Doctor's Review: Medicine on the Move

October 24, 2017
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No smooth ride

Until the emergence of the ambulance, patients had no choice but to wait for help to come

For millennia, the house call reigned as the standard site for doctor-patient interaction. Instead of holding court over crowded waiting rooms or ERs, physicians pounded the pavement in order to practise medicine. This didn't always work in the patient's favour, however. In the absence of telephones, sending for the doctor could mean a wait of many hours or even days, depending on one's distance from town — and one's ability to pay. Until the concept of the hospital emerged, people had no choice but to stay put and wait for help to come.

Once hospitals took off around the 11th century, medical care expanded to include the delicate art of patient transportation. At last, Mohammed could be brought to the mountain! A thousand years ago, the two main reasons people left home were religion and war. Accordingly, it was along the pilgrim trails and on the battlefields that ambulances were born.

From the late 11th to the end of the 13th century, Christian Europeans backed by the Pope waged a religious war to recover the Holy Land and stop the spread of Islam. The Crusades were a bloody and brutal series of military campaigns that brought many young men far from home to fall on strange battlefields. The first known paramedics emerged during this time — the Knights Hospitaller of the Order of St. John of Jerusalem.

Along the dangerous pilgrim route from Europe to Jerusalem, a group of Benedictine monks known as the Order of St. John were entrusted with the care of the pilgrims, providing food, shelter and medical care. In Jerusalem in the early 1100s, they founded what are considered to be the first two modern hospitals, one for men and one for women. The order evolved into two distinct entities — a military division entrusted with winning battles and escorting pilgrims, and the Knights Hospitaller, which cared for the sick pilgrims and the Crusades' fallen soldiers.

The Knights Hospitaller learned first aid from both Greek and Arab physicians. Aside from the hospitals they founded in Jerusalem, they also set up small tents alongside battles, dashing onto the field to scoop up the wounded in litters — canvas stretchers hung between two poles and carried by two men.

Alternately, any soldier who temporarily suspended his axing and macing to transport a wounded brother off the field to the medical tents received a small fee. Interestingly, the Knights Hospitaller didn't discriminate as to a soldier's side and worked to help both Christians and Muslims with equal dedication.

There was some precedent for battle-side treatment. In Ancient Greece and Rome, injured soldiers were transported off the battlefield by chariot and protected from further harm in tents along the sidelines. But since these chariots didn't have such hot brakes — and also because they were driven by maimed centurion veterans — these downhill journeys were often more dangerous than the wounds sustained in battle.

After the Crusades, the Knights Hospitaller brought their basic knowledge of first-aid concepts back to Europe. There, the Normans applied it to serve the public good by combining the new medical techniques with their invention of the horse litter — a hammock slung between two horses. This meant that patients could be transported safely across longer distances, provided that nothing spooked the horses, which were occasionally prone to take off in opposite directions.

Aside from the Inquisition
Historians credit King Ferdinand and Queen Isabella of Spain with coining the term "ambulance" in the late 15th century. During the royal couple's campaign to drive out the Moors, ambulancias were the field hospitals in which physicians and supplies awaited wounded soldiers to be transported off the battlefield.

Though this small contribution to the greater good doesn't quite counterbalance the centuries of torture and death spawned by their infamous Inquisition, Ferdinand and Isabella's interest in emergency care inspired great advances in the field of medicine.

 

The French would revive battlefield care under Napoleon's top army surgeon, Baron Dominique-Jean Larrey (1766-1842). In 1792, he designed the first official military medical corps in Europe. Like the Knights Hospitaller, Larrey's brave teams of trained medics worked on the sidelines and, for the first time, on the battlefield itself, thanks to a fleet of well-stocked but lightweight ambulances volantes (flying ambulances) — covered wagons pulled by medics on horseback. Soldiers seriously wounded enough to require extensive treatment were transported either to nearby medical tents or farther away to the field hospitals. Amazing though it may sound, prior to Larrey's initiatives, wounded soldiers were simply left to their fate until the battle stopped at the end of the day and they could be safely carried off the field.

War was certainly the driving force behind ambulance improvement for many centuries. And, although in the 19th century New York City's Bellevue Hospital became the first to offer hospital-based, civilian ambulance service in North America, there was still a war-time connection. The service was the brainchild of Dr Edward L. Dalton, the chief Civil War army surgeon and hospital administrator, who'd earlier developed a huge network of horse-drawn ambulances to service the military.

In June of 1869, Bellevue Hospital's first two horse-drawn ambulances were put into service. Within the first year, they had responded to more than 1400 calls. Pretty soon, a fleet of specially equipped horse-drawn carriages crisscrossed the city to pick up patients and deliver them back to the hospital. An elaborate zoning system was established which took into account ambulance services popping up at other hospitals. Laws were enacted to guarantee ambulances the right of way. Indeed, the only vehicles which could trump an ambulance's passage during that time were fire trucks and US postal-service vehicles. Apparently, mail delivery was deemed a matter of life or death.

Each of the new horse-drawn ambulances had to contain a strictly defined set of equipment, including various bandages, splints, tourniquets and tonics, as well as an ample supply of that most important of medicines: brandy. Handcuffs and straightjackets were also on hand in case things got rowdy. The vehicles themselves were thoughtfully designed — lightweight wagons with movable floors that could be pulled out to facilitate patient placement. Ambulance drivers soon became highly specialized workers, priding themselves on how rapidly they could respond to a call and return their charges to the hospitals.

Canuck Trucks
In Canada, the first civilian ambulance service hit the scene in Toronto in 1883. Two state-of-the-art, horse-drawn carts were commanded by the Toronto Department of Public Health. Their primary purpose wasn't geared to general medical emergencies, however, but rather toward matters of public safety. The ambulances' main priority was to remove patients suspected of having infectious diseases and transport them to the Toronto Sanitarium.

The city's first emergency-oriented service came a few years later in 1888 and, unlike those servicing individual hospitals south of the border, was run by the police department. Hearses often doubled as ambulances during this time. Toronto's first dedicated ambulance station came into being in 1907, somewhat unoptimistically, at the city morgue. It actually remained in operation until 1992.

Ambulance service improved by leaps and bounds as soon as motorized vehicles made their appearance at the beginning of the 20th century. Chicago had the first in 1899 — a 1600-pound behemoth that travelled 26 kilometres an hour, about the same speed as a half-decent horse — at Michael Reese Hospital. New York's St. Vincent Hospital followed a year later. In Toronto, 1916 saw the introduction of the first motorized ambulance, thanks not to a forward-thinking hospital, but rather a funeral home. By the time World War I rolled around, most hospitals north and south of the border were employing their own motorized fleets. During the Great War, 1000 modified Ford Model-T ambulances accompanied American troops to France. Airplane ambulance service soon followed.

And what happened to the Knights Hospitaller of the Order of St. John? Well, there aren't any knights trawling the Gaza Strip these days, but the Order of St. John is still around and is one of the oldest humanitarian organizations in the world. The Order began its own civilian ambulance service in England in 1872. Today, it is a leading first-aid, transport and care charity active in 42 countries, including Canada, where it is known simply as St. John Ambulance. The eight-pointed white cross which flew above the hospitals and battlefield tents a millennium ago remains a familiar symbol on ambulances to this very day.

 

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