Ludwig on Leadership: Managing Your Ambulance Service 50 Years Ago

Ed's Note: Gary Ludwig is a featured speaker at EMS World Expo, October 3–7, in New Orleans, LA.

This year marks the 50th anniversary of the publication of Accidental Death and Disability: The Neglected Disease of Modern Society, the landmark white paper from the National Academy of Sciences that helped set the stage for the development of modern-day EMS. How far we have come in 50 years?

Although we still have a long way to go, as a profession EMS has made tremendous strides from the care we delivered some five decades ago.

The statistics were staggering a year before the white paper was published. In 1965 there were 52 million accidental injuries leading to 107,000 deaths, 10 million people were temporarily disabled, and 400,000 people were permanently impaired, at an estimated cost of $18 billion (1965 dollars).

The white paper stated that accidents were the leading cause of death for persons aged 1–37 and the fourth-leading cause of death for all ages. For people under 75 motor vehicle accidents constituted the leading cause of accidental death. In 1965 there were 47,089 traffic fatalities, compared to 32,675 deaths in 2014. That is a significant reduction in deaths during a time when the U.S. population increased by approximately 124 million people.

But what was it like to manage an ambulance service 50 years ago?

Location, Location, Location

Well, it all depended on where you worked. If you were the director of a funeral home, you might also have to manage an ambulance, since many funeral homes also operated ambulance services. (I always thought it was a conflict of interest, since if you delivered poor care on the ambulance, your funeral home was ultimately rewarded in the end.)

Although not many fire departments operated ambulance services, a fire chief who found himself in this situation—unless he was a visionary—probably saw operating an ambulance service as a necessary evil, since the primary role of the fire service back in the day was to fight fires.

There were some private ambulances, but in talking to people who worked on ambulances 50 years ago, the owner of the ambulance service was in business to make money and always looking to where he could save costs.

Many government hospitals in large cities also operated ambulance services in the 1960s. If you found yourself running an ambulance service for a hospital, chances are you were somewhere in the hospital chain of management; you might also have the clinics under your responsibility, since many hospitals had ambulances to move patients between healthcare facilities.

There were even a few police departments in the ambulance business, and some of those still exist. Even though the St. Louis Police Department did not operate ambulances, I can remember growing up in south St. Louis and seeing police department prisoner transport vans called “paddy wagons” into which injured people were loaded on canvas stretchers before being raced as fast as possible to the city hospital.

It did not matter if you were a funeral home director, fire chief, business owner or hospital executive, you probably tried to do the best you could with what you knew. It was not about medicine, it was about staffing, dollars and maintenance of the ambulance.

No Standards

Back in 1966 EMS did not really exist. Ambulance services were mostly limited to transporting people without really providing any care. If you were lucky, there might be oxygen in the back of the ambulance. Look at old pictures of ambulances, and they might have sign on them saying oxygen equipped, as though this was some type of marketing tool. Sometimes the people working on the ambulance had advanced first aid training from the American Red Cross, since no EMT or paramedic curricula existed.

There were no standards on how ambulances were built. Many were Cadillac ambulances designed to give a smooth ride, but not accommodating of patient care. There was no headroom in the ambulance to work on a patient—that is, even if there was an attendant in the back, since many services had none.

Other ambulances were panel trucks or station wagons. I’ve even seen a picture of an ambulance that was a large delivery truck with a tailgate—the type that might deliver your refrigerator or stove. States usually had no laws on how to operate an ambulance service, so many services made it up as they went.

Personnel did not need a medical license, and background checks usually consisted of checking to see if there was a driver’s license. Unfortunately we still fight that stigma when some still call us “ambulance drivers.”

As an ambulance manager you did not have to worry about response time standards, advanced medical equipment, training, quality improvement programs, medical direction and many other facets today’s leadership must deal with.

Although your job as the leader of EMS organization may be more difficult these days, with all the moving parts, there should also be much more satisfaction than our counterparts had five decades ago because of the improved differences we make in our systems and people’s lives.

Gary Ludwig, MS, EMT-P, is chief of the Champaign (IL) Fire Department. He is a well-known author and lecturer who has managed award-winning metropolitan fire-based EMS systems in St. Louis and Memphis. He has a total of 37 years of fire and EMS experience and has been a paramedic for over 35 years. Contact him at garyludwig.com.