On March 17, 1996, the Fire Department of New York (FDNY) became not only the primary provider of pre-hospital care in the five (5) boroughs, but the largest fire department-based EMS in the country. Many of the improvements in pre-hospital medical care that have been implemented since that time have been a direct result of this merger. Implementation of the Certified First Responder Defibrillator (CFR-D ) has created a true, three-tiered emergency medical system (EMS) in New York City. CFR-D is the first – and basic – level, followed by Basic Life Support (BLS ), and Advanced Life Support (ALS ).
Recent studies by the American Heart Association (AHA) have shown a dramatic increase in the survival rate for out-of-hospital cardiac arrest victims who have quick and efficient CPR and defibrillation, followed by rapid access to the 911 system. The merger of the FDNY and NYC EMS has made the tiered response more seamless and effective, creating a downward trend in response times and saving countless lives each year.
Sadly, however, such trends were not always the case. . .
In the early years of “pre-hospital” emergency care in New York, City, ambulances (pictured at left) were dispatched via telegraph from Bellevue Hospital’s Centre Street branch. These ambulances were staffed by a highly-trained medical doctor or surgeon from the hospital. In the first year of operation, these ambulances responded to more than 1,800 calls for help throughout the city.
However, as the call volume increased, if a doctor was not available to respond to a call, the hospital would place other personnel (such as an orderly) on the ambulance. With little or no training, the “ambulance driver” would respond to calls for help from the sick or injured – frequently arriving at the scene hours later without proper equipment or training to treat the patient. Due to this lack of training and technology, the majority of the more seriously injured patients had already expired by the time the ambulance reached them and almost surely by the time they reached the hospital. As the population of New York continued to grow throughout the 19 th century – and into the industrial revolution of the early 20 th century – the need for additional training and easier access to rapid pre-hospital emergency medical care became apparent.
From 1909 until 1929, ambulances in New York City operated under the supervision of the Board of Ambulance Service , which was overseen by the Police Commissioner. It was during this period that the medical community began to realize the benefits of good pre-hospital medical care as well as rapid transport. During this period, there were forty-five (45) hospital-based ambulances – twelve (12) municipal and thirty-three (33) volunteer which responded to almost 343,000 calls annually.
During those early days of pre-hospital care, an ambulance crew was comprised of a motor vehicle operator (ambulance driver) and patient care personnel with varying levels of training – ranging from hospital-ward orderlies to physicians and so-called “ambulance surgeons”. As strange as it sounds, operating the ambulance was not the personnel’s primary job and they had to be “called out” when a request for an ambulance was received. The result was extended response times and, occasionally, poor medical care. Each hospital had its own interpretation of administrative procedures and practices concerning ambulance service and operated according to their own set of rules which almost always resulted in a significant variation in the service provided.
During its infancy, pre-hospital care was basically a “scoop and run” operation. In addition, an ambulance would generally transport a patient back to that particular ambulance’s hospital of origin – regardless of whether another hospital might be closer or better equipped to handle the patient’s specific injury or illness. This practice often left entire areas of the city without ambulance coverage. It’s interesting to note that, despite the fact that ambulances were under the office of the Police Commissioner, the police department had no real jurisdiction over the ambulances; the result was they – police – were powerless in preventing hospital administrators from assigning all of their ambulances to (non-emergency) transfers leaving none available for emergencies.
By the late 1960s, with annual emergency runs nearing the 400,000 mark, the commissioner of the Department of Hospitals centralized all of the city municipal ambulances under the control and direction of the Ambulance and Transportation Division of his department. For the first time in nearly one hundred (100) years, it was again possible to re-establish uniformity in the city ambulance service thereby allowing a more structured approach to pre-hospital care. In 1969 New York City’s ambulance service was an integral part of the many changes related to the delivery of pre-hospital care. Ironically, as these improvements were occurring, the number of hospitals participating in the EMS system decreased resulting in a decline in the number of ambulance on the street and available for service.
In 1970 the New York State Legislature chartered the New York City Health and Hospital Corporation (HHC ) as a Public Benefit Corporation to assume the responsibilities of the Department of Hospitals . The new corporation’s stated purpose was ” to provide high-quality, dignified, and comprehensive care to all regardless of ability to pay .” The Ambulance and Transportation Division became the Division of Emergency Medical Services and this was further shortened to the now familiar Emergency Medical Services (EMS). It was also during this time that the United States Department of Transportation (USDOT ) developed guidelines for both the training and certification of ambulance personnel. As a result, all patient care personnel were upgraded to New York State Certified Emergency Medical Technicians (NYS-EMT). Prior to this, training varied from agency to agency.
Prior to the USDOT guidelines, a New York City ambulance crew consisted of a Motor Vehicle Operator (MVO) and an Emergency Medical Technician (EMT). The MVO was not responsible for patient care and, likewise, the EMT never drove the ambulance. The only drawback to operating in this fashion was that it severely limited the number of patient care resources available. As a result, in 1973, a program was implemented to cross-train all ambulance personnel. The graduates of this class were known as Ambulance Corpsmen and they could provide patient care as well as driving the ambulance.
For the former MVOs, this meant learning a new set of skills such as oxygen therapy, patient assessment, and the application of mechanical equipment such as the Thomas Half-Ring Traction Splint. Many of the motor vehicle operators, rather than facing the prospect of additional duties and training, opted not to upgrade to the corpsman position. Over the next ten (10) years, they were either phased out completely or placed in other positions in the agency. Today, many of the EMTs, Paramedics, and officers who remained are proud to say they started as MVOs during those early days.
In 1974, a federally funded pilot program for training Paramedics was begun at the Albert Einstein College of Medicine. The first group consisted of twenty-one (21) emergency medical technicians, supervisors, and motor vehicle operators. Graduates of the program were New York State and Department of Health certified EMT-Paramedics. The program, which was hundreds of hours long, consisted of many “skill-based”, “hands-on” components, Due to the fact the program was in its infancy, the didactic portions differed from what they are today.During those early days of the program, many of the skills were competency based and had no testing procedure. Apart from this training, students were required to spend additional rotation time training in both hospital emergency and operating rooms – learning to perform skills that could only be practiced on real patients. Upon completion of the program, the new paramedics were able to insert endotracheal (ET) tubes, perform defibrillation, and start IVs.
On July 7, 1975, the first two New York City Paramedic units were placed into service at the Bronx Municipal Hospital Center. EMS Paramedics were now able to perform skills in the field that had once been reserved for “doctors only”. Although patients would still be transported to the emergency room, the emergency room was effectively being brought to the patient thereby allowing the Paramedics to perform 20 – 30 minutes of advanced care prior to transport, greatly improving the patient’s chance of recovery.