Paramedics not always the saviors of cardiac-arrest patients
Wednesday, March 2nd, 2005 at 4:35 pm
So maybe the old axiom "EMT's save Medics" is true… Or even First Responders… Or even firefighters… 
Cities with the highest survival rates, the data suggest, train firefighters and citizens to respond first with defibrillators and CPR, sending in a smaller, closely supervised corps of paramedics minutes later to give advanced care.
This is the great divide in emergency medicine. Should a paramedic be on every fire truck, even though most of the calls are not matters of life or death? Or should paramedics be a smaller, more skilled corps that arrives to take over a few minutes after firefighters who just have basic emergency medical training?
Most cities opt for more paramedics, despite the expense and evidence that the approach does not necessarily save more lives.
Of the cities studied by USA TODAY, Seattle saves more cardiac arrest patients - 45% - with 1.48 paramedics per 10,000 residents. Boston has the second-highest survival rate - 40% - and the lowest paramedics ratio at 0.86.
Many of the other cities have substantially lower survival rates and markedly higher numbers of paramedics per 10,000 population. Nashville, for example, has an 8% survival rate with a 3.33 paramedics ratio. Omaha has the highest ratio at 4.70 with a 16% survival rate.
…Seattle, Boston and Tulsa represent cities with fewer paramedics. They believe that a paramedic who rides a fire engine to every call doesn't get enough practice providing skilled care because so few calls are real medical emergencies.
So firefighters in these cities are trained in rapid response and basic medical care. They save many victims of cardiac arrest with a shock from an automated external defibrillator (AED).
Paramedics, rescuers with more training, experience and medical oversight, typically arrive in an ambulance minutes later. They provide advanced life support - administering drugs through IVs and inserting a breathing tube - to stabilize patients before transporting them to the hospital.
These cities put a premium on having no more paramedics than their medical director can closely monitor. "We have a small group of people who are highly experienced and trained, who work only in their specialty," says William Hepburn, assistant Seattle fire chief.
Seattle also teaches its citizens CPR. "Most people equate EMS with paramedics," Hepburn says. "EMS should be an integrated system of trained citizens, first responders, paramedics and hospitals. Quick and effective CPR first saves lives."
…Omaha and Nashville represent cities with more paramedics. Their philosophy: Fire engines are almost always first on the scene of an emergency, and a paramedic on the engine means the most trained rescuer arrives first.
So they continue to hire, train and employ more paramedics to ride on fire engines.
Nashville fire officials put paramedics on seven of the department's 39 fire engines, and reduced the time it takes for a paramedic to reach a victim by 21% to 25%.
There have been no scientific studies showing that this approach saves more lives. But it consistently appears to be what the public and most politicians want.
"In my experience, response times, response times, response times are of greatest concerns to those we serve," says Stephen Halford, Nashville's fire chief.
…After considering the USA TODAY findings, a number of fire and EMS officials say that a national, scientific study should be undertaken to determine how paramedics should be deployed in big cities.
Brilliant idea! Using Evidenced-Based Practices in medicine, rather than "that's the way we've always done it," or "that's how I think it should work, but I don't have any evidence to back up my assertions." Now who's going to pay for this national, scientific study?
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sonja Says:
And anaphylaxis? Epi-pens are a BLS skill (well, actually, a citizen bystander/self-skill), which would generally mitigate the symptoms enough until the medic ambulance gets there a few minutes later.
It’s true- in my fifteen years as a paramedic I never saved a code where someone wasn’t doing good CPR when I arrived.
My department has assigned paramedics to engine companies to create ALS First Responder Apparatus resulting in a phenomenon I call the “EMS Box Alarm”- the closest engine, the closest AFRA, the closest ambulance and the closest ALS unit- four units and ten people for one chest pain patient and the AFRA usually arrives no more than a minute or two before the medic unit. This wastes money and resources with no appreciable benefit to the patient.
Seems like a waste to me… Chest Pain requires two people - a medic and a driver, not 10. If the pt is having an MI, what’s a medic on an engine going to do? You need transport to a cath lab, and only an ambulance can provide that, not fire trucks. (Despite what Johnny and Roy did…)
Where I am we have 7 FD’s run first-reponse BLS for my ambulance corps (well actually 5 - 2 gave up, since we beat them to the scene every time.) We also end up with way too many people on-scene. I can see extra manpower/first reponse on a 1-E Cardiac Arrest or Ineffective Breathing, but to send them to every 1-C Chest Pain or Abdominal Pain, or to health facilities with RN’s/MD’s present just seems silly to me.