The integrated chain of survival - paramedic care in the US

The following article appeared in the May, 2000,  issue of Fire International.
© 2000 writer-tech.com

In the US, the role of paramedics and first responders increasingly involves hospital levels of care en route to emergency departments. ED COMEAU looks at the implications of providing this level of service

Within the United States, the delivery of emergency medicine has changed dramatically over the years. Initially, it was often a service that simply picked up injured people and brought them to the local hospital without any specialised treatment. Today, the emergency medical response system has evolved into one where care and intervention begins from the moment a dispatcher receives a call until the patient is delivered to the hospital.

Dr Conway, the director of emergency services since 1982 for Cooley Dickinson Hospital in Northampton, Massachusetts, calls it the "integrated chain of survival." In a number of communities, the person taking the 911 call is trained to advise the caller how to provide emergency, life-saving actions until the arrival of the responders. The dispatcher can talk the person through the incident and give pre-arrival instructions.

Technology has given the basic first responder, a part of this chain of survival, the ability to save lives through innovations such as semi-automatic defibrillation. Lives can be saved by the use of equipment previously reserved only for use in a hospital emergency room, and then more definitive treatment is provided as the paramedics arrive on the scene to continue the care.

The value of being able to deliver a higher level of pre-hospital care to the patient is hard to quantify. According to Deputy Chief Russ Bovee, head of the emergency medical services division for the Phoenix Fire Department, "How do you prove a negative? How can you prove that someone didn't die because of our ability to bring the hospital to the patient?" While he cannot quantify it, he feels strongly that his department's advanced life support capabilities have indeed made the difference.

Chief Bovee was one of the initial 12 paramedics when Phoenix first started its paramedic service. "The difference is between day and night. We bring the hospital into the street. We're able to deliver fluids, pacing, cardio-conversion, and defibrillation. We're able to bring them back," he adds.

While it may be hard to quantify how many lives are saved by paramedic intervention, it is possible to identify how the level of paramedic response is a major part of the Phoenix Fire Department's operations. In 1999, out of almost 125,000 calls, 78 per cent were medical responses. The department's 50 paramedic units responded to 47,325 advanced life support (ALS) calls, which is 38 per cent of the total.

None of this comes cheap, however. According to Dr Conway, a paramedic must complete 1,500 hours of training beyond that of the basic EMT. In Phoenix, future paramedics undergo 29 weeks of full time training. Out of the 1,207 members of the department, a third are now paramedic, while the remaining are trained to EMT-II level.

Nationwide, this growth is indicated by the number of certified paramedics. According to the National Registry of Emergency Medical Technicians, in 1986 there were 37,000 registered paramedics. In 1999, this number had grown to over 122,000.

Phoenix is a major city, with a number of hospitals and trauma centres within a reasonable distance. What role does paramedic service play in the more rural areas?

Communities that are remotely located from hospitals can realise the value of having a high level of medical care brought directly to the patient. In years past, a seriously injured patient was stabilised with, by some of today's medical standards, minimal medical treatment and then packaged and transported to the hospital. CPR would be done on patients in full arrest while being transported as quickly as possible over long distances.

Today, when an ALS unit arrives on the scene to a patient in cardiac arrest, it can now provide a secure airway through intubation, provide fluids, drugs, and defibrillate. It may be possible to 'bring the patient back' before beginning a long transport to the hospital.

This capability also streamlines the operation in the hospital. "If the paramedic starts an IV in the field, it is one less thing the nurse has to do in a busy emergency room," says Dr Conway. In addition, the ratio of care givers to patient is of a benefit, he continues. In this case, there are two EMTs or paramedics per patient, compared to a hospital where it can be six patients to a nurse.

Advanced life support extends to the air, too. The National Flight Paramedic Association estimates that there are 1,400 flight paramedics in the United States. In areas where a ground-based paramedic service may not be available, by using air-medicine helicopters ALS can be brought quickly to rural communities, and the patient can receive aggressive treatment and rapid transportation back to a hospital. Medical helicopters also provide the ability to transport patients to specialised facilities, such as burn units, very rapidly. 

Whatever term it may go by - paramedic service, advanced life support, pre-hospital care - it all comes down to the same thing: the ability to save lives by providing care in the first critical moments, which often do make the difference between life and death.

Ed Comeau is the principal writer for writer-tech.com, a technical writing firm. He is the former chief fire investigator for the National Fire Protection Association, an emergency medical technician with the Amherst Fire Department and a fire protection engineer with the Phoenix Fire Department.