HISTORY OF EMERGENCY MEDICINE

While the practice of rendering medical care in emergent situations has coexisted alongside humanity since the very beginning, emergency medicine as an independent specialty is still in the formative stages, tracing its establishment back to mid-20th century where rapid urbanization along with coinciding scientific and economic factors lead to the widespread development of a dedicated system of care. To fully appreciate the recent boom in the field, one must chart the gradual advancements throughout the ages that have led to it.

One of the oldest medical texts ever discovered is the Edwin Smith Papyrus which dates back to Ancient Egypt (c. 1600 BCE). It is believed that this nearly 3500-year-old document, which contains the first recorded mentions of the brain, the pulse as well as the role of the heart in circulating blood, is in fact an incomplete copy of a far older manuscript that would have been written sometime between 3000-2500 BCE. The Edwin Smith Papyrus firmly established that emergency medical care was already well developed in ancient times. Of the 48 cases described in the text, 27 pertain to head traumas and 6 deal with spinal traumas. A prominent example would be case 25 which described how to set a dislocated jaw: “If thou examines a man having a dislocation in his mandible, shouldst thou find this mouth open (and) his mouth cannot close for him, thou shouldst put thy thumb(s) upon the ends of the two rami of the mandible in the inside of his mouth, (and) thy two claws (meaning two groups of fingers) under his chin, (and) thou shouldst cause them to fall back so that they rest in their places.” This method of treatment to reduce jaw dislocations is still the standard of care today. Furthermore, the rationale presented for the diagnosis and treatment of spinal injuries is still regarded as state-of-the-art reasoning for modern clinical practice. Despite all that, the safe transport of a patient to medical was not even a consideration until much later.

Patient transport is often a major logistical obstacle in the successful treatment of trauma owing to the critical state of the patient. The first record of ambulances being used for emergency purposes corresponds to the military troops of Isabella I of Castille (c. 1487). However, injured troops were not picked up for treatment until after the cessation of battle which resulted in many deaths in the field. This modus operandi was in effect until the development of “flying ambulances” by Dominique Jean Larrey in the Napoleonic era. He prioritized the system of immediate care in the field followed by rapid transport to hospitals. This eventually led to the development of hospital-based ambulance services in the civilian world by 1865 with the first one being based out of Commercial Hospital, Cincinnati, Ohio. The ambulances even carried various medical equipment such as splints, stomach pumps and morphine. With industrialization and improvement of public works, it soon became apparent that a dedicated ambulance would be much more efficient and effective with patient outcomes. By 1890, Britain had created such a system, the benefits of which furthered widespread adoption in western countries. While early ambulances were horse drawn carriages, motor units were introduced at the beginning of the 20th century which resulted in more equipment being carried, faster response times as well as a wider area of coverage similar to how the system runs today.

With emergent patients being treated by physicians of various specialties at hospitals in the lead up to the 1960s, population booms, high speed traffic accidents, industrial injuries and an aging population lead to hospital systems being overcrowded and overtaxed. Combined with the rapid progress of trauma management owing to large scale military conflicts and the realization of the “golden hour” concept, it became apparent that emergency departments should be placed in the hands of dedicated professionals who were fully committed to the immediate care of a patient. The first 24/7 dedicated emergency room was established in the US in 1961. In addition, the late 60s and early 70s was a watershed moment in the establishment of emergency medicine as a dedicated specialty. This era coincided with successes in resuscitation and life support measures along with advances in anaesthesiology, surgery, cardiology, critical and intensive care which meant that lives that were previously considered unsalvageable now had a very real chance at survival. The first emergency medicine residency program started at the University of Cincinnati in 1971. However, emergency medicine was not a recognized medical specialty until 1979 when the American Board of Medical Specialties voted in favour of it. This was the defining moment which cemented emergency medicine as one of the most vital parts of medical practice, the ramifications of which will echo through the ages just as how the Edwin Smith papyrus or the “flying ambulances” have done so in the past.