Improvisation was required when it came to transporting the injured. Someone hurt in an auto accident might be taken to the hospital by the police or in the back seat of a passing car. Except in large cities, no organized system or authority existed to provide care. Rescue squads evolved to address these deficiencies.

As I write, I have on my desk a Motorola radio about the size of a pack of cigarettes that silently monitors the airwaves. On detecting a pair of tones designating the Milan Rescue Squad, it squawks an electronic alarm. A dispatcher recites the type and location of the emergency.

A squad member for the past seven years, I carry in my car a kit of supplies not all that different from what Julian Wise’s men used in 1928: a tank of oxygen, gauze dressings, bandages, and a blanket. Since I maintain an office in my home, I am available to help out on weekdays when manpower is in short supply. Our district, in New York’s Hudson Valley, covers a township of more than fifty-five square miles with no central business area.

The squad consists of about thirty men and women who are on call around the clock. We respond to auto accidents and diabetic emergencies; to heart attacks, nosebleeds, and sprained ankles; to the unexpected arrival of the newborn and the last moments of the elderly. Today, it might be a man who’s had a chain saw kick back on him, tomorrow a widow suffering the vague malaise of terminal loneliness.

The rescue squad idea was not entirely new when Julian Wise’s crew responded to its first call in 1928. The volunteer Goodwill Fire Department in Pottstown, Pennsylvania, had added a horse-drawn ambulance as early as 1890 and had begun to offer first aid in 1911. Wise’s innovation was to combine rescue, first aid, and lifesavihg into one independent agency. The nine members of the original crew all worked with Wise at the railroad. Citizens were invited to call in alarms to a phone that rang on the desk of the chief clerk, Harry Avis. Avis sent word to his fellow crew members, who rushed to the scene of the emergency. They received only six calls during the first year of operation, and in most cases the crew arrived too late to do any good.

“At that time, we could keep all our equipment in my Reo,” Wise said. The squad’s first-aid kit was a three-dollar fishing-tackle box, stocked with supplies that included poison ivy wash, tannic acid compound, ammonia inhalant, and tincture of Merthiolate.

IN 1931, WlSE AND HIS MEN WERE called out for a drowning. They reached the scene in eleven minutes and effectively revived a sixteenyear-old boy. The feat attracted national publicity. Interest in

the volunteer rescue movement began to grow. Wise, a tireless promoter of his cause, traveled to cities in Virginia, the Carolinas, and elsewhere to help start squads, many of which copied the structure and philosophy of his crew.

In Roanoke itself, a new group of volunteers under the leadership of Alexander A. Terrell formed a squad a few weeks after Pearl Harbor. The Hunton Life Saving and First Aid Crew, the first all-black rescue squad in the nation, served the city’s predominantly African-American northwest side. “We made calls to people we knew personally,” explains Lewis Peery, a soft-spoken man of 74 who served on the Hunton crew for more than thirty years beginning in 1955 and who currently sits on the board of the original Roanoke group. “It made it hard when you’d lose somebody. But we knew we’d done all we could.”

To get to the scene, rescue-squad members would drive their own cars or wait on the corner for another member to pick them up. One of the original Roanoke members remembered riding to a call on his brother’s bicycle. The core of Wise’s idea, the essence of all emergency work, is speed: to bring help to the injured or critically ill as quickly as possible. “Save seconds and you have a better chance of saving a life,” Wise said.

In this he echoed the sentiments of the man who is known as the father of ambulance service. Late in the eighteenth century Dominique-Jean Larrey, surgeon-in-chief in Napoleon’s army, observed that because military field hospitals remained at least three miles to the rear of the fighting, casualties did not reach them for twentyfour hours after a battle. “Most of the wounded died from want of assistance,” he noted, and he invented the ambulance volante , a light two- or fourwheeled carriage with room for a number of litters. The vehicle carried into the battle zone a medical officer and assistant, who were able to treat wounded soldiers where they fell.

Larrey wrote, “The first four hours are an isolated period of calm which nature is able to maintain, and advantage should be taken of this to administer the appropriate remedy.” This advice rings true down to today, when as emergency medical technicians we are trained to heed the “golden hour” after a traumatic accident, a window of opportunity to stabilize patients and transport them to an emergency facility.

While many of the developments of emergency medicine would emerge from the military, civilian volunteers have a long history of providing care. Perhaps the oldest continuously active group of volunteers is the Misericordia di Firenze, which was founded in 1240 to help the sick and transport the dead of medieval Florence. Hundreds of branches remain active in northern Italy, and volunteers are still inducted with elaborate robed ceremonies. In Britain the St. John Ambulance Association was formed in 1877. Despite opposition from the medical establishment, the organization trained volunteers in

the stopgap treatment of wounds and illnesses, a practice for which members invented the term first aid .

In 1859, French, Italian, and Austrian troops engaged in a one-day blood-bath known as the Battle of Solferino, a fight that left thirty-eight thousand dead or dying soldiers strewn across the battlefield. Jean-Henri Dunant, a Swiss tourist on hand for the spectacle, was appalled, and he later organized a conference to establish humane rules of warfare. He set up a group to coordinate civilian aid to wounded soldiers. To honor Dunant, the organization adopted the Swiss flag with its colors reversed: a red cross on a white field. Dunant’s group became the International Red Cross, which in 1911 greatly expanded the training of laypeople in the techniques of first aid.

Civilian ambulance service began in large cities in the second half of the nineteenth century. In 1865, Cincinnati’s Commercial Hospital established what was probably the first regular ambulance operation in the United States. Most large cities developed some semblance of organized ambulance service in the years before World War I. Chicago saw the first motorized ambulance in 1899, with St. Vincent’s Hospital in New York City introducing electric vehicles a year later. An electric ambulance with hard rubber tires carried President McKinley to Buffalo’s Exhibition Hospital after an anarchist shot him at the Pan-American Exhibition’s Temple of Music in 1901.

In many communities, undertakers possessed the only vehicles capable of carrying recumbent patients. They dominated the ambulance business for decades, usually charging only a few dollars for a ride to a hospital or doctor’s office. For many of them ambulance service was a way to build goodwill, with an eye to the more lucrative funeral business down the road. Some undertakers maintained actual ambulances; others merely used hearses modified to accept a stretcher. Even Julian Wise’s resourceful Roanoke squad deferred to the city’s undertakers until 1959, when the volunteers began to provide transport as well as first aid.

For 50 years after World War I, ambulance and hearse manufacture were closely associated. Ambulances of the 1920s often featured leadedglass windows and stained mahogany interiors. Styles and horsepower changed over the years, but the basic form of the ambulance as an enlarged passenger car on a limousine frame remained constant. “Those ambulances had the advantage of comfort, speed, drivability, and a low center of gravity,” says Myron Gitell, an ambulance collector and the publisher of a history called The Ambulance . “They didn’t have that much room in back, but in those days patients rarely received any treatment on the way to the hospital anyway.”

By 1940, the Roanoke squad had fifty-eight members and could deploy a carbon monoxide detector, field telephones, an acetylene torch, and portable floodlights. That same year

the first of several serious polio epidemics hit Roanoke. The volunteers arranged for the purchase of iron lungs, 750-pound tanks that used negative air pressure to breathe for paralyzed patients. During the 1944 epidemic, which involved more than 750 cases, area rescue squads supplied twenty-one iron lungs. Julian Wise set up a statewide training program on how to use the unwieldy devices.

The rescue-squad movement continued to spread. When the Hindenburg exploded in 1937, the New Jersey First Aid Council was able to summon 29 ambulances to the scene in Lakehurst. A 1945 Reader’s Digest article featured Wise and his crew, with the subtitle “An Idea for Your Town.” That piece and a followup article eleven years later boosted interest in rescue squads around the country. Wise did his bit, helping to form 25 squads in Virginia alone and advising volunteers from Michigan to Alabama as well as in Canada and Europe. He would phone squad captains across his state monthly just to find out how things were going. By 1956, 26,000 members were participating in 850 squads around the world. “The credit goes to the crews,” Wise insisted. “I was only the pusher.”

Many squads were associated with volunteer fire departments. During the 1920s, fire departments in New Jersey and Texas pioneered efforts to add rescue and first-aid capabilities. Legion posts were another common sponsor of squads. Charles Myers remembers when his group of veterans in the little upstate New York town of Eldred started an ambulance service in 1948. “We handed out cards with our phone numbers on them. When someone had an emergency, they called until they reached a member who was home. That member called the others, and off we went. I still get calls; people have those old cards tacked on the wall.” Myers has served nearly 50 years with his squad.

In Roanoke I spent some time with the volunteers who carry on the tradition of Julian Wise’s original crew. The excitement of riding in a speeding ambulance, with lights flashing and the siren screaming a passage through traffic, is very real. One young emergency medical technician (EMT) told me she joined the squad “for the adrenaline rush and to be in the middle of the action.” Certainly there is an element of “trauma junkie” in most volunteers, who are eager to go out on a “good” call—one involving sufficient life-and-death mayhem.

But the reality of the calls is often very different. Tonight in one of Roanoke’s poorer neighborhoods, an old lady has fallen in her home; she needs to go to the hospital to be checked out. Pulse seventy-four and regular. On the wall, a framed Mother’s Day card. Patient is awake and oriented. A needlepoint sampler: “What is life without love?” Blood pressure 150 over 80. The stretcher is wheeled in. A quiet ride to the hospital.

Later an alarm goes out for a “code” at a

nursing home. It means a person whose heart has stopped beating, a woman teetering on the edge of death. The experienced crew of volunteers is unflappable throughout. The driver, Kathy Hagy, is a mother of five; EMT Lena Speck is studying premed at a local college; the crew leader, Luke Chambers, is a respiratory therapist.

At the woman’s bedside in minutes, they follow a practiced routine: Begin cardiopulmonary resuscitation; insert an endotracheal tube, a clear passage for supplying oxygen to the woman’s lungs; establish an intravenous line to administer fluids and drugs; connect a heart monitor (the green line shows the feeble quivering motions of the woman’s heart); apply the paddles of the defibrillator three times (each time the woman stiffens as if startled by a loud noise). No signs of life appear.

The crew wheels the patient to the ambulance, one member astride the gurney to continue chest compressions. As the ambulance rolls, more drugs are administered: epinephrine, lidocame. Another round of shocks. For a moment a pulse returns; the woman’s heart, after seventy-four years of beating, doesn’t want to give up. Stop chest compressions. The patient’s pupils remain fixed and dilated.

As she’s wheeled into the emergency room, the line on the monitor flattens, and the patient “codes” again. Begin CPR. The crew turns her over to waiting physicians and nurses. They proceed with a similar round of efforts. To no avail. A few minutes later the woman is pronounced dead.

Resuscitation, the most heroic of the rescue squad’s storehouse of treatments, always involves swimming against the tide. Something has caused the patient’s heart to stop, and the resulting oxygen starvation quickly diminishes the person’s ability to recover.

The ambulance crew retires to a corner of the emergency ward to wash up and complete the paperwork that will document its futile efforts to save this woman’s life. The ability to look at and accept death is one of the first lessons that every rescue worker learns. Luke Chambers, 29, muses afterward, “Sometimes, you meet somebody in the mall—maybe you don’t even recognize them—whom you helped in an auto accident. But they actually come up to you and say thank you. Things like that make it worthwhile.”

Despite the steady spread of rescue squads, ambulance service in the early 1960s left much to be desired. Undertakers continued to provide emergency transportation to half the country. In many places, even large cities, ambulances ran with only a driver; the patient rode alone in the back. Of two hundred thousand ambulance and rescue personnel, fewer than half were trained to the level of Red Cross advanced first aid. Only six states offered standard courses for rescuers, and only four regulated ambulances.

Washtenaw County, Michigan, which includes the city of Ann Arbor, provides a typical picture. In 1966 the county’s twenty-three ambulances were operated by seventeen different concerns, including hospitals, gas stations, taxi companies, and funeral homes. Service outside urban areas was spotty at

best. No standards of any kind were enforced.

Part of the reason emergency care advanced so slowly in the four decades after Wise founded his squad was the determination of the medical establishment to keep laypeople from trespassing on the physician’s territory. Rescue volunteers, their duties only sketchily defined, could be accused of practicing medicine without a license. The American Red Cross, which supervised first-aid training, never took an active role in organizing or supporting rescue squads. Indeed, Julian Wise came into conflict with Red Cross bureaucrats who believed his approach was too progressive. Volunteers wanted to do more, but the tools and skills were kept out of their reach.

The rescue worker’s motto in those days was “Load and go.” “Pre-hospital care was limited solely to transportation,” says a report of the American College of Emergency Physicians. “Medical treatment didn’t begin until the patient arrived at the hospital.”

But the ten years between 1966 and 1976 saw a transformation in emergency medical services (EMS) that affected volunteers profoundly and would permanently alter the public’s expectations about ambulance service. These changes were closely linked to that ubiquitous plague of modern life: the auto accident.

An automobile killed a New Yorker on September 14, 1899. That inaugural death was a harbinger of a coming slaughter on the highways, which would surpass all the casualties of all the wars in the nation’s history.

In the 1960 presidential campaign, John F. Kennedy labeled traffic accidents “the greatest of the nation’s public health problems.” His choice of words was significant. Researchers and policy makers were beginning to change their perspective on accidents. Instead of framing the problem as one involving random acts of carelessness, they began to see an epidemic that followed the pattern of a disease and offered opportunities for prevention and cure.

The problem was a grave one. By 1965, annual motor-vehicle deaths had reached 49,000. Traffic accidents had permanently disabled a hundred and fifty thousand and were the number one cause of death in people up to the age of thirty-seven. During the late sixties observers routinely asserted that a soldier wounded in the jungles of Vietnam had a better chance of survival than did a citizen hurt in a traffic accident back home.

In 1966, a seminal report from the National Academy of Sciences cataloged the inadequacies of the country’s emergency medical services and recommended solutions in terms of training and standards. The time for action had come. Lyndon Johnson’s Washington was a can-do place, and the sea change that would sweep over the country’s ambulance service was a textbook case of big government in effective action.

THE HIGHWAY SAFETY ACT of 1966 set federal standards for training, equipment, and procedures, which the states busied themselves implementing. While auto accidents were the target, the legislation transformed EMS across the board. The momentum of the changes was maintained in the 1970s as “systems” became the rallying cry. Emergency service began to

become organized for the first time.

As the states began to flesh out the concepts devised in Washington, Congress picked up the tab. Hundreds of millions of dollars were poured into demonstration projects, pilot programs, and block grants to states. Government funding in the 1970s essentially put EMS on its feet.

Communications and ambulance design were enhanced as a result of federal involvement. The 911 telephone system spread, allowing for more efficient dispatch. Ambulances acquired radios that attendants could use to communicate with hospitals, a helpful link when a serious case raised questions of treatment. Standards for ambulances emphasized adequate room to treat patients en route.

The development that would have the most direct impact on volunteers was the new standard for training. By the end of the 1960s the National Highway Traffic Safety Administration had established a comprehensive 81-hour course for emergency medical technicians. In 1969, two hundred people took the EMT course; they were the first emergency responders to be trained to a national standard. The course, which was later expanded to 110 hours, has become a rite of passage for rescue volunteers.

The new training and testing represented a challenge, but one that volunteers met with enthusiasm. “All our members, old and young, welcomed the EMT concept,” says Sidney Robertson, a veteran of rescue work in Roanoke and the current head of its volunteer squad, “We wanted to learn more, and we were proud to call ourselves EMTs.”

Like every emergency tech, I’ve spent many hours committing to memory the grievous effects of trauma on the human body, with names like tension pneumothorax and subdural hematoma. Where first-aid training takes a surface view of injury and illness, the EMT course helps us fully assess the patient’s condition before we act. We practice taking blood pressures, using oxygen, and immobilizing the spine. We learn how to extricate an injured person from a wreck, how to stop arterial bleeding, how to apply a traction splint to a broken femur. We cover everything from the complications of childbirth to the best way to treat a nosebleed.

Another facet of modern EMS was initiated by Dr. J. Frank Pantridge, who headed the cardiology department of the Royal Victoria Hospital in Belfast, Northern Ireland. Pantridge turned an ambulance into a mobile cardiac-care unit. In fifteen months he saved ten patients by bringing to the scene of heart attacks the full arsenal of modern resuscitation, including CPR and stimulative drugs like epinephrine. He used two car batteries to build up the current for the 7000-volt jolt needed for electric defibrillation.

By the late sixties, the idea was afloat to disseminate Pantridge’s concept by training EMTs to apply techniques that were once the jealous preserve of physicians. Technicians would learn to interpret electrocardiograms, establish

intravenous lines, administer drugs, and defibrillate patients. These “paramedic” skills were officially recognized in 1969 by the American Academy of Orthopedic Surgeons.

The first volunteer group to make use of them was the Haywood County Rescue Squad in the hills of western North Carolina. A local internist, Dr. Ralph Feitcher, noting Pantridge’s work, brought together forty volunteers for extensive training in 1968. The members began applying their new skills a year later.

Many rescue squads now have added paramedic skills to the services they offer their communities. The training required is rigorous—anywhere from four hundred to fifteen hundred hours, plus additional hours of continuing education. But the advanced life support that paramedics provide, nearly the functional equivalent of a mobile emergency room, saves lives.

Today’s EMTs have at their disposal rescue tools that Julian Wise would have envied back in 1928. In the late sixties an inventor named George Hurst designed an oversize hydraulic can opener to help remove drivers from the tangled metal of wrecked race cars. Dubbed the Jaws of Life, this tool, which can generate five tons of force, quickly found a market among rescue workers who were faced with highway crashes just as severe as those on the Indy track.

The biggest impact of the computer on emergency volunteers has been in the development of automated defibrillation. Battery-powered defibrillators became available during the 1960s, but use of the units required an ability to interpret the heart rhythm displayed on the monitor. The new machines perform this analysis internally, requiring the operator only to press a button if they indicate the need for a shock. This type of defibrillation is rapidly becoming a standard EMT skill.

AIR TRANSPORT OF PA- tients represents the state of the art in emergency medical services, taking Larrey’s concept of an ambulance volante to its literal limit. Again the military led the way. During the Korean conflict helicopters ferried wounded soldiers to the mobile army surgical hospitals made famous on the television show “M*A*S*H*.” The Vietnam War familiarized the nation with the “dust-off” helicopter that brought medical evacuation right into the battle zone. The civilian version of the idea took off in the 1980s. Today, hundreds of hospitals, police departments, and private firms offer helicopter service.

The squad started by Julian Wise still operates out of a large brick building constructed in 1955 near downtown Roanoke. The headquarters houses a rescue truck, nine ambulances, a dormitory, a meeting hall, and a kitchen. Rotating crews of six or more volunteers man the station for 12-hour shifts. None of them works for the railroad now. The average age of members has dropped to the early twenties. Kristine File, a newer squad member, is one of those who are very much aware of the crew’s long history. “It gets into your blood,” she says, talking over the drone of the television in the squad lounge. “It’s a rush for me

to stand where Julian Wise stood. I never met him, but I feel I know him.”

But the world that File and the other Roanoke volunteers contend with is far different from the one Wise knew sixty years ago. Even in the late 1950s the crew was handling about a dozen calls a day. The city now generates an average of more than forty. “We have some sixty-eight names on the membership roster,” says Sidney Robertson, chairman of the group’s board of directors since 1989, “but only about forty are really active.”

A bright-eyed man whose energy belies his 77 years, Robertson is leading the organization through a time of extensive change. During the 1980s paid city personnel increasingly assumed responsibility for the burgeoning load of calls. The Hunton crew, unable to recruit enough members, folded. The Roanoke squad merged with the other volunteer crew in the city to form the Roanoke Emergency Medical Services, Inc. And in 1989, financial constraints required the squad to begin charging patients for their service.

“People don’t understand,” Robertson says, “how they can be treated by two volunteers and then receive a bill for a hundred ninety dollars.” But the group’s annual operating budget has climbed to more than three hundred thousand dollars. Additional assumption of EMS responsibilities by the municipal authorities is inevitable.

Many of the Roanoke squad’s problems are shared by volunteers around the country. A single rescue truck can cost ninety thousand dollars, and automated defibrillation units run as high as eighty-five hundred each. Bakedfood sales and fundraising appeals don’t always pay the bills. In Vermont, where 86 percent of emergency medical services are provided by volunteers, nearly three-quarters of the squads bill those who use their services. “In the future you’ll see a lot more hybrid squads, part volunteer and part paid,” says Dan Manz, who heads the EMS in Vermont and is president of the National Association of State EMS Directors. “But volunteers are still strong across the country.”

The types of calls are changing too, especially in cities. The urban poor often use the 911 system indiscriminately. “Another taxi call,” one of the Roanoke EMTs says with a sneer after a nonemergency run. Abuse of ambulance service is common. Like hospital emergency rooms, rescue squads feel the strains that are affecting the nation’s medical system as a whole.

Recruiting is a perennial issue among volunteers. Nationwide, turnover runs about 25 percent a year. A slew of factors has made it hard for volunteer squads to maintain coverage twentyfour hours a day. Employers are less agreeable than in the past to letting workers take off from their jobs. More people work away from the community. The time demands of the rescue squad compete with second jobs and family duties. The ever-larger numbers of women entering

the work force has left fewer volunteers available during weekdays. And EMS has become a much more attractive career in recent years. Some of the better, more committed volunteers move into career positions and find they no longer have time to volunteer.

Calls to domestic disputes, drug overdoses, or the aftermaths of shootings repeatedly remind the volunteer of the possibility of violence. Adding to the uneasiness is the peril of AIDS, hepatitis, and tuberculosis. EMTs are taught to assume that every patient is a carrier, every drop of blood a danger.

Despite all these drawbacks, unpaid providers continue to play a major role in emergency medical services. In rural areas volunteers are still the ones who arrive with the ambulance, who turn out at three in the morning to help neighbors and strangers in distress. “We’re committed to keeping the volunteer tradition alive in Roanoke,” Robertson told me. Indeed, as a symbol of that commitment, the city is now the home of the first museum dedicated to the story of volunteer rescue squads. “To the Rescue” is a $1.2 million exhibit mounted under the auspices of the Julian S. Wise Foundation. Besides educating the public, it commemorates those emergency responders who have lost their lives in the line of duty.

One of the questions that those outside the field ask rescue volunteers is “How do you handle the blood and gore?” In practice, training and experience turn blood from an emblem of horror into a sign that some action needs to be taken. “You have a bystander mentality that is purely emotional,” says Pat Ivey, who has written two books about her volunteerrescue experience. “But when you’re the one responsible, you shut that down and do what you need to do. Only after a call does that bystander perspective kick back in. We’ve had some terrible calls, but I’ve never seen an EMT who didn’t do what needed to be done at the time.”

Volunteers are a resilient lot who learn to walk a narrow path between cynicism and sentimentality, between callousness and tears. But the reason for enduring the countless hours of training, drills, and meetings, the frivolous calls and the horrific calls, the danger and the drudgery, is clear. The sense of fulfillment is worth more than any paycheck.

“I’ve never done anything that gave me the same satisfaction,” says Gordon Watson, a longtime veteran of the Roanoke squad and a colleague of Julian Wise. “It was an honor and a privilege to serve with the squad.”

My radio breaks the silence at two in the afternoon, a somber second day of deer-hunting season. “Serious-injury auto accident.” A woman driving on the highway that cuts through our district has veered off the road. Maybe she was distracted by one of her two young children in the back seat. The car has careened down an embankment, flipped over, and thrown the driver out. The four-year-old has crawled from the battered vehicle and

is found bleeding nearby. The two-year-old, rescued from his car seat, sits on the lap of a passerby and gloomily surveys the activity around him.

Squad officers direct our members as they arrive. We strap the mother to a plywood backboard; critically injured, she will prove to have suffered fractured vertebrae. Because we offer only basic life support, we summon a paid crew of paramedics to supply the woman with needed advanced life support on the way to the hospital. We bandage the older son’s lacerations and send him off in a different ambulance along with his uninjured brother.

It is an ordinary call. We’ve done what we could. For a few minutes, the crew members who haven’t gone with the ambulance stand around speculating about the cause of the mishap, trading a few jokes and some gossip, unwinding. Then we remove our protective turnout gear, stash oxygen and first-aid kits back in our cars, and go home.

This was like all other fine adventures,” Julian Wise said, looking back on his life in volunteer rescue. “All we need to do is reach out and there are people to respond.”

Wise died on a July afternoon in 1985, not unlike the one during which he’d watched two men drown seventysix years earlier. In one of those dreamy coincidences, five hours after he took his last breath, a call came into Roanoke’s 911 system about a thirteen-year-old boy who’d gone down in the river. Volunteers rushed to the scene, found the boy unconscious, and in minutes had him breathing again.

And that, as every volunteer will tell you, is what it’s all about.