Can’t swing a dead cat…

USA today had an article dated May 21, 2006 on paramedics, well, too many paramedics… A new study found that survival rates for out-of-hospital cardiac arrest were higher in cities with fewer paramedics per capita. This mirrors USA Today’s findings, first published in their special report, “Six Minutes to Live or Die,” in 2003, that called into question the national trend of putting firefighter-paramedics on fire companies.

The reason, at least the one stated publicly, that fire apparatus are carrying paramedics is to decrease the response time for paramedics in medical emergencies. Fire stations are everywhere, and it’s extremely impressive on paper to have ALS capabilities in less than 4 minutes on every medical call. In cardiac arrests, especially ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), it is absolutely essential to have a defibrillator on scene within 4-6 minutes for the patient to have any chance of meaningful survival with limited disability.

However, the majority of 911 calls for medical assistance are not cardiac arrests; instead they are for such minor medical problems as cut fingers, ‘flu-like symptoms, homeless alcoholics, baby spitting up, etc. This is not to discount such requests, but certainly an ALS engine response and an ALS ambulance response is a bit of a waste of resources, like arresting, without evidence, a teenager who wasn’t driving for a hit-and-run that no one saw. In tiered systems, calls deemed to be not life-threatening are handled by BLS units, simply because there is no need for ALS personnel who can be better used on more serious calls. In other words, save the paramedics for the good stuff. Paramedics would be thrilled to be able to avoid calls that any taxi can take care of.

Now, some have suggested that the use of paramedics on fire apparatus is motivated by self-interest. Fire departments have – along with powerful unions and excellent public relations machinery – big budgets. But years of public education, prevention and enforcement, coupled with modern construction techniques and strict building safety codes, have so dramatically reduced the number of fires that fire departments don’t have much to do these days. Simply put, in order to justify their budgets, they respond to medical calls to bump up their call volume, which, for the reasons stated above, isn’t necessarily a bad thing, especially in VF/VT arrests. Fully 70-80% of a typical fire department’s responses are for medical assistance, and the other 20-30% are not all for working fires.

The other problem with ALS fire apparatus is more subtle and wasn’t easily envisioned before it actually happened. In some regions, a paramedic license increases enormously one’s chance of getting through the ultra-competitive firefighter recruitment process, so some of these paramedics may not have the right motivation to begin with. Also, many  firefighters are firefighters because they want to respond to fires, not medicals. As a result, some firefighters view medicals as something they’re forced to do by their management, and we all know what happens when you have to do something you don’t want do. This is a source of tension between ambulance crews and ALS fire crews. (I personally don’t care as long as everyone’s nice to each other.) Add to this the longstanding fact that EMS is extremely trying on your patience most of the time anyway, and sometimes quality goes straight out the window.

Back to cardiac arrests and having so many paramedics that you can’t swing a dead cat without hitting one on medicals… The defibrillator needs to be available within 4-6 minutes of the onset of cardiac arrest, but it doesn’t have to come with a paramedic. So why not have BLS fire apparatus (and their very short response times) equipped with defibrillators respond to cardiac arrests, followed by an ALS ambulance? As it turns out, the EMS systems with the best survival rates do exactly this, and they have been doing it way before these specials and studies were produced.

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