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February 23, 2004 Issue

By Chuck Staresinic

John Moon was a young paramedic eager to increase his professional skills and confidence when he walked into the emergency room at Allegheny General Hospital. He’d performed a physical exam on the patient en route from downtown. He’d even rehearsed presenting the patient to the emergency room staff until he had it down to a T—blood pressure, pulse, history, and more. At that time, in 1974, sophisticated ambulance service was practically unheard of. Throughout Pittsburgh and the entire nation, ambulance attendants routinely brought critical accident victims and the gravely ill to the hospital with little or no medical attention. Few people even knew what a paramedic was. Police officers with no specialized training and no equipment drove ambulances like they were driving delivery trucks, and proper care generally began at the hospital doors, provided the patient was still alive.

Emergency medical technicians (EMTs) like Moon, working for the Freedom House Enterprises Ambulance Service, were the vanguard of change. Trained to exacting standards under the iron gaze of the University of Pittsburgh’s Peter Safar [the late Distinguished Professor of Resuscitation Medicine in Pitt’s School of Medicine], the Freedom House EMTs primarily served Pittsburgh’s Hill District and Oakland from a base of operations at Presbyterian-University Hospital beginning in 1968. The vehicles they drove were designed to Safar’s specifications and outfitted with EKG monitors, IV drips, intubation kits, blood pressure cuffs, and defibrillators. They looked more like roving exam rooms than the hearselike vehicles the public knew as ambulances.

Top: Philip Hallen (left) brought Freedom House Enterprises together with Presbyterian-University Hospital and Peter Safar (right).

Bottom: From 1968 to 1975, one of the safest places to be was in the hands of a Freedom House EMT. (Although the cat seems uncomfortable in the hands of Hallen).

Nancy Caroline went into the ER with Moon that day. She was a critical care physician at the University of Pittsburgh whom Safar had handpicked as medical director for Freedom House. In the ambulance, she had prepped and encouraged Moon. As they entered the hospital, a nurse came to help, and Moon launched into his presentation. Moon, in addition to being a Black man in a mostly White arena, personified the most advanced prehospital care available anywhere in the nation. The nurse, apparently unaccustomed to being addressed in this way by an ambulance attendant, laughed at him and walked away before he could finish.

Moon turned to Caroline and said, “This is useless. I don’t know why we even went through that.” Caroline looked straight back at him. Despite her gentle features and youth, she was tougher than nails on her EMTs. She was always watching them, listening to them on the radio, telling them how they could be better, how they had to be better. She was tough. She was their mentor. And they absolutely loved her for it. She replied, “If you don’t learn to talk to the emergency room staff on their own terms and in their language, no one will ever listen to you.” She wasn’t letting him go anywhere until he did his job.

In 1967, Freedom House Enterprises was a fledgling nonprofit corporation in the Hill District trying to uplift the community by creating African American-owned businesses that would provide meaningful employment and job training. They started a service that sold fruits and vegetables out of trucks on the Hill. Philip Hallen, director of the Maurice Falk Medical Fund, figured if Freedom House could bring produce to a neighborhood that was lacking grocery stores, they could run a commercial service to transport people for hospital visits and routine checkups. Hallen introduced Freedom House board members to his former classmate from Yale, Ed Noroian, who was the director of Presbyterian-University Hospital. Noroian offered to house an ambulance service at Presbyterian, and he asked Safar to train the paramedics. At that point, an interesting idea blossomed into a revolutionary one.

Safar was a consummate scientist and an uncompromising humanist. The anesthesiologist from Vienna had helped develop the formula for cardiopulmonary resuscitation and demonstrated that Boy Scouts and firefighters could be trained to provide basic life support. Now he wanted to demonstrate that sophisticated care administered by trained laypeople would save a great many lives. When Noroian approached him, he was already working on standards for ambulance attendants.

It was an audacious plan. Some would say ridiculous—a poverty program that would take unemployed people from the Hill District and train them to provide emergency medical care in the streets. The day before training began, Jim McCoy, the president and founder of Freedom House Enterprises, recruited people right off the street. Nearly half had not completed high school. Some needed help with basic skills like reading and math before more advanced training could begin.

In the hospitals, Safar and Noroian paved their way, instantly legitimizing the unexpected arrival of a few dozen African Americans in white uniforms. They wore patches that read “Ambulance Attendant Trainee.” Their training far exceeded any existing standards—300 hours of classroom and clinical work in anatomy and physiology, first aid, resuscitation, medical ethics, and legalities. They did rotations in the operating room, recovery room, intensive care unit, morgue, emergency room, and maternity ward.

The first Freedom House ambulances hit the streets in the summer of 1968. By October, Safar was writing to the mayor, describing the success of the service and urging that Freedom House’s contract with the city be expanded.

But despite its unqualified success in demonstrating and delivering cutting-edge ambulance care, Freedom House was in for a bumpy ride. It relied on grants, and financial stability was difficult to achieve. City police continued to run ambulances throughout the city, frequently rushing in to transport accident victims without any stabilization before Freedom House could arrive. Freedom House began racing police ambulances to the scene. Hallen says that racism prevented elements of the police and city government from appreciating Freedom House for the unparalleled asset it was.

One paramedic told filmmaker Gene Starzenski, who is producing a documentary on Freedom House, “We were determined to succeed because everyone told us we would fail.”

Their successes were many, from small personal victories to individual lives saved, and, eventually, to the shaping of national standards.

A 1971 study found that 62 percent of patients received inappropriate care from the police, while 11 percent received inappropriate care from Freedom House. Eventually, police officers in need of an ambulance for themselves or a family member would call the Freedom House dispatcher instead of the police.

Above: Nancy Caroline (front and center) and John Moon (behind her in glasses) with ambulance service staff.
When Caroline came on as medical director in 1974, she instituted a rigorous system of monitoring, or, as she called it in Pittsburgh magazine in 1977, “an Orwellian reign of terror.” She went on ambulance runs with the paramedics, even when she’d already worked so many hours that most people would have gone home. She monitored radio traffic and picked up the microphone at all hours to “question, chastise, harangue.” Given a chance, she would catch a few hours of sleep on the cot in the ambulance.

Moon says that Caroline was “warm, gentle, kind, and intimidating.” She developed a close camaraderie with the paramedics, many of whom would have followed her anywhere. She made sure they got the training and support they needed. “There were many times,” says Moon, “she’d be walking down the hall with five Freedom House paramedics walking right with her, going into the ICU to look at a particular patient.”

Caroline, who died of cancer in 2002, remembered with particular pride Moon’s struggle for respect in the emergency room. Describing the scene in Pittsburgh magazine, she picked up the story after the nurse turned her back on Moon, writing that he then cornered the ER physician and with “military precision” said, “We have a 19-year-old man who experienced a dizzy spell without syncope while lifting some cartons at work. His past medical history is negative except for a heart murmur present since childhood. His pulse was irregular, ranging from 38 to 110, his blood pressure was 110/70 and his respirations 20. The rest of the physical exam was negative except for a short systolic murmur. His EKG shows evidence of bradytachy syndrome.”

With a smile, Moon then handed the EKG strip to the physician and proceeded to help the nurses move the patient. Caroline said they laughed all the way back to Presbyterian.

In 1975, Freedom House paramedics presented a disaster drill for an international symposium on critical care medicine. They were judged among the most sophisticated and skilled in the nation. Drawing heavily on lessons learned with Freedom House, Caroline would go on to write Emergency Care in the Streets—for years, the only textbook for paramedics. Under Safar’s direction, Freedom House EMTs tested and implemented the U.S. Department of Transportation’s standards for ambulance training and equipment eventually adopted by 40 states.

In 1975, the City of Pittsburgh ended its contract with Freedom House and instituted its own modern ambulance service—Emergency Medical Services (EMS), which exists to this day. There was anger and bitterness within Freedom House, whose paramedics were assured they could be hired by the city if they passed a test. Many felt that the city should have committed to expanding Freedom House into a citywide operation. One of the more outspoken paramedics was quoted in the Pittsburgh Post-Gazette saying, “If this was a mostly White organization, I don’t think this thing would be happening.”

About a dozen Freedom House paramedics did go to work for the city. Moon is currently an assistant chief with EMS, and one of its longest-serving employees. Mitchell Brown moved from Freedom House to the city and is now public safety director for the City of Columbus, Ohio. Many pursued advanced degrees and careers in health services like these two. Some became unemployed or drifted back to unskilled work.

Hallen notes that at a memorial service last year for Peter Safar, amid all the descriptions of his achievements, there was no mention of his work with Freedom House. Moon still laments that the vast majority of paramedics, even in Pittsburgh, know nothing about Freedom House. He considers the organization one of the greatest blessings in his life. So would many others, paramedics and patients alike, if only they knew.

This article was published in Pitt Med magazine’s February 2004 issue. It is reprinted with permission.



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