PARAMEDIC ENGINES—A PROVEN PROGRAM

PARAMEDIC ENGINES— A PROVEN PROGRAM

RESCUE/EMS

Paramedic units are providing effective mobile intensive care services, irregardless of jurisdictional boundaries, through the cooperation of all emergency personnel.

Perhaps there were those who could see beyond the humble beginnings of Los Angeles County’s paramedic and emergency medical service which started up in 1969. Chief Simpson admits that he was not one of them. The first meeting ever held in Los Angeles County regarding paramedics was attended by L.A. County Supervisor Kenneth Hahn; Professor Robert Andrews, dean of the graduate school of business administration at UCLA; Ron Granite, business administration graduate student, UCLA; Davis Lear of Hahn’s staff; and Simpson.

UCLA had received a federal grant to do a six-month pilot study to determine if it was feasible to train and use fire fighters as an existing resource to perform paramedic duties. It was agreed we would move ahead, albeit skeptically from the fire department’s viewpoint. That skepticism was not to be short lived.

There were myriad questions to be answered. Who would develop the curriculum? Where would training be done? What kind of vehicle would be used? How would personnel be selected? How many? What were the legal ramifications? Could the personnel selected operate as paramedics as well as firefighters? How about radio frequencies? These and dozens of other questions were answered, if not routinely, most certainly without jeopardy to the program.

Dr. Michael Criley, chief cardiologist for the UCLA Medical School at Harbor Hospital, was one of the fathers of the program and remains one of its strongest supporters. He developed the training curriculum and took a personal part in every phase of the training. The personnel were not selected on the basis of training or education, but rather because of their proximity to Harbor Hospital when the training was done. Of those selected, not one failed and most remained in the program for several years.

The original vehicle was a dilapidated station wagon (not much priority was given to the program initially). When Supervisor Hahn saw the vehicle, he ordered the head of the County Mechanical Department to buy a new one immediately without regard to bid or any other red tape. (The vehicle was delivered the same day.)

In the beginning, there was no legislation allowing the fire fighter/paramedics to administer drugs, start IVs or do any of the things we’ve come to take for granted. Because of that, when an alarm came in the fire fighter/paramedics left the station, went to the coronary care unit, picked up a cardiac nurse and responded to the emergency. Despite these drawbacks, the program quickly gained acceptance, and legislation enabling the fire fighter/paramedics to perform advanced life support services was sponsored by Senators Wedworth and Townsend.

Only a very limited number of radio frequencies were available, but as the program gained popularity and the number of units began to increase, the demand for frequencies became acute. Since no coordination was required for frequencies (no qualified agency could be refused) we formed the Los Angeles County Paramedic Radio-Telemetry Planning Committee. The committee’s purpose was to encourage agencies to cooperate in some logical plan for frequency allocation. Chief Simpson had the somewhat dubious honor of chairing the original committee and almost everyone did cooperate.

The television show “Emergency” did more to publicize the paramedic program than did any other single thing. Even today, questions are often asked about the program and the role the Los Angeles County Fire Department played in it. To answer the obvious, yes, fire fighters were used in the program but not in starring roles, and we did serve as technical advisors on every show.

After these series of events, the rest is history. The paramedic program is, in the opinion of many, the best thing to happen for the public and the fire service in many years.

Orange County units

Many benefitted from the early experiences of Los Angeles County— Orange County, Calif., for one. Orange County wisely watched, listened and learned. As a result, it has developed one of the most effective EMS systems in the nation.

Early in 1974, four paramedic units began servicing the citizens of Orange County, a sprawling urban area containing municipal fire departments in 26 cities and a county fire department that covers all remaining unincorporated land. Since then, the number has risen to 39, somewhat more than the county’s original master plan called for.

Just a word about the Orange County master plan. It was originated in 1974, revised in 1976, reviewed in 1979 and revised again in 1983. The plan was approved and adopted by the County Board of Supervisors, by every city in the county, and by every agency involved in any facet of EMS. The goal was and is to coordinate the efforts of all agencies, personnel and resources to provide efficient and effective mobile intensive care services and to do so without regard to jurisdictional boundaries.

The master plan identifies and addresses several objectives: to provide adequate numbers of trained personnel and paramedic units; to furnish sufficient supplies, equipment and facilities; to supply funding for training; and to maintain a complete voice and biomedical telemetry communications systems.

The stated and accepted policy is to deliver mobile intensive care to all citizens in Orange CountyIt is further agreed as policy that service will be provided in five minutes to 80 percent of the citizens and in six to ten minutes to the remaining 20 percent.

One paramedic unit is assigned for every (three miles response) 16 square miles and for every 64,000 people. Also, if any units approach 3600 runs per year, consideration will be given to adding another unit.

While the plan details the role of all involved agencies, what really makes it work is everyone’s cooperation.

Having benefitted from the Los Angeles County experience, Orange County developed a network second to none in the United States. With direction provided by three major bodies (the Emergency Medical Care Committee (EMCC), the Emergency Medical Services Agency (EMSA) and a subcommittee of the Orange County Fire Chiefs Association), a series of checks and balances was created to provide a wide variety of backgrounds and experience to guide the program to the high level of effectiveness it enjoys today.

Four “base station” hospitals strategically located throughout the county were initially selected to house the radio-telemetry equipment capable of handling two simultaneous calls at any time of day. Due to an increase in unit assignments and demands on the system, two additional base stations were added, one in 1975 and one in 1976. A central communications center for assignment of frequency and base station was established so that one agency controls all communications for the entire county, thereby eliminating the chance of interruption of radio transmissions at critical times. In addition to the base hospitals, there are 32 certified “receiving center” hospitals designated, based on their ability to meet strict criteria, one being their ability to staff an emergency room 24 hours a day every day with a complete medical staff.

In 1981, the county went a step further and, based on a demonstrated need, developed a system of “trauma centers” to handle those patients with injuries significant enough to warrant immediate surgical intervention by trained specialists. This concept has flourished and has already shown excellent results in patient viability.

Perhaps one of the most important factors in the success of the Orange County system is that all training of potential candidates takes place at one facility. The six-month, 1024-hour course is taught by a cadre of skilled nurses and doctors. The combination of teaching time and 480 hours of field internship with certified paramedics provides each candidate the opportunity to learn under controlled and actual experiences so that each is readv to return to service upon completion of and graduation from the course.

Side rear compartment converted for storage of drugs and solutions, etc.

Even with all the county-wide guidelines and controls, each fire service agency has individual operational policies to meet its own needs. Most agencies operate out of ambulance-style vans with two paramedics assigned to each, some departments choose to transport, others prefer to use private ambulance agreements.

The City of Anaheim, Calif., in Orange County, with a population of 228,000 and an additional 10-million tourists, chose to take a somewhat different approach to providing paramedical service.

The Anaheim Fire Department is charged with providing cost-effective emergency medical service to its residents. Fire fighter/paramedics serve 24-hour shifts and cover a 45-squaremile area. Prior to March 1981, the city utilized a three-paramedic van squad system. This system provided six trained fire fighter/paramedics (two per van) to serve one-third of the city and its population, or 15 square miles and 75,500 residents. The squads responded to some 8000 emergency calls annually.

A reorganization, which the Anaheim Fire Department effected in 1981, increased the number of paramedic units from three to five and placed the highly trained paramedic personnel back on engines. The change is well within the intent of the original paramedic concept, to utilize fire fighters in a dual role as both fire fighters and trained paramedics.

The new system provides 10 trained fire fighter/paramedics (two per engine) to serve one-fifth of the city and its population, or 9 square miles and 45,300 residents. City paramedics now respond to 9000 emergency calls each year. More specific benefits realized through this conversion include:

Improved service. By reducing the service area from 15 to 9 square miles, emergency call response times have been reduced to 3 to 5 minutes in 95 percent of all emergency calls. The Orange County paramedic master plan stipulates that 80 percent of emergency calls should be answered in not more than five minutes. Second and third due unit response times are reduced even more graphically, and paramedic teams arrive on emergency scenes sooner.

The new system uses five fire fighters on all paramedic engines, thus we are able to leave paramedics at the scene, if necessary, and still maintain a threeman fire fighting unit. This was made possible, in part, by the cooperation of Southland Ambulance Company, a privately owned ambulance organization which does medical transport for the city. The local ambulance service is playing a more important role in medical emergencies, responding Code 3 (red light and siren) with each call and working as part of the team assisting the paramedics. In the past, the ambulance crew waited until the patient was stabilized before being transported.

Rear compartments hold the bulk of the paramedical hardware: Life-Pak 5 monitor/defibrilator, Apcor telemetry radio, drug boxes and splint materials.

Cost effectiveness. The Anaheim Fire Department is budgeted for 65 people per platoon. However, the department utilizes a situational manning concept requiring a reduction of five people per platoon before calling for overtime personnel. By converting to paramedic engine companies, the department can use 61 people per day, cover all absences with overtime and phase 12 people out of the system by attrition. It has taken three years to phase these people out. At the end of the third year (fiscal year 1982/1983) the system showed a net salary savings of over $100,000 and still provided a better level of service.

No additional work force. The present fire fighter/paramedic work force is at full strength. The crosstraining and certification that is required is identified in the department’s annual budget. Trained personnel are more inclined to stay in this job position since promotions no longer result in trained personnel leaving for other fire fighter assignments.

Minimal changes. The new system has had little or no effect on our training, continuous education and recertification efforts. The additional units have not overloaded radio frequencies at peak periods.

Greater flexibility. The increase in the number of fire fighter/paramedic units allows the department more flexibility in responding to mutual aid requests; provides a better base for automatic aid (boundary drops); and increases flexibility in fire fighting operations. Residual or backup cover within the city has been enhanced. Emergency medical service is not materially affected by pulling a unit out for training.

Problem solver. The conversion to engine companies has assisted in the recruitment of fire fighter/paramedics; has reduced individual burnout; and has allowed recently promoted medics to retain their status and apply their expertise while serving as engineers or captains.

We are currently planning a sixth conversion of a pumper in the Disneyland/Convention Center complex to paramedic service. This extremely populous area has proven to be a prime location for medical aids as well as a potential fire problem due to the many high-rise office and hotel complexes.

Paramedic engine companies are only one of several accepted profiles for delivering EMS, and while it may not work in every community, it has worked most satisfactorily in our city.

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