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With permission from the Chief, Nagel began training firefighters in the use of defibrillators. After receiving a grant from the Florida Heart Association, he purchased one of the first portable defibrillators and began looking for a vehicle. Not a disease specific vehicle like the cardiac program in Belfast, because Miami needed a multi-purpose vehicle to cover all life-threatening emergencies, including trauma.

About the same time, Nagel consulted Camp Brooke, an Army post in San Antonio where most of the medics trained. The term Medic worked for Army personnel but it had too close a connotation to doctor to be applied to firemen in the field. However, by adopting the term of Para, which referred to the airborne contingent of the military, he came up with the useful word, Paramedic. Though the term was new, it would soon have universal application.

By 1969, the Miami fire rescue squads were going "full-bore". The department had quickly expanded to three trucks and Nagel then asked the chief to authorize the paramedics to administer IVs. The chief was skeptical. First defibrillators and now this! One must remember that all of these advances were startling to fire department administrators. They had a certain profile in the community and didn't want that image to be tarnished, so it was a courageous act on the part of Fire Department chiefs across the country to agree to merge medical applications with fire and rescue. Nagel recalled, "I let a paramedic start an IV in me, lying on the table in front of the city commissioners at a public meeting. There were a lot of people in the audience, including the chief. I told the commissioners that these men had been well trained, and that I had as much confidence in them as I did in most of the people at the hospital, and they accepted it." Once the struggle for intravenous lines had been won, Nagel convinced the chief to allow medications and, with a little more difficulty, intubation.

There was a prolific exchange of information among those physicians interested in pre-hospital cardiac-care programs, says Nagel. "We were talking to Grace and Cobb. It was like a small town - everything they did, we knew. It was a very close community."

In Los Angeles, California, Dr. J. Michael Criley, head of the Cardiology Division at Harbor General Hospital, had also been aware of Pantridge's pioneering efforts at the Royal Victoria. "I don't remember where I first heard of Pantridge, but his work was the buzz around the cardiologists and the American Heart Association." As Criley began to study Pantridge's system he, as had Nagel in Miami, felt that trying to apply the concept of one doctor, one vehicle to the extensive geography of Los Angeles would prove impossible.

Walter Graf, cardiologist at Daniel Freeman Hospital, was another strong proponent of a mobile care unit for Los Angeles. With grant funds provided by the local chapter of the American Heart Association, of which he was President, he launched a Mobile Coronary Care Unit based on the Pantridge model in 1969 - a fully equipped vehicle staffed by nurses who were empowered to start intravenous infusions, administer drugs, and defibrillate. Criley watched Graf's plan from the sidelines and was forthcoming with opinions, "This is nuts. How are you going to cover anything more than a few square miles with one ambulance, and where are you going to get the personnel to staff it?"

Criley knew he would have to re-vamp Pantridge's initial idea in order to create a successful mobile care unit to function throughout the vast expanse of Los Angeles County without adding another independent service or layer of personnel to staff it. The fire departments were already geared to respond to a variety of non-fire related emergencies with their fire rescue systems. The Los Angeles County Fire Department responded to medical emergencies with conventional vehicles and portable rescue equipment, while Los Angeles City provided ambulances that could transport victims to the hospital. Over 70 separate incorporated cities coexisted within the County, some with their own fire departments, while others were covered by the L.A. County Fire Department.

Criley turned first to the County because they provided rescue services to the largest area of the county.

The Los Angeles County Fire Department offered six firemen for the first class of paramedics in the summer of 1969. The City Department would later offer six to the second class of twelve trainees. Criley and the first class of L.A. County Paramedics had their initial mobile unit operating by December, 1969. It was a station wagon commandeered from the Forestry Service, with "Rescue Heart Unit" lettered on its side. However, a nurse was still needed on-board, and paramedic authority in the field was still a bone of contention.

The Wedworth-Townsend Paramedic Act was drafted to allow paramedics to operate in the field, without a nurse on board. In the summer of 1970, the Bill was introduced into the California Legislature. The fight in California (later to be mirrored in many other states) was difficult, as medical special-interest groups, including proponents of private ambulance service, were exerting enormous pressure to kill the bill. Walter Graf proved helpful. He leaned on his friend and patient, Kenneth Hahn, for support. Hahn happened to be Chairman of the Los Angeles County Board of Supervisors, and wielded political power that would later be of great benefit to California's paramedic program.

"It was June or July of 1970," recalled Criley. "Several of us had made repeated trips to Sacramento to lobby various legislators. And we were just getting a blank stare. So Kenneth Hahn went directly to Governor Ronald Reagan. Right into his office. He lobbied Reagan into getting it passed." In July of 1970, the Los Angeles paramedics were 'cut loose' and began functioning without the presence of a nurse. As with the paramedics in Miami, medical supervision was at the other end of the radio.

But added to the problems of covering such a wide swath of area with one unit, there was also developing a rivalry between private ambulance services and the County Fire Department. According to Criley, "After we successfully launched our program, there were problems of jurisdictional boundaries, for one thing. Someone having a heart attack on the west side of Normandie Avenue could not be treated by County Paramedics, but if the victim could just stagger across the street, he was within their operating zone. It turned into a nightmare."

Paramedics were beginning to be recognized for a distinct esprit de corps. Criley related the following anecdote: "In '71, we had the Sylmar earthquake and several hospitals were reduced to rubble. So we dispatched what paramedics we had out to the scene. Later, one of our more skeptical administrators arrived on the scene. He steps out of a helicopter and sees all of these guys with white coats and stethoscopes in their pockets. And they're pulling these victims out of the rubble, getting EKGs, starting IVs, taking blood pressure, while many of their victims were still trapped. So this official stares at all these men in white coats and asks, 'Where did these residents and interns come from?' He was told 'Those are not residents and interns. Those are the residents and interns, standing over there out of trouble.' Pointing again to the white coats, he said, 'Well, what are they?' And the answer was 'They are paramedics.' Well, the man was incensed. 'They are impersonating doctors. They have white coats. They have stethoscopes in their pockets. This has got to stop.'" Criley laughs at the memory.

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