The Charge of the Ambulance Brigade


Since the dawn of civilisation, time has been a critical factor in the treatment of the infirm. Even before modern medicine, those caring for the badly injured and the seriously ill would be acutely aware of the urgency of the situation. There are no qualifications required to recognise pain and suffering. The only thing that has really changed is how those circumstances are managed.

Fortunately, for the most part, things have improved.

The Common Miracle

Hippocrates: The Father of Western Medicine
The evolution of medicine itself spans thousands of years, with the Ancient Greeks being responsible for the Hippocratic Oath which, even today, underpins the ethical and honest practice of medical treatment. The Greeks also did much to advance the understanding of human anatomy and physiology and the names of most of the organs and structures in the body are Greek in origin. Physicians through the ages have built on this, expanding the biological sciences and developing new skills, all contributing to phenomenal wealth of medical knowledge no single person could ever hope to absorb.

We are all extremely fortunate to be living in today's enlightened age, where there are specialist treatments and life-saving procedures for many conditions which would previously have killed. With access to the right equipment in a hospital environment, the modern doctor's ability to diagnose and treat would, in the past, have been viewed as miraculous. For some, it still is.

But for those who cannot get to that hospital, it is irrelevant. This is why the ambulance service was born.

Bringing Out the Dead

The earliest evidence of medical transport (and I use the term loosely) was little more than a cart to move the plague-ridden, the leperous or the insane. There are wartime accounts dating back as far as the 7th century of post-battle transport of the injured soldiers to infirmaries for treatment. Notable for their contribution to what would much later become known as "first aid" are the Knights Hospitaller, who were formed during The Crusades to care for injured and infirm pilgrims in the Holy Land.

It wasn't until the Napoleonic Period that the French surgeon Dominique Jean Larrey conceived an early form of pre-hospital care, with patients being "triaged" in the field and first aid being administered to stabilise the patient prior to being transported on a horse-drawn wagon.

Whilst pre-hospital emergency treatment developed on the battlefields of the 18th Century, it was 1832 that saw a similar service introduced for civilian populations. During the cholera pandemic of 1829-1851, horse-drawn transport carriages were deployed in London to better enable the conveyance of patients to hospitals.

Late 19th Century Ambulance
The Times newspaper reported, "The curative process commences the instant the patient is put in to the carriage; time is saved which can be given to the care of the patient; the patient may be driven to the hospital so speedily that the hospitals may be less numerous and located at greater distances from each other."

It is interesting to note that, in a direct echo of modern strategic policy, the reaction to this increased transport efficiency was to move the hospitals further away - a bizarre line of logic that I will explore further at another time.

Later, in 1867, a more advanced carriage was designed for the transport of smallpox sufferers. These carriages featured a cleanable passenger compartment able to accommodate an attendant and a bed, loadable and removable by means of wide doors and rollers in the floor.

Provision of Service

In 1863, Henry Dunant formed the International Committee of the Red Cross following his harrowing experiences in the aftermath of the Battle of Solferino in 1859, where a clash between the Napoleonic French and Austrian forces saw thirty-eight thousand dead and dying soldiers abandoned on the battlefield. Along with President of the Geneva Society for Public Welfare and jurist Gustave Moynier, Dunant formed what would become the International Red Cross and Red Crescent Movement with aims to provide emergency care and relief aid throughout the world and to "protect human life and health, to ensure respect for all human beings, and to prevent and alleviate human suffering, without any discrimination based on nationality, race, sex, religious beliefs, class or political opinions."

It was in the United States of America that the first true Ambulance Service was put into motion. In 1865, Commercial Hospital (now Cincinnati General) in Ohio provided ambulance coverage, followed by Bellevue Hospital in New York in 1869. This service was created by Edward Dalton, a surgeon who had served in the Union Army. His vision was similar in many ways to modern Ambulance Services. They provided pre-hospital care in the form of pain relief (morphine & brandy) and assorted medical aids such as splints. They adhered to similar reponse time principles, attempting to mobilise in 30 seconds of receiving a call.

In another parallel to modern ambulance challenges, the Bellevue Ambulance Service struggled to cope with an dramatic increase in demand, with 1,401 calls in 1870 rising to 4,392 in 1891.* The initial plan was to crew these ambulances with junior surgeons, but the poor pay offered and the demanding shifts soon saw the role foisted upon interns instead.

In 1877, St. John Ambulance Service was formed, founded on the principles of the Knights Hospitaller, to teach first aid to civilians. They operated under the key principles of first aid, which were to:
  • Preserve life
  • Prevent further harm
  • Promote recovery
Ten years later, they began providing emergency cover and ambulance services at public events in London.

[*The population of New York rose by 161% (from 942,000 to 1.5m) in this period, whilst ambulance calls rose by 313%. This may have been due to improving communications rather than an increase in demand as this was the dawn of the telephonic era.]

The Modern Ambulance

The first part of the twentieth century saw the introduction of motorised ambulances and additional equipment such as traction splints. World War I gave rise to the first air ambulances. This innovation later found use in sparsely populated civilian regions and led to the Royal Flying Doctor Service of Australia. Two-way radio communications were put into use to improve response times and dissemination of information.

In the United Kingdom, basic ambulance services in London were run by the Metropolitan Asylums Board until 1930 when government reorganisation saw the responsibility passed to local authorities. The Second World War saw a dearth of ambulance coverage as physicians were withdrawn from civilian duties and reassigned to the armed services. In London, an auxiliary ambulance service was established to provide some service during the blitz.

It wasn't until the post-WWII era that the modern concept of an emergency ambulance was given form. In 1945, a newly-elected Labour Government under Clement Attlee announced that they would action Sir William Beveridge's 1942 Report to the Parliament Social Insurance and Allied Services, which saw the introduction of a regular national insurance contribution in support of a Welfare State to ensure a minimum standard of living "below which no one should be allowed to fall" and asserted that the government should fight the "five giant evils of Want, Disease, Ignorance, Squalor and Idleness". Following the presentation of a White Paper by Minister for Health Aneurin Bevan, on 5th July 1948 the National Health Service was born, bringing healthcare professionals under one banner nationwide in an effort to make the UK the "envy of the world."

Ambulance services were still under the control of local governments, but whereas previously coverage had often been limited to towns and cities, under the 1946 National Health Services Act, they were now required to be available "where necessary."

The Professional Paramedic

Initially staffed by volunteers, early post-war ambulances were often only able to provide transport and basic care. It was not until the Millar report in 1964 that recommendations were made to also provide treatment. Regional in-house training was provided to the ambulance workforce, then commonly referred to as technicians. In 1970, Paramedics were introduced to UK ambulance services but as training was provided in-house, practical skills varied widely from region to region. In 1974, NHS reorganisation saw control of ambulance services transferred to Regional Health Authorities. In 1985, a national course for "extended care ambulance staff" gave rise to a more homogenised skillset amongst Paramedics.

Due to continuing technological and medical advances, ambulance services were able to embrace new medical techniques in cardio-pulmonary resuscitation and defibrillation along with fluid, drug and oxygen therapy. Combined with the rising quality of training and the mobility of the ambulance, it was becoming increasingly viable to treat critical patients with live-saving interventions in the pre-hospital environment.

Throughout the next decades, the emergency ambulance would be equipped with increasingly more advanced technology to further aid ambulance practitioners in dealing with the unpredictable situations they would be tasked to resolve.

Over the next twenty years, representative and guidance organisations were formed in support of the developing ambulance services in the UK. The Joint Royal Colleges Ambulance Liaison Committee first met in 1989 to "provide robust clinical speciality advice to ambulance services." In 2001 the British Paramedic Association (now the College of Paramedics) was created in order to represent Paramedics as a professional body to the Health Professions Council.

Today, the Paramedic is furnished with the skills, drugs and equipment to perform a wide range of medical procedures such as advanced life support resuscitation techniques, intravenous cannulation and drug administration to treat a wide range of life-threatening conditions such as epilepsy, cardiac arrythmias, diabetic coma and opiate overdoses.

With sophisticated hardware and dedicated support staff, the modern ambulance service in the UK should be able to provide world-class pre-hospital care and transport to a place of treatment in a timely manner.

Should.

But despite this bold charge through history led by altruistic visionaries who overcame the challenges of war and ignorance to provide aid where previously there was none, the modern ambulance service in the UK faces its own nemesis; overpopulation, underfunding, mismanagement and systemic abuse now threaten to set the standard of ambulance care back decades. Over the centuries people have striven to provide care far beyond simply picking up the injured and the dying from abandoned battlefields. Yet these domestic cannons of the modern age are bearing down on the charging ambulance brigade, leaving them with little choice but to do just that and hope at least they might survive the coming onslaught.


Sources: 
Wikipedia
London Ambulance Service
The College of Paramedics
JRCALC
Mike-Lee
Kingston University London
The Journal
Malta.com
The New York Sinus Center

3 comments:

  1. Thanks for putting together a historical piece of work that describes our historical origns so well.
    Sometimes it is only by looking back at our history can we refocus On where our future Ambulance Service should strive to go.
    Our targets should be be driven by the patients we seek to treat and not the numbers dictated to us by the over paid directors of performance.
    Keep up the good work.

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  2. I was one of those first extended skilled Ambulance men, we attended lectures, meetings teachings at the Royal Sussex County Hospital.

    Under the guidance of Douglas Chamberlain we worked hard in our own time at our own expense, the cardiac course was twelve weeks long but we believed in what we was doing, when we whinged or complained it was about the fact that we wanted to do more and was not being allowed to.

    I once believed and still do that a workforce is not totally demoralized whilst they are fighting for a better service for the public, look at what the staff are making the most fuss about, it's not more pay or less work or more sleep on night shifts.........they are fighting because the delays, the downgrading of clinical qualifications and the pressures put on staff are having a detrimental effect Not On Them But On Patients.

    The danger is in the future the staff will stop complaining, they will just turn up and take the pay then go home, they will no longer rush to clear up their vehicle at hospital so they can answer that cardiac arrest general broadcast, instead they will just shrug and stretch out every minute they can.

    That's the day my history will come to an end.

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  3. Unfortunately Paul that day has arrived. The pace is such (and with no down time) that it is now a fight for survival in the job. The all stick no carrot policies being persued by senior management leaves us with little choice. Many of us are too long in the tooth to seek alternative employment so we survive on our instincts. A great shame but now a necessity.

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