In honor of the 50th anniversary of the development of CPR, here is a glimpse by his students of a doctor who played a large role in the development of emergency medical services.
by JP Martin
New York City’s municipal ambulance service began in 1869 with horse-drawn wagons and “ambulance surgeons” (actually interns) providing medical care. Doctors were removed from ambulance duties during World War II and were replaced by orderlies, nurse’s aides, and later ambulance technicians. As late as 1970, there was no standard of care or training—each hospital established its own policies and procedures for its ambulance crews.
Thus was the state of affairs when, in 1973, Sheldon Jacobson, MD, director of emergency medicine at Jacobi Hospital in the Bronx, was asked by the administration of New York City’s Emergency Medical Service (then a part of the Health and Hospitals Corporation, which ran the city’s municipal hospital system) to start a paramedic training program. NYC EMS had obtained a Federal Department of Transportation grant to set up the program based on the spike in traumatic injuries that befell the Bronx in the late 1960s and early 70s. When classes began in early 1974, there was no formal curriculum, no textbook, and no established skill sets for the paramedic students. Dr. Jacobson decided what would be taught and how, and remained the medical director for the first five paramedic classes.
In addition, Shelly established the Medical Advisory Committee, made up of the emergency medicine directors from several NYC hospitals, to establish a common set of advanced life support protocols for all paramedics operating in New York City, so that all would be working under the same guidelines.
I was fortunate enough to have been a member of Shelly Jacobson’s last paramedic class, Jacobi 5, which graduated in February of 1979. I don’t recall him ever lecturing from notes, but then he didn’t need them; he knew everything.
One of Jacobson’s key themes was: “take a tip from the jockey.” This had nothing to do with playing the horses but everything to do with listening to the patient...the one who was riding the horse, or in this case, experiencing the acute medical condition. While vital signs, EKGs, medications, and past histories were important, Shelly stressed that dialogue with the patient was the most effective way to determine the acute complaint.
Shelly extended that individual, caring approach to his paramedic students. The paramedics, in turn, extended the tenets of academic medicine to their BLS brethren and effectively lifted NYC’s EMS system up by its bootstraps. We owe all this (and much more) to Sheldon Jacobson.
Following graduation, Jacobson provided continuing medical education on payday every 2 weeks when he (and later one of his attending physicians) would perform case reviews starting with paramedics reading their call reports then providing follow-up on our patients. Not unlike grand rounds for residents, this confirmation (or correction) of our presumptive diagnoses closed the educational loop for us young paramedics, giving us the reinforcement (positive and negative) that is missing from many systems today.
Shelly was a true inspiration to hundreds of paramedics, nurses, and physician assistants. Words cannot describe the depth of his medical knowledge, the breath of his compassion, or the richness of his sense of humor. While some practitioners may save hundreds of lives in the course of their practice, Shelly probably saved thousands by giving his insight into patient/provider communication. All who knew him will miss him greatly.
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JP Martin is EMS division chief (retired) and former chief of EMS Training, FDNY.
Another Perspective From “Jacobi Class 2”
by Mark Peck
In 1973, the New York City Emergency Medical Service, like most of the ambulance services around the country, provided little more than basic first aid and a fast ride for the critically injured patient. Our ambulances were affectionately known as “Bread Boxes” because they were built on the step van chassis favored by the bread and bakery delivery services. Our arsenal of medical equipment consisted of splints, bandages, an obstetrics kit, a foam-filled bag-valve-mask, a useless foot-operated suction pump, a RevivaLife resuscitator incapable of free-flow oxygen, stair chair, and a scoop stretcher. As explained to me during my first days on the job: “Kid, Dead is Dead. You only do CPR if they drop in front of you, and it don’t work anyway. But no one is ever listed as ‘Died in Transit’ on the call report.”
The TV show Emergency! went on the air in January 1972, depicting a totally new concept—nonphysician paramedics trained to interpret EKGs, start IVs, and administer fluids and medications, to control the airway, and defibrillate at the scene of the emergency. The hospital could come to the patient 20 to 30 minutes faster than ever before. The nation was fascinated with the show and real-life pilot programs were starting in many major US cities. Until this time there had been limited successes with physicians responding to the scene in Belfast, Ireland, the Heartmobile in Columbus, Ohio, and a Mobile Coronary Care Unit out of St. Vincent’s Hospital in New York City.
The world of EMS in New York City changed radically because of Sheldon Jacobson, MD. Then chief of emergency services at Jacobi Hospital in the Bronx, he recognized that both emergency department physicians and emergency medical technicians needed better training to have any meaningful impact on patient outcomes. He formed the Institute of Emergency Medicine at Albert Einstein College of Medicine where the first Emergency Residency Program in NYC was conducted. The first class of paramedics—Jacobi 1—hit the streets in July 1974 with two medic units out of Jacobi Hospital.
The program was judged a success, but funding for the next class and expansion would not come until June 1977. It was clear from the outset that there was a very close relationship between Jacobson and the Jacobi 1 medics. He took a very hands-on approach to our class, as he had done with the first, delivering many of the major lectures himself. I often wondered how he could give an entire day’s presentation without any notes or aids. He surrounded us with expert lecturers—nurses, physicians, respiratory therapists—and many of the class 1 paramedics filled in the gaps and made the material relevant for the prehospital environment. There were no paramedic textbooks in print, but he managed to obtain prepublication manuscript photocopies of the first textbook published in the US by Dr. Nancy Caroline.
But it was the values he taught us that have served me best for more 30 years. We were to be trained to be thinking practitioners—we must understand the mechanism of the disease process to make correct decisions. We were NOT going to be trained like the paramedics in Los Angeles, California, routinely asking for direction and permission over the radio. We would operate primarily under standing orders; we were ultimately responsible for any treatment decisions or drugs administered, not the physician on the radio. We had a responsibility to continue our education and to pass our knowledge and experience on to others. At our graduation he asked that we take the Oath of Geneva, affirming our responsibility to practice our profession with honor, to make the patient our first consideration, to respect our teachers, treat our patients without prejudice, and respect life.
Dr. J served as the first chair of the Regional Medical Advisory Committee, bringing together the directors of the major EDs around the city that would serve as our base station medical control directors. They developed the first regional protocols and the first testing and certification processes for paramedics and medical control physicians. He had his greatest influence in firmly establishing that it would be the MAC physicians making the major medical decisions in the system, not the bureaucrats.
Dr. Jacobson left us for a position as ED director at the University of Pennsylvania in 1979 but continued to maintain close relationships with many of the Jacobi medics for the next 30 years. Many of those medics went on to become influential emergency physicians and the next generation of leaders in EMS.
I sat this week watching one of his last lectures on medical errors that is preserved on the internet. [http://www.med.miami.edu/grandrounds/player.asp?id=256.] It is typical Dr. J, a lecture causing us to recognize our human weaknesses so we can overcome them in the quest for treating our patients more effectively, delivered with ease, understanding, and a sense of humor. Despite the accompanying slide display, I remain certain he still didn’t need to refer to it.
Among his lifetime of contributions to emergency medicine—teacher, professor, chief of service, author, lecturer and mentor, it is as Father of the New York City Paramedic Program that all the Jacobi medics will remember him. As to that dismal advice about resuscitation given me in my rookie years, thousands of New Yorkers who have been resuscitated by New York City paramedics have Sheldon Jacobson to thank for teaching that, sometimes, you can postpone the inevitable.
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Mark Peck, Jacobi 2, was a senior paramedic with the FDNY EMS.
Briefer glimpses:
Shelly taught the police how to perform first aid and CPR in the Bronx. He developed care protocols for acute myocardial infarction patients: focusing on stabilizing vital signs and treating cardiac dysrhythmias rather than racing to the hospital using lights and sirens.
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Kevin Brown, MD.
Shelly Jacobson was a real pioneer in emergency medicine, helping define the field at a time when many obstacles had to be overcome. He created New York City’s first emergency medicine residency and NYC’s first paramedic program. He was a pioneer in a literal sense for me, breaking the trail I followed. He taught the first 4 classes of that paramedic program, then handed the program off to me. I taught the next 10 classes. He inspired me to go on to Boston University to chair the Department of Emergency Medicine and then become medical director of Boston EMS, Fire and Police.
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Peter Moyer, MD.
Shelly taught us in the medic program that we had a responsibility to advocate for our patients and instilled a sense of compassion and integrity that has stuck with me throughout 3 decades as a practicing field medic.
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Bob Elling, Jacobi 3, is an EMT-P and member of AHA National Faculty.
Saving a Galaxy
Jacobson performed a miracle in 1974. He took a group of ambulance drivers and attendants and turned them into a new group of medical professionals who provided emergency medical care at the scenes of emergencies. Perhaps the best indicator of Jacobson’s success is what these men became after their paramedic careers. Five became physicians, some of them still leading emergency departments in the New York area. Three became physician assistants. One became the chief of the NYC EMS. One became the chief of EMS in St. Louis. One became a respected homicide detective. And one (me) joined the NYS Health Department’s EMS, later becoming the statewide EMS examination coordinator.
Shelley Jacobson took these 19 young men from a simple existence and turned them into highly respected professionals who compounded his ability to save lives. I am forever in his debt for what he did with this group. When the efforts of Shelly are considered, both his own and the efforts of those he trained, I’m sure he has saved a galaxy. Hardly a day went by in my career with NYS Department of Health without me thinking, “What would Shelly do?”
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Thomas Dean worked with the NYS Health Department’s EMS and was the statewide EMS examination coordinator.
Sheldon Jacobson, MD. He saved the lives of those he treated, and he burnished the lives of those he taught.