Continued from Page 1

Dr. Leonard Cobb recognized that the city of Belfast and the city of Seattle had many things in common, among them a relatively central disbursement of citizens with one hospital radiating out to them in many diverse directions. He felt that Pantridge's program might be worked out with a little different angle and perhaps address emergencies of a more diverse nature. A key meeting with Fire Chief Gordon Vickery revealed that the Fire Department already had some emergency vehicles. They called them 'aid cars'. It was decided to evolve an 'add-on program'. The Fire Department was used to responding and they had the personnel that could do basic life support. "So we decided to avoid a situation where patients call a doctor - they would just call the Fire Department and we'd send out an emergency vehicle." Cobb had two goals: "One of them was to actually see if we could save lives, and the second was to learn about the some of the features of sudden death."

In 1968, Cobb submitted his proposal for pre-hospital cardiac care in Seattle and received a grant for a trial program. "We paid for all the salaries. We bought the rig. We had only one rig for the city. And we paid for the fireman. There were ten. And we gave very rudimentary training. We didn't know what they could do if they were trained."

The concept was to provide a tiered response in which first responders would continue to be standard first-aid providers. For a full year, a doctor would ride on every run. "It turns out that was the substance of the program. They started out and the doctors did just about everything. That led us to the notion that a training program has to be about 75% hands-on experience."

Again, not that dissimilar from Belfast, with the exception that a collaboration was formed between the Hospital and the Fire Department and it was precisely this effort that influenced similar collaborations across the country. Cobb and Chief Vickery now wondered what to call their new unit. "We started pondering acronyms like 'MCCU'.", Vickery said. "Well, in our engine companies we all have number designations - like Engine Company 34 and so on - so why don't we call this one Medic I?" On March 7th, 1970, Seattle's "Medic One" had its first response.

As Cobb points out, the mobile unit was not the real innovation - the real innovation was the concept of a 'tiered response' to medical emergencies. The idea was that " we would get someone out there quickly" - via the fire department's already-existing mobile first aid units - "and then a secondary response would come from the mobile intensive coronary care unit." This system allowed aid to reach the scene quickly, on an average of three minutes, to start CPR. A few minutes later paramedics arrived to provide more definitive care, such as defibrillation. In this way the brain could be kept alive until the electric shock converted the heart to normal rhythm. After the patient was stabilized, the paramedics would transport the patient to the hospital.

"When we started this program, you had to dial seven digits on the telephone to reach the fire department. And then very shortly thereafter, 911 came into being. A single emergency number. That had a major impact. It's a very reassuring thing - to pick up a phone and dial 911 and in a matter of minutes, know that someone is going to be there."

The biggest issue in this new century continues Cobb, "as far as resuscitation is concerned, is the possibility of brain damage. It ought to be prevented. It is preventable…that is one thing I want to see happen."

The Seattle paramedic program was also the first program in the world to make citizens an active part of the emergency room. Cobb remembers, "The Chief and I were sitting out in back of the hospital, and he said if you think CPR is that important and effective, why does it have to be just a fireman? Why not train the general public? And so we started up a program and it was the Chief's instigation. The goal was to train 100,000 citizens when and how to initiate CPR. It's now a three-hour session, and 700,000 people have gone through the program."

Fortunately, the Seattle program is closely tied to the University of Washington, so that case histories have been steadily monitored over the years. The information gained from this follow-up procedure has greatly increased the knowledge needed to further combat heart disease and the onslaught of sudden death. Modern technology has brought some sophistication to the field. Instruments now employ micro-processors. It's much easier to take an EKG in the field. Data management is better because of computers. But most of the duties that EMS performs in the field are not so high tech. With technology, oftentimes, you use it because it's there. No matter what the tool or how expert the care, the time before arrival often spells the difference between life and sudden death. "The biggest delay in medical care," says Cobb, "comes from the patient. Often, when you look at a patient's delay in getting to the hospital for a heart attack, it's the patient. The single biggest delay and the one most difficult to minimize is patient reluctance to call."

The Seattle program is the envy of many across the country. It has an excellent Bystander CPR Program, a foundation that aids in its funding, and a University that supports its research. But there is still the steady growth of population and the proliferation of transportation problems common to most large cities in the country. Still Cobb remains optimistic and committed.

"I think we were all hangers-on after Pantridge. He was seminal. It's a lot different than what Pantridge envisioned. His was a mobile coronary care unit. Nonetheless, his was the first organized effort for bringing hospital-type care outside the walls of the hospital. And it evolved in the US with a much broader emphasis on other types of illness and injuries."

"During the 60's", wrote Dr. Eugene Nagel, "a series of epic events helped form EMS as we know it today. First and foremost was the discovery of CPR by Dr, James Jude and two of his engineering coworkers at Johns Hopkins. Of nearly equal importance were the efforts of Peter Safar and other physicians whose names were linked to mouth-to-mouth breathing and the introduction of direct-current defibrillation by Dr. Paul Zoll."

On a parallel course, in 1962, Dr. Nagel, a second year resident at New York's Columbia-Presbyterian hospital, began studying information relating to a new technique in the medical field, called Cardiovascular Pulmonary Resuscitation (CPR). Later that year Dr. Nagel had taken a position at Jackson Memorial Hospital in Miami, Florida and had become a local expert on the subject. A few months later, Dr. James Jude became Chief of Cardiovascular Surgery at Jackson and the two bonded in their efforts to organize a CPR program in Miami. Shortly thereafter, Nagel visited Fire Station No. 1 and introduced himself.

The Captain seemed interested in Nagel's proposal to teach CPR. Several men had years of experience at doing rescues, but no recent training. According to Nagel, "They were like eager sponges, willing to learn anything that made sense to them. They knew as much as I did about the art of CPR, but there were facets of resuscitation management, the airway particularly, that they were a bit foggy on." Although the fire department routinely initiated CPR in the field before transporting the patients to the hospital, Lieutenant McCullough said, "They all die." This was when Nagel realized that if they were to save many lives in the street, there had to be more than CPR. There had to be IV drugs and defibrillators, just like the doctors utilized inside the hospital.

Nagel was aware of Pantridge's work. However Nagel became convinced that it was time to move away from a doctor-staffed set-up, and to treat more than just cardiac patients. Rather than a doctor-staffed unit, he and his associate, Dr. Jim Hirschman, utilized telemetry in voice radio to permit medical treatment to be performed by paramedics in the field. Refined in the space program, telemetry allowed mission control in Houston to monitor each astronaut's heart rate. "The fact that I, or a doctor like me, could be on the radio and give specific verbal orders to a fireman to perform a specific maneuver he'd been trained to do - well, that seemed OK to the medical school and the fire chief."

© 1999-2005 Project 51 & CLAFMA
Site originally designed by Stacey L. Howe
Webmistress and tweaker is Desire' Gonzales