District Physician Control Enlarges Responsibility of Seattle Paramedics

District Physician Control Enlarges Responsibility of Seattle Paramedics

FEATURES

On March 9th of this year, the Seattle Fire Department’s advanced life support system started its ninth year of operation in rather routine fashion.

During the 24-hour period, there were 67 calls for emergency medical assistance which involved 106 pieces of fire equipment. Under Seattle’s layered response system, this required the assistance of 21 engine companies, 49 aid units and 36 paramedic responses. The actual alarms were also routine. They included incidents of cardiac arrest, industrial accidents, overdoses, vehicle accidents, obstetric cases and a shooting—a very routine day.

Described by some as the finest prehospital emergency medical care in the nation, the concept was originally developed by Dr. Leonard A. Cobb, professor of medicine at the University of Washington and director of the division of cardiology at Seattle Harborview Medical Center, and the Seattle fire chief at that time, Gordon F. Vickery. Together they reasoned that by combining and coordinating existing manpower, skills, equipment, facilities and technology available from the fire department and medical community, hundreds of lives might be saved in Seattle each year.

This was in 1969 and before the term paramedic had become common. At that time, it was considered a significant departure from normal pre-hospital emergency medical care being delivered throughout the countrry.

Federal funds obtained

An application for federal funds was made under the title, “A Community Approach to the Therapy of LifeThreatening Arrhythmias and Acute Myocardial Infarction Outside the Hospital.” Application was approved by the Washington/Alaska Regional Medical Program and the project was funded by the Department of Health, Education and Welfare. It was a three-year research program to run to June 20, 1972. This early RMP money should not be confused with the title XII funds that are currently being used to fund paramedic programs throughout the country.

The initial unit, a modified mobile home, 24 feet long and almost 10 feet wide (which almost immediately proved to be too large and cumbersome) was to be staffed with two Seattle fire fighter/ paramedics and a training physician. As it became evident that the fire fighter/paramedics were capable of operating without immediate and direct supervision, the riding physician was eliminated and replaced by a consulting physician on duty at the hospital.

Nineteen fire fighter volunteers were selected and the training was basically centered on advanced cardiac life support—combating ventricular fibrillation.

Financial crisis arises

By the end of the first 30-day period, the unit—Medic One—had responded to 115 alarms and it was becoming apparent to the entire community that Seattle had developed an exceptional lifesaving program. Yet, by the end of the sixth month, the future of the Medic One was in serious jeopardy. Federal funds were to be withdrawn, leaving the program $100,000 short. The City of Seattle was unwilling to support the project until after the end of the third year.

“Although we didn’t realize it at the time, what ensued was probably the finest thing that could have happened to the project,” Fire Chief Frank R. Hanson stated. “Suddenly this became a Seattle citizens vs. the federal government war. There was a constant barrage of editorials. As an example, the Seattle Times, the city’s leading newspaper, charged that the Washington/ Alaska Regional Medical Program was going to spend $397,500 for education and publicity while planning to allot only $27,498 to Medic One.”

It was a knockdown-drag-out fight, but to no avail—the federal funds were withdrawn and the project lacked $102,500. If Medic One was to continue, the citizens of Seattle would have to contribute the needed money through public subscription.

“In short, we collected over $200,000,” Hanson explained, “mainly in one and two-dollar donations, and Medic One was on its way to becoming a political untouchable. People actually applauded as the unit passed through downtown streets. It became their unit. They had helped save it, and heaven help the politician who dared to tamper with it! In the seven years since that fight, several have tried and each time they have been forced to almost issue what amounted to a public apology.”

CPR program started

Within a year after the start of the Medic One project, several notable and far-reaching decisions were made— changes that would ultimately raise Seattle’s level of service to the high performance standards of today. They included the decision to start a citizen CPR program, the decision to use a layered response system to medical emergencies and, the decision to broaden the scope of the paramedics to include all forms of trauma—an advanced life support system comparable to hospital care.

“The citizen CPR program (Medic II) was a natural spin-off to our Medic One project,” Hanson explained. “It was initially proposed by a paramedic who wanted permission to teach CPR to the families of Seattle fire fighters. From there it grew until today, 185,000 Seattle/King County citizens are trained in CPR.

“In 1971, national leaders in CPR thought that it was folly for Seattle to teach CPR to citizens. We believe the initiation of the citizen CPR teaching program, and its successes, is probably the most significant contribution that the City of Seattle has made to the rest of the country,” the chief declared.

Most of the initial funding came from the city’s largest Rotary Club. The club was looking for a new program sponsorship and Medic II was exactly what they were seeking. Today the citizen CPR program is a United Way project.

Effectiveness of program

The effectiveness of CPR training in saving lives cannot be overlooked. Some 34 percent of all Medic One cardiac responses are summoned by a bystander who has started CPR before the unit arrives.

The January issue of the Journal of the American Medical Association contained a report of a study conducted by Dr. Robert G. Thompson, clinical instructor in medicine at the University of Washington, involving a series of 316 attempted resuscitations by emergency teams, of which 109 were preceded by CPR performed by a lay bystander. Immediate resuscitation rates were nearly the the same—67 percent for bystander CPR, 61 percent for the other—but the similarity ended there. Two thirds of those whom a layman aided lived; only a third of the others survived.

Heart attack then an auto crash puts driver in hands of Seattle paramedics, fire fighters and even a civilian on a downtown street.

Seattle Times photo, Bruce McKim

Survival rates for those helped by bystander-administered CPR also fared better. A detailed study of the 118 who reached the hospital alive showed 86 had received CPR from laymen at the site of their attacks; 82 had to wait for other assistance. The first group fared much better in important ways; 22 of the 26 regained consciousness on the first hospital day—18 by the time of admission—as opposed to seven of the other 82. Seven of the first-aid patients (19 percent) remained in a coma until death or discharge; 39 of the other 82 (48 percent) had a similar outcome.

Altogether 72 patients regained consciousness—29 in the immediate CPR group, 43 in the delayed-treatment group. Only one patient in the first group had prolonged disorientation, while nearly half (21) in the less-favored group were disoriented for prolonged periods.

Clearly, citizens performing CPR on heart victims play a major role in Seattle’s advanced life support concept.

In one form or another, the Seattle Fire Department has been involved in providing emergency medical assistance for the better part of 40 years. Starting with nothing more than ladder company responses, it grew to a single 1941 sedan, to station wagons, to various types of aid units. When Medic One was introduced, aid units were still being dispatched to the same alarms.

“At the end of the first year, it became evident there was a direct correlation between a quick response and lives being saved;” Hanson said. “In other words, when an aid unit could reach a victim within four minutes, the chances of survival greatly improved. Based on this, we decided to dispatch engine companies any time they are two minutes closer in response time than the closest aid or medic unit. The average response time for an engine company in Seattle is 2.47 minutes, which means some type of trained personnel will be on the scene in less than 2 1/2 minutes after being dispatched.”

Simultaneously with the decision to dispatch engine company, newly-trained paramedics, accompanied by physicians, were sent to all stations to sharpen CPR skills. Cardiopulmonary resuscitation had been taught to Seattle fire fighters since 1965, but if they were to become a part of emergency response teams, fire administrators wanted them to be experts.

As was mentioned before, the decision to expand Seattle’s basic cardiac life support system was made approximately a year after the introduction of the program, at the start of the second paramedic training class.

Training expanded

Captain Michael F. Olsen, a member of that class and now the department’s medical services administrator, explained the changes, “When group 2 started, we received the same initial training module, just slightly refined. Then as an add-on, we received both didactic classes and laboratory sessions in areas such as trauma, blood volume resuscitation, advanced obstetrics, management of the overdose, etc. When our training was complete, the initial class was returned for their secondary training and the number of lives being saved started a dramatic upswing.”

Recently, someone suggested that the continued talking about “Seattle-this, and Seattle-that,” is like French wine; it may not travel well.” In any event, if the contention that Seattle is the EMS leader, perhaps a description of the entire system as of today is appropriate.

Struck by a vehicle, man receives emergency treatment on a wet Seattle street. Tarps put in place by fire fighters keep victim dry while paramedics work to stabilize him for transportation

Seatle Times photo, Bruec McKim.

There are presently four paramedic units fully equipped to handle pre-hospital advanced life support. Two are stationed at Harborview Medical Center in downtown Seattle; another operates from a fire station in the north-central portion of the city, and the fourth is stationed in the city’s industrial area in the south part of Seattle. The medic units are backed by seven aid cars, geographically located throughout the remainder of Seattle’s 94 square miles, generally in a two-company station, with manpower taken from the base engine and ladder companies. These 11 units are backed by 35 engine companies.

On an average, approximately 100 pieces of fire/aid/medic equipment will be dispatched to answer calls for emergency medical assistance during a 24-hour period. Approximately 65 percent of the city’s 1000-man fire department is trained to the EMT level. The remainder is trained to a minimum of advanced first aid and is currently being trained at the EMT level.

DOT criteria exceeded

Paramedic training of today is formalized and is styled to meet the training requirements of the University of Washington School of Medicine. The training program follows a published course outline that far exceeds the Department of Transportation’s national outlined course for paramedics.

Seattle fire fighters are selected to become paramedics from a list of volunteers who have received endorsements from all of their supervisors. Oral interviews are conducted first by Olsen and then by a board composed of doctors and paramedics. Other than a state requirement that the applicant must be an EMT and a department requirement that he be experienced in riding a basic life support aid unit, the selection is not based on medical knowledge. Emphasis is placed on trainability, motivation and attitude.

Once the applicant is accepted, he is placed on detached duty from the normal fire combat ranks and is detailed to the training program at the University’s Harborview Medical Center. This 55-hour-per-week course lasts from 10 to 12 months, depending on the size of the class. The formal training runs approximately 5500 hours with 1500 hours covered in the published course outline.

From outward appearance, Seattle medic and aid units look identical. The only difference is the designation number on the side of the apparatus. The unit itself is a GMC wide-body van, with dual rear wheels. The department purchases it stripped, then the insulation, wiring, walls, ceiling, and compartmentation are done in the fire department’s own shop. The total cost, including radios, lights, etc., runs around $14,000. As the Seattle program does not receive federal funding, the apparatus are built to meet the specific needs of the City of Seattle and not to conform to any federal model.

Minimum telemetry

The telemetry equipment used in Seattle is a relatively small investment.

“If there is any specific, unique feature to the system, it would probably be its simplicity,” Olsen explained. “In the formative years, it was felt that biomedical telemetry was a useful adjunct to the existing communications system, while not requiring continuous ECG transmission. For this reason, short diagnostic telemetry electrocardiograms are transmitted by telephone or on the existing fire department radio communications network.

“As the program is not felt to require continuous ECG telemetry monitoring, the hardware is limited to a simple ECG modulator at the scene and an equally simple demodulator and write-out at the hospital’s physician station. This signal encoder/decoder/writer system limits the costs and simplifies the system. Because we already had a field monitor, telephones and portable radios, our actual telemetry equipment costs were less than $2,000,” Olsen explained.

Newest model of ambulances in Seattle Fire Department is shown above.

Paramedics in Seattle experience what is probably the tightest physician control in the nation, yet have perhaps the greatest latitude when it comes to determining the condition of the patient.

Use of standing orders

“We operate from standing orders— prewritten protocols in cardiac arrest,” Olsen said. “The physicians in charge of this program feel we shouldn’t have to spend time talking to the hospital when we could very well be doing something to prevent further damage. There’s a great deal of misconception about standing orders as we use them. These orders are limited to four drugs and to specific loading dosages of those drugs under tight written protocol. When we want to go beyond the specific loading, a doctor must be contacted.”

This same concept has been extending to starting blood volume replacement in patients who are in shock as the result of trauma.

The program is also different in other respects. As an example, Seattle paramedics are expected to present the patient symptoms to the doctor, not to wait for the doctor to make determination.

“When talking to the physician from the scene of an emergency, our people are taught to present the patient, give the vital signs, history, the results of their examination, and medications,” Olsen explained. “Then, unless it is something extremely bizarre, they give their appraisal of the patient and subsequently suggest a course of treatment.

Difference explained.

“Let me give you an example of how our operation differs from most other cities with paramedic programs,” he said. “Recently, we had a visitor from a large metropolitan fire department— one that is very involved in paramedic operations and one that we all admire. While visiting in our office, this visitor overheard a presentation from a Seattle paramedic in the field to the Medic One physician.

“After the paramedic had made his initial presentation, he concluded with, ‘We believe this woman to be in acute pulmonary edema, secondary to her chronic congestive heart failure. We have rotating tourniquets on her, and we request permission for plan B (permission to start an IV), TKO (to keep open), 200cc phlebotomy, give IV morphine 4+2+2, and administer 80 milligrams of lasix, as she takes 40 milligrams in her daily dose’.

“It was an excellent presentation, and he was absolutely correct in his appraisal, yet the visiting officer literally exploded. He said that he would immediately have reprimanded the paramedic for being so presumptuous as to tell the doctor what was wrong with the patient and to suggest the course of treatment.

“We disagree. We believe our paramedics on the scene have the training to properly present the patient to the physician. There is no doubt that if the patient’s condition were outside the scope of the paramedic’s training, he would request more help of the physician. Through all this, it must be clearly understood that while the presentation may be different, the final say and final authority still remains with the doctor,” Olson emphasized.

Advanced techniques used

In addition to the equipment and techniques outlined in the American Heart Association’s advanced cardiac life support course, Seattle had gone a bit further. The Seattle program is now confident enough in the skills of the paramedics and physician control to allow the use of respiratory paralyzers in airway management. When a patient with a massive trauma is in need of an endotracheal tube, Seattle paramedics are allowed (under physician direction) to use a drug which paralyzes the respiratory center—succinylcholine (much like curare). They are also among the few in the nation who are allowed to insert valves in the chest to relieve tension—pneumothorax. Added to this are the skills of inter-cardiac injection and central venous line IVs, specifically, subclavian lines and lines in the internal jugular.

As for the future, Chief Hanson sees little or no need to expand the number of paramedic units in the city.

“If skill degradation is a factor in pump training—and we know it is because we’ve run studies—then it becomes a supreme factor in medical care,” he explained. “It’s the mechanical skills around which you build confidence. The skills become reflexive because they are done frequently.

Skill degradation avoided

“Let’s arbitrarily say that on any given day our people handle five cardiac arrests. That’s five people who need to be given endotracheal tubes and definitive therapy. Now, if we tripled the number of paramedics, we know there won’t be an equal increase in number of cardiac arrests, so we would then decrease the skills of our individual personnel.”

“To put it altogether, I believe Seattle’s system epitomizes a community effort in pre-hospital care,” Hanson declared. “It includes 185,000 citizens who have been trained to recognize problems and provide some form of therapy before the arrival of the first unit, a coin-free 911 emergency telephone number, a quick response from the neighborhood fire engine, aid units which can be used to treat citizens requiring acute care, and finally, the paramedic units with all their capabilities plus direct coronary care unit admission to all 14 local hospitals.

“We are very proud of this program. In an era where the salaries of fire fighters continue to come under close scrutiny, we feel we are providing the local citizen with the greatest possible return for his fire service dollar.”

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