care. Cincinnati
residents from the primarily black neighborhoods around Cincinnati General Hospital
became so frustrated with the mediocre care and long await

(24:38):
times at the hospital that a group of demonstrators marched
on the facility. Their protests led to meaningful change to
fill the gap in dedicated emergency physicians in the city.
The University of Cincinnati started the country's first emergency medicine
residency training program. When the program began in nineteen it
had only one resident, but it quickly grew, and other

(25:00):
cities around the country that had similarly left teaching hospital
emergency departments without dedicated full time physicians also began partnering
with their local universities to offer similar programs. Even so,
it took almost a full decade for emergency medicine to
be recognized as a Board certified specialty by the American

(25:20):
Board of Medical Specialties. And that is where we will
leave this off for today. Next time we will kick
off by talking about a paper that addressed all the
problems and emergency medical care in the US as the
need for that care was on the rise. I have,
instead of listener mail today a plea sort of. It's
not really a plea, UM. It is a request that

(25:42):
was put out by the Atlanta History Center UM and
I saw it and I think it's a really cool
idea because it enables our listeners, particularly if they are
in the Atlanta area, to take part in documenting history.
They posted a blog at the History Center on the
seventh of this month, that's April uh and they are

(26:04):
asking for people because they recognize that we are living
through a very unique time. So they are asking for people,
particularly Atlanta residents, to send them documentation of how they
are living in what is going on. They have an
online donation form and if you are interested in participating,
they're like, you can do this with photo, video, social

(26:24):
media posts, your grocery lists, lesson plans, of your teacher letters, etcetera.
That you can share with them, so they will make
an archive of what we are living through, which is
so cool. Uh. If you want information on this, you
can go to Atlanta History Center dot com, slash blogs,
slash Coronavirus, dash Collective, or you can just go to
Atlanta History Center um and if you just do a

(26:47):
search for Corona Collective, it comes up. I just think
it's a really cool thing. Atlanta is in a weird place.
This won't air for a little bit, but our restrictions
on what businesses can be open have just been shifted
to opening a lot of things well earlier than anybody anticipated.
I hope everybody is still saying very safe, and I

(27:09):
really really hope that they take advantage of this opportunity
if you live in Atlanta, to contribute and make your
voice part of this, this ongoing record. They have some
specific things that they would love answered from different parts
of the community, like if you work in a medical
profession or if you're a local business owner, etcetera. And

(27:30):
that's all in that that blog post I referenced. I
hope that everybody goes and participates in this from the
Atlanta area. If you're not from the Atlanta area, it's
worth taking a look at just to think about the
kinds of things you're doing in your day to day
life that might seem mundane or every day but are
important to documents. Uh. And see if there is a
similar program in your area. So again, that's at the
Atlanta History Center dot com. There's no the and that

(27:53):
it's just Atlanta History Center dot com. Uh. And you
can go to their blog and look for it, or
you can do a search for Corona Collective to super
cool program. If you would like to write to us,
you can do so at History podcast at i heeart
radio dot com. You can also find us everywhere on
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(28:14):
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