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Become a member and receive career-enhancing benefits
Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.
Pennsylvania Ambulance Service Leads to Modern Day EMS
Megan Fulton
May 6, 2025
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Freedom House Ambulance Service employees attend their first day on June 16, 1968, at Presbyterian University Hospital in Pittsburgh, Pennsylvania. (Credit: Heinz History Center)
In November 1954, at the 40th Clinical Congress, past-Chair of the ACS Committee on Trauma (COT) Robert H. Kennedy, MD, FACS, delivered the Oration on Trauma, calling for the need to improve two of the biggest weaknesses in trauma care: transport of the injured patient and prompt, efficient first aid.
Thirteen years later, these inefficiencies would be addressed, and an emergency response system would begin to take shape in the US.
During the 1960s, Pittsburgh, Pennsylvania, was a city in dire need of economic rejuvenation. In the predominantly Black Hill District, most individuals fell below the poverty line and were deemed “unemployable” by welfare offices.1
The Freedom House Enterprise, a nonprofit created by a grant from the federal government,2 sought to provide economic stimulation to those in the Hill District by preparing them for employment through increased opportunities for job training.
Creating Opportunity
At that time, Peter Safar, MD, an anesthesiologist, was instrumental in the proliferation of improved acute and critical care throughout the US. In 1957, alongside James Elam, MD, Dr. Safar established the initial steps to CPR,3 including inventing the ABC method, the head tilt and chin lift maneuver, and mouth-to-mouth resuscitation.
Dr. Safar founded the first intensive care unit at Baltimore City Hospital and co-founded both the Society of Critical Care Medicine and World Association for Disaster and Emergency Medicine. His drive to develop emergency response services, however, had a much more personal beginning.
Freedom House Ambulance Medical Director Dr. Nancy Caroline (left) and paramedic John Moon sit in a newly equipped ambulance. (Credit: National EMS Museum Subject Files, NEMSM-0001 Date: c. 1968)
In 1966, now at the University of Pittsburgh and galvanized by the death of his 12-year-old daughter from cardiac arrest following a severe asthma attack,4 Dr. Safar turned to Freedom House Enterprises. Together, they not only developed standards for emergency medical technicians (EMTs) but also trained residents of the Hill District to become EMTs.
In 1967, Freedom House Enterprises started an ambulance service and marked the beginning of a new age in emergency care. The Freedom House Ambulance Service paramedics were the first to be trained to administer emergency care onsite beyond first aid in the US. Dr. Safar was responsible for overseeing the entire project and named Nancy Caroline, MD, medical director.
“Freedom House did something others didn’t or wouldn’t—perform advanced procedures in the field. They were bringing care directly to the patient,” said Peter E. Fischer, MD, FACS, a trauma surgeon and current chair of the COT’s EMS Committee. “Treatment at the point of injury drastically increases the likelihood of survivorship.”
Dr. Peter Safar, from the University of Pittsburgh, trained Freedom House attendants, equipped the ambulances, and assured quality control. (Credit: University of Pittsburgh)
Humble Beginnings
Until the 1960s, most emergency medical care was provided by law enforcement or funeral homes.5 For acute medical conditions like seizure, stroke, or heart attack, untrained people and underequipped vehicles could mean the difference between life and death.
“Before the late '60s and early '70s, emergency response was purely about moving patients. Little to no care was delivered,” said Michael J. Sutherland, MD, MBA, FACS, who, before becoming Senior Vice President of Member Services at the ACS and a trauma surgeon, was an EMT in Baton Rouge, Louisiana.
Dr. Safar’s 32-week program worked with recruits from the Hill District for more than 300 hours, training them in anatomy, physiology, CPR, advanced first aid, nursing, and defensive driving.6 By using donated and refitted ambulances—which inspired the designs used today—Freedom House paramedics created a way to provide emergency care en route to hospitals.
In their first year, the Freedom House Ambulance Service responded to almost 6,000 calls and transported more than 4,500 patients. In data collected by Dr. Safar, these paramedics saved 200 lives.6
Freedom House paramedics, who first were deployed in the 1960s, provided a crucial service for Pittsburgh residents. The program became a national model for emergency medical transport and care.
Multiple Factors at Play
Throughout history, there have been versions of emergency response systems. Dominique-Jean Larrey, Napoleon Bonaparte’s chief physician, developed such a system for French soldiers. The Union soldiers created another to evacuate the injured during the Civil War. But no system had ever been formalized in the US.
Leading up to the 1960s, treating heart disease, stroke, trauma, and cancer were the most important public health initiatives because of the common belief that they formed much of the public health burden.7 Trauma specifically was identified as a crisis due to the steady increase of traffic accidents, eventually leading Congress to pass the Highway Safety Act of 1966.
Members of the COT and the Subcommittee on Transportation of the Injured were instrumental in changing the face of EMS. Citing the Highway Safety Act, COT leaders pointed out the failure to include built-in guidelines for proposed action on EMS.8
It was projected that 350,000 deaths from heart disease and thousands of trauma-related deaths and injuries could be mitigated by rapid, quality care. Data presented alongside the American Medical Association and the American Heart Association showed that only 7% of EMS vehicles met design standards, and 35% of staff had minimally acceptable training.7
“EMS has been going through an intentional evolution,” said Dr. Sutherland. “Paramedics didn’t always have the independent ability to perform certain prehospital care, but now most of it has been given a protocol. Thirty years ago, a paramedic in the field needed to talk to a doctor 100% of the time to deliver care. It’s probably 1% today.”
Local Success, National Change
The Freedom House Ambulance Service continued its work into the 1970s and its profile as a leader in emergency response grew. At its height, it had 35 crew members, received 7,000 calls a year, and its leaders had established the National Registry of Emergency Medical Technicians.
The crew introduced physicians around Pittsburgh to ambulance work, which allowed the paramedics to learn how to transmit EKGs, use air casts to stabilize injured bones, and administer Narcan.9 Freedom House further expanded its paramedic training to include intubation, defibrillation, and intravenous drug administration.
In June 1967, J. D. Farrington, MD, FACS, authored a Bulletin article titled “Death in a Ditch,” which was the first time a physician had formally outlined the minimum equipment that should be available on emergency vehicles.
“The ACS helped develop the first equipment list, and the COT still to this day has a part in the revisions,” Dr. Fischer said. It includes tools to practice procedures trailblazed by Freedom House paramedics.
Basic equipment like oxygen masks, gauze, and cervical collars are stored alongside advanced life support equipment like laryngoscopes, defibrillators, and monitoring devices. Dr. Sutherland specifically noted the advances in using AEDs and the transition to treating cardiac arrest in the field without transporting the patient since the time of the Freedom House paramedics.
In 1973, the US Department of Transportation and President Gerald Ford’s administration created an interagency council6 on emergency medical services. Dr. Safar was brought on to a five-person committee, and shortly thereafter, the Emergency Medical Services Systems Act of 1973 was passed.
The defibrillator allowed the Freedom House Ambulance Service in the late 1960s to detect and monitor heart rates for emergency patients. Freedom House paramedics became the first to gather data using tools such as this and transmit the information to the hospital over the radio while in transit. (Credit: Heinz History Center)
Finding a Path Forward
While EMS vehicle readiness has been optimized by paramedics with the highest training and the most robust equipment, there are still major challenges in the form of workforce development and access to care.
“In many states, EMS isn’t considered an essential service like police or fire departments,” said Dr. Fischer. “A lot of them are still volunteer agencies, and volunteerism is dwindling. There are places where you call 911 and no one comes.”
This obstacle presents great difficulties for a key population in the US—rural communities. If the availability of ambulances goes down, resources go down, and the need to transfer patients for more severe issues becomes a larger problem.
There have been strides to address some of these barriers for rural populations, but major questions remain. What happens if your hospital is under-resourced? What happens when the already limited resources are fully utilized?
“In bigger cities like San Francisco or Chicago, EMS is part of the fire department. In addition to their ambulances, they can put medics on fire trucks to bring care to the patients quicker,” explained Dr. Sutherland. “But if you’re in a small town or county with only one or two ambulances, that’s not possible.”
There is an effort to push paramedics further into the field, but they are in short supply. As the delivery of care gets more expensive, driven by increases in the cost of ambulances and medical supplies, paramedics’ pay has lagged behind.
“Medicare reimbursement doesn’t adequately cover the cost of the delivery of care,” said Dr. Sutherland.
This model of Resusci Baby and tools of resuscitation were used by Dr. Peter Safar to train Freedom House ambulance paramedics and others. (Credit: Heinz History Center)
Zero Preventable Deaths
Prehospital care has been a discussion point at the ACS since the 1920s when the COT was the Committee on Fractures and there were debates over how to treat and transport those with broken bones.
For Warren C. Dorlac, MD, FACS, a trauma surgeon, COT Vice Chair, and prehospital trauma medical director for the National Association of Emergency Medical Technicians, addressing these issues in prehospital care is paramount.
“Most patients die in the prehospital setting,” he said. “Some deaths are nonpreventable—if you get decapitated or hit by a train—but some are. Approximately 25% of prehospital deaths are potentially preventable.”
Rural communities are not the only settings that can have issues with prehospital care. “Traffic and weather are universal problems that can play a significant role in delaying care,” explained Dr. Dorlac. “Every state has weather events—hurricanes, tornadoes, earthquakes, which can vastly impact the ability of EMS to find you in an emergency.” But, on the quest to achieve zero preventable deaths, there are actions we can take.
Bystander intervention, like ACS Stop the Bleed and emergency notification systems, are two small ways to help EMS. The potential of emergency notification systems is currently being studied at length by ACS Fellows and Future Trauma Leaders.
Pushing advanced life support, like whole blood, closer to the point of injury to prevent secondary injury is where EMS is the most critical, a strategy Freedom House put into practice. All these elements working together help improve the likelihood of survivorship. But the most important thing anyone can do is prevention.
“Wear a helmet, wear a seatbelt, drive the speed limit,” said Dr. Dorlac. “The best way to protect yourself is to do the right thing first.”
Fire of Time
The work of the Freedom House Ambulance Service and the strides it made for paramedics set a standard still used today. Parts of history will inevitably be lost to the fire of time, but honoring these trailblazers and the ways they impacted public health is important.
Bringing advanced life support care directly to the patient is a relatively new practice in the US and will continue to change as the needs of the populations they serve change. The Freedom House Ambulance Service, Dr. Safar, and the COT changed the trajectory of prehospital care, and though the Freedom House Ambulance Service has been discontinued, its legacy lives on.
Megan Fulton is the Senior Social Media Strategist in the ACS Division of Integrated Communications in Chicago, IL.
Acierno L J, Worrell TL. Peter Safar: Father of modern cardiopulmonary resuscitation (2007). Faculty bibliography 2000s. 6796.Available at: https://stars.library.ucf.edu/facultybib2000/6796. Accessed March 22, 2025.
