- Kyle Zielinski
The Emergency Medical Technician (EMT) is a pre-hospital medical professional that specializes in stabilizing patients with acute illness or injury in the field until they can be transported to a higher-level facility like a hospital. In the modern era, EMTs treat patients in ambulances to minimize the time between incident and advanced care at hospitals and clinics.
It almost seems second-nature to think that triage should be performed by a peripheral care provider, like an EMT, during a rapid, coordinated transportation effort to a larger healthcare facility. In reality, this rapid response procedure was not developed until the American Civil War during the mid-to-late-nineteenth century. The modern emergency medical technician operates on principles proposed hundreds of years ago by a military and health care pioneer named Jon Letterman.
In the early days of the Civil War, wounded were left for dead on the battlefield. Battlefield medicine was disorganized and chaotic in part because the war was not expected to last longer than a few weeks. Medical supply shortages were common and poorly executed rescue efforts would often leave the wounded stranded for days after the battle had ceased. Once rescued, the organizational structure of surgeons and hospitals was not much better. The concept of triage had not yet been employed by the Union and the Confederates: the injured would be treated based on the order in which they suffered their wounds, not by the severity of their injuries.
Then came along Jonathan Letterman, a surgeon who eventually rose to the ranks of major and was assigned medical director for the Army of the Potomac in June 1862. Prior to his arrival, regimental musicians would double as stretcher bearers and ineffectively carry the wounded off the battlefield. After a failure to rapidly recover the wounded from the battlefield at Second Manassas, General George McClellan gave Letterman free reign to make changes to battlefield medical services that still influence how emergency care is delivered in the 21st century.
One of Letterman’s most important innovations in battlefield medicine was establishing the first Ambulance Corps. Men were trained to operate wagons and act as stretcher bearers to recover the wounded from battle. In its infancy, the distribution of medical supplies among the wagons was not equal. Letterman established a standardized protocol to ensure that all necessary medical supplies were on each wagon instead of individual wagons carrying certain supplies for specific injuries or ailments. Even today, EMTs and paramedics utilize checklists to ensure that each ambulance contains the necessary medical supplies for any emergency. Modern protocols are particular about inventory locations within the ambulance to expedite the response in an emergency.
Once rescued by ambulance corpsmen, Civil War soldiers were evacuated according to Letterman’s new facility organizational structure. The Letterman system comprised three stations: the field dressing station, field hospital, and a large hospital. The field dressing station is where the wounded were administered initial treatment, often found close to battle lines, and protected by natural defenses. A single regimental surgeon would operate the field station and apply rough dressings and offer pulls of whiskey. The field hospital was the second station in the evacuation system that was located close to the battlefield in homes or barns. Additional treatment and emergency surgery such as amputation was performed at field hospitals. Large hospitals were the final station, located a distance from the battlefield and intended to provide more long-term care of wounded soldiers. The three-tiered system proposed by Letterman is analogous to the modern health care system which undoubtedly took inspiration from his successes. Today, civilians experiencing a minor emergency such as a traumatic bone fracture may receive rapid treatment at an urgent care clinic, like the field dressing station. Most individuals who are seen at an urgent care can transport themselves to the facility as it is not a life-threatening event. In more serious medical emergencies, one may be transported to the emergency department at a local hospital where advanced care can be administered, and surgical suites are available for emergency surgery. The local hospital in this case is analogous to the field hospital of the Civil War. In extreme cases, individuals involved in severely traumatic incidents may be transported to high-level trauma centers by ambulance or helicopter. These facilities have superior resources to deal with high-level emergencies just as the large hospitals did in the Civil War. But who decides what emergency goes where?
Triage is the process used by medical professionals and first responders to determine the order of priority for providing treatment so those who can benefit most from it receive it first. Letterman was not the first to propose this process–its first documented use was in France during the early 1800s by Dominique-Jean Larrey. Jon Letterman applied the system he saw in Europe to medical response in the American Civil War. The Letterman Plan was a structured approach to caring for the wounded. Those who were lightly wounded were sent back to battle; those with more significant wounds were evaluated and sent to the appropriate station. Often, soldiers would follow the logical escalation of services, from field hospital to brigade hospital to general hospital. Although the process isn’t entirely the same today, the principles from the Letterman Plan are evident in emergency response protocols used by EMTs and paramedics. The Simple Triage and Rapid Transport (START) algorithm is used for scene management when the number of patients exceeds the number of first responders. The goal is to triage patients, determine their need for transport, and communicate with dispatch to free up resources.
The EMT in the 21st century is an invaluable contributor to emergency medical response. Many of the principles and processes used by EMTs and first responders, such as ambulances, the tiered healthcare system, and triage can be traced back to the Civil War. Jonathan Letterman was a pioneer in battlefield medicine whose contributions have extended far beyond the battlefield and have greatly outlived the American Civil War.
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References:
1. The development of Triage. National Museum of Civil War Medicine. (2017, October 2). https://www.civilwarmed.org/surgeons-call/triage1/
2. EMTprep. (n.d.). https://emtprep.com/resources/article/utilizing-start-triage
3. Jonathan Letterman. American Battlefield Trust. (n.d.). https://www.battlefields.org/learn/biographies/jonathan-letterman
4. National Institutes of Health. (n.d.). Following the rear: Travails of the Union Army’s Ambulance Corps – Circulating Now from the NLM Historical Collections. U.S. National Library of Medicine. https://circulatingnow.nlm.nih.gov/2019/08/02/following-the-rear-travails-of-the-union-armys-ambulance-corps/
5. Regimental Dressing Stations. Regimental Dressing Stations ~. (n.d.). http://civilwarrx.blogspot.com/2015/08/regimental-dressing-stations.html
6. U.S. Department of the Interior. (n.d.). Jonathan Letterman (U.S. National Park Service). National Parks Service. https://www.nps.gov/articles/000/jonathan-letterman.htm
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