The history of patient transport begins before the invention of the wheel, when patients were carried or dragged to care. Ambulance systems were first established in the 1400s for the transportation of war casualties. These ambulances assumed many forms, from horse-pulled stretchers to wagons developed specifically for patient transport.

During the Civil War, the United States Army developed an organized ambulance system for transport of the wounded. Plans also were developed for effective evacuation and treatment of casualties from the battlefield. At this time, trains and steamboats were used in addition to conventional ambulance transport. ^4,6,11,38

An intense interest in resuscitation began in the 18th century. The first organized effort was started in 1767 in Amsterdam by a group of wealthy men known as the Society for the Recovery of Drowned Persons. One of the group’s suggestions was that persons who needed resuscitation should be taken to receiving houses (hospitals) where trained individuals could resuscitate them. ⁵ Identification of a method of civilian-based transport thus became an important issue.

In 1865, the first hospital-based ambulance service in the United States was started at Cincinnati Commercial Hospital (Figure 1-1).

The first electric ambulance was used in 1899 at the Michael Reese Hospital in Chicago. In 1905, a bulletproof ambulance was introduced for military use on the battlefield. During World War I, buses were converted into mobile surgical units for treatment of the wounded. The Model T Ford was also placed into action during World War I for transport of patients. As ground and air transport of the ill and injured progressed, the care needed before and during transport also advanced. Not until the 20th century were reliable methods of resuscitation developed, studied, and used consistently outside the hospital. In the 1960s, the work of Safar and Elam, mouth-to-mouth-resuscitation or the “kiss of life,” was combined with that of Kouwenhoven, who demonstrated the benefits of cardiac massage.

A Mobile Coronary Care Unit, staffed with both nurses and physicians, was started in Belfast in 1966. In 1968, similar units went into service in Great Britain, the United States, and Australia. In the United States, cardiopulmonary resuscitation then was taken from within the walls of the hospital to the field through the pioneering work of emergency medical systems in Los Angeles, Miami, and Warren, Ohio, in the late 1960s and 1970s. ^{5.6. and 7.}

The initial equipment used in hospital resuscitation was large and not transportable; it operated only on AC power. The advent of battery-operated portable monitors and defibrillators greatly improved the care of the critically ill or injured patient during transport. The safety of equipment was improved so that it could be used in any type of transport vehicle without interference with vehicle operations. Today, the monitors used during transport offer multiple functions, such as continuous multilead rhythm monitoring, 12-lead analysis, waveform capnography, invasive monitoring, noninvasive blood pressure (NIBP) monitoring, pulse oximetry (SpO ₂) monitoring, defibrillation, and external pacing. ⁸ The value of trained personnel who provide critical care outside the hospital continues to grow into the systems that exist throughout the world today. ⁵

Despite an old claim that balloons once were used to transport the injured from the battlefield, patient air medical transport was not used until 1915. ¹⁰ The French successfully used planes to evacuate patients during World War I, which led to their development of ambulance aircraft.

During World War I, the United States successfully completed air ambulance transports with old JN-4 aircraft that were converted into air ambulances. The JN-4 aircraft were large, old, and costly to maintain. As the aircraft started to break down, the military decided against investing in their maintenance. The military was interested in a smaller, less costly aircraft for patient transport. A military air ambulance service was used to evacuate wounded from the Spanish Civil War in 1936 for treatment in Nazi Germany. ^15,16

The first fixed-wing civilian air ambulance service in the world was established in 1928 in the Australian outback. This organization became the Royal Flying Doctor Service, which is still in operation today, with more than 35,000 evacuations annually. ^17,18

The first civil air service in the United Kingdom was sponsored by the Department of Health for Scotland through local authorities who continued development and gradual expansion over the decades. It continues to this day as the Scottish Ambulance Service (Air Wing). ¹⁹

The first civilian air ambulance service in Africa was established in Morocco in 1934 by the legendary French nurse and pilot Marie Marvingt. ^{20.21. and 22.} That same year, Austin Airways started operations in Northern Canada with two Waco cabin biplanes, one of which had a new feature: a removable panel on the port side behind the cabin that facilitated the loading of a stretcher. This aircraft became North America’s first private air ambulance. ²³

The first government-funded civilian fixed-wing air ambulance in North America was established by the Saskatchewan government in 1946 and is still in operation today. ^24,25 Schaefer Air Service became the first commercial civilian air ambulance service in the United States in 1947; it was also the first Federal Aviation Administration (FAA)–certified air ambulance service in the United States. ²⁶

African Medical and Research Foundation (AMREF) in Kenya was established in 1957 by three surgeons; since then, the Flying Doctors have been involved in many healthcare projects in East Africa, including the Air Ambulance Services. ²⁷

Today, fixed-wing transport continues to play a major role in patient transport, particularly in rural, underdeveloped parts of the world.

The French pioneer Paul Cornu lifted an untethered twin-rotored helicopter into the air entirely without assistance from the ground for a few seconds on November 1907. By 1936, many problems that had prevented the helicopter from becoming a useful aircraft had solutions. With the introduction of the Focke-Wulf Fw 61 for the German military, the practical helicopter was a reality. ²⁸ The first useful helicopter was the Focke-Achgelis Fa 223 Drache, which first flew in October 1940. ²⁹ It could reach speeds of up to 109 mph and heights up to 23,294 ft. The Dragon, as the aircraft came to be known, could transport loads up to 2200 lbs. ³⁰

Igor Sirkorsky is considered to be the “father” of modern helicopters; he invented the first commercially successful helicopters on which further designs were based. The military subsequently became interested in the potential of helicopters. The US Army commissioned Sirkorsky to produce several helicopters for general military use. They found that the helicopter was successful at getting into small areas, and thus, the military used it to drop off special units in remote areas. ³¹

The first helicopter patient evacuation took place in April 1944. A US Army Sikorsky YR-4B helicopter was used to rescue a wounded British soldier from more than 100 miles behind Japanese lines, 15 miles west of Mawlu, Burma. ³² This rescue was the beginning of patient transport by helicopter in the military.

Two weeks after arrival in Korea, Marine Corp pilots of the HMR-161 made the first of 20,000 medical evacuations by helicopter. Seventy-four casualties were flown a distance of 7 miles in a Sikorsky HRS-1 cargo helicopter. ³³ A special helicopter unit soon was formed; it used the smaller Bell 47 and was attached to the Mobile Army Surgical Hospital (MASH; Figure 1-2).

Swiss Air-Rescue (REGA) was established in April 1952. ³³ REGA is still the only air service that provides emergency air medical assistance in Switzerland. REGA brings citizens by fixed-wing or helicopter from anywhere in the world. REGA is believed to be the first civilian-based helicopter in the world to routinely use a hoist for rescue. REGA also is believed to be the first civilian-based program that is solely funded by donations and volunteer service groups. ^{34.35. and 36.}

During the Vietnam War, the care and transport of the ill and injured continued to mature. Approximately 200,000 injured were transported by helicopter during this conflict. Medics were placed on ships to provide triage and care from the battlefield to the field hospital. ³

Two programs were implemented by the US government in 1969 to assess the impact of medical helicopters on mortality and morbidity rates in the civilian area. Project CARESOM was established in Mississippi. Three helicopters were purchased through a federal grant and located strategically in the northern, central, and southern areas of the state. On completion of the project, which was considered a success, each area was afforded the opportunity to keep the aircraft; only the one located in Hattiesburg chose to keep the helicopter. This program became the first civilian-based helicopter program in the United States. ³⁷

The second program, the Military Assistance to Safety and Traffic (MAST) system, was established at Fort Sam Houston in San Antonio, Texas, in 1969. This program was an experiment (established in several areas of the United States) by the Department of Transportation to study the feasibility of military helicopter use to augment existing civilian emergency medical services. ³⁹

The first permanent civilian ambulance helicopter in Germany, Christoph 1, entered service at the Hospital of Harlaching, Munich, in 1970. The program’s success led to a quick expansion of the concept of helicopter transport throughout Germany. As of 2007, 77 helicopters in Germany were named after St Christopher and performed more than 90,000 flights a year. ^39,41

In May 1972, Loma Linda Medical Center in California started the first American hospital-based helicopter program; this was followed by St Anthony’s Hospital in Denver in October 1972 (Figure 1-3). Loma Linda closed after 6 months of operations because of a lack of funding and reopened the program the following year. Flight for Life Colorado began with a single Aloutte III helicopter, based at St Anthony Central Hospital in Denver, in October 1972 and continues today, making St Anthony’s Hospital the longest running hospital-based program in the United States. ^14,40

During the 1980s, hospital-based programs opened at an amazing pace. By 1987, 150 programs existed. Special operations were added to the Helicopter Emergency Medical Services (HEMS) role in the 1990s when STAR Flight in Austin, Texas, became the first American HEMS program to offer long-line helicopter rescue in 1993. ⁴³ Intermountain Life Flight in Salt Lake City became the first FAA-approved civilian helicopter hoisting program in the United States in 2001 (Figure 1-4). By the start of the second millennium, more than 400 air medical transport programs existed worldwide. ⁴²

The word nursing is derived from the Latin word nutrire, to nourish. ¹ Florence Nightingale is considered the founder of modern nursing practice and was one of the original nurses to practice in the “field.”¹ In 1854, Florence Nightingale was put in charge of the Female Nursing Establishment of the English General Hospitals in Turkey during the Crimean War. Within 6 months, the death rate in the military hospitals went from 47% to 2.2% under her leadership. She went to the front lines where she visited and cared for the ill and injured until she became ill with Crimean fever and was sent back to England. Her work during the Crimean War laid the foundation for prehospital nursing practice.

In the United States, the history of transport nursing began with the Civil War, which furnished nurses with an opportunity to demonstrate their skills and administer care to ill and injured soldiers. Nurses served in volunteer corps and offered care to both the Union and Confederate Armies.

Clara Barton emerged as the symbol of nursing’s philosophy to meet the health needs of all humans, regardless of race, creed, or color. She was an outspoken opponent of slavery, and she gave care on the battlefield to Northerners, Southerners, blacks, and whites. ⁴ She went on to establish the American Red Cross in 1882. Many transport nurses today are Mobile Assist Teams (MAT) nurses who play an integral role in the delivering of care to victims of disasters.

In the 20th century, nurses were active participants in World War I, World War II, the Korean and Vietnam Wars, and more recently, the Gulf War. Nurses, physicians, and corpsmen, working only miles from the battlefront, have staffed hospitals known as MASH and Medical Unit Self-contained Transportable (MUST). The war experiences of the 20th century have shown that field stabilization and rapid transport can decrease mortality and morbidity rates. Nurses have played a significant role in the delivery of this care in the field, particularly through flight nursing.