Opportunities for Breakthroughs

You’re on a sidewalk, heading up the block to grab a soda from the corner store, and you trip on some uneven pavement. You hit your head as you tumble to the ground. If this accident happened today, you or somebody near you might call an ambulance. Emergency medical technicians (EMTs) or paramedics would manage your care as they transport you to a hospital emergency department, where you’d be treated for a concussion or other injuries.

But none of that would have happened in 1966. If someone were able to find the number of an ambulance service in the phonebook (the 911 system didn’t exist yet), and if someone answered when the helper called, you might be met with and transported in a station wagon—or a hearse should the mortuary have one to spare. Your driver would likely have had only some basic first aid training, and they definitely didn’t have any medical supplies or any way to communicate to the hospital that you were en route.

It was around this time that emergency medicine started to form as a specialty, and the United States was becoming more aware of the need for—and opportunity in—emergency services. In 1966, the National Academy of Sciences and the National Research Council published a report called Accidental Death and Disability: The Neglected Disease of Modern Society, which detailed the state of emergency care, the findings of trauma research, and the researchers’ recommendations for reducing the number of deaths and injuries resulting from accidents.

“That title really grabbed us,” says Blair Sadler, JD. Blair and his twin brother, Alfred Sadler, MD, who goes by Fred, have had long careers in health care, with notable tenures at the National Institutes of Health (NIH) and the Robert Wood Johnson Foundation. In 1970, the medico-legal duo arrived at Yale School of Medicine (YSM), recruited by the then-chair of the Department of Surgery, Jack Westley Cole, MD, to conduct a study of emergency medical services (EMS). Cole had been impressed with the Sadlers’ work at the NIH involving organ donation and the Uniform Anatomical Gift Act, which had been widely adopted.

“I want Yale’s Department of Surgery to do something about our country’s woeful state of emergency care,” Blair and Fred recall Cole saying to them at the time, as they recount in their book P(luck): Lessons We Learned for Improving Healthcare and the World. Cole had just started a trauma program at Yale with its primary goal being to first understand the shape of emergency services outside the hospital, and then identify areas for improvement across the whole system. “No leading medical school had put a stake in the ground like Jack Cole did,” says Blair.

At Yale, the Sadlers teamed up with Samuel B. Webb Jr., PhD, a professor of public health, to start their study. They began collecting data and talking to key people across Connecticut, including leaders in local government, hospital emergency departments, ambulance associations, and police and fire departments. Their immediate takeaway was that none of these people were in regular communication with one another, even though all of their jobs intersected with emergency services in some way.

“We started inviting them to meet,” says Blair. “We’d have monthly meetings over pizza, and people got to know each other.” Those meetings then turned into discussions about what it would take to establish a real EMS system, then to laying out plans, then to reviewing the data coming in from the ongoing study.

The Sadlers and Webb also met with other pioneers in emergency care, traveling to Miami, Baltimore, and Chicago, among other cities. In Pittsburgh, they learned from the Freedom House Ambulance Service, a Black emergency unit and the first EMS service in the country whose staff had medical training. Meanwhile, Webb’s Yale School of Public Health graduate students collected data from across the state through interviews and surveys.

The research team completed their study in 1972, detailing it in a whopping 700-page report published as a book in 1977, Emergency Medical Care: The Neglected Public Service: The Connecticut Experience. Among the team’s findings: Only 22% of Connecticut’s ambulance services required their drivers to have a Red Cross Advanced First Aid certificate; and few carried such supplies as splints, medicine, or bandages.

Understanding that 700 pages is a lot to take in, the research team condensed their findings and recommendations into a 52-page version—Emergency Medical Services in Connecticut: A Blueprint for Change—with a bright red cover that would stand out on the desks of the leaders and policymakers whose attention the researchers were hoping to grab. And it worked.

By 1975, the state of Connect-icut had passed two emergency medical services acts. By 1976, state leaders had implemented all the priorities laid out in Blueprint for Change, vastly improving emergency service communication, ambulance record-keeping, and level of expertise among emergency department and EMS staff. The Sadlers and their colleagues at YSM had already launched an EMT training course in 1971. Five years later, they had trained around 6,000 ambulance staff and 155 EMT instructors. And while few ambulances were carrying critical supplies when this work started, by 1976 99% of the state’s ambulances were doing so.

“This work was a testimony to the interdisciplinary power of YSM and Yale School of Public Health,” says Fred.

These achievements took place as emergency medicine was gaining recognition as a specialty, and YSM has had an enduring imprint on the field ever since. David Cone, MD, now retired, led efforts to establish EMS as a subspecialty and nationalize training standards. Sandy Bogucki, MD, PhD, professor emeritus of emergency medicine, co-founded the Section of EMS in the Department of Emergency Medicine with Cone, and is lauded for advancing the science of EMS. Charles Wira, MD, associate professor of emergency medicine, helped create a Connecticut-wide EMS stroke response system.

“There has always been this unique impact of our department’s work, not just measured in publications, but as being the leaders to elevate the standards of emergency care statewide and nationally,” says Arjun Venkatesh, MD, MBA, chair and Anthony N. Brady Professor of Emergency Medicine, whose own contributions include spearheading new measures for hospital capacity that will soon be applied nationwide.

Currently, YSM’s Department of Emergency Medicine conducts more NIH-funded research than any other emergency medicine department in the country. And it leads a statewide EMS operation, helmed by Thomas Lardaro, MD, MPH, the department’s EMS section chief. “We’ll continue to change the landscape,” says Venkatesh.

The Yale Trauma Program succeeded in establishing EMS across Connecticut, and it ended up having a national influence when the Sadler brothers joined the Robert Wood Johnson Foundation in 1973 and recommended the foundation choose improving EMS nationally as its first major priority. The foundation provided grants to 44 regions in 32 states across the country to develop their own EMS systems.

“It was a direct throughline from the Yale work to the foundation’s first national program and EMS becoming a recognized health care specialty,” says Blair.

Fred and Blair now live in California, where Fred practiced internal medicine and Blair served as president of San Diego’s Rady Children’s Hospital. At 84 they are still writing, teaching, and involved in health care improvement. Looking back on their work with the Yale Trauma Program and later the Robert Wood Johnson Foundation, one takeaway is the impact people can have on health care in a relatively short period of time when they work together on a shared goal.

“And there are still opportunities for pioneers,” says Fred. “There are still opportunities for breakthroughs.”