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The term ambulance comes from the Latin word ambulare which means to walk or move about which is a reference to early medical care where patients were moved by lifting or wheeling.

The earliest record of this type of ambulance was a hammock based cart constructed around 900 A.D. by the Anglo-Saxons.

The Normans used a litter suspended between horses on two poles. Variations on the horse litter and horse-drawn wagons were used from then right up to the 20th century.

During the Muslim conquests of the 7th century, the Muslim armies during the time of Muhammad were reported to have had a mobile dispensary following them for the treatment of soldiers on the battlefield. In particular, a Muslim woman called Amina bint Qais at the age of seventeen was the youngest woman to lead a medical team in one of these early battles. This feature was incorporated into the Bimaristan hospital institution from the 8th century. By the 10th century, doctors were often assigned to mobile medical teams to treat patients outside of the hospital, e.g. Ali Ibn Isa assigned Sinan ibn Thabit the task of sending doctors to treat the inmates of prisons, who were likely to have diseases because of their numbers and the harshness of their whereabouts. He also asked Sinan to send a mobile medical team to tour the countryside of southern Iraq and treat the residents there, whether Muslim or non-Muslim and also the cattle.

The Knights of St John were founded as a holy order by the Pope in 1080 to provide care to the poor, sick and injured pilgrims in the Holy Land during the crusades.

During the Crusades of the 11th Century, the Knights of St John received instruction in first-aid treatment from Arab and Greek doctors. The Knights of St John then acted as the first emergency workers, treating soldiers on both sides of the war of the battlefield and bringing in the wounded to nearby tents for further treatment. The concept of ambulance service started in Europe with the Knights of St John; at the same time it had also become common practice for small rewards to be paid to soldiers who carried the wounded bodies of other soldiers in for medical treatment.

The Knights of St John (A.K.A. the Knights Hospitalier or the Knights of Malta). The ‘Maltese Cross’ which is often associated with emergency services derives its name from the cross that the Knights wore on their tunics. Also, the “Red Cross” is also derived from this symbol.

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At the start of the American Revolutionary War, there were approximately 3,500 ‘Physicians’ in the colonies. Only about 200 had actual medical degrees (usually trained in Europe) and the rest were attendants or barbers. The concept of ambulance service did not exist and the technology for transporting the wounded from the battlefield had not changed much since the Knights of St John began the service.

A fact of war was wounded soldiers were expected to die. At the Battle of Bunker Hill in June of 1775, General Horatio Gates left his wounded troops for up to 3 days. If the wounded survived and were retrieved from the battlefield, they had to pay a pricey sum for their quarters while they received some sort of treatment.

The first act of mandating treatment for the wounded followed after the battle by the Massachusetts Provincial Congress authorizing the establishment of military hospitals. Each regiment was required to find and fund quarters that could be used as a field hospital. Early medical care for the wounded was patterned after the British model but this was inconsistent even in the British army.

In 1776 common war diseases were rampant in the Continental Army. Such diseases were small pox, malnutrition, pneumonia, frostbite and dysentery. General George Washington petitioned the Continental Congress for a general medical corps. This was established in 1777 and set to serve an army of 20,000. Surgeons in the army medical corps were paid $1.66 a day (approximately $28.00 in 2010) which was considerably less than the lowest paid army quartermaster.

By 1781 the War Department was established and oversaw the medical corps. By the war’s end, 1,200 ‘Physicians’ served the Continental Army but the death rate was still very high. Approximately 250,000 soldiers served in the Continental Army and 25,000 died in service. Of those, 6,500 died in battle; 10,000 died in hospital and the rest died enroute. The wounded were transported in open carts with 25% of those dying from infection. The common treatment for leg fractures was amputation with about 50% of those patients dying.

In the first few battles of the Civil War, regimental doctors set up aid stations within a few hundred yards of the battle and raised a red flag so soldiers could find them. Frequently doctors would not release their patients to often better equipped and less crowded rear hospitals because of the desire to care for the ‘Local Boys’ and the desire on the soldiers part to stay with their unit.

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At the battle of Bull Run in July 1861 the Union Army suffered 2,708 casualties. Many of the appointed stretcher bearers fled the field and the wounded were left for days. Those wounded who could walk, walked 27 miles back to Washington. Those who made it to aid stations were more often than not, worked on by physicians who had never operated on a patient before.

The Office Surgeon General had been created by the War Department prior to the start of the war. This was a first in the history of ambulances in the United States. Never before was there a cabinet position dedicated to the health of soldiers.

There were several aged and ineffective Surgeon Generals who were eventually replace by a 34 year old William A. Hammond in January of 1862. He created several innovations in military medical treatment. He is also considered the Father of Modern Ambulance Services. During his tenure as Surgeon General of the Army he implemented procedures to sanitize hospital camps. The concepts of bacterial infection would not be discovered till the years after the war but it was thought that cleaning up the hospitals would reduce deaths. He was correct in his assumptions.

Hammond also removed from general service several drugs that were common place but considered dangerous e.g. mercury and arsenic. Army hospitals were usually set up in old buildings such as warehouses having ventilation and light insufficient for patient care. He adopted an idea from Europe of a Pavilion type of hospital with large well lighted and ventilated spaces. This type of hospital design was in use well into the 1970’s.

Hammond’s greatest achievements to care for the wounded involved the transportion. The military command and control structure were reworked and he removed the responsibility of transporting the wounded from line officers to the medical corps. A Military Occupational Specialty Unit (MOS) was created designating specific litter bearer and ambulance-wagon drivers. This MOS still exists in the military today. He also designed a superior ambulance-wagon; this was the first purpose built ambulance.

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Hammond demanded and got one ambulance for every 150 soldiers and two medical supply wagons for each regimental corps. His improved transportation system proved so good that at the battle of Antietam (September 1862) his stretcher bearers and ambulance-wagons had every one of the Union Army’s 9,420 wounded soldiers off the battlefield before the day ended. A remarkable feat for those days.

The Surgeon-in-Chief of the French Grand Army, Baron Dominiquie Larrey created the first official army medical corps in 1792. Trained attendants with equipment moved out from the field hospitals to give first-aid to the wounded on the battlefield and/or carried them back by stretcher, hand-carts and wagons to the field hospitals.

The first hospital based ambulance service began in the United States in 1865 at the Commercial Hospital in Cincinnati, Ohio.

In 1867, London, England started a service to convey smallpox victims to the hospital. London received 6 horse-drawn carriages which had been modified to accept specially designed litters to carry patients. These are the first dedicated ambulance stretchers. The users of this service had to pay a fee for the service.

In 1869 Bellevue Hospital in New York City started an ambulance service under the direction of Edward Dalton - a former Union Army surgeon. He believed that the faster the service the better the patient outcome. His ambulance-wagons carried much of the equipment that was in vogue at the time. The equipment was splints, stomach pumps, morphine and brandy. Horse teams were standing by on-call and responded within 30 seconds of being called.

The first ambulance that was staffed by doctors (Duncan Lee and Robert Taylor) from the hospital. They are considered to be New York’s first emergency responders. The service was extremely popular. In 1870 they responded to 1,401 calls but this increased to over 4,392 calls in 1891.

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Dedicated ambulance services began in London in 1887 as the St John Ambulance Brigade. This brigade is still in service today in England as well as Australia.

The late 19th century saw the invention of the automobile. These automobiles were petroleum (petrol) or gasoline (Yankee petrol), electric and steam powered. The first motor powered (electric) ambulance was in Chicago at the Michael Reese Hospital in 1899. It was purchases with donations from 500 prominent Chicago businessmen. In 1900 New York City acquired its first motor powered (electric) ambulance.

The first petroleum powered ambulance was the Palliser Ambulance introduced by Major Palliser of the Canadian Army. This ambulance was heavily armoured and had a single steering wheel and tracks. It was designed for military use. The first mass-produced ambulance appeared in 1909 and was manufactured by the James Cunningham, So and Company of Rochester, N.Y. This company was noted for building hearses and carriages. This ambulance had some notable features. It had electric lights which was unusual at the time. The cot used to transport patients had its own suspension and there were 2 seats for ambulance attendants. It had pneumatic (air filled) tires; most tires at the time were solid. This provided better patient comfort in that is smoothed out the bumps. The ambulance had a 32 horsepower 4 cylinder internal combustion engine. It also had a side mounted gong (the prelude to the siren) to alert other carriages and pedestrians that an ambulance was coming through.

World War I saw motorized ambulances replacing horse-drawn types.

In the civilian world, ambulances were being based out of hospitals and were being staffed by doctors. Some country areas used the telegraph or telephone to call the police who would then dispatch the ambulance.

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The equipment on board ambulances was also changing. Besides the standard splinting, traction splints were being used to immobilize femur (thigh bone) fractures. This was borne out of evidence collected during World War I where these devices had a positive outcome on patient morbidity (death).

Communications were improving. Many ambulances began to have two-way radios. This allowed for a more effective use of resources. Police dispatchers could now send ambulances to where they were needed the most.

The beginnings of air ambulances were beginning to take shape. On 15 May 1928 was the opening of the Australian Inland Mission Aerial Medical Service (later renamed the Royal Flying Doctor Service) in Cloncurry, Queensland. It began as the dream of the Rev John Flynn, a minister with the Presbyterian Church. He had witnessed the daily struggle of pioneers living in remote areas where just two doctors provided the only medical care for an area of almost 2 million square kilometres. Flynn’s vision was to provide a ‘mantle of safety’ for these people.

During World War II, doctors were in short supply for the war effort. Many doctors were drafted into military service and pulled from the ambulances. Many funeral services picked up the pace since their vehicles could transport a patient in the supine position.

Ambulances began to change in 1952 after a horrific train wreck in Great Britain known as the Harrow and Wealdstone Rail Crash. This crashed kill 112 and injured 340 others. Many of the dead could have been saved if they had the proper equipment on scene. Ambulances were beginning to be restructured to become mobile hospitals rather than just a vehicle to transport patients.

Korea saw the use of helicopters to transport the wounded to MASH units. During the Korean conflict, over 18,000 wounded soldiers were transported via helicopter.

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New lifesaving techniques and equipment were also becoming available. Cardiopulmonary resuscitation (CPR) and defibrillation were becoming a standard out of hospital procedure for cardiac arrest. Oxygen delivery systems and the need to have more room in the back of the ambulance necessitated the need for bigger and better supplied ambulances.

The car chassis based ambulances that had been in use were too underpowered and too small to carry the new loads. New standards had to be developed to create safe ambulances.

The Royal Flying Doctor Service began as the dream of the Rev John Flynn, a minister with the Presbyterian Church. He witnessed the daily struggle of pioneers living in remote areas where just two doctors provided the only medical care for an area of almost 2 million square kilometres. Flynn’s vision was to provide a ‘mantle of safety’ for these people and on 15th May 1928, his dream had become a reality with the opening of the Australian Inland Mission Aerial Medical Service ( Later named R.F.D.S.) in Cloncurry, Queensland.

In 1966 the National Academy of Sciences published a ground breaking paper ‘Accidental Death and Disability: The Neglected Disease of Modern Society’. This paper outlined what was currently wrong in the ambulance services at the time. It recommended changes in ambulance attendant training. The paper also outlined changes to ambulance construction. This resulted in the General Services Administration ambulance specification.

The history of Ambulances will continue to evolve. What is commonplace now will be looked upon as archaic in the future.

Sources: Jack E. McCallum book ‘Military Medicine’, 2008; Royal Flying Doctor Service.

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