Do We Need Paramedics On Fire Engines?

Twilley, 71, was in cardiac arrest.
He was lucky. He was one of an estimated 165 Americans who collapse each day in the most saveable form of sudden cardiac arrest — most saveable because it can be reversed by a shock from a defibrillator, and because it happens in public, where bystanders can summon emergency help.

Twilley was saved, but not by paramedics. He was saved by Conway's cardiopulmonary resuscitation and by firefighters who arrived before the paramedics and shocked his heart back to normal.

There was no paramedic on the fire engine. In fact, there are no paramedics in the Jenks Fire Department at all, and no plans to hire any. At a time when more cities are trying to put a paramedic on every fire engine — often the first vehicle to reach a medical emergency — Tulsa, which provides emergency medical services to Jenks, is limiting the number of its paramedics.
Yet Tulsa's emergency medical system is considered one of the nation's best as measured by the EMS "gold standard," the survival rate of its saveable cardiac arrests. Tulsa's survival rate is 26%. The national average is an estimated 6% to 10%.
The city's EMS philosophy — and Twilley's story — illustrate the findings of a USA TODAY study of emergency medical data from 12 of the nation's biggest cities that suggest that victims of cardiac arrest are more likely to be revived in cities that spend fewer taxpayer dollars on paramedics. (Related: Six minutes to live or die)
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.
Fewer paramedics

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."
Twilley's case in Jenks is a perfect example: While a waitress at the diner dialed 911, Conway dropped to his knees and began CPR.
The firefighters arrived, applied their AEDs and shocked Twilley once, five minutes after the 911 call was made. He was waking up when the paramedics arrived four minutes after that. He was asking for his cap before they wheeled him out.
In Boston, the focus is on giving paramedics more opportunities to practice both their technical and clinical judgment skills. "We don't believe in sending our paramedics on every call," says Boston EMS chief Rich Serino. "We want to have highly trained paramedics who utilize their skills often so there is minimal skill deterioration."

In Tulsa, Emergency Medical Services Authority (EMSA) medical director John Sacra was instrumental in persuading Tulsa officials to keep a smaller, more skilled and more supervised corps of paramedics.

"The more paramedics you put into the system, the more medics that are doing fewer procedures," Sacra says. "It's a problem."

Tulsa stands on the opposite side of this great theoretical divide from Oklahoma City, which is increasing its paramedics corps.

The two cities, 100 miles apart, save about the same percentage of cardiac arrest victims — 26% in Tulsa and 27% in Oklahoma City. But their fire departments have different views on how many paramedics they need.
In Tulsa, each resident spends $3.29 per year in taxes for 128 paramedics. In Oklahoma City, residents each pay $11.40 for 226 paramedics.
In Tulsa, five of 30 fire engines have paramedics. In Oklahoma City, almost half of its fire engines have paramedics — 17 of 35.
More paramedics

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.
Robert Dahlquist, Omaha's fire chief, says paramedics are the best way to provide emergency medical services to his community. "I'd like to have more paramedics," he says.
James Love, Omaha's assistant fire chief, says 42% of the EMS calls require advanced life support. "This is the reason that we staff the paramedic coverage that we do. We continue to strive for 100% paramedic engine coverage," Love says.
Los Angeles is an anomaly because it has both a low survival rate — 6% — and a low paramedic ratio per 10,000 population at 1.55.
But in raw numbers it has the most paramedics of any city studied, boosting its paramedic force from 594 to 730 in the past year. "We have so many calls and so many sick patients," says Marc Eckstein, the city fire department's medical director. "I live in the city. I want a paramedic at my neighborhood fire station."

But Eckstein acknowledges he can't keep track of all his paramedics and their skill levels.
"If you have 500 paramedics spread out over 500 square miles going to 60-some-odd receiving hospitals, it is clearly impossible to get a handle on how well the medics are performing," he says.

Corey Slovis, Nashville's EMS medical director, who oversees 196 paramedics, agrees. "If you have 50 or 60 paramedics, you are able to tell which ones are great, which ones are mediocre and which ones need to come in and get checked out," he says.
"Between 80 and 100, you can't keep track of them all."
What's next?

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.

"Fire departments have been (adding more paramedics) because they think it's going to make a positive difference," says John Sinclair, a fire chief and former paramedic who heads the EMS section at the International Association of Fire Chiefs. "Maybe we do have a problem. It's not really counterintuitive if you look at it. The more medics, the fewer that are taking care of really sick people."

U.S. Surgeon General Richard Carmona, a former paramedic and EMS medical director, says cities must look at their paramedic deployment and ask, "What did a paramedic add to this call to reduce pain or morbidity?"

"It's not a matter of right or wrong, but how can we do this better?" he says. "Fire chiefs and police chiefs and EMS directors should always say, 'Show me the science. Show me how this will benefit my citizens.' The idea is to do better with meager resources."
For 25 years, Slovis says, he has believed that having a paramedic on every fire engine was the best way to save more lives.

"Now I realize that the best systems may be the ones with the limited number of paramedics who are elite — highly trained," he says. "I have completely changed."