I ; I l_} ADVANCED LIFE SUPPORT
Keynote Address by James o. Page, J.D. , Executive Director , ACT Foundation, prepared for presentation to the Texas Emergency Medical Services Symposium, Austin, Texas on March 18, 1977.
Just to make certain that we are all on the same wave length,
I would like to commence by defining " advanced life support. "
According to the new Model State EMS Statute , advanced life
support is a sophisticated level of pre- hospital and inter
hospital emergency care which includes all basic life support
functions (including cardiopulmonary resuscitation (CPR), plus
cardiac monitoring , cardiac defibrillation , telemetered electro
cardiography , administrat ion of antiarrythmic agents , intravenous
therapy, administration of specific medications , drugs and
solutions, use of adjunctive ventilation devices , trauma care
and other authorized techniques and procedures.
The most significant words in that definition are pre- hospital
and interhospital . Virtually every one of the functions described
are long-standing procedures in in-hospital settings . But it is
only in the last decade that we have seen such sophisticated
procedures taken outside the hospital and onto the streets .
The concept of pre- hospital advanced life support is credited
in large part to the pioneering efforts of Dr . J . Frank Pantridge ,
a cardiologist in Belfast, Northern Ireland . And it got a big
boost by the success of crisis medicine on the battlefields
of Viet Nam .
I was with Dr. Pantridge in Las Vegas a couple of weeks ago .
And he had just been interviewed by a newspaper reporter. The
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reporter asked, " Dr. Pantridge, why did you devise your
system of "flying squads" in Belfast? He replied, "It's (
not unlike Willie Sutton's law. When asked why he robbed
banks, Mr . Sutton replied, 'Because that's where the money is. '
We took emergency coronary care to the streets because that's
where people were dying. "
Pantridge , then and now , uses a team of specialists, including
medical residents, to respond from the hospital to the scene
of the reported heart attack . And the first American version
of the concept , at New York City ' s St. Vincent ' s Hospital,
likewise used medical professionals. But it wasn ' t long
before someone figured that a more flexible, more available,
and less expensive approach was I
possible in the U.S.
Thus , ten years ago , in Miami, Dr . Eugene Nagel sponsored
a small group of specially-trained firefighters to take pre
hospital coronary care to the streets of that city. But the
new breed was not to be totall y unleashed. Dr. Nagel had
also designed some electronics gear which would allow him to
monitor the patient and the paramedics from his distant post
at a hospital.
Close on the heels of Miami were programs in Jacksonville,
Seattle , Columbus and Los Angeles . But it was a television
program that gave credibility to the domino theory in emergency
medical services. In May, 1971, while working as a fire officer
in Los Angeles, I was contacted by a representative of TV
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producer Jack Webb. They had some vague thoughts about a new
show involving rescue . We quickly put them in touch with our
paramedic program and the rest is history.
At the time, it was an incredibly exciting adventure . We
knew that our paramedic program was working well - saving lives
too young to die . But we hadn't been able to attract much
attention to it , even in our own community . For several
months while the world premier of " Emergency " was in the
making , we salivated at the opportunity to show our system
to the nation - in prime time .
In the meantime, however , we have been given cause to worry .
In Los Angeles , for example , the television depictions suddenly
raised the interest of elected political officials. Planned
development of a comprehensive emergency medical services
system went out the window as the politicians demanded more
and more paramedics in their districts . The training staff
was badly strained by the task of keeping up with demand .
Training facilities were doubled overnight and for three years
two new paramedic units were unveiled every five weeks .
During this time , the basics were overlooked . Paramedics
were springing into the community without a foundation of basic
l ife suppor t services. The proposal for a continuing education
program grew a coat of dust as political demands continued to
"get a paramedic unit in my district ."
Haste makes waste . And it also can make a badly faulted emergency
care system. I visited my old home town within the last month
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and I am quite distressed with what I found . Fresh from
that experience, my comments to you will reflect the avoid
able mistakes that have been made in Los Angeles and e l se
where.
The first major issue is that of basic life support . It is
absolutely necessary as a foundation for any effort at ad
vanced life support. The system of basic life support
should involve all public safety personnel, all so-called
"first-responders," and even the general public.
The TV show has probably raised public expectations to an
unreasonable level. And it has made a lot of rescue, ambu
lance , and public safety people somewhat embarrassed to
admit that they are only an EMT. Well, public expectations
be damned. Basic life support is where its at!
At last November ' s meeting of the American Heart Association,
Dr . Donald Copley of Birmingham reported that almost anything
done later is a waste of time if a heart attack victim has
not received early CPR. He made his statement on the basis
of a study of patients who showed "dramatic differences" be
tween those who got early CPR and those who did not. Yet, there
are locations in America where paramedics operate without the
support of CPR-trained police officers , firefighters, ambul ance
personnel, or members of the general public . In too many cases ,
almost anything those paramedics do is a waste of time.
The March, 1967 issue of American Cities magazine contained
a startling statistic . It reported that as many as 25 , 000
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Americans are either crippled or left permanently disabled
as a result of the efforts of untrained or poorly trained
ambul ance personnel. What that means, folks , is mismanagemen t
of fractured limbs . What that means is cervical spinal injur-
ies turned into paraplegia and quadraplegia - the most devas
tating of disabilities . Yet , in many areas of this country ,
ten years later, there are still rescue and ambulance person
nel who lack training in spinal injury management . There are
sti ll people - functioning in the name of public service - who
pull and yank , jerk and run to the hospital .
An EMT has nothing to be embarrassed about . They are the
underpinnings of any system that is truly a system. But , as
pioneers in this national effort to improve emergency medical
care , EMTs have a responsibility to make sur e that that
designation is a whole lot more than just a shoulder patch .
Given what I have seen on my many trips to and through Texas ,
this is a very rural state. And there may be some question
in your mind as t o whet her you can develop a good basic life
support system in your area , muc h less an advance life
support system .
You may be rural , but you ' re not the most rural. And I would
point to Kansas , Minnesot a and North Carolina as examples of
what can be done under t he most difficul t circumstances . In
Kansas , the Women ' s Division of the Kansas Farm Bureau has
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taken on a big task for 1977 . They have sponsored a CPR
training program that is expected to put a CPR-trained person
in every farm family during this year . That ' s an ambitious
project but those farm ladies seem to mean business!
There is a little farm town of 1100 people in Minnesota.
In one weekend , they trained 360 of their citizens in CPR .
And their volunteer ambulance service is 100% certified as
EMTs. They have radio communications with the hospital to
which they transport patients. And the hospital staff is
tuned in to EMS - providing the volunteers with abundant
training opportunities and an atmosphere as part of the
family .
In North Carolina , in 1973 , ambulance service was the trea
sured bastion of several hundred good ol ' boys who had
turned volunteerism into a well-oiled country political
machine. But with a healthy infusion of State money, and a
unique opportunity to recruit from all over the country in
building a State EMS staff, the whole scene was turned into
turmoil . The turmoil cost me my job as State EMS Director.
It also cost my former boss an opportunity to spend four
years in the Governor's office. But more important , it
made basic life support a reality in North Carolina.
We developed a tough training program with a tough exam,
administered under the tightest security. 12 , 000 EMTs were
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trained in 30 months. We got the support of the doctors
and nurses . We made EMS communications something more than
citizens band . And we did it in a state where 60 % of the
population lives on farms.
Among the achievements in North Carolina was the passage of
a comprehensive EMS law . And that law provides for the devel
opment of advanced life support services . But not without an
underlying foundation of basic life support.
The turmoil in North Carolina generated a lot of press
coverage . And the complaints of a few led the p ublic to be
lieve that an EMT certificate was an almost unachievable
goal. Thus, when the volunteers had final l y made it , they
were looked on by their fellow citizens with more respect
than that given the town lawyer. And the new EMTs began to
clamor for more. Some were heard to say , "We wanna be para
medics like them there felle r s on "Mergency ."
That goal wasn ' t practical in many areas of the state . But
t here was a need for something more than the traditional
approach to basic l ife support . So we went to the Board of
Medical Ex aminers with a proposal . We sought permission to
develop t he EMT- I . V. - a mid- level technician , well- versed
in basic life support but trained to start and maintain IVs
while in communication with a hospital .
The proposal called for an additional 21 hour training pro-
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gram beyond the basic EMT level . The Board of Medical Exam
iners bought it and by the end of this year , 72% of the
citizens of North Carolina will be served by these new
mid-level EMTs .
An important element in the EMT- 1.V. program was that the
EMS staff sought and got legal authorization before implement
ing the program. And the legal authorization provided arma
ment to exclude the " cowboys" and "hotdogs " who would aspire
to this level without first completing the very important
basics.
In a few areas of North Carolina , advanced life support has
become a reality. And some of those areas are very rural and
remote . Without exception , these programs have had the support ,
backing and active leadership of a medical doctor .
Whether rural or urban , advanced life support is a medical pro
gram . Being a medical program, advanced life support must have
medical direction . Not just in name. Not just a committee of
physicians giving lip service to the program. But a tiger of
a doctor who truly believes in the program, is willing to fight
for it , is eager to lay his reputation and license on the line
for it, and who isstrong enough to fight off political compromises .
Lack of strong medical control is the major weakness that I re
cently detected in Los Angeles . Oh , there were plenty of para
medics talking to plenty of doctors over plenty of radi os . But
everyone was just a number . Someone can screw up under such
circumstances and there is no follow-up. No medical control .
BA
As a former Fire Chief , I'm soJl'ry to report that the attitudes and performance of
a few Chiefs in Los Angeles have brought the problems to the surface, jeopardizing
the whole program. One Chief, for example, has refused to allow Paramedic training
nurses to ride his Department's Paramedic units and monitor skil ls and performance.
Another Chief has not refused, but has instituted restrictions that make such
monitoring all but impossible. In the meantime, the County Health Director -
a non-medical bureaucrat who is responsible for certifying the Paramedics - has
turned a deaf ear to the problem. He has caved in to a couple of fire chiefs in
a political confrontation.
The pawns in this melodrama are the Paramedics and the Patients. No Paramedic
in Los Angeles has ever been subjected to a practical recertification of their
Paramedic ski lls - and some of them are seven years down the road from their
initial training. The only recertification Exam administered thus far was a
written exam - and the first-time failure rate ran more than 30% with some groups.
From the beginning of the L.A. program, there has been no single medical doctor
with the clear-cut authority and political strength to force the critical issues
of continuing education, practical competance, recertification, and medical
control. In the absence of such strong medical control, non-medical people
(namely politicians, fire chiefs, ambulance company owners, and the Sheriff) have
become dominant in making medical policy decisions.
I single out the fire chiefs as culprits because I understand them and their
motivations. In the early stages of the program, they were urged by their staffs
to plan and budget for continuing education. But once again, there was no medical
back-up to those reco11111endations. So the staff recommendations were ignored. And,
as you say in Texas, the Dadgum Ch ickens have come home to roost.
BB
The distressing situation in L.A . could be called 11 PROBLEM AVOIDANCE 11 • There is
a conscious effort to cover up the problems of skill decay by denying access to
those with responsibility for maintaining skills. It won't work. The word eventually
gets out. In fact, by the time I finish this speech, the word will be all over
Texas.
The answer for L.A. and all areas is to recognize advanced life support as a
medical program. The answer is to consciously admit shortcomings and problems, not
try to hide them.
But there is another lesson for rural folks, that is, bigness is not necessarily
goodness. 100 Paramedic units are not necessarily 100 times (or even two times)
better than an advanced life support system with only one unit. In fact, it's
beginning to look like the opposite may be true.
One of the most interesting examples of a small advanced life support system
exists in the wilderness of Northern Michigan - the upper peninsula. There, a
very strong and capable medical doctor has developed a system by training local
volunteers as paramedics. There are many reasons why it could'nt or shouldn't
be done in that area where emergency responses often run 45 minutes - each way.
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But Dr . David Gilbert is a soft- spoken tiger . He has given
the program his time , his reputation and his determination
and he has made it work. He has built the system on a founda
tion of basic life support. He has proven that time and
distance and geography are not as significant as personal
dedication and commitment.
If this conference is like most I have attended in recent
months , many of you have been thinking about and talking
about advanced life support in your town . If so , I woul d
urge you to take a s hort step backward and survey the
situati on.
First , let ' s look at the legal s i tuation. Throughout the
U.S . dur i ng the last ten years , there have only been a few
l awsuits relating to paramedic or advanced life support
oper ations. To our knowledge , no paramedic or his employer
has suffered a loss as a result of those suits. But not
every State is operating under the authority of a 1943 law .
have seen your Attor ney General ' s opinion concerning
advanced life support . But I think it is questionable
authority. The first step in Texas , it would seem to me ,
would be the introduction and passage of a comprehensive
emergency medical services law. A lot has happened in
the 34 years since 1 943 .
Then I woul d suggest you look at basic life support in your
community. Does it really exist? Is your hospital on
board or is it just t olerating you? If the latter is true ,
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what are you doi ng about it? Those old-time barriers never
fall without some effort involving personal skills of some
key individuals.
What is the level of ambulance attendant training in your
community? Are you really satisfied with the ECA course?
The old argument that volunteers can ' t handle an EMT course
should be dead by now . Too many volunteers in too many
places have proven it wrong.
Does your community have a CPR training program for citizens?
Not likely if your ambulance attendants don ' t know it. Cost?
You would be amazed what citizens and their service clubs and
social organizations are willing to donate if you offer to
provide them with a lifesaving skill . CPR training is the
best public educati on tool we have ever seen .
What about medical support~ Do you have that rare doctor
that can make it work? This is probabl y the most critical
issue. And without that special kind of medical support, your
effort at advanced life support is likely to go awry at an
early stage .
Finally , how about thinking of a special skills approach ,
similar to North Carol ina ' s EMT- 1.V. program? Would it be
a reasonabl e alternative to paramedics in the more rural
regi ons of Texas? Are you prepared to support a State EMS
law which would define and authorize the mid- level EMT?
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Texas presents an interesting situation for development
of emergency medical services systems. 254 counties would,
at first glance, seem to present an insurmountable task .
But the existence of 24 COGs provides a regional framework
for EMS organization, management and monitoring.
Even though 70% of your State ' s population resides within
metropolitan areas, you still have 188 counties with less
than 25,000 persons. As demonstrated in Dallas, Houston ,
San Antonio and other urban centers, EMS systems and advanced
life support is a reality for the majority of Texans. And
true to Texas tradition, you have done it better.
As I see it , your challenge is in the rural areas of the Lone
Star State. Most likely, it will not be a shortage of money
that stands in the way of improvements in these remote areas .
It has been shown that most of the important improvements can
be accomplished at littl e cost. It takes motivated people -
people who believe in themselves and each other . People who
are willing to work dauntlessly at breaking down the people
barriers of apathy , tradition for the sake of tradition , fear
of somethi ng new and different, lack of accurate information,
and anxiety over changes in role and territory.
Many years ago , as Texas was being settled by pioneers, there
were many reasons why the land could not be tamed. There were
many hardships and barriers to be faced by those brave and
hardy souls. But they persisted, and they beat some incredible
odds .
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Many of you are a new generation of pioneers in Texas. You
are faced with many reasons why better emergency care cannot
be accomplished in the barren and remote frontiers of your
State. You are facing many hardships and barriers in your
efforts to make even small amounts of progress . The odds
against success may look awesome.
hope you will persist, just as your ancestors did. Texas
deserves nothing but the best. That may be hard to remember
when you are faced with a County Judge who thinks we are
still in 1943. Certainly , he can ' t be any more discouraging
than a devastating dust storm was a hundred years ago. The
pioneer rancher somehow survived the calamities . He faced up
to adversity and tried again. As you return to your communi
ties and all the depressing problems you left behind , I hope
you will think of basic life support , advanced life support
and EMS as a battle against the elements. You can win the
battle. True to Texas tradition - I know you will .
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