NFPA Journal

On a chilly November evening in Pittsburgh in 1966, David Lawrence, the city’s former mayor and recent governor of Pennsylvania, collapsed suddenly as he was set to give a speech at a campaign rally. An onlooker called for help, and city police quickly arrived to carry Lawrence off on a crude canvas stretcher and load him into a police vehicle. During the bumpy 10-minute ride to a local hospital, the former mayor lay in the back of the van in cardiac arrest, dying alone. By the time he arrived, it was too late for doctors to save him. 

In 2023, similar treatment of a critical patient would constitute gross malpractice, but in the 1960s, in the United States and virtually everywhere else, it was standard for responders to offer a ride and nothing more, says Kevin Hazzard, a former paramedic and the author of the stunning new book, American Sirens: The Incredible Story of the Black Men Who Became America’s First Paramedics.

“It might be the police or a volunteer fire department who responded to your call, but the one constant is that they wouldn’t have had much equipment or training, and they certainly would not be prepared to handle your emergency,” Hazzard told NFPA Journal about the care patients could expect at the time. “In some places, you might get two undertakers from a funeral home arriving at your house in a hearse with flower petals in the back from the previous funeral.” 

As Hazzard details in American Sirens, the seeds of change that would transform emergency medical services were planted in Pittsburgh not long after Lawrence’s death—coincidentally by the same doctor who received the politician’s lifeless body at the hospital that night, an Austrian-born physician named Peter Safar.
 
To Safar—who by that time was well known as the inventor of cardio-pulmonary resuscitation (CPR)—the limited response that had failed Lawrence and tens of thousands of other patients each year was absurd. In 1966, a study undertaken by the National Academy of Sciences found that at least 50,000 deaths each year in the US were the result of inadequate treatment prior to arrival at a hospital. To fix it, Safar advocated for ambulances stocked with sophisticated emergency room equipment and staffed with highly trained emergency field medics who could provide life-saving care, similar to the military field medics he witnessed in Europe during the world wars. 

How Safar and a dedicated group of unheralded black men from an impoverished Pittsburgh neighborhood achieved this vision—creating the foundations of modern EMS along the way—is the story that Hazzard expertly tells in American Sirens. It’s a tale that, until recently, had been largely forgotten to history. 
  
NFPA Journal spoke with Hazzard about the book and the legacy of the heroes of this history: the black paramedics from the Freedom House Ambulance Service in 1960s and 1970s Pittsburgh.

How did you first come across this story and what inspired you to write a book about it?
After my first book [A Thousand Naked Strangers: A Paramedic’s Wild Ride to the Edge and Back, published in 2016], somebody who read it shot me an email and said, ‘Hey, your book was interesting, but do you know how all this began? Have you ever heard of Freedom House?’ And of course, I had never heard of Freedom House. I was versed in this history of the Wild West version of EMS, when EMTs arrived at your house in a hearse, but I didn’t know how we made the leap from that to all these highly trained people. So I started digging into Freedom House and realized that there is this tiny bridge that exists in the late 1960s where everything is kind of born. At the heart of this story are 24 black guys from a neighborhood in Pittsburgh called the Hill District. I immediately got intrigued and I thought, ‘Any moment here I’m gonna uncover the definitive story of these guys,’ but nobody had written the definitive story. And once I got into it, the story just kept getting bigger and bigger and bigger, and I started to realize it wasn’t just a small hole—it was a huge cavern that no one had ever explored. That’s how it felt. It was the most obvious thing in the world, in my opinion, to have written.

Dr. Peter Safar with Freedom House medic trainees. Safar believed paramedics should be trained in a wide variety of medical practices. Courtesy of University of Pittsburg/Peter Safar Collection

The story begins in Pittsburgh with a doctor named Peter Safar. Tell us about him and why he believed that emergency medicine needed to change.
Safar was an Austrian-born American anesthesiologist who grew up in Vienna and survived World War I by the skin of his teeth. He finished his medical training and came to the US. This is a guy who had seen one of history’s great meat grinders up close and was aware of the improbability of his own survival—he had a great deal of survivor’s guilt. And so he told himself, ‘If I survive while all these people died, then there needs to be a good reason for it. I need to give something back to the world.’ And what he had to give back, of course, was medicine. He tried to spread medicine as far as he could, and he worked on that throughout his life. The first thing he did was invent CPR, which is a crazy story on its own. The next phase for him is to say, ‘OK, if we can train people to do these rescue breaths and chest compressions, then maybe we can take this a step further and train someone to actually deliver other types of care.’ 

How did he do that? 
He sat down and methodically developed the concept of the paramedic. He developed a training regimen, what they’ll be equipped with, what they’ll drive. At that point, you have hearses and police vans, but you don’t have specialized vehicles. So he designed the ambulance—if you look at an ambulance today, Peter Safar’s fingerprints are all over it. So he devised this program and had everything he needed for it except for the professionals to staff it. Nurses and doctors had been tried in the past, as had police officers and firefighters, but nothing had stuck. That’s because it was a new form of medicine, and it required people who could provide a very specific type of care. That’s why Safar decided to create the paramedic—a word that didn’t exist yet—and found himself on the hunt for these new people who could carry out his idea.

As this is going on, a community organization called Freedom House was established in the Hill District, a historically Black and impoverished part of Pittsburgh. What were its aims? 
Freedom House was a nonprofit organization whose goal was to provide job training opportunities for people in the Hill District. The founder, Jim McCoy, had worked for a number of years on various civil rights causes. Pittsburgh was in the midst of a massive upheaval in the mid-1960s—it was shedding the old steel city image and trying to create this city of the future. A lot was happening, but the city’s black residents were not benefiting from this growth, and they weren’t offered any of the jobs that were being created. So McCoy creates Freedom House, but the only jobs he can really find for people are low-level positions like housekeeping and landscaping, jobs that don’t take a lot of training and aren’t very uplifting or aspirational careers. Early on he created a vegetable delivery service. There were very few grocery stores in the Hill at that time, so he got a truck and they started delivering produce around the neighborhood. Meanwhile, a man named Phil Hallen, who led a local philanthropic organization, had this idea of creating what today we would call a private ambulance service, to bring people to and from hospital appointments—a very lo-fi kind of system. He saw Freedom House employees delivering these vegetables and he said, ‘Well, if you can deliver a vegetable, you can deliver a person.’ Hallen linked up with McCoy, and the two of them envisioned this ambulance service working as part of Freedom House’s job training effort. 

In late 1966, Hallen and McCoy learned about Safar’s ideas for emergency care, and the three of them met to discuss the ambulance idea. What happened at that meeting?
They asked Safar if he wanted to be involved in their ambulance project and Safar had zero interest in something that small. He started laying out in a very animated and passionate fashion the idea he’d been cooking up in his head for training a new brand of medical professional and how it would take months, how it would be hundreds of hours. Trainees would be in emergency rooms and the ICU, they’d be trained to treat seizures and heart attacks and strokes and trauma. They’d be able to deliver babies. They’d have this brand-new kind of ambulance that would be really advanced, with narcotics on board, with an orange and white color scheme so it could be seen a million miles away. Hallen and McCoy sit there listening to all of this. They’re very progressive men, one white, one black, but they live in a world where nothing like this exists. They listen to this thing raining down on them and they’re aware instantly that what Safar is describing is nothing short of a medical revolution. And they were also aware that they have nobody capable of doing what he’s suggesting. 

What did they tell him? 
What Safar was suggesting was incredibly advanced and required highly skilled people. They said, ‘Look, all this sounds wonderful, we love your idea, but we don’t think you understand what we bring to the table. We bring very ordinary people.’ But that was the crux of it, because Safar knew that in order for this thing to be reproduced—not once, not twice, but 2,000 times, in every city across America and beyond—you needed to prove that ordinary people could do this job. You take someone off the street, you train them, and you empower them to go ahead and practice medicine in the street. And once Safar said that, Hallen and McCoy were all in. They said, ‘Fine, we can do that, but there’s a catch: every person in this ambulance service has to be black. We set out to create a training program for people from this neighborhood, and on that point we will not deviate.’ And Safar, being a very progressive citizen of the world, without batting an eye, said, ‘Let it be done.’ And the world’s first paramedic program from that moment on was ordained to be entirely black.

You write that they recruited a few dozen men from The Hill and put them through an intense, 32-week course that Safar designed. This was the first paramedic training of its kind in the world. What were some of the skills that they were taught?
They were taught to read EKGs, to defibrillate, and to administer CPR. They were taught how to deliver babies and how to recognize respiratory emergencies and treat them properly. They were taught how to treat heart attacks and traumatic injuries: how to splint, how to do a traction splint, how to stop a hemorrhage. Basically everything that we do today. It’s worth mentioning again that, if you go to any city in America in the mid-1960s, the people who are sitting in the back of an ambulance have about the same training as a lifeguard at the public pool. They certainly haven’t spent time in various parts of the hospital like the Freedom House trainees did. The training Safar created was like a miniature version of medical school. 

Nearly 50 recruits completed the program in the first two years. They began working from a base of operations at a local hospital in 1968, running two ambulances. How did that first year go? 
It’s an unqualified success from the jump. I mean, instead of two police officers without any sort of training throwing patients in the back of a van, suddenly you’ve got guys who have nine months of training and who are as well-equipped as somebody in 2023. The difference in care is immediate and explosively evident. A study was done fairly quickly on critical patients that were brought into the hospital, and the numbers were crazy. It found that volunteer fire department and police were doing the wrong thing for these patients something like 70 percent of the time, and Freedom House was doing the right thing 80 percent of the time. There’s no way to understate just how radical and rapid that change was.

A Freedom House Ambulance, designed by Dr. Peter Safar. CREDIT: Harvard University, Schlesinger Library on the history of Women in America, mc531-40-6-2 (2)

How was Freedom House received by the public in Pittsburgh?
In their own primarily black neighborhoods, it was up and down at first. There was certainly skepticism. There are stories that these guys tell of treating a patient—and you know, all of us paramedics have been there—where the family members were like, ‘What the hell are you still doing here? I called you to take them to the hospital, not for you to sit here and play with them!’ So they had to overcome the public’s ignorance and skepticism about advanced medicine being practiced in their homes. But once the public got a handle on what was happening, people in their neighborhood were incredibly proud, and they are incredibly grateful. Freedom House became this really important thing for people in the Hill District. 

Freedom House’s ambulances also covered downtown Pittsburgh, which was primarily White. How did that go?
Not always well. There are many stories of the Freedom House paramedics essentially having to beg white patients to allow them to treat them because they don’t want to be touched by black men. It’s a bewildering thing. I can’t imagine a world where my life is in danger but I’m going to split hairs over who the person is who’s delivering my care. But more importantly, how you can recognize intellectually that this service is working and it’s good, but then resist it emotionally when they arrive at your door? I don’t know how you square that, but that was the reaction they got from many white Pittsburghers.

There are also a number of anecdotes in your book about the uneasy relationship between Freedom House and the police, who were used to responding to emergency calls. Is there a story that helps illustrate the situation? 
John Moon, who was one of the Freedom House paramedics, is dispatched late one afternoon to a car accident on Center Avenue, which is this big road that goes downhill from the top of the Hill District all the way down to the river. This speeding car veers off to the right, smashes into a telephone pole; it’s the early 1970s so there are very few safety mechanisms in the car. Nobody's wearing a seatbelt, the injuries are grave. John and his partner arrive to find a crumpled smoking car at the base of a telephone pole that's canted at a very perilous angle, and they see that they were beaten to the scene by maybe 10 seconds by the police ambulance service.

John jumps out, and the first thing he sees when his boots hit the street is this cop pull open the driver's side door and start yanking the driver out. In early 1970s, as far as all medicine knew, the way to treat someone with a suspected spinal fracture was complete spinal immobilization. And John looks over and sees a driver who is grievously injured, who's been in a very bad wreck, who's got a very high mechanism of injury, being yanked out of a car with no care whatsoever being given to what injuries he might have. And for just a second, John forgets that he's a Black man, and that these are White police officers, and he runs over there and he starts yelling, ‘No, no, no, no, you gotta stop!’ He's trying to explain to them that this guy's just been in a head-on collision and this cop is exacerbating the situation. As he starts to try and explain this, and police officer spins on him and suddenly all the things he forgotten, all the dynamics about race and power and America, come crashing back down on him, and the cop looks at him and puts a finger in his face and says, ‘You need to shut the hell up or I'm gonna take your to jail.’ Here he is, a trained paramedic who's been employed, trained and dispatched to a scene to save a life and he's being told either you shut up and stand there and allow me to mistreat this patient or I'm gonna arrest you. It's a humiliating moment. It's a frustrating moment. But in so many ways, it encapsulates what these guys were up against every day. 

You write that, by 1974, Freedom House had fallen on some hard times financially. Funding was hard to come by and the city's new mayor announced that he was going to cut off funding in favor of having the police run these emergency medical calls. Safar at that point is on a national committee that's trying to coordinate the development of national emergency care standards. That committee was looking to fund one EMS system as a pilot and testing ground, and Safar saw this as a way to save Freedom House. But he knew that he needed to improve and professionalize it to have a chance of being selected for that grant. So he hired Freedom House's first medical director, a young White woman named Nancy Caroline, who was a fellow under Safar and later went on herself to write the seminal book, Emergency Care in the Streets, and become this towering figure in the history of EMS. Tell us about her.
At the time, Nancy Caroline had just finished her residency, she's brand new. The fact that she's been given this fellowship under Safar is testament to just how bright she was. But she's very much unproven and unknown. She had never even heard of a paramedic. She had never seen the inside of an ambulance, so she has no idea what she's doing. She's also a young Jewish woman from the suburbs of Boston who finds herself in Western Pennsylvania, which is a vastly different world and surrounded an entirely by Black men.

She's completely out of element in every aspect, but she's also an incredibly dedicated and passionate person. And she recognizes the possibilities of EMS and so she decides that if she is going to be additive to this situation, she needs to figure out exactly what's going on. She spends a ton of time listening in on the radio to figure out what they do, what are they doing wrong, and how they can improve

How did Caroline transform Freedom House when she was brought aboard, and by extension, help shape modern EMS?
At first there's a very wide bridge between her and these guys. Every doctor who had shown up until then had kind of come and left Freedom House, including Safar who has got a million things going on. Nobody has been there full-time, and they don’t expect her to be there full-time either. But she throws herself into this thing, and she realizes the only way to really get a handle on this is to start riding with the paramedics. So she puts a cot in the crew room and she rides on as many calls as she can. She sleeps there, she eats there, for all intents and purposes, she lives there. She basically gives up on her fellowship and becomes an EMS doctor, which again, did not exist at the time. And she dedicates herself 24/7 to this job. And she terrorizes people for a month. I mean, everything they do she criticizes, she questions, she critiques. She makes them second guess themselves at all times. But the point of the second guessing is, are you doing the right thing? Before you do it, are you sure it's the right thing? And she has them going through very intense classroom programs so that they're learning new things and then putting them into use in the streets at night.

And within about a month or two, the paramedics are working themselves to the bone, doing everything they can for this service. But so is she. They see that she's on these calls with them— every time they go into an abandoned building, a crime scene, a housing project, she's right there. She's in this as much as they are. And that creates not only a sense of trust, but also bond of friendship. If you mention Nancy Caroline to any of the Freedom House paramedics, their tone changes. There's this sense of reverence and kinship and love and friendship that is immediately apparent. 

It's through that, that this organization reaches its full potential. Not only is she working very hard in the classroom to train them, not only is she sneaking them into various parts of the hospitals where they're not supposed to be; not only is she there on all these calls helping them to put all their training into practice, but they're becoming friends. They're becoming a unit. And the confidence that she helps to instill in them turns them into the paramedic organization that in the spring of 1975 is selected by this national council to serve as the standard for EMS care across the country.

The city had been resistant to this program for quite some time. They were frankly resistant to the idea of paramedics, period. They spent years fighting it, suggesting that it wasn’t viable, that they didn’t want to pay for it, that they didn’t have to pay for it, that nobody else was doing it, that this would be proven in the long term to be a wasteful lark, which of course was all untrue. Eventually they had to acknowledge that this thing was happening all over the country and that it was born in Pittsburgh, yet they were the only people who hadn’t embraced it, so maybe they should actually do something. But rather than expand upon this groundbreaking, revolutionary standard of EMS care, they decided to scrap what they had and start over. They told Freedom House that at the end of 1975 they would stop paying them and revoke their charter, in which case Freedom House would just cease to be. And that’s what happened. And the city developed its own new EMS program that was essentially entirely White. 

It’s been about 50 years since the end of Freedom House. You’ve immersed yourself in this story during the writing of this book. How do you look at the legacy of the Freedom House paramedics and everything they managed to accomplish?
There’s this practical legacy of ambulance design, the role of the medical director, the first training manual, the use of Narcan, and a ton of other things that you can point to and say that these modern things stem directly from what Freedom House was. And there are people who have had successful careers that grew out of all this. But I think the real legacy is this truly American story of a group of guys that the world had overlooked who see their opportunity to serve and who step up and do an incredible job in spite of their background and in spite of official indifference. If there’s anything more American than a bad news bear story, I don’t know what it is. This underdog crew who nobody believed in went out and changed the world. The tremendous work that they did when everybody was very happy to put them down and smear them with every sort of racist brush that you could possibly use is what’s most impressive. None of that stopped them. None of that, in their minds, took away from the job that they did. To me that feels like the legacy.

JESSE ROMAN is senior editor of NFPA Journal. Top photograph: Harvard University, Schlesinger Library on the History of Women in America, mc531-40-6-2 (2)