Emergency medical service

Emergency medical service (EMS), in the Middle Ages, was little more than a wagoneer calling "bring out your dead". Of course, little could be offered then to a victim of trauma or acute illness. Today, one of the challenges of EMS is how much care to render on site or in an ambulance equipped for advanced cardiac and trauma life support, and when "scoop and run" is far more important. EMS is part of critical infrastructure.

Battlefield insights

One of the few good things to come from war tends to be advances in medicine, especially trauma medicine. Still, it was well into the twentieth century before there were services to which rapid evacuation would produce dramatic results. Clearly, however, mortality and morbidity decreased dramatically during the Korean War, where evacuation helicopters met forward-deployed surgical hospitals. Greater helicopter availability, coupled with a much better understanding of trauma, led to even better performance during the Vietnam War. Literally, a soldier, severely wounded in battle in the late sixties, had a better chance of survival than a comparably injured victim of an automobile accident in his civilian home. The died-of-wounds figure was slightly greater in Vietnam than Korea, because better field stabilization and rapid evacuation brought mortally injured victims to the hospital where they died.

War	Death as a percentage of hits	Ratio of killed to wounded
Second World War	29%	1: 3.1
Korean War	26%	1: 4.1
Vietnam War	19%	1: 5.6

Civilian recognition of shock and trauma

In the U.S. civilian context, the key event in developing modern EMS systems came in 1966, when the Committees on Trauma and Shock, of the National Academies of Science, published what is widely called "the white paper", Accidental Death and Disability: the Neglected Disease of Modern Society."

Golden Hour

The idea that survival, in severely injured victims, depended on the quality of supportive care provided in the "golden hour" before definitive surgical care is most associated with R Adams Cowley.

There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later -- but something has happened in your body that is irreparable

To reduce the time to surgery, Cowley's program emphasized helicopter evacuation in civilian situations, a practice that is now being reevaluated given that there is a high accident rate in aeromedical evacuation.

While early studies suggested that an hour was, in fact, a realistic estimate of time before irreversible shock, new methods, such as permissive hypotension, hypothermia, and aggressive oxygenation may have extended the period.