The history of our history: 50 years of prehospital medicine
A transatlantic tale of former army doctors, paramedic development, cardiac arrest survival, and Johnny and Roy
Fifty years ago, on July 15, 1970, then California Governor Ronald Reagan signed into law the Wedworth-Townsend Paramedic Act. The law created the conditions for the establishment of the first accredited paramedic training program in the United States.
The story of American paramedicine did not begin in California or even in the U.S., but in Belfast, Northern Ireland. The inspiration for this program came from World War II era British Royal Army Medical Corps (RAMC) Medical Officer, Professor Frank Pantridge, MD.
A cardiac consultant to the Royal Victoria Hospital in Belfast, Pantridge established a specialist cardiology unit in the 1950s, where he introduced the modern system of cardiopulmonary resuscitation (CPR) for the early treatment of cardiac arrest. Further study by Pantridge identified that many deaths resulted from ventricular fibrillation which should have been treated before the patient was admitted to hospital. This led Pantridge to introduce a mobile coronary care unit (MCCU) – an ambulance with specialist equipment and staff to provide pre-hospital care. The rest, as they say, is history!
Meanwhile, across the pond, LA cardiologist Walter S. Graf, himself a former U.S. Army physician, became concerned about the lack of actual medical care being given to coronary patients during emergency transportation to a hospital. Following Pantridge’s Belfast model, Graf created a mobile critical care unit, known as the Heart Emergency Ambulance Rescue Team (the HEART Ambulance) which was essentially a bread truck/UPS-looking utility van, with a registered nurse and a portable defibrillator.
This also coincided with the LA County Fire Department’s gaining permission to begin training as Mobile Intensive Care Paramedics, with the first class beginning in September of 1969, at LA’s Harbor General Hospital (these days, the Harbor-UCLA Medical Center) under the Direction of Dr. J. Michael Criley. There was one small problem – the need to create the legislation to allow these fledgling paramedics to deliver emergency care; until then, the preserve of doctors and nurses.
Enter California Assemblymen James Q. Wedworth and Larry Townsend, who successfully sponsored the legislation, drafted by Dr. Graf and LA County Supervisor, Kenneth Hahn to formalize and legalize the practice of paramedicine. Despite the objections of doctors and nurses at the time, Governor Reagan signed the act into law on July 15, 1970. Reagan only signed off after gaining assurance that paramedics would be allowed to cross city lines freely within Los Angeles County. This could have been a showstopper, as Reagan's father had died in 1940 at the age of 57 of a heart attack after a Los Angeles-based ambulance was restricted from entering Beverly Hills to attend the call. Paramedic training began the next month under Dr. Graf’s direction. It was the first nationally accredited paramedic training program in the United States.
Early paramedic scope of practice
The legislation identified that “any hospital operated by or contracting with, a county with a population of over 6,000,000 may conduct a pilot program utilizing mobile intensive care paramedics for the delivery of emergency medical care to the sick and injured at the scene of an emergency, and during transport to a hospital, while in the hospital emergency department, and until care responsibility is assumed by the regular hospital staff.”
The act allowed trained paramedics to render rescue, first-aid and resuscitation services, administer parenteral medications under the direct supervision of a registered nurse, and perform cardiopulmonary resuscitation and defibrillation in a pulseless, non-breathing patient.
Also when acting under physicians' or nurses' orders, paramedics could administer intravenous saline or glucose solutions and perform gastric suction by intubation. Paramedics were also authorized to administer parenteral injections of antiarrhythmic, vagolytic, chronotropic, alkalinizing and vasopressor agents. The act identified that, “no physician or nurse, who in good faith gives emergency instructions to a paramedic at the scene of an emergency, shall be liable for any civil damages as a result of issuing the instructions.”
A subsequent 1973 follow-up study of transported cardiac patients indicated that:
- Trained paramedic firefighters performed as well as nurses
- Trained personnel performed equally well whether using the special coronary response van or a regular ambulance
- Response time was twice as fast when paramedics were called compared to when a physician was called
‘Emergency!’ mirrors real EMS life
Art then mirrored life when Hollywood TV producers seeking to create a show based on firefighters met with LA County Fire Captain James O. Page, who suggested that they look to the LA County Fire Paramedic program for ideas. The pilot episode of the show was aptly titled “The Wedworth-Townsend Act.” In the same way that “Top Gun” served to be a magnate for naval aviator recruitment, 10 years earlier, “Emergency!” became the recruiting draw for a generation of EMTs and paramedics, and Johnny and Roy became national EMS treasures.
Going full circle back across the Atlantic,1970 also has significance as another former RAMC doctor, Douglas Chamberlain, directed the training of ambulance personnel in cardiac resuscitation. This was the pivotal moment in the development of UK paramedics who are now acknowledged as an autonomous and regulated profession. Professor Chamberlain's 1970’s work is widely acknowledged as the beginning of paramedicine in Europe. Chamberlain went on to be a founding member of the European Resuscitation Council and an early influential leader in the International Liaison Committee on Resuscitation (ILCOR). Chamberlain and ILCOR then all met at Utstien Abbey near Stavanger, Norway, to create a uniform system for reporting cardiac arrest survival, and the rest of that story, too, is history!
A historic day for many reasons and a very happy anniversary day and year to medics on both sides of the pond – In Arduis Fidelis – Faithful in Adversity.
50 years of prehospital medicine: EMS One-Stop With Rob Lawrence
For an audio version of this article, listen below.
Further Watching with Randolph Mantooth
Ten years ago in 2010, on the 40th anniversary of the Wedworth-Townsend Paramedic Act, the LA County Fire Museum produced a video of historic importance when Johnny and Roy themselves, Randolph Mantooth and Kevin Tighe, together with UCLA’s Dr. Baxter Larmon, interviewed the pioneers of original paramedicine, including Dr. Leonard Cobb, Dr. J. Michael Criley, Dr. Walter Graf and Dr. Eugene Nagel.
My thanks to Dr. Baxter Larmon for keeping me straight on the history, dates and attributions.