Complete Story
11/19/2020
History of Emergency Medicine
Torree McGowan, MD
Emergency physicians are a critical wartime specialty. No one wants to go into combat today without emergency physicians nearby as part of their medical team. It hasn't always been that way. Thanks to the pioneering vision of many military physicians, emergency medicine grew from a non-existent specialty to flourish over the next forty years as a result of their efforts. GSACEP is working to collect and compile stories, accounts, and oral histories from military emergency medicine physicians as part of the “History of Military Emergency Medicine” project, with the goal of creating a definitive, first-hand history of this unique medical specialty. In the next several issues, we will be bringing you selected, abridged transcripts from this project, beginning with its introduction. If you want to learn more about how you can support the project, or have a story you feel should be included, click here
Emergency Medicine is a young specialty, but its roots stretch back centuries, intricately intertwined with the history of military conflicts. The battlefield has served as a catalyst for creating some of the basic ideas which define emergency medicine as a distinct medical discipline, and a crucible for refining existing medical knowledge. No other human condition consistently produces large numbers of traumatic injuries and communicable diseases like wars, and the development of emergency medicine can be traced through the evolving conflicts of the past millennia.
It has only been in the past 50 years that emergency medicine has emerged as a recognized specialty in the house of medicine. A small but influential subset of those early emergency physicians served in the US Armed Forces, and they made significant contributions to the specialty of emergency medicine at large, as well as having made a unique impact on the culture of military medicine. This volume will trace the path of the remarkable evolution of military emergency medicine, told in the words of the pioneers who led the Department of Defense in the creation of the modern military emergency physician.
Physicians profiled in this book include Surgeons General of the Army and Air Force, Department Chairs and Residency directors for the various military residencies, generals, and national and international health leaders. They come from varied backgrounds in their medical specialty training, a trait they share with most early emergency medicine pioneers. This project was made possible by generous support from the American College of Emergency Physicians and the Government Services Chapter of ACEP.
Emergency medicine’s earliest hints can be seen as far back as the 1400s on the battlefields of Queen Isabella of Spain. The first recorded use of “ambulancias” to evacuate wounded was in 1487. These horse-drawn carriages waited until the battle concluded before picking up wounded.
Significant improvements in battlefield evacuation were made by Dominique Jean Larrey (1766–1842), physician to Napoleon Bonaparte during the Napoleonic wars. Larrey is regarded by many as the father of emergency medicine for his development of the “flying ambulance.” Larrey was dissatisfied with the ambulances being staged 2.5 miles behind the front lines at the Battle of Spires until after the fighting ended. He created a system of 2 horse and 4 horse drawn wagons that would collect wounded after early stabilization on the battlefield. Ambulances were staffed by trained drivers, corpsmen, and litter bearers, and would transport patients to centralized field hospitals for treatment.
The Army of the Rhine first used this system in 1793, and the concept quickly spread across the continent, and even as far as Egypt, where they even modified litters to be carried by camel.
The concept of combat casualty care and casualty evacuation was born, and has continued to make advances up through our current conflicts. Helicopter evacuation was first seen in the Korean War, which saw over 17,000 casualties moved via rotary wing transport for medical care.
The evolution of the aeroevac system continued during the Vietnam War, which saw patients moving from the point of injury to field hospitals in under 2 hours. By comparison, patients during World War I would only reach hospitals after 12-48 hours after injury.
Battlefield care and evacuation has continued to change through Desert Storm, which saw the first idea of pushing physicians forward in armored vehicles to be present at the fighting to provide care at the point of injury. Emergency medicine physicians were hand-picked by the US Marines to fill this role. The Army leads our casualty evacuation by rotary wing aircraft, and the Afghanistan conflict has seen the rise of the TACCT team, or Tactical Critical Care Team, which puts an Air Force emergency physician on a helicopter to pick up patients at the point of injury. The Air Force has created the concept of the flying ICU with Critical Care Air Transport Teams, or CCATT teams, which move critically injured and ill patients while still actively providing critical care resuscitation.
As we will see in this volume, the Vietnam War coincided with the birth of emergency medicine as a specialty, and the concepts of rapid movement of casualties and stabilization on the battlefield served to highlight the importance of a physician dedicated to the acute stabilization of the severely ill and injured patient in the first few hours of their disease process. The need for the emergency physician was crystalizing, and physicians from all specialities stepped forward to bring their unique skills to the fledgling specialty.
One of the greatest contributions of the most recent generation of military physicians is the Joint Theater Trauma System, which contains a database of all US, coalition forces, and local national trauma patients seen in the current theaters of operations. Thousands of data points are collected on each patient, ranging from prehospital cricothyroidotomy placement to presenting vital signs to antibiotic selection, and follows them through their spectrum of care. Thousands of research papers have been based on this body of data, leading to our updated understanding of blood transfusions, hemorrhage control, tourniquet use, antibiotic selection, wound management, ventilator management, and dozens of other aspects of the care of the severely injured trauma patient.
Emergency medicine physicians have been pioneers in the field of disaster management, helping write disaster response plans for hospitals both home and abroad. The real-time application of the principles of disaster planning to deal with the common 6-10 patient surges that occur with nearly every combat operation during our current conflict has allowed the honing of the disaster team concept, identifying both the strengths and weakness of the planning in real world situations. These mass casualty planning efforts can be seen coming to life after situations as diverse as the Japanese tsunami to the Boston Marathon bombing.
The framework for these incredible advances that have occurred over the past forty years was created by the first generation of military emergency physicians. These leaders created the concept of the military emergency physician, and carved a place in the military medical hierarchy for the specialty.
Perhaps the largest impact of the innovators profiled in this book is the creation of the military emergency medicine residencies. These men created a legacy of military emergency physicians training future military doctors in military hospitals, sharing the unique skills learned by caring for patients in war zones with the next generation of physicians. These Air Force, Army, and Navy residencies train dozens of physicians every year, who then carry the mantle of the military emergency physician across the globe in support of warriors in the field.
In less than half a century, emergency medicine has risen from the place where interns were sent with no training and little supervision to the center for acute resuscitation and critical care for our current medical system. Emergency medicine is well respected, not only by the medical establishment, but by line commanders who often request emergency physicians as their unit medical officers. The unique skills inherent in emergency medicine physicians of a broad range of clinical knowledge, an understanding of medicine as a system, and the ability to prioritize and innovate have cemented the emergency physician as a sought after unit asset in many military organizations.
These are the stories of the people who wrote the history of military emergency medicine, never before told. These stories often intersect and overlap, as the cadre of physicians who started emergency medicine in the military were a small and close knit group. They are the foundation for the current level of excellence in the US military emergency medicine community, which is leading trauma resuscitation research and innovation for our nation.
