Seattle EMS remains a model for cardiac arrest response
By Jim Doyle
San Francisco Chronicle
Copyright 2008 The San Francisco Chronicle
SEATTLE — For decades, Seattle has led the nation in 911 medical response with a strategy of basic life-support services by firefighters trained as emergency medical technicians, advanced care by paramedics when needed, and citizen participation in lifesaving.
The local ambulance system is "based on a medical model," said Michele Plorde, a section manager for strategic planning and data management at King County Emergency Medical Services, which includes Seattle and surrounding communities. "The design flowed from wanting to best serve patients with an appropriate amount of care."
Seattle firefighters take pride in getting quickly to the scene of a medical emergency - employing measures such as defibrillating a stalled heart with electrical shocks and blocking a hemorrhage. All of Seattle's firefighters are trained as emergency medical technicians who can provide basic lifesaving skills. Seattle's paramedics are drawn from the ranks of its firefighters.
"We do things a little differently from most other cities around the country," said Bill Hepburn, Seattle's assistant fire chief for operations. "Seattle is a city that probably has the fewest paramedics on duty in the country. ... The system has been here so long that if someone wants to come into the Fire Department just to go to fires, they've come to the wrong place."
With fewer paramedics than San Francisco, Seattle does not station them on fire engines; they are assigned to two-person ambulances. They are used sparingly to help those in need of advanced care such as special medications and intubation in cardiac arrest cases. "Our paramedics are not assigned to a fire engine because it waters down their skills," said Plorde, adding that King County's paramedics work in pairs. "We try to concentrate their response."
They receive advanced training and specialize in the toughest cases - or 30 percent of King County's emergency medical calls, including cases of heart failure.
One result: Seattle has the highest survival rate for cardiac arrest cases among larger U.S. cities, saving 41 percent of those in 2006 who went into ventricular fibrillation, a type of sudden cardiac arrest characterized by a rapid, irregular heart rhythm. Those patients were discharged from the hospital with full neurological function intact.
By contrast, San Francisco's cardiac-survival rate was 17 percent in 2004, when fire officials stopped tracking cardiac arrest data as a result of budget concerns. They plan to start collecting this data again this year as part of a nationwide registry of cardiac cases.
"No one has been able to emulate the (cardiac) survival rates that Seattle has published, and in fact some people have questioned them," said Dr. Jim Pointer, medical director for Alameda County's office of emergency medical services. "But we ought to be trying to emulate them. For cardiac arrest cases, it means getting there quickly, providing effective CPR and early defibrillation."
Without immediate medical treatment, cardiac arrest can cause sudden death, and brain damage can occur in 4 to 6 minutes.
Washington's King County has an average response time of about 5 minutes for cases in which a cardiac arrest patient survived, and its overall response time to urgent medical calls is about the same as San Francisco's - 8 minutes or less 90 percent of the time.
Many cities including San Francisco immediately send paramedics and firefighters trained as emergency medical technicians to the scene of urgent medical incidents. In King County, paramedics are dispatched only when the most sophisticated, life-saving procedures for cardiac arrest victims and other critical care patients are needed, and these paramedics typically arrive minutes later than the first responders.
One key to Seattle's success involves the education and participation of residents. In a majority of King County's cardiac survival cases, cardiopulmonary resuscitation and defibrillation of the victim by a bystander play a vital role. Medical studies show that early CPR can increase the survival rates of these cases.
Emergency medical agencies, nonprofits and fire departments in King County provide training and education in CPR and the use of "automated external defibrillators" each year to about 18,000 students (grades six through 12), along with thousands of county and private employees.
San Francisco has fostered the installation of defibrillators at public sites such as the Powell Street Municipal Railway station and the airport. Downtown office towers and AT&T Park also have installed defibrillators.
Dr. John Brown, who runs the Public Health Department's emergency medical services agency, estimates that 10 percent of adult residents in the city are trained in CPR. "We want to get better," he said. "We do want to catch up to cities like Seattle."
Alameda County has begun a pilot program to teach CPR to students in public high schools. Besides classroom instruction, students are given an instructional video and resuscitation mannequin with the hope that they will help train friends and family.
"Our goal is to train 20,000 students, every single 10th-grader in the county, in the next year," said Alameda County's Pointer. "We want to saturate every classroom and have students pass it on."