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The true origins of the concept of prehospital emergency care may not be clear, but there is no doubt that this philosophy has existed for centuries. Early hunters and warriors provided care for the injured. Although the methods used to staunch bleeding, stabilize fractures, and provide nourishment were primitive, the need for treatment was undoubtedly recognized. The basic elements of prehistoric response to injury still guide contemporary emergency medical services (EMS) activities. Recognition of the need for action led to the development of medical and surgical emergency treatment techniques. These techniques in turn made way for systems of communication, treatment, and transport, all geared toward reducing morbidity and mortality.

The Edwin Smith Papyrus, written in 1500 BC, vividly describes triage and treatment protocols [1]. Reference to emergency care is also found in the Babylonian Code of Hammurabi, where a detailed protocol for treatment of the injured is described [2]. In the Old Testament, Elisha breathed into the mouth of a dead child and brought the child back to life [3]. The Good Samaritan not only treated the injured traveler but also instructed others to do likewise [4]. Greeks and Romans had surgeons present during battle to treat the wounded.

The most direct evidence of modern prehospital systems is found in the efforts of Jean Dominique Larrey, Napoleon’s chief military physician. Larrey developed a prehospital system in which the injured were treated on the battlefield before using horse‐drawn wagons to carry them away [5]. In 1797, Larrey built “ambulance volantes” of two or four wheels to rescue the wounded. He introduced a new concept in military surgery: early transport from the battlefield to aid stations and then to the frontline hospital. This method is comparable to the way that modern physicians modified the military use of helicopters in the Korean and Vietnam wars. Larrey also initiated detailed treatment protocols, such as the early amputation of shattered limbs to prevent gangrene.

The Civil War is the starting point for what we know as EMS systems in the United States [6]. Learning from the lessons of the Napoleonic and Crimean wars, military physicians led by Joseph Barnes and Jonathan Letterman established an extensive system of prehospital care. The Union army trained medical corpsmen to provide treatment in the field. A transportation system, which included railroads, was developed to bring the wounded to medical facilities. However, the wounded received suboptimal treatment in these facilities, stirring Clara Barton’s crusade for better care [7].

The medical experiences of the Civil War stimulated the beginning of civilian urban ambulance services. The first were established in cities such as Cincinnati, New York, London, and Paris. Edward Dalton, Sanitary Superintendent of the Board of Health in New York City, established a city ambulance program in 1869. Dalton, a former surgeon in the Union Army, spearheaded the development of urban civilian ambulances to permit greater speed, enhance comfort, and increase maneuverability on city streets [8]. His ambulances carried medical equipment such as splints, bandages, straitjackets, and a stomach pump, as well as a medicine chest of antidotes, anesthetics, brandy, and morphine. By the turn of the century, physician interns accompanied the ambulances. Care was rendered and often the patient was left at home. Ambulance drivers had virtually no medical training. Our knowledge of turn‐of‐the‐century urban ambulance service comes from the writings of Emily Barringer, the first woman ambulance surgeon in New York City [9].

Further development of urban ambulance services continued in the years before World War I. Electric, steam, and gasoline‐powered carriages were used as ambulances. Calls for service were generally processed and dispatched by individual hospitals, although improved telegraph and telephone systems with signal boxes throughout New York City were developed to connect the police department and the hospitals. In some cities, the first ambulances and hospitals, in fact, were developed as part of the police department [10]. During World War I, the introduction of the Thomas traction splint for the stabilization of patients with leg fractures led to a decrease in morbidity and mortality.

Between the two World Wars, ambulances began to be dispatched by mobile radios. In the 1920s, in Roanoke, Virginia, the first volunteer rescue squad was started. In many areas, volunteer rescue or ambulance squads gradually developed and provided an alternative to the local police department, fire department, or undertaker. In areas where medical resources were available, those ambulances were staffed with physicians, often interns. After the entry of America into World War II, the military demand for physicians pulled the interns from American ambulances, never to return, resulting in poorly trained staff and non‐standardized prehospital care. Postwar ambulances were underequipped hearses and similar vehicles staffed by untrained personnel. Half of the ambulances were operated by mortuary attendants, most of whom had never taken even a first aid course [11].

Throughout the 1950s and 1960s, two geographic patterns of ambulance service evolved. In cities, hospital‐based ambulances gradually coalesced into more centrally coordinated citywide programs, usually administered and staffed by the municipal hospital or fire department. In rural areas, funeral home hearses were sporadically replaced by a variety of units operated by the local fire department or a newly formed rescue squad. Additionally, in both urban and rural areas, a few profit‐making providers delivered transport services and occasionally contracted with local government to provide emergency prehospital services and transport. Before 1966, very little legislation and regulation applicable to ambulance services existed, limiting consistency among services. Ambulance attendants had relatively little formal training, and physician involvement at all levels was minimal.

A number of factors combined in the mid‐1960s to stimulate a revolution in prehospital care. Advances in medical treatments led to a perception that decreases in mortality and morbidity were possible. Closed‐chest cardiopulmonary resuscitation (CPR), reported as successful in 1960 by W.B. Kouwenhoven and Peter Safar, was eventually adopted as the medical standard for cardiac arrest in the prehospital and hospital settings [12, 13]. New evidence that CPR, pharmaceuticals, and defibrillation could save lives immediately created a demand for physician providers of those interventions in both the hospital and prehospital environments. Throughout the 1960s, fundamental understanding of the pathophysiology of potentially fatal dysrhythmias expanded significantly. The use of rescue breathing and defibrillation was refined by Peter Safar, Leonard Cobb, Herbert Loon, and Eugene Nagel [14]. Safar persuaded many others that defibrillation and resuscitation were viable areas of medical research and clinical intervention.

In 1966, Pantridge and Geddes pioneered and documented the use of a mobile coronary care ambulance for prehospital resuscitation of patients in Belfast, Northern Ireland. Their treatment protocols, originally developed for the treatment of myocardial infarction in intensive care units, were moved into the field [15]. Because the physician‐led medical team was often with the patient at the time of cardiac arrest, the resuscitation rate was a remarkable 20%. Their “flying squads” added a dimension of heroic excitement to the job of being an ambulance attendant, and their performance data helped convince American city health officials and physicians that a more medically sophisticated prehospital advanced life support (ALS) system was possible.