CREDIT: Excerpted from AMERICAN SIRENS: The Incredible Story of the Black Men Who Became America’s First Paramedics by Kevin Hazzard. Copyright © 2022. Available from Hachette Books, an imprint of Hachette Book Group, Inc.
Hard facts first: paramedics give drugs; they diagnose (not really, but we’re splitting hairs) and treat cardiac irregularities; they slip tubes into the lungs and breathe for anyone not breathing; they shock hearts that aren’t beating. All this they do outside of the hospital, generally on an ambulance. They’re often partnered with EMTs, who are skilled providers but have less training and cannot perform the advanced life support techniques that medics do.
Beyond their duties, paramedics represent an ideal. An assurance from society, backed by money, that human lives are sacred and will be saved anywhere and everywhere they’re in danger. Society has often shrugged its burden and reneged on the deal. America pretended the burden didn’t exist until 1965. But it’s always been there.
Primitive versions of what you’d call a paramedic have been popping up in one country or another for much of history, always fizzling out and disappearing—sometimes for hundreds of years—only to remerge someplace else looking brand new. It’s the falling cat that somehow lands on its feet.
Jesus made the earliest recorded reference to practicing medicine in the street. Gospel of Luke: A lawyer asks how to receive eternal life, and Jesus tells the story of the Good Samaritan. A man traveling from Jerusalem to Jericho gets attacked by bandits. Beaten, stripped, and left for dead. Several people, including a priest, see him lying naked but pass him by. Finally, the Samaritan comes along. He treats and bandages the man’s injuries and then transports him on the back of a donkey to an inn so he can recover.
From there the story gets fuzzy, and whether the man lived or died, if the oil and wine helped or compounded his problem—who knows. We do know the promise of eternal life wasn’t enough to convince people to start delivering medical aid at the scene of an emergency. That would take another twelve hundred years. Thirteenth-century Florence: A man named Pietro di Luca Borsi put a swear jar in the cellar where his friends gathered to drink. They were so numerous and so profane that the jar quickly overflowed. And kept on flowing. Before long, they had enough loose change to do with it something of significance. They settled on the unlikely decision to create a civilian ambulance service and called themselves the Brothers of Mercy. The Brothers covered themselves head-to-toe in heavy robes and carried the sick and injured to the hospital by hand on crimson litters. They were summoned by the tolling of a bell—one for common illness or injury and two for anything more serious. If the bell tolled three times, they’d essentially be carrying a hearse instead of a stretcher.
Eventually the Brothers faded away. Need for them remained, but the field never formalized. Others came and went. Taxis during the plague, horses during war. Despite not dying being the chief preoccupation of humankind, nobody put serious thought into creating a lasting service to deal with it. Until Napoleon.
Dominique Jean Larrey was born into obscurity in 1766, the son of a shoemaker from the French Pyrenees. At thirteen, Larrey was orphaned and sent to live with his uncle, overnight going from cobbler’s kid to ward of the chief surgeon for the town of Toulouse. Guided by his uncle into a surgical apprenticeship, he showed a tremendous aptitude that eventually landed him a post in Napoleon’s army. Larrey—who in civilian life would later perform mastectomies without anesthesia, a procedure patient Frances Burney described as terrifying “beyond all description”—was horrified by what he encountered on the battlefield.
The Napoleonic wars were long and brutal. Bullets, bayonets, grapeshot. Men dropping in columns, left to suffer and die where they fell. And no one did anything about it. Surgeons never got near the fight. No one was there to treat casualties or even decide who should get treatment and in what order. So Larrey devised a solution, and in 1797 he brought it to Napoleon: surgeons should be given the same nimble horse-drawn carriages that carried the army’s “flying artillery” to use as ambulances. This way, rather than lying in misery and waiting to bleed out or die of infection, casualties could rapidly be transported to the hospital. He also proposed establishing a system to categorize the wounded by severity and transport those in need first. Napoleon liked the idea of saving rather than burying soldiers and said yes. In a single, brilliant stroke Larrey had invented not just the first dedicated ambulance corps but also the modern system of triage.
And for the next thirty-five years, the civilian world ignored it. Then came cholera.
Though it had existed in isolated pockets for centuries, cholera first made the leap to global pandemic in 1817. The outbreak started in the humid marshlands of India’s Ganges Delta, sparked by contaminated rice. From there it followed European trade routes, spreading unchecked throughout the Indian subcontinent and across Asia. It’s a nasty disease: the first symptoms—diarrhea and vomiting—come on suddenly and are joined shortly by severe abdominal cramps. The skin becomes shrunken with a distinctive bluish tint. Excessive fluid loss and septic shock lead to complete circulatory collapse and death. The whole thing takes only twenty-four hours. In its inaugural run, the disease raged through Thailand, Indonesia, the Philippines, China, and the Persian Gulf. Then it hit Turkey, Syria, and Russia before finally dying out in the harsh winter of 1823. It returned six years later, this time to stalk Europe.
“The scarcity of ambulances,” he wrote to the surgeon general, “the want of organization, the drunkenness and incompetency of the drivers, the total absence of ambulance attendants are now working their results.” Bowditch’s own son, a second lieutenant shot through the jaw, died lying in the field and waiting for help.
Heartbroken and enraged, the fiery abolitionist had a new crusade. Bowditch took his ambulance fight to anyone who would listen, and many who wouldn’t, eventually penning a passionate missive titled, in part, “A Brief Plea for an Ambulance System.” Widely disseminated, “A Brief Plea” struck a chord in Washington and helped spur a reluctant Congress to create the country’s first organized ambulance system. Since none existed—and the war was still raging—it would have to be built. Fast. Cincinnati, a town whose pork-based economy shriveled during the war, leading its factories to sit idle, stepped into the breach and became the nation’s largest producer of ambulances.
After the war, with unused ambulances sitting around, Cincinnati became the home of America’s first civilian ambulance service. These were primitive things, horse-drawn and incredibly uncomfortable. No equipment, no doctors or trained medical personnel. Their first driver, a man named James Jackson, was paid $360 a year to sling patients around the city. For a moment, Cincinnati was on the cutting edge. Then New York took over.
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Nineteenth-century New York was crowded and chaotic, prone to violence, industrial accidents, and the odd bout of cholera. But Edward Barry Dalton, a former regimental surgeon newly hired as New York’s sanitary superintendent, developed a cure: a brand-new, hospital-based ambulance system that would one-up London, Cincinnati, and anything else the world had ever seen. It took some doing, but he convinced the city, and on June 4, 1869, Dalton’s ambulances hit the streets.
The system was innovative but complex. It started with the police. Alerted to an emergency, a beat cop would fire off a telegraph to the eighteenth precinct—neighbor to New York’s infamous Bellevue Hospital—with the nature and location of the emergency. A runner from the precinct would grab the dispatch and sprint to Bellevue’s front gate to request an ambulance. Deep inside the bowels of the hospital, a horse would be hitched, the two-man crew readied, and out into the streets the whole team would race.
In the beginning, Bellevue had just two drivers, Daniel McGuire and James Stone, who were each paid $30 per month to be on standby all day every day. Together, driver and horse were the brains and brawn behind this state-of-the-art machine. It was seven feet of wood painted a gleaming black with crisp canvas sides, the whole thing lit by oil lamps that swung from the corners. There was a foot powered gong mounted up front to scatter crowds, while the floor in the back—doubling as a stretcher—was specifically designed to slide out.
This alone set the curve, but Dalton took it a step further. Each ambulance would also carry an array of medical equipment. Tourniquets, splints, blankets, straps for immobilizing fractures, bandages, sponges, a two-ounce bottle of persulfate of iron (for bleeding) and a quart flask of brandy (for everything else). Over time, a straitjacket was added to the kit. The final stroke of genius, perched jauntily on the back, facing sideways and bracing himself against the opposite side with his feet, was perhaps Bellevue’s greatest innovation: a doctor.
By the end of the year, the service had run 558 calls—everything from suicides and explosions to a man who’d been tossed from a third-story window by his wife. New Yorkers slowly grew accustomed to the sight of black Bellevue ambulances racing by in a clatter of gongs and thundering hooves, leaving in their wake startled onlookers and the lingering scent of lamp oil and wood varnish. In its first few months, Bellevue crews lost only four patients during the cross-city ride to the hospital. Calls grew more frequent as people who previously had no access to health care suddenly had doctors rushed right to their side free of charge.
There were issues along the way, the whole thing grew in fits and starts, but from here emergency medicine began to move very quickly. It remained, however, the domain of men.
In 1849, Elizabeth Blackwell had become America’s first female physician, yet fifty years later it was only the rare woman who joined her. Those who did were generally restricted to treating women and children, but in 1901 a doctor named Emily Dunning bucked the trend by convincing New York officials to let her test for the position of ambulance surgeon. The job was considered prestigious by then, and she was matched against some of the country’s best young doctors—all of whom she outperformed by placing first on the exam. Still she was refused a job. But Dunning didn’t give up. She fought the hospital board, took her case to the mayor, and finally, in July 1903, a full two years after acing the exam, became the first female ambulance surgeon.
Her first call was for a peanut vendor whose right leg got crushed beneath the wheel of a brewery truck. Reporters followed Dunning to the scene, where she stabilized and splinted the vendor’s leg—badly broken, the bone jutting out from the skin—and got him loaded and off to the hospital so quickly that a cop watching the whole thing turned to a reporter and said, “She’ll do.”
Across the country, Bellevue’s system was borrowed from and altered liberally. Not always for the better. Cleveland’s ambulances were based out of funeral homes, and morticians quite literally caught people going and coming. Rochester, Seattle, and Los Angeles turned to the police. In San Francisco, then still a wild and exotic dot on the Barbary Coast, patients were taken to drugstores, the most famous of which—the Port of Broken Heads—treated a half dozen or more patients every night of the week.
Then the nascent field received a push by necessity. The year 1914 marked the start of World War I, one of history’s great meat grinders, which advanced ambulance technology further in just a few years than all the previous centuries combined. Mounted cavalry charges and open-field advances were met with mustard gas, artillery, planes, and machine guns. In just one day at the Somme, fifty-seven thousand British troops were killed or wounded. That battle was no anomaly. The question of what to do with all these causalities arose, and in the scramble to save and reuse the Allied wounded, America—officially neutral until 1917—lent a much-needed hand.
The Ford Motor Company donated Model Ts to be repurposed as ambulances, as did philanthropists like the Vanderbilts, and scores of young Americans—twenty-five hundred by the end of the war volunteered to drive them. They bounced along bombed-out and darkened roads, picking up the wounded within reach of the front lines. It was dangerous work. Ernest Hemingway, who drove a Red Cross ambulance in Italy, was injured by shrapnel and spent months convalescing in an Allied hospital, an experience he turned into A Farewell to Arms.
When the US joined the fight in 1917, the army’s medical department took this early ambulance work a step further, assigning a unique pair of enlisted men to each company stationed on the Western Front. Trained in first aid, these troops treated the injured right in the trenches, a shift in thinking that became the first-known use of medics anywhere in the world. While this on-the-scene treatment greatly improved the chances of survival, it marked just the first step in a newly designed tiered system of care. After medics stabilized the wounded, they were carried to a company aid station for further treatment—including tetanus shots—before being transferred to a battalion aid station. There they were evaluated, treated, and loaded into ambulances for transport to definitive care at a field hospital.
By 1918 ambulance medicine had made a quantum leap. The advent of two-way radio communication sped the delivery of care, which by the war’s final days even arrived by plane. Traction splints—medieval-looking devices that pulled apart and stabilized the jagged ends of a broken femur—proved remarkably effective at saving lives. As did the medics themselves. Selected directly from the ranks of soldiers, medics spent ten weeks learning to splint fractures and dress wounds. They learned to recognize and treat trench foot and how, under supervision, to give morphine. This brief and hyper-focused education meant medics could be trained in much higher numbers than
doctors and placed right in the middle of the action.
After the war, all this knowledge, equipment, and personnel returned home. Ambulance service in the US seemed poised to flourish as never before.
And it did. For a minute. Municipalities that could afford them established paid ambulance services, and volunteers stepped in for many that couldn’t. Even as the ambulance surgeon was slowly replaced by the cheaper and more plentiful ambulance technician, the field remained attached to local hospitals and maintained a reasonable standard of care. But America was growing and changing, and the ensuing decades were marked by upheaval that once again stunted the growth of its emergency medical services.
Hospitals were the first link in the chain to break. Between 1934 and 1949, hospital admissions rose by a total of ten million patients, placing the health system under a tremendous strain that only got worse with the outbreak of World War II. As the war effort ramped up, hospitals were hit hard by rationing. They were short on doctors, supplies, and funding. Those institutions that still maintained an ambulance service quickly dumped it.
Overnight, the ambulance transformed from a medical service into a municipal one, as police and fire departments grudgingly picked up the slack. It never truly fit in either place and was treated like a Frankenstein limb rather than a full-fledged arm of public safety. The ambulance was all but ignored by police departments, which were focused on the nation’s rising crime rate, while among firefighters ambulance duty was regarded as a form of punishment. The song was much the same across the swathes of America still relying on funeral homes for emergency care. Running a medical call required use of a hearse and two morticians but brought in only a fraction of what a funeral did. For budget conscious mortuaries, transporting the living became little more than an advertisement for the inevitable—and much more lucrative—last ride of the dead.
Regardless of who was providing it, emergency medical services suffered from an unwillingness to invest either the time or the money required to keep technicians sufficiently trained and equipped. And in the absence of state- or federally mandated standards, sufficient became a term loosely interpreted at the local level to mean the absolute bare minimum. By the 1950s—nearly a century after Bellevue had assigned surgeons to the job—the American ambulance was staffed by attendants with all the expertise of a lifeguard at the public pool.
That this decline occurred simultaneous to the military medic’s rise in prowess and stature threw the problem into stark relief. In World War II, shouts of “Corpsman!” echoed across the European and Pacific theatres, while soldiers and surgeons alike returned from Korea with the knowledge that their lives and careers had been saved by corpsmen. The medical community was well aware of the corpsman’s potential, but efforts to create a civilian analog were met with indifference. The field hadn’t just stalled; it’d gone backward. And it showed. After a 1956 train derailment in Los Angeles, competing ambulance companies were so busy fighting one another over who would transport the injured that the victims were transported instead in private vehicles. This might’ve been scandalous if anyone really cared. A survey conducted a few years later revealed that only 22 percent of US cities regulated ambulances, and only 8 percent required advanced first aid training to work on them. On any given day, the patient in an ambulance may have been better qualified to handle their own emergency than the person paid to save them. By the 1960s, preventable deaths had become a public health crisis.
In 1965, forty-nine thousand Americans died in car accidents, more than were killed in the entirety of the Korean War. Many of these deaths were considered preventable with the right combination of automotive safety standards and emergency medical response, and this fact, along with the sheer number of fatalities, prompted passage of the Highway Safety Act in September 1966. As that bill was making its way through Congress, the National Research Council published a thin pamphlet called “Accidental Death and Disability: The Neglected Disease of Modern Society.” Known simply today as the White Paper, it made a lot of accusations and suggestions, though the thrust of it could be boiled down to a simple truth: ambulance technicians were too few to be there when needed, and too unskilled to be of much use when they arrived.
Just how few and unskilled? According to the White Paper, things had gotten so bad that an American shot in Vietnam was more likely to survive than if he’d been shot right here in the States. The reason for this was simple: the soldier had a corpsman crouching over him. The civilian had no help at all. Those are the kind of incendiary facts that should’ve turned 1966 into a watershed moment for street medicine. And it almost did. Instead, Washington, which had already tasked the Department of Transportation with improving highway safety standards, now added to this burden the job of elevating the medicine practiced on ambulances to a level somewhere above lethal.
The DOT may seem a strange band of bureaucrats to trust with medical advances, but they gamely set to work, issuing a decree that highway funds would only go to states that created an effective ambulance system (the same tactic Congress leveraged again twenty years later to get the drinking age changed). This was a good start. But they never made good on the threat. Nor did they define what effective meant. Or suggest minimum standards for training and equipping this medical force or even who would pay for it. Instead, everything was left to local officials, the very people whose indifference created the current crisis and who time and again had let the blueprint for street medicine slip through their fingers. Nevertheless, the White Paper set some very slow moving wheels in motion, and eventually, years down the road, action did follow.
But for now, no clear path had been set, and no true rewards or punishment existed for those who followed or strayed from it. So things carried on as they always had. Fixing this would require untangling a century of antiquated and ineffective methods and replacing them with something politicians instinctively identified (and avoided) as expensive. And even if you had the money, did you have the ability, the stamina, the right mix of genius and hubris and hard-headedness to actually pull it off ? Mostly the answer was no. But one person did, and history had put him on a collision course with Freedom House.