The First ALS Ambulance in the World

After a devastating world war, the second one during the course of the 20th century, European countries, both winners and losers alike, were still in ruins. To reconstruct their normal ways of life, all nations tried to speed up the growth of their economy, agriculture, industrialization, and transportation. Unfortunately, some unwanted side effects of these efforts appeared, such as increasing numbers of traffic accidents, industrial injuries, and later the acute cardiac syndromes caused by the challenges of a modern society. Hospitals tried to measure up to the growing number of acute cases, but the road from the site of the injury to the hospital was usually long and stressful. Picking up the patient on the scene and running with him/her to the hospital (the scoop-and-run method) was the earliest possible attempt at medical help. Surprisingly, patients arrived at the hospital in worse condition than their original medical problem could explain. As for cardiac patients, two-thirds of them died before they could even reach the hospital. The solution was hypothetical: if an ambulance service could bring advanced medical treatment to the scene, maybe patients would gain valuable minutes (stay-and-stabilize method). However, at that time, neither the medical staff nor the medical equipment was prepared for this kind of intervention. The first effective step to preventing further “health-care damages” before arriving at the hospital was taken in Hungary.

In 1899, Michael Reese Hospital in Chicago 5 acquired the first electric motor-powered ambulance.In Hungary, the first motorized vehicle showed up in 1902 (Figure 2).This was not so much an ambulance as a "first intervention car".An emergency doctor was transported to the scene, and the horse-coach-driving ambulance met with the doctor there.This method is now called the "rendezvous rescue system".
Demands for a more advanced rescue service always increase when socio-industrial development speeds up, in both America and Europe.In the United States, the frequent smoke-poisoning cases of firemen triggered the establishment of the rapid deployment of a respirator, seen as early as 1915. 6fter the second world war, rapid industrialization began in European countries, because they were heavily affected by wartime destruction.
Due to the post-war agreements of the Allies, Hungary belonged in the Soviet sphere of interest.Naturally, institutions had to copy the Soviet system; thus, a centralized and monopolized emergency and ambulance system was established.Because of forced industrialization, industrial accidents (mainly electric shock) grew rapidly in number.To provide a faster and more effective treatment (which used to be successful often; for example, in cases of electric injuries), the special service team known as the National Emergency Service (NES) was established.The newly-formed team had four tasks: the first and obvious one was to rescue patients by providing advanced medical first aid on the scene; secondly, to transport the patient by a less stressful manner to the hospital; third, to teach the young generation of emergency doctors; and fourth, to try out the latest rescue devices and methods, including finding the most appropriate car for an emergency ambulance.
In order to fulfill these tasks, the most experienced and ambitious young doctors and medical personnel were selected to staff this new branch of the NES.One of the young doctors, Thomas Felkai, was appointed as chief medical officer of this special service.(Later, he also became the founder the Hungarian Rescue and Ambulance Museum in Budapest.)Numerous meetings were held before the start of this special service, which was baptized the "Storm Ambulance Service" (SAS).Thomas Felkai compiled medical protocols for different emergency situations and carefully studied the literature looking for new medicines and methods in the field of emergency medicine.A detailed observation chart was introduced for medical and scientific research reasons, upon which the on-site and during-transport therapies and interventions applied for the patients were recorded.Since the SAS was intended to treat all kinds of serious emergency cases (Table 1), it was equipped with all the necessary devices, from a pulmotor to a delivery kit. 7The recent literature states that the multipurpose, sole-provider, all-advanced life support ambulance service proved extremely effective in the field of prehospital emergency treatment. 8Thus, the prototype of this "all-ALS type" of rescue service was born.
In the early 1950s, Hungary lacked almost every modern technical device; new cars and medical tools were even less than rare.Thus, the first emergency ambulance was an Eastern-Germany made IFA Granit Phänomen-type van, the inner space of which was reshaped into an ambulance (Figure 3).The special ambulance was equipped with all the up-to-date medical devices and tools available at that time.In addition to large-scale equipment and tools, this first ambulance in Hungary was also equipped with a siren.
During the anti-Soviet revolution in 1956, all special ambulances were destroyed.After the revolution was suppressed, the US-made Dodge Job-Rated ambulance, donated by the International Red Cross, went into service.Some homemade refurbishing was done, and finally, a useful, state-of-the-art, modern emergency ambulance was produced (Figure 4 and Figure 5).
Here it must be noted that this model had a revolving blue light and was equipped with a shortwave radio communications system for the first time in the medical history of Hungary.Later, different vehicle types were tried to determine their suitability for advanced medical on-site first intervention (Figure 6).
All medical experiences were evaluated or firstly elaborated in the NES's own hospital (established in 1956), where a small trauma and internal medicine ward (later ICU) were created.The procedures that were tried by the patient's bedside in the hospital were soon put into practice (Figure 7) on-site as well.
Therefore, contrary to any other emergency system, the NES had a hospital; it was not that a hospital had an ambulance service.Within years, the SAS system was introduced in almost all major towns in Hungary.The realization and establishment of the first rescue vehicle with an emergency doctor on board can be considered the first mobile emergency ambulance in the world.Today, the demand for the centralization of EMS and the physician-on-board idea seems to have returned, 9,10 mainly in countries facing geographical or climatic difficulties. 11The discipline of on-site emergency medicine was called "oxyology" in Hungary.
The first International Emergency Services' Congress in Budapest (1958) approved the Hungarian SAS methods, results, and experiences with advanced medical first aid.This was the triumph of the idea.As a result of the Congress's opinion, the idea of a special emergency ambulance spread worldwide.In different cities of West Germany, a traumatology-oriented emergency ambulance was implemented 12,13 in response to the increasing number of traffic accidents.The French SMUR (Service Mobile d'Urgence et de Réanimation, 1957)    was dubbed "l'antenne chirurgical, " a reference to the young doctors on board who were in constant contact with the senior officer in the hospital 14 via radio telecommunication.

Discussion
The timeline of the newly-formed special ambulance services (Table 2) suggests that the first wave of on-site emergency treatments and the establishment of some special ambulance services were triggered by the increasing number of road accidents.In the late 1970s, when more epidemical data had been collected on heart disease and the appropriate treatments and devices were invented, the special services had to provide first aid on-site to victims of myocardial infarction, too.
Acute cardiac deaths reached enormous proportions in modern societies, striking more and more young people.Unfortunately, more than two-thirds of all fatalities occurred before the patients reached the hospital. 15Picking up the patient and running to the hospital at top speed did not help.The average time interval between the first symptoms of a cardiac problem and hospital admission was around 8 hours. 16he main reason for circulation stopping was early rhythm disturbances.When some simply-performed methods were elaborated (defibrillation 17 with cardiopulmonary resuscitation, 18 and a cardiac pacemaker 19 ), the possibility of on-site treatment was given.A skilled team was required on the scene of the attack to provide first therapy (mainly treatment of the early rhythm disturbances and later for thrombolytic interventions) to the cardiac patient within that time limit now known as the "golden hour." To reduce the number of sudden cardiac deaths, a mobile coronary care unit (MCCU) was developed at the Royal Victoria Hospital in Belfast in 1966, 20 parallel to the development of coronary intensive care units in hospitals worldwide.Encouraged by the

Figure 1 .Figure 2 .Table 1 .
Figure 1.Patient Transportation and Transferal Order From 1633 From the Misericordia di Firenze

Figure 4 .
Figure 4.The Second Generation of SAS: Dodge Job-Rated Ambulance.

Figure 5 .
Figure 5.The first version of the SAS (1957) was refurbished in 1960.Two of this type of ambulance remained in charge until 1963.

Figure 6 .
Figure 6.Two Types of SAS Vehicle: Dodge Van R-6 and Nysa N59M (right) in 1959

Figure 7 .
Figure 7.The Chief Medical Officer and Founder of SAS, Thomas Felkai MD PhD (Right) Discussing Medical Protocol With Aurel Gabor MD PhD, Senior Internist of the National Emergency Service Hospital.

Table 2 .
Entry to Service of All-Purpose Ambulances by Countries, Their Equipment, and Their Medical Team

Town, Country Vehicle Name Triggering Factor or Aim of Invention Date of the First Appearance Staff Equipment
Abbreviations: SMUR, Service Mobile d'Urgence et de Réanimation; NAW, notfallartzwagen; URW, Unfall rettungswagen;