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 .

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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 .