VOLUME 36, ISSUE 2

Christopher T. Stephens, M.D., FAEMS

Chief of Trauma and Professor of Anesthesiology
McGovern Medical School
Houston, TX

Anesthesiologist Pioneers Who Trained the First Paramedics in the United States

“Squad 51, start an IV D5W and send EKG. Roger, Rampart, starting IV and sending EKG now. Rampart, the patient is now unconscious and is in ventricular tachycardia! Roger, 51, go ahead and defibrillate patient now! 10-4, Rampart!” This is an all too familiar quote from the popular TV series, EMERGENCY!, which aired from 1972 – 1977. This TV program was the very first time that the work of the Los Angeles County Fire Department paramedics was shown to the general public and the medical advisors to the original series were, in fact, anesthesiologists! 1,2

If you research the history of Emergency Medical Services (EMS) in the United States, you will learn that the origins of this unique field began with both anesthesiologists and cardiologists. These two specialties taught lay persons how to perform advanced cardiac life support and resuscitation techniques outside of the hospital in communities which lacked direct access to emergency care. The resulting “para-medic” training programs were a tremendous success. This all took place in the 1960’s and 1970’s. 2

It was a young and ambitious anesthesiologist from Austria who founded, educated, and trained the very first advanced life support paramedics in the United States. The three-time nominee for the Nobel Prize in Medicine, Dr. Peter Safar, had joined the faculty at University of Pittsburgh after pioneering cardiopulmonary resuscitation (CPR) and rescue ventilation techniques for fire fighters, boy scouts, and even the lay public in Baltimore, Maryland. The pioneering Dr. Safar published his rescue ventilation techniques in the Journal of the American Medical Association in 1958 and was deemed the “Father of CPR”. 3,4 It was after he left Baltimore and joined the University of Pittsburgh that Dr. Safar realized the lack of access to emergency health care within the neighborhoods of inner city Pittsburgh. At the time, all medical emergencies within the city were responded to by police officers driving police wagons with little to no medical supplies or equipment, let alone any medical training. Hence, the level of care en route to Pittsburgh’s Presbyterian Hospital was essentially non-existent and Dr. Safar had the vision to change this. Thus, Dr. Safar, along with several key hospital and city officials agreed to support the idea of having a city run ambulance service. Dr. Safar, Phil Hallen, and James McCoy, Jr., founder of the Hill District’s Freedom House Enterprise Corporation, and the city mayor were the key stakeholders to get an organized EMS system developed from scratch. Their plan was to recruit unemployed African American men from the Hill District who had no previous medical education so they could be trained in basic life-saving measures by Dr. Safar at Presbyterian Hospital. The program launched and was successful, despite many roadblocks along the way. The fact that Dr. Safar was training these men the techniques of resuscitation within the operating rooms (OR), intensive care units, and the emergency room was extremely controversial and progressive for that time period.5

Peter Safar, M.D. (third from left) demonstrates airway management techniques to paramedic trainees

In April of 1967, the Freedom House Ambulance Service Committee congregated for its first official meeting. Dr. Safar graduated his first class of 20 men, who then commenced their nine months of on-the-job training using two donated used police ambulance vehicles dispatched from Presbyterian hospital. In the first year, Freedom House paramedics were dispatched to 5,868 calls and transported 4,627 patients, with an average of 15 calls per day. Hence, Freedom House crews were the very first trained paramedics in the United States and it was them who set the stage for paramedic training programs in the future. As the years progressed, Freedom House responded to more than 45,000 calls for help with five updated mobile intensive care ambulances.6

Eugene Nagel, M.D.

Another pioneer Anesthesiologist, Dr. Eugene Nagel, was instrumental in educating and training the Miami Fire Department paramedics in the early 1970’s on the heels of Dr. Safar’s groundbreaking work.1 Dr. Nagel completed his residency in anesthesiology in New York before relocating to Miami, where he joined the University of Miami School of Medicine’s Department of Anesthesiology. After witnessing the fire fighters’ attempt at reviving a man suffering from cardiac arrest, he walked into the fire station days later and offered his expertise in training them in CPR, IV placement, medication delivery, and advanced airway management techniques. He convinced the fire chief, as well as the city council, that this training was desperately needed in the City of Miami. He won the battles and became the first medical director of the city fire department! A very interesting side note, Dr. Nagel along with his engineering colleague, developed the first telemetry “Biophone” which allowed the fire fighter paramedics to call the hospital and speak directly with physicians in the emergency room, in addition to sending the electrocardiogram rhythm strip to the physician for medication and defibrillation orders! This was groundbreaking technology invented and pioneered by Dr. Nagel.7

Interestingly, emergency medicine (EM) was not recognized as a specialty until 1979, with the first board certification exam being offered in 1980.8 Subsequently, it is no surprise that EM physicians effectively took over the education, training, and medical oversight for paramedic programs, including medical direction for larger EMS agencies. Hence, anesthesiologists essentially stopped educating and training these motivated pre-hospital providers except for the occasional paramedic student who is sent to the operating room for the required “live” intubations to graduate from their respective program. Today, the overwhelming majority of paramedic students are teamed up with a CRNA or anesthesiologist with little to no experience or expertise in EMS and the pre-hospital environment. The result is a lack of solid education and training on the use of airway adjuncts such as oropharyngeal and nasopharyngeal airways, basic hand-ventilation skills using a bag-valve-mask, laryngeal mask airway placement, laryngoscopy skills, video laryngoscopy, and, most importantly, bougie-assisted intubations along with the physiological and pharmacological considerations when caring for the sick and injured in the field. These are all skills that a well-educated and trained paramedic must be comfortable using when starting their career out in the field environment. Sadly, the paramedic student will graduate and likely never see the walls of an operating room again throughout their career. The hospitals where these medics transport their patients to on each shift likely have anesthesiologists in the OR performing the same advanced skills each and every day, which the paramedic rarely performs but for which they are expected to maintain expertise.

The Texas Society of Anesthesiologists now has an EMS Ad Hoc Committee to specifically address issues related to the longitudinal education and training of pre-hospital providers in the OR around the state. Goals of this committee include how best to harness our special skill set as anesthesiologists to improve the overall knowledge and skills of practicing pre-hospital providers in Texas. Over the last four decades, our specialty has essentially lost touch with the EMS community by rarely if ever taking time to have an emergency medical technician (EMT) or paramedic shadow us in the operating room, so they can observe and learn from our talented group of physicians! After completing my EMS fellowship and becoming board-certified in EMS by the American Board of Emergency Medicine, I became medical director for two busy fire departments in the Houston area. As a result, I have my paramedics and EMTs shadow me in the OR at our academic level I trauma center. They learn a tremendous amount by observing the physiology, pharmacology, and airway techniques which we manage each day. Furthermore, I educate and train every flight paramedic and flight nurse who is hired on with our busy Air Medical Service. During this full immersion training, we cover shock physiology, pharmacological considerations, rapid and delayed sequence intubations, ventilator management, and post-intubation resuscitation knowledge.

Christopher T. Stephens, M.D., in his role as EMS Director

It is one of my career goals to engage my anesthesiologist colleagues around the state of Texas, as well as the entire country, to reunite with our beloved first responders and allow them to observe our practice within the OR in order to enhance their knowledge and training in basic and advanced airway techniques, as well as resuscitation. Let’s get back to our roots of educating and training our paramedics and make Drs. Safar and Nagel proud!

References:

  1. EMERGENCY! Behind the scene. 2012. Yokley, R and Sutherland, R. Jones & Bartlett Publishers.
  2. Edgerly, D. Birth of EMS: The history of the paramedic. 2013, Journal of EMS.
  3. Safar, P. Ventilatory efficacy of mouth-to-mouth artificial respiration. JAMA. 1958;167 (3):335-341
  4. Safar P. Classical Article: From control of airway and breathing to cardiopulmonary-cerebral resuscitation. 1958. Anesthesiology. 2001 Sep;95(3):789-91. doi: 10.1097/00000542-200109000-00035. PMID: 11575555.
  5. American Sirens. 2022. Hazard, K. Hachette Books.
  6. Dr. Peter Safar (A Retrospective): The Forgotten Heroes of Freedom House. Department of Anesthesiology & Perioperative Medicine, University of Pittsburgh https://www.anesthesiology.pitt.edu/news/profiles-diversity-peter-safar-md Accessed May 13th, 2024.
  7. White, G. Winter Haven doctor, a pioneer of emergency medical services in 1960’s, dies at age 98. The Ledger. 2023. https://www.theledger.com/story/news/local/2023/01/12/winter-haven-doctor-pioneer-of-emergency-medical-services-dies-at-98/69797874007/#:~:text=Nagel%20died%20Tuesday%20at%20age,EMS%20Museum%2C%20along%20with%20Dr. Accessed May 13th, 2024.
  8. Huecker, M, et al. Emergency Medicine History and Expansion into the Future: A Narrative Review. West J Emerg Med. 2022;23(3): 418-423.

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