Founding Fathers of EMS

     As a profession, EMS is just a mere child, struggling to come to terms with its identity and wishing to make its own mark in the world. A benefit to being so young is that we are not so far removed from the true beginnings of the organized delivery of prehospital emergency care. The "hows" and "whys" of our origins are still easily available-and, for the most part, from the very people who were instrumental in establishing the systems and practices we take for granted today.

     The term founding fathers is often used in reverential treatments of history, and the achievements and motivations of EMS' founding fathers are appropriately impressive. Their accomplishments-from establishing standardized training for providers to improving prehospital cardiac resuscitation to creating better system management-helped move EMS forward. The individuals highlighted in this article took personal and professional chances on fledgling ideas in order to build systems they believed would save lives. They allowed the next generation to build on a foundation with clinical, operational and administrative improvements that helped EMS survive and thrive. Knowing these individuals and their contributions is a critical step in coming to terms with where we've been, understanding where we are and identifying future directions for our profession.

A Tribute to Karl William Edmark, MD
     Karl William Edmark, MD, was a cardiovascular surgeon and lifelong inventor who was committed to improving outcomes for patients undergoing cardiac surgery. His best-known contribution was to defibrillation science. In the early to mid 1950s, defibrillators used alternating current (AC), which was unreliable and used a high-voltage wave form. Edmark developed a defibrillator that utilized direct current (DC), which provided lower-energy shocks with less trauma to patients and was more reliable and effective in terminating ventricular fibrillation. Edmark's invention, known as the Edmark Pulse Defibrillator, was first used to save the life of a 12-year-old girl in Seattle in 1961.

     Edmark founded Physio-Control in 1955. He later hired W. Hunter Simpson to direct the company's growth, while he continued to develop products to benefit patients with cardiac conditions. Edmark's company went on to revolutionize emergency medical care by introducing the first portable defibrillator/monitor that enabled paramedics to provide defibrillation in the field, before transporting the patient to the hospital. This improvement was an important factor in the advent of Seattle's Medic One, a pioneering emergency medical service founded in 1970.

David Boyd, MD
     An Illinois trauma surgeon responsible for establishing trauma centers in the Chicago area, Boyd in 1974 became the director of the federal Division of EMS within the Department of Health, Education and Welfare (the precursor to the Department of Health and Human Services). He developed the framework and guidelines necessary to implement EMS systems throughout the United States and utilized federal grant funds as an incentive for EMS system development, which resulted in the creation of state and local EMS regions across the country. Although the HEW Division of EMS would be short-lived, his efforts and leadership left a lasting impression on the structure of EMS delivery systems nationwide. Boyd served on EMS Magazine's editorial advisory board for several years.

Nancy Caroline, MD (1944-2002)
     Caroline was one of the first physicians to understand that nonphysicians could perform emergency skills traditionally relegated solely to docs. She was mentored by early EMS pioneer Dr. Peter Safar and became involved in one of the first paramedic education projects in the United States, training members of the pioneering Freedom House Enterprises Ambulance Service in the Pittsburgh area. During the late 1970s, spurred by the fact that paramedics had to utilize nursing or medical textbooks that did not take into account EMS' unique working environments, she authored the now-revered original paramedic textbook, Emergency Care in the Streets. For a decade her book was the only resource available for paramedic care. Caroline followed her efforts in the U.S. with work overseas in Israel as the first medical director of Magen David Adom, Israel's Red Cross equivalent. There she developed a training program that enabled emergency workers to respond to terrorist attacks within minutes. Until the end of her life, Caroline continued to write books for EMS education, and her first textbook, now in its sixth revision, remains well-known by EMS educators and is venerated by the many paramedics who began their careers through her words.

Jeff Clawson, MD
     In the late 1970s, as part of its program to improve survival of vehicle crash victims on the nation's highways, the U.S. Department of Transportation drafted curriculum guidelines for Emergency Medical Dispatch (EMD). A plan to train EMTs to be dispatchers was developed, but never took off. In 1978, Dr. Jeff Clawson, medical consultant for the Salt Lake City Fire Department, established a second set of protocols, based in part from these federal guidelines, as part of an attempt to reduce the number of Code 3 medical runs and, relatedly, the number of fire department-related vehicle accidents. These protocols employed key questions, prearrival instructions and dispatch priorities for a full range of medical emergencies. Although not widely embraced initially, Clawson's system has since evolved into the Medical Priority Dispatch System, the nation's leading commercial EMD product. The recognition of EMD as a vital link in the emergency medical response chain led to the founding of the National Academies of Emergency Dispatch in 1988. Throughout the years, Clawson has worked tirelessly to promote high standards in training and education and a universal emergency dispatch protocol, impacting countless lives. He is commonly, and appropriately, referred to as the father of modern emergency dispatch.

R. Adams Cowley, MD (1917-1991)
      Cowley was a pioneer in the field of open-heart surgery in the U.S., performing operations before the heart-lung machine was widely used. Despite his expertise and the success of the operations, patients were still dying from shock, not always immediately but sometimes within days or weeks. Cowley referred to shock as "a momentary pause in the act of death," a process that, once set in motion, was irreversible. Developing the concept of the "golden hour," Cowley recognized that if you could get a trauma victim to the appropriate care before that point, the patient was more likely to survive. Starting with one trauma unit in 1960, the Baltimore Shock Trauma Center was born. Encouraging trauma patients everywhere to be transported to trauma centers, Cowley pushed the Maryland State Police's Aviation Division to become one of the first ALS medevac transport systems in the world; in 1973, he convinced Maryland's governor to issue an executive order establishing the Maryland Institute for Emergency Medicine, which later absorbed EMS and became the Maryland Institute for Emergency Medical Services Systems (MIEMSS), the first statewide EMS system. Cowley was appointed as its director. Over 30 years later, MIEMSS is still recognized as one of the world's best EMS oversight systems.

Leonard Cobb, MD
      In 1967, Seattle cardiologist Dr. Leonard Cobb read an article about a mobile intensive care unit treating heart attack victims in the field in Belfast, Northern Ireland. He was intrigued by the premise that treatment was being brought to the victim, rather than waiting for the victim to be brought to the hospital. Cobb worked with colleagues in four other cities to pursue a vision of firefighters trained as paramedics who could initiate prehospital emergency cardiac care. In 1970, the Seattle Fire Department, in cooperation with Harborview Medical Center and the University of Washington, trained its first class of firefighters as paramedics. These first paramedics began to serve King County in a program called Medic One. During its first year, Medic One resuscitated and admitted 61 patients to the hospital, of whom 31 were ultimately discharged. Cobb's program went well beyond addressing the delivery of ALS, also focusing on training a significant portion of the general population in CPR. The King County system has gone on to become a model for many other areas throughout the world. Today Seattle is renowned for one of the finest EMS systems in the country and is the site of significant resuscitation research. The city's out-of-hospital cardiac arrest survival rates remain among the best in the United States.

Mickey Eisenberg, MD, PhD
     At a time when some of the major concepts that shaped EMS and our handling of sudden cardiac arrest-specifically layperson CPR, public access defibrillation and defibrillation by first responders-weren't yet on the collective radar screen, Dr. Mickey Eisenberg was one of the first physicians to begin making them reality. When King County (WA) EMS started to explore the concept of early defibrillation in the mid to late 1970s, Eisenberg became one of the first physicians genuinely interested in realizing the concept of adding semiautomatic external defibrillators to fire departments' first-responding units. As early as 1984, he published articles demonstrating the effectiveness of the aforementioned interventions in the context of an established EMS system, and he was instrumental in establishing these programs in the Seattle/King County area. Eisenberg brought Seattle's results to national attention by publishing several landmark studies, and these programs remain models for lay-CPR and early-defibrillation success across the world. Eisenberg continues to serve as the medical program director for King County EMS, codirector of the Center for the Evaluation of Emergency Medical Services and a professor at the University of Washington's School of Public Health.

J.D. "Deke" Farrington, MD
      In the mid 1950s, Farrington, often called the father of modern EMS, and some colleagues questioned why lessons learned by the military medical corps in World War II and Korea weren't being incorporated into civilian medical systems. At the time, physician interns were assigned to ambulances to provide care for medical, trauma and other emergencies, and hospitals were not set up to handle accident victims or serious trauma. Among Farrington's accomplishments were bringing this disparity regarding emergency care to the forefront of debate, promoting the use of vehicle extrication, inventing the predecessor to the spineboard and establishing the original 81-hour first aid training curriculum (the prototype of what later became the EMT-Ambulance course).

Norman McSwain, MD
     McSwain has devoted much of his efforts over the last 30 years to the prompt delivery of trauma care and advocating for prehospital providers. After reviewing and analyzing trauma trends following prehospital intervention in the 1970s, Mc Swain and other leaders from NAEMT spearheaded the PHTLS movement, which was largely an attempt to provide an Advanced Trauma Life Support-type program for prehospital providers. Today McSwain remains the medical director for the PHTLS program, which, in its various permutations, has been taught to more than 300,000 prehospital professionals in the United States and more than 25 other countries. The author or coauthor of more than 317 published articles, 35 audiovisuals, 24 books and book revisions, and 93 book chapters, McSwain has spent more than 30 years educating, assisting and mentoring EMS providers across the world. His dedication was never clearer than in 2005, when he was among the medical providers who stayed behind to assist in handling the aftermath of Hurricane Katrina. As director of trauma surgery at Charity Hospital in New Orleans, McSwain remained at the hospital to care for patients during the crisis, and waded through contaminated floodwaters to try to find help for the hundreds subsequently trapped without food or water. When the hospital was evacuated, McSwain was one of the last to leave. He currently serves on EMS Magazine's editorial advisory board.

Rocco Morando
     One of only two nonphysicians on this list, Morando assisted in establishing not one, but two of the main unifying voices integral to EMS in our country today. In 1970, a multidisciplinary task force made up of EMS stakeholders-a group that ranged from the Ambulance Association of America to the National Forestry Service to funeral directors-met to address the charge given by President Lyndon Johnson and the U.S. Department of Transportation to establish uniform standards for training and examination of personnel delivering emergency ambulance services. Morando was also instrumental in establishing educational guidelines by serving on the task force that set up the first EMT-Ambulance program. Another result of this task force was the creation of the National Registry of Emergency Medical Technicians (NREMT); Morando was selected to serve as its founding executive director. That year the first NREMT-Ambulance exam was administered simultaneously to 1,520 ambulance personnel at 51 test sites throughout the U.S. But there were no national-level associations or organizations to link the newly certified EMT-As being created around the country. In 1975, starting with just a handful of state EMS organizations, Morando and the NREMT organized and funded the first meeting of the National Association of Emergency Medical Technicians (NAEMT). From this humble beginning, Morando worked tirelessly as a consensus builder, serving on the organization's board of directors as it grew from a loose group of affiliated state associations to a leader in the world of EMS. He persevered at a time when EMS was largely unknown, supporters were few and barriers were plentiful.

Eugene Nagel, MD
     At a 1964 meeting of the International Rescue and First Aid Association, Nagel met some rescue officers who told him that despite their good CPR, all their patients kept dying. Mobile intensive coronary care units combining CPR, resuscitative drugs and early defibrillation were being tried in a few American cities, but the systems were requiring that doctors be aboard the vehicles. Nagel thought a disease-specific vehicle carrying a physician was not reasonable and wanted to find a more practical way to bring these lifesaving treatments to the field. He proposed to Miami-Dade fire officials to link a mobile intensive care vehicle to hospital-based medical command and control with radio voice telemetry. A telemetry package was put together, and a defibrillator was ordered from a little-known Seattle company called Physio-Control. The first LifePak 33 shook apart within two weeks of service. It was returned to the company to be redesigned. Fire-rescue personnel were taught to defibrillate, start IVs, administer drugs and intubate without guidelines, textbooks or legislation. Through this work, Nagel helped form the Medical Committee of the International Association of Fire Chiefs in the late 1960s. He later served on one the first federal HEW review committees that gave grants to communities for EMS systems. He saw the global importance of EMS as well and lobbied successfully in Washington in 1973 to overturn President Richard Nixon's veto of the EMS Systems Act. His later posts included Harbor General Hospital (UCLA) in 1974 and Johns Hopkins in 1976, where he was a fire surgeon with Baltimore County Fire Department. Nagel was a frequent contributor to EMS Magazine during the 1970s and early 1980s and served on the editorial advisory board for many years.

Jim Page, JD (1936-2004)
     Possibly the most recognizable of all the founding figures of EMS, James O. Page had a career in public service throughout the latter half of the 20th century that veritably is the history of EMS during that time: Los Angeles County Fire Department EMS innovator, advisor to the TV show Emergency!, director of the Advanced Coronary Treatment (ACT) Foundation, early proponent of citizen CPR, North Carolina EMS director, magazine founder, EMS advocate, attorney, prolific speaker and educator-he is, notably, one of only two nonphysicians on this list. Page began his lifelong relationship with EMS as an L.A. County firefighter. During his fire career in the late 1950s and 1960s, he rose quickly through the ranks and also finished his undergraduate and law degrees. In 1971, just as a number of large cities were considering the innovative concept of training firefighters to take on roles previously carried out by doctors, Page coordinated the countywide implementation of paramedic rescue services through the L.A. County Fire Department. As one of this new breed of emergency responders, he was asked to be a technical consultant for the groundbreaking TV program Emergency! In 1973, he resigned from LACFD to accept the new position of chief of EMS for the state of North Carolina, and in 1976 he was selected as executive director of the nonprofit ACT Foundation. During the 1970s, Page both wrote for EMS Magazine and served on its editorial advisory board, going on to found the Journal of Emergency Medical Services in 1979. By 1984 Page had returned to the California fire service while maintaining a leadership role in JEMS. He retired as fire chief for the city of Monterey Park in 1989 and returned to full-time service as chair and CEO of JEMS Communications. While serving as publisher emeritus of JEMS, Page assisted in founding the EMS law firm Page, Wolfberg and Wirth. His legacy also includes establishing an EMS educational foundation at Palomar College near San Diego. Up until his death, Page continued to be one of the most eloquent and articulate advocates for the field of EMS.

Peter Safar, MD (1923-2003)
     As an intensive care specialist in the late 1950s, Safar pioneered the development of the ABCs (airway, breathing, circulation) of cardiopulmonary resuscitation. He demonstrated in a series of experiments on paralyzed human volunteers that mouth-to-mouth rescue breathing could maintain satisfactory oxygen levels in the nonbreathing victim, and showed that even laypeople could effectively perform these techniques. Working with then-dollmaker Asmund Laerdal, Safar gave birth to the noted EMS training tool Resusci Anne. His CPR studies with the Baltimore Fire Department led him to realize that prehospital care across the nation was completed via station wagons or hearses, with no treatment given en route. Subsequently he and his department chief designed a modern ambulance, with a large compartment for a patient bed and seating for an attendant. It had an oxygen source and equipment to insert an airway tube to support breathing. He then taught Baltimore firefighters to add intubation to basic CPR, leading to the first ambulance staffed by trained emergency medical responders. Safar also went on to found the Freedom House Enterprises Ambulance Service in Pittsburgh, staffed by paramedics who were trained along national guidelines Safar helped create. Already responsible for developing benchmarks for EMT education and training, identifying the standards for mobile intensive care ambulance design and equipment and putting EMS on the path to recognition as a valuable component of acute medical care in this country, Safar remained vital to the advance of resuscitation to the very end of his life, continuing to spearhead research in hypothermic therapies, some of which are seen in EMS practice today.

Frank Pantridge, MD (1916-2005)
     Pantridge has been referred to as the grandfather of prehospital ALS. Working in Belfast, Northern Ireland, in the late 1950s and early 1960s, he supported the use of the relatively new resuscitative system of CPR for the early treatment of heart attack, but also saw there were limitations to its efficacy. Pantridge knew that the longer ventricular fibrillation was present, the less likely survival became. Hospital-based defibrillators were already being used in North America, but Pantridge doubted their impact, since data had shown that the majority of sudden cardiac arrests happened outside the hospital. It was known that most coronary deaths resulted from ventricular fibrillation. He believed that immediate correction of v-fib could and should be done at the scene of the event. However, a major problem was that defibrillators of the time could only be operated using main power supply. Using his research, he developed the first portable defibrillator-a svelte model that was powered by car batteries and weighed 70 kg. This led to his introduction of the mobile coronary care unit (MCCU), an ambulance with the new portable unit and staff to provide prehospital care. With this new tool, the Belfast treatment system became adopted throughout the world. Pantridge believed defibrillators needed to be as prevalent as fire extinguishers, and that if nonphysician responders could do CPR, then they could use defibrillators. To make the devices safer, Pantridge and his colleagues worked to improve the design, and after harnessing a miniature capacitor manufactured for NASA, he was able to create a defibrillator weighing only 3 kg. Pantridge's portable defibrillator would become a key tool in EMS, and after further refinement it has become the automated external defibrillator (AED), the cornerstone of response to cardiac arrests. Pantridge served on EMS Magazine's editorial advisory board for several years.

Conclusion
     Although picking out the founding figures in any field without eliciting controversy over names left out is easier said than done, it is equally as difficult to synopsize the accomplishments of many years of thought, work and debate into a few sentences without glossing over vital accomplishments. But in the end, these discussions serve us all. In re-examining (and arguing over) our not-too-distant past, we come away with greater appreciation of these individuals. Where would EMS be today were it not for the foresight, vision and energy of these founders? In representing the future of EMS, our charge is to take up where these extraordinary people left off, accept the challenge to never be satisfied, and strive to keep EMS moving ever forward with as much thought, compassion and integrity as they did.

Raphael M. Barishansky, MPH, EMT-B, is executive director of the Hudson Valley Regional EMS Council in Newburgh, NY, and a member of EMS Magazine's editorial advisory board. He can be reached at rbarishansky@gmail.com.

EMS Magazine would like to thank Physio-Control for underwriting this section dedicated to honoring the founders of modern-day EMS, and pay a special tribute to Dr. Karl Edmark, whose invention of the defibrillator played a significant role in prehospital emergency cardiac care.

Ray Barishansky is a featured speaker at EMS EXPO, October 11-13, in Orlando, FL. For more information, visit www.emsexpo2007.com.