Book Review: The Ambulance: A History

I consider myself fairly well-read when it comes to EMS systems textbooks and was surprised when I’d not heard of Ryan Bell’s The Ambulance: A History. Don’t be fooled by the title; the book reaches deeper than merely describing the vehicular aspects of ambulances over time. Rather it aims to explain their origin, purpose and development in the larger context of the advances in medical care and societal growth. The author, a clinical psychiatrist and former district attorney in Alaska, perceived a void in the relevant literature and visited hospitals, clinics and infirmaries worldwide in the course of writing a well-researched history of the ambulance and, in effect, emergency medical services systems development in the U.S.

The book begins with a look back to the ancient Greeks and what the author considers to be the “prelude to the ambulance,” then quickly moves to the advent of Larrey’s “flying ambulances,” which saw service in the Napoleonic wars and for the first time sent trained providers onto the battlefield to collect the wounded, do triage and provide first aid and removal to definitive care. These lessons were duplicated by others in conflicts such as the Crimean War.

Moving forward, Bell deliberately limits his history to the civilian world, “referring to the battlefield only when necessary to understand developments on the boulevard.” To be sure, he gives necessary coverage to Civil War ambulance services, a precursor of much that developed in the late 1860s and 1870s in urban America. Sadly that is the extent of his coverage of the military elements of EMS—leaving out critical developments and lessons learned from conflicts such as World Wars I and II, Korea, Vietnam, and even Iraq and Afghanistan. The sad reality is that many of these more recent conflicts have brought significant knowledge regarding trauma patient treatment and transport to civilian EMS systems back in the U.S.

A fascinating chapter is Chapter 10, “Siren Call: The Lure of Speed.” This digs into detail about the emergence of the ambulance as a response entity and, interestingly, the use of sirens. Bell utilizes an overview of two cities—New York City and Portland, OR—and their views on how ambulances should employ sirens in their response paradigms. The questions that conclude this chapter—specifically the question of when speed and aggressive driving are appropriate—are still debated and relevant in the modern EMS era. This called to mind studies I’ve seen in academic journals regarding siren use in EMS vehicles transporting patients to definitive care and how much time is saved, or not, with their use. 

Bell goes on to trace interesting developments such as the initial utilization of police to deliver prehospital care in some areas, the shift from physician-based services to the EMTs and paramedics we currently see as the predominant EMS model, and even the metamorphosis from EMS being delivered in the back of a hearse by funeral home attendants with little or no training to the more modern, standardized personnel we now see responding in ambulances and other vehicles.

One of the more compelling chapters is Chapter 13, “The 1960s: Changing Tactics.” This highlights some agencies that saw a real need in their communities and took the bull by the horns to, without much regulation and usually on a shoestring budget, develop systems to respond to emergencies and deliver sophisticated care to the injured and ill. This includes the Freedom House paramedics of Pittsburgh in the 1970s as well as the lesser-known Haywood County Rescue Squad in North Carolina. This chapter also delves into the first Department of Transportation (DOT) standards developed for EMTs as well as vehicle standards for ambulances. The lessons and experiences outlined in this chapter are known to most of today’s EMS leaders and have impacted many facets of modern EMS delivery.

The last chapters in the book speak to various items that changed the face of today’s EMS, including the National Academy of Sciences White Paper of 1966 (aka Accidental Death and Disability: The Neglected Disease of Modern Society), the EMS Systems Act of 1973 and David Boyd’s regionalization efforts through the Department of Health, Education and Welfare, with the resultant Section 1200 grants and how these initiatives were a beachhead for regionalized, coordinated EMS systems. These latter chapters also highlight how EMS has suffered with the funding cuts to these programs under COBRA in the early 1980s, how some states have dedicated funds to keep these regional systems alive while others have not, and how EMS continues be disorganized on a national level, with a plethora of providers providing differing levels of care.

Is this book for everyone? No, but anyone with an interest in EMS system development will gain useful knowledge from it. This book takes the work of Carl Post’s groundbreaking text Omaha Orange and combines it with some of the depth and breadth of the NAEMSP’s Prehospital Systems and Medical Oversight to create a seminal volume.

Raphael M. Barishansky, MPH, MS, CPM, is director of EMS for the Connecticut Department of Public Health. A frequent contributor to and editorial advisory board member for EMS World, he can be reached at rbarishansky@gmail.com.