The Evolution Of Prehospital Tools

Emergency medical services and the gear we use have developed significantly over the past 30 years – the span of my career. While EMS is a modern concept, prehospital care has a much longer history.

EMS can trace its roots to the battlefield. While doctors were still making house calls and patients' families found ways to get them to hospitals, battlefield situations always called for the wounded to be brought from harms way to treatment.

The earliest recorded specifications for an ambulance, rooted in the Latin word "ambulo," meaning to travel, walk or move, dates back over 200 years to France and Napoleon's chief surgeon. Battlefield surgeons were lamenting about how soldiers with treatable injuries were dying before they could get to care.

Here in the United States, the failed attempt to evacuate wounded soldiers during the 1861 battle of Bull Run (Manassas) during the Civil War, where it took a week to remove wounded soldiers from the field, led Dr. Jonathan Letterman, head of Medical Services of the Army of the Potomac, to develop the horse-drawn Rucker ambulance. Dr. Letterman went on to design a system for the Army Medical Corps for staging and deploying ambulances and even described the training levels ambulance personnel should have. It became the nation's first ambulance corps.

In 1865 Cincinnati General Hospital started the first civilian ambulance operation. Grady Hospital in Atlanta wasn't far behind, and it is longest continuously running ambulance service in the nation.

Funeral Homes

Charity Hospital in New Orleans came on line at about the same time. Civilian ambulance programs began to proliferate in response to the good results from the military ambulance programs. The eight percent death rate of World War I improved to 4.5 percent in World War II, 2.5 percent in the Korean War and two percent in Vietnam.

As recently as 1965, 50 percent of the ambulance service in the United States was provided by funeral homes. It should be no surprise then that modern American ambulances started out as converted hearses or station wagons. These vehicles worked fine when there was minimal equipment and training for ambulance staff, but as EMS became more complex, space became an issue.

The first innovation was the conversion of panel trucks and vans into ambulances. Manufacturers also began to experiment with modifying vans, making them wider or taller. As more equipment and treatments were added to the EMS arsenal, the box concept began to get traction with boxes built and mounted on van or truck chassis.

While ambulance options continued to expand, options proliferated for different applications. Many fire services opt for large truck chassis and boxes allowing for storage of fire gear along with EMS equipment, but private EMS-only operations have small European and Japanese van options that allow for fuel economy and easy urban operations.

Going hand in hand with ambulances are patient handling devices. The earliest stretchers used in ambulances were the Army cot-type canvas and wooden stretchers. As ambulances moved from horse drawn to motorized, wheeled stretchers began to evolve.

Ambulance Cots

Early designers of ambulance cots struggled with materials, looking for durability and light weight. Having to carry patients up and down stairs made weight an issue equal to strength.

Early stretchers required a great deal of maintenance. You may remember that the companies selling the stretchers either trained department personnel to do maintenance and repair on the stretchers or provided a contract service. Failure of stretcher components was so common that aggressive care was a must.

Over the last decade, there have been big changes in the stretchers available for use in our ambulances. Carbon-based polymers have provided strength while reducing weight. Stability when moving over uneven surfaces has been enhanced by larger, specially-designed wheels. The mechanisms that allow us to raise and lower the stretcher or the head or foot of it have been redesigned for ease of use, stability and safety and durability.

Portable stretchers evolved from wood and heavy canvas to lightweight aluminum and canvas. They also stored easily, folding to fit into smaller compartments.

Stair Chairs

Basket stretchers have also improved over the years. Originally made of wire and steel, they evolved into lightweight, strong, easy-to-clean plastic.

Early stair chairs were pretty much just that, a chair upon which we could carry the patient in and out of the house. Over the years, wheels were added, but early versions were useless on just about anything but perfectly flat surfaces. New stair chairs are virtually all terrain chairs. The tractor-tread like wheels allow EMS personnel to lower a patient down stairs without having to carry the patient.

Backboards have evolved over the years as well. Our younger peers may not remember wooden backboards, but 30 years ago, that's all we had. The first boards were just that, boards. Refinements included holes for straps that evolved into standard openings that nearly all manufacturers offer.

One of my favorite improvements was the runners that were placed on the backs of the board so your fingers would not get smashed or jammed under the patient. There were some hiccups in the early attempts at using plastic boards, but the technology improved to make them the standard presently used in the field.

While some may still use wooden boards, most of us have moved to plastic or carbon-fiber products for their light weight, strength and because they are easier to keep clean.

Speaking of cleaning boards, getting them clean has always been a problem. A trend that I have been very happy to see is that some hospitals have installed backboard cleaning machines. These are relatively inexpensive and easy to use. They ensure that the boards are adequately cleaned, and if your hospitals don't have them, I would consider purchasing one for your department. That being said, the hospital is the best place for them so that a dirty board is not transported in a clean ambulance.

Airway Devices

Ambulances and patient handling devices were not the only innovations in prehospital care. The breath of life came onto the scene in the 1950s, and mouth-to-mouth resuscitation became a part of our history.

Following that, devices to help us open and keep the airway open came along. Oropharyngeal airways at first were constructed of steel. They looked like wire cages shaped like the oral airways we have now.

 Other devices were developed to solve other airway problems. Some of them faired better than others. One example of a device that disappeared was the mouth screw. I'm not even certain that this was the name of the product, but that's what it was. It was a plastic screw that you would use if the patients teeth were clenched forcing the mouth open. There were concerns with this device, including broken teeth fouling the airway so the device was not recommended and faded away.

Mouth-To-Mask

The breath of life and cardiopulmonary resuscitation protocols had manufacturers coming up with devices to help us. Concerns about mouth-to-mouth contact brought about development of a variety of mouth-to-mask devices that allowed us to ventilate without the risk of contamination.

Some of the mouth-to-mask devices had an oral airway attached at the patient end of the mask. Manufacturers also tried to assist us with breathing for patients. When I first started in EMS, our dispatchers sent us out with the announcement that there was an "inhalator call." This came from the inhalator boxes that ambulances carried in the '60s and early '70s. These were oxygen tanks with tubing and masks that were strapped on to the patient and cycled ventilations powered by the tank pressure through a regulator.

While early devices were bulky and largely ineffective, recent innovations are promising. Mechanical and gas-powered ventilators have become affordable and can help us to manage ventilations precisely. With recent literature that has shown that poor managing of ventilatory rates is affecting patient outcomes negatively, this may be the biggest innovation to date.

Manufacturers also tried to help us out with CPR. The "Thumper" and "HLR" devices were machines that would provide compressions and in the case of the Thumper, ventilations. The Thumper came with a contoured plastic platform that slid under the patient and the compressing piston was inserted into the platform. The piston was then rotated over the patient and it had a type of caliper measuring device so you could set the correct depth of compressions. The HLR was a piston set on a pad that was strapped to the patient's chest.

The Thumper

I used the Thumper when I first started and particularly when the patient was intubated. I felt like the CPR provided was better than what we could do manually. Both of these devices required training and close monitoring to ensure that the machine did what it was designed to do. Inconsistencies in training and diligence negatively affected the wide or continued use of these devices. As of this writing, manufacturers continue to provide us with CPR devices. For example, the auto-pulse device wraps around the chest and squeezes to provide circulation along with coordinating compression and ventilation to the optimal rhythms according to the latest American Heart Association (AHA) standards.

Suction Devices

Suction devices have moved in opposite directions over time – simple to complex and back to simple. Early suction units were limited to use in the ambulance for want of a power source. One response to the need for portable suction was oxygen-powered aspirators. Attached to your portable oxygen tank, these units created suction by blowing oxygen at pressure through a chamber creating suction to another tube attached to the chamber. This worked on the venturi principle.

Portable suction units continued to improve getting smaller, more durable and making improvements in battery performance.

Probably the earliest and simplest suction device is a simple bulb syringe or turkey baster. These don't require a power source and are easy to clear if occluded. Over the years manufacturers have given us a variety of manually-powered suction devices using bellows or bulb type systems. Personally, I think all ambulances should be equipped with a good portable mechanical suction unit and a manual one. I kept turkey basters in our ambulances on our department, and I think one should be in everyone's jump bag.

Defibrillators in the field debuted in the '70s. In the beginning these units weighed about 45 pounds. Couple that with 25-pound radios and everything else we had to bring, and we had a lot of gear to haul.

The monitor defibrillators have gotten smaller and lighter and have added features that allow us to monitor vitals and perform 12-lead EKGs.

Cell phones and standard operating procedures have largely replaced the bulky radios we used for voice and telemetry transmission of cardiograms. Modern monitors have moved far beyond a screen showing three leads of complexes. The modern monitors can defibrillate, cardiovert, act as a pacemaker, perform 12-lead EKGs and show all of the patient's vital signs on the screen. Pulse, respirations, blood pressure along with oxygen and carbon dioxide levels can be monitored on a single screen.

Fracture Management

For fracture management earlier in prehospital care, the equipment we had available wasn't designed for use in the field. It was pretty much hospital equipment. In a femur fracture, for example, we used Thomas half rings – metal frames that had a padded base, which could be flipped to accommodate use on either leg. Once placed under the leg, a triangular bandage was used to wrap around the ankle with a loop beyond the foot that could be attached to the end of the splint. A tongue blade or a stick was then used to twist the bandage between the foot and the end of the splint until some traction was applied. While it may not have worked to apply much traction, the ankle hitch using the triangular bandage was a device and skill I continued to use when the ankle straps for my Hare Traction devices would not hold or were damaged.

While triangular bandages have largely disappeared, I like them a lot. They are great for making slings, holding dressings in place or attaching splints. In fact, they did a much better job of holding dressings to head injuries than the gauze rolls most of us use now. You can still find triangular bandages, and I feel that they should be in every ambulance. In addition, the skill of using them should be taught widely. Some of you may remember Boy Scout and Girl Scout training featuring the use of triangular bandages.

Splinting

Splinting fractures in the beginning involved a variety of boards – and later padded boards – held in place at first with triangular bandages or roller gauze.

Over time, manufactures have provided a variety of anatomically designed devices made of cardboard, plastic and metal. Traction devices have developed into bipolar and monopolar devices that have ratcheting mechanisms to provide the traction. Some of the most recent developments have added articulation at the knee to allow for greater adaptability to the injury and anatomy.

Air splints were widely popular in the '70s and are still in use. While air splints are easy to apply, they are not useful with angulated extremities. When applied, the air splint forces the extremity straight. It also makes it tough to keep an eye on pulse and sensation.

Recent vacuum splint technology has provided devices for management of extremity fractures and also as an augment or replacement for spine boards. The vacuum devices are vinyl bags full of small Styrofoam balls that compress when the air is vacuumed out of the bag forming a rigid splint to whatever area it is applied.

Bleeding control has always been about pressure. Beginning with holding a dressing in place, and ending by wrapping it in place with roller gauze. Air splints have also been used to apply pressure. Tourniquets have been in and out of favor. Recent military experience has shown tourniquets to be effective and safer than we thought, and their use is being more widely recommended.

Modern tactical tourniquets are easy to apply and provide bleeding control when direct pressure is ineffective or unsafe to apply. Another development in bleeding control is hemostatic agents. These devices use a variety of chemical compounds to promote clotting – again in situations where direct pressure is not practical or effective. Military studies are describing considerable lives saved through their use.

In civilian situations, direct pressure is still the standard with tourniquets reserved for when direct pressure is ineffective or not possible.

Even starting an IV has changed a lot over the years. Early ambulances would have used glass bottles and steel needles. When I started, the solutions came in vinyl bags, with the exception of nitroglycerin drips which came in glass.

IV Insertion Kits

The IV catheters I used in 1975 were much simpler than what's being used today. The first one I used was a "medicut" catheter which featured a Teflon catheter over a steel needle and a syringe attached at the end to draw back on when into the vein to confirm placement. We soon switched to much simpler angiocaths that were just a Teflon catheter over the steel needle. With the concern over blood-borne pathogens, changes were made to prevent needle sticks.

The newer IV insertion kits prevent contact with the needle by drawing into a protective cover as it is pulled out of the Teflon catheter. Securing the line in place also has more options. While many of us still use simple tape to secure the catheter in place, manufacturers have provided us with IV kits that protect the IV site and secure the catheter.

I'm sure I've missed some things, but this is a kind of snapshot of where we've been and where we're going in EMS gear. Our vendors have improved every aspect of work, but there will always be a few things that are timeless. Take advantage of the new technology to make your practice safer and more effective.

Also, think about a turkey baster or two and some triangular bandages.

Editor's Note: Will Chapleau, who has 30 years of EMS experience, is the Advanced Trauma Life Support (ATLS) program manager for the American College of Surgeons. He is the former chief of the Chicago Heights (Ill.) Fire Department, has served since 1996 as the chairperson for the Prehospital Trauma Life Support (PHTLS) program of the National Association of Emergency Medical Technicians and has been a member of its international faculty since 1984. He is a board member of the National Association of EMS Educators.

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