Recently on Twitter someone asked if anyone knew why patients are loaded headfirst into ambulances. I looked into the history of EMS stretcher transport for an answer.
The earliest recorded stretchers were noted on paintings in Egypt, where patients were carried on panniers on the sides of horses, typically on their sides. During the Roman Empire wounded centurions were carried off battlefields on their own shields. Based on the paintings it seems as if patient direction had no bearing. Native Americans used travois—sticks with a sling in the middle hooked up to a horse or dog to be dragged along. In most of these images the patient’s head is located closer to the animal, and their feet are closer to the ground, similar to what might be found in an ambulance.
During the Napoleonic era Dominique Jean Larrey, a medical doctor of the time, designed horse-drawn customized covered wagons with double wheels that contained hanging canvas hammocks supported by poles to transport the wounded. Patient direction is not noted.
The earliest stretchers used in wagon ambulances were the Army cot-type canvas and wooden stretchers. As ambulances moved from horse-drawn to motorized, wheeled stretchers began to evolve. As recently as 1965, 50% of the ambulance service in the United States was provided by funeral homes. Many modern American ambulances started out as converted hearses or station wagons. Funeral homes’ large, fast vehicles could accommodate supine patients.
In these earlier ambulances, there wasn’t a bench seat next to the patient. Vehicles that functioned as hearses had no need for one. The “action wall” that evolved starting in the 1940s with oxygen and suction (if equipped) was located toward the front end of the ambulance. If the patient’s head was in the back, the masks and catheters couldn’t reach, leading providers to load patients headfirst. In the Cadillac ambulances there was typically a provider chair located toward the front to tend to the patient.
After seeing the mechanism for an ironing board, Richard “Dick” Ferneau and El Bourgraf developed a stretcher that worked with a similar lever. The first elevated cot was manufactured in 1952 and called the X Frame, and the later version became the Model 30. Both were designed for headfirst loading into the ambulance.
Research from 30 years ago shows no medical reason for feet-first or headfirst loading. According to a British Medical Journal study from 1979, 11 patients with chronic respiratory failure were studied with electrocardiography and blood gas estimations during a journey in both feet-first and headfirst stretcher positions, with frequent hard stops. The study showed no significant change in blood gases or cardiac rhythms in either direction. The study concluded there is no physiological reason to prefer a headfirst or feet-first position.
Over the last decade battery-operated power stretchers have become the norm for most EMS services, and with the included loading function, stretchers are designed to enter ambulances headfirst. While head- or feet-first loading may not matter to the patient, power stretchers have been shown to significantly improve the health and well-being of EMS providers. A 2017 study showed powered stretchers can reduce peak biomechanical and psychophysical exposures associated with the development of musculoskeletal disorders during routine stretcher-handling activities with minimal increases in cumulative exposures. Since power stretchers are configured for headfirst loading, this practice will continue for EMS for the future.
Cole G. The Influence of Manual and Hydraulic Stretchers on Recruitment, Retention, and Turnover in the Emergency Medical Services Workforce. University of Southern Mississippi, Aquila Digital Community, http://pdfs.semanticscholar.org/aec0/440d9f618cba779b4ef3a3012bf9b5c2ec3b.pdf.
Heightman AJ. He Gave Us All a Lift: Remembering EMS Pioneer Richard Ferneau. J Emerg Med Serv, 2009; 34(11).
Prairie J, Plamondon A, Larouche D, Hegg-Deloye S, Corbeil P. Paramedics’ working strategies while loading a stretcher into an ambulance. Appl Ergon, 2017 Nov; 65: 112–22.
Robbins VD. A history of emergency medical services and medical transportation systems in America. Thesis: American College of Healthcare Executives, 2005; www.researchgate.net/publication/36143449_A_history_of_emergency_medical_ services_and_medical_transportation_systems_in_America.
Barry A. Bachenheimer, EdD, FF/EMT, is a frequent contributor to EMS World. He is a career educator and university professor. Active in EMS since 1986, he is currently a firefighter with the Roseland (N.J.) Fire Department and an EMT with the South Orange (N.J.) Rescue Squad. He is also an instructor at the National Center for Homeland Security and Preparedness in New York. Reach him at firstname.lastname@example.org.