New York City had an ambulance service for sick horses, in 1867, two years before there was an ambulance service for people. The American Society for the Prevention of Cruelty to Animals decided that ambulances were needed for horses, two years before Bellevue Hospital decided the same thing. (Needless to say, neither horses nor humans were offered a patient satisfaction survey.)
Astonishingly, even after many cities and towns had ambulance services, there were few federal laws regulating them until the 1970s. Of course transportation was changing at the beginning of the twentieth century, so an ambulance could be horse-drawn or powered by a gas, steam or electric engine. However, even the coach of the ambulance was not standardized.
In many places, the vehicles that served as ambulances were hearses, simply because the hearse was the only locally available vehicle designed to carry someone lying down. Thus, across the United States, the local undertaker was likely to be running the ambulance service. Sometimes this job was combined with ownership of the local furniture store: the mortician could build coffins, plan funerals, and run the ambulance service. (This seems, at best, a conflict of interests.)
In 1966, 50% of U.S. ambulance services (about 12,000) were still provided by morticians. The National Traffic and Motor Safety Act of 1966 finally set out standards for the design and construction of ambulances, which was so late that the report simultaneously addressed how to build and equip an ambulance and recommended the use of helicopters for rescues, something that had proved successful during wartime.
Nearly everything that we take for granted today about ambulances was, at various times a matter for debate: Should ambulances have lights and gongs or sirens? Should ambulances have the right to go faster than the speed limit and to run red lights? Those in charge of ambulance services were concerned about accidents but also about improving patient satisfaction: they worried that the experience of riding in a speeding ambulance would frighten or further injure the patient. A debate that in many circumstances is still being argued today.
The one significant advantage that we have today is the availability of EMS data. Thoughtful review and use of this data can help us make decisions that truly improve outcomes and the patient experience.