quo vadis, rampart one?

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EME~GRGENCY FORUM Quo Vadis, Rampart One? Nancy L. Caroline, MD Pittsburgh, Pennsylvania caroline NL: Quo vadis, Rampart One? JACEP 6:376- 3"79, August, 1977. mobile coronary care units; paramed- ical personnel; prehospital care. INTRODUCTION Each week, millions of Americans sit raptly in front of their television sets watching the Los Angeles firemen/ paramedics wage their battle against disease and death. The highlight of any episode is usually the cardiac arrest scene. The firemen start cardiopulmonary resuscitation and radio for instructions to an emergency physician c0de-named ~'Rampart One." With furrowed brow, this exemplary doctor listens to their report and issues in- structions. He looks perpetually worried, and well he should. For Rampart One practices in the no man's land of medicine, the shadowy region of prehospital emergency care, where physicians must, by remote control, treat critically ill and injured patients whom they cannot see, hear or touch_ This television fare reflects a relatively new and rapidly burgeoning phenomenon in American medicine, the paramedic-staffed mobile intensive care unit (MICU). The principle underlying the MICU is to bring-the emer- gency department to the patient, enabling earlier stabili- zation of the critically ill or injured, for whom minutes may mean the difference between life and death. The success or failure of such a venture depends, in the last analysis, upon two variables: the paramedic in the street and the physician at the other end of the radio. Both paramedic and Rampart One were born out of necessity to fill a vacuum in the emergency health care system. Each has been shaped by regional needs, re- sources and constraints, as well as by personal predilec- tions andgoals. And the role of each has undergone swift and largely unpremeditated change. The future directions From the Department of Anesthesiology, University of Pit~-~ burgh, Pittsburgh, Pennsylvania. ~'~ Address ['or reprints: Nancy L. Caroline, MD, Department of Anesthesiology, 1060C Scaife Hall, University of Pittsburgh, Pittsburgh, Pennsylvania 15261. of such change may determine whether prehospital emer- gency care becomes an exercise in mediocrity and ostenta- tion or whether it becomes an essential component in de- livering quality medical care. We shall first examine the role of the paramedic as it has evolved in this country over the past ten years and then turn our attention to the physician who bears ulti- mate responsibility for the paramedic's actions. THE PARAMEDIC In western countries the first ambulances equipped to deliver advanced life support in the prehospital setting were the mobile coronary care units developed in Belfast in the early 1960s_ ~ From the outset, they were physician- staffed, and this pattern has remained characteristic of all MICUs abroad. However, since their inception in the mid-1960s, MICUs in this country have been almost ex- clusively staffed by paramedics, a new breed of profession- als who are still, to a large extent, searching for an iden- tity. Indeed, there is considerable disparity among the ways paramedics view themselves and the ways others view them. They have been termed, by the director of one large urban MICU system, "the new heroes of the street" (L. Lester, MD, personal communication). They have been viewed by some as anathema and by others as man's last hope for salvation. The fact is that there are currently be- tween 8,000 and 10,000 individuals in the United States designated by themselves or by local agencies as "para- medics" (US Department of Transportation estimate, personal communication). However, until the spring of 1976, there was no agreed upon definition of this health professional or his requisite skills. Training programs around the country varied from 100 to 1400 hours in length. Individuals called paramedics varied from basic emergency medical technicians trained only to initiate intravenous (IV) lines to those carrying out pleural drain- age, transthoracic cardiac pacing and cricothyrotomy in the field. In January, 1975, the President's Interagency Commit- tee on Emergency Medical Services recommended that a standard curricultim for paramedic training, having the sanction of all involved national agencies, be de- J~P 6:8 (Aug) 1977 376/51

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EME~GRGENCY FORUM

Quo Vadis, Rampart One?

Nancy L. Caroline, MD Pittsburgh, Pennsylvania

caroline NL: Quo vadis, Rampart One? JACEP 6:376- 3"79, August, 1977. mobile coronary care units; paramed- ical personnel; prehospital care.

INTRODUCTION Each week, mil l ions of Amer icans sit r ap t ly in front of

their television sets watch ing the Los A n g e l e s f i remen/ paramedics wage the i r ba t t l e aga ins t disease and death . The h ighl ight of any episode is usua l ly the cardiac a r r e s t scene. The f i remen s ta r t ca rd iopu lmonary resusc i ta t ion and radio for ins t ruc t ions to an emergency phys ic i an c0de-named ~'Rampart One." Wi th furrowed brow, th is exemplary doctor l is tens to the i r repor t and issues in- structions. He looks p e r p e t u a l l y worr ied , and wel l he should. For Rampar t One pract ices in the no man ' s l and of medicine, the shadowy region of prehospi ta l emergency care, where phys ic ians must , by remote control, t r e a t critically ill and injured pa t i en t s whom they cannot see, hear or touch_

This t e l e v i s i o n fare r e f l ec t s a r e l a t i v e l y new and rapidly burgeoning phenomenon in Amer ican medicine, the paramedic-s taffed mobile in tens ive care uni t (MICU). The principle under ly ing the MICU is to br ing- the emer- gency depa r tmen t to the pa t ien t , enab l ing ea r l i e r s tabi l i - zation of the cr i t ica l ly i l l or injured, for whom minu tes may mean the difference be tween life and dea th . The success or fa i lure of such a ven ture depends, in the las t analysis, upon two var iables: the paramedic in the s t ree t and the phys ic ian at the o ther end of the radio.

Both pa ramedic and R a m p a r t One were born out of necessity to fill a vacuum in the emergency hea l th care system. Each has been shaped by r eg iona l needs, re- sources and constra ints , as well as by personal predilec- tions a n d g o a l s . And the role of each has undergone swift and la rge ly unpremed i t a t ed change. The future direct ions

From the Department of Anesthesiology, University of Pit~-~ burgh, Pittsburgh, Pennsylvania. ~'~

Address ['or reprints: Nancy L. Caroline, MD, Department of Anesthesiology, 1060C Scaife Hall, University of Pittsburgh, Pittsburgh, Pennsylvania 15261.

of such change may de te rmine whe the r prehospi ta l emer- gency care becomes an exercise in mediocri ty and ostenta- tion or whe the r i t becomes an essent ia l component in de- l iver ing qua l i ty medical care.

We shal l f irst examine the role of the paramedic as i t has evolved in th is country over the past ten years and then turn our a t t en t ion to the physic ian who bears ult i- mate respons ib i l i ty for the paramedic ' s actions.

THE PARAMEDIC

In western countr ies the f irst ambulances equipped to deliver advanced life suppor t in the prehospi ta l se t t ing were the mobile coronary care uni ts developed in Belfast in the ear ly 1960s_ ~ From the outset , they were physician- staffed, and this pa t t e rn has r emained charac ter i s t ic of all MICUs abroad. However, since the i r inception in the mid-1960s, MICUs in th is country have been a lmost ex- clusively staffed by paramedics , a new breed of profession- als who are still , to a large extent , searching for an iden- ti ty. Indeed, there is considerable d i spar i ty among the ways pa ramedics view themse lves and the ways others view them. They have been termed, by the director of one large u rban MICU system, "the new heroes of the s t reet" (L. Lester, MD, persona l communicat ion) . They have been viewed by some as a n a t h e m a and by others as man 's las t hope for salvat ion. The fact is t ha t there are cur ren t ly be- tween 8,000 and 10,000 ind iv idua ls in the Uni ted Sta tes des ignated by themse lves or by local agencies as "para- medics" (US D e p a r t m e n t of T r a n s p o r t a t i o n e s t i m a t e , personal communicat ion) . However, unt i l the spr ing of 1976, there was no agreed upon definit ion of this hea l th professional or his requis i te skills. T ra in ing programs a round the count ry va r ied from 100 to 1400 hours in length. Ind iv idua l s cal led paramedics var ied from basic emergency medical t echnic ians t ra ined only to in i t i a te in t ravenous (IV) l ines to those ca r ry ing out p leura l drain- age, t r ans thorac ic cardiac pacing and cr icothyrotomy in the field.

In J a n u a r y , 1975, the Pres ident ' s In te ragency Commit- tee on Emergency Medical Services recommended tha t a s t anda rd curr icu l t im for paramedic t ra in ing, hav ing the s a n c t i o n of a l l i n v o l v e d n a t i o n a l a g e n c i e s , be de-

J ~ P 6:8 (Aug) 1977 376/51

veloped. Accordingly, in July , 1975, the Uni ted S ta tes D e p a r t m e n t of Transpor ta t ion awarded a contract to the Unive r s i ty of P i t t sburgh Depa r tmen t of Anes thes io logy to p repare th is cur r icu lum - - and the reby define the ski l l and knowledge objectives requis i te to the paramedic . The c u r r i c u l u m was completed in April , 1976 and received federal endorsement as well as ra t i f ica t ion by a number of s ta te legis la tures .

The cur r icu lum is exacting. I t spells out expl ic i t ly the ski l l s t ha t a paramedic mus t be able to perform (Table 1). Fur the rmore , in 1100 pages of Ins t ruc tor Lesson Plans, the cu r r i cu lum del inea tes the level of medical knowledge expected of paramedics . Thus, the a sp i r ing pa ramed ic mus t unde r s t and the pathophysiology and m a n a g e m e n t of a wide va r i e ty of medical, t r aumat ic , pediatr ic , obstet- ric and psychia t r ic emergencies . He mus t be conversan t wi th the proper t ies of approx imate ly 20 pharmacologic agents . He mus t know the fundamen ta l s of radio com- m u n i c a t i o n s and be ab le to p r e s e n t a concise, wel l - ordered repor t on the pa t ien t ' s h i s to ry and phys ica l find- ings.

It is an impress ive list. And the cur r icu lum is designed so t ha t each e lement can be expl ic i t ly tested; knowledge and competency levels can be ensured. Unfor tuna te ly , however, the cur r icu lum has no bui l t - in mechan i sm for ensur ing humi l i ty .

The pa ramedic does a few very impor t an t th ings , and he does those well. He has ski l ls t ha t m a n y phys ic ians do not possess. In general , he t akes pride in his competence and becomes comfortable wi th his de l imi ted a rea of spe- cific responses to specific s i tuat ions . Things go t e r r ib ly wrong, however , when the p a r a m e d i c becomes suffi- c ient ly in toxica ted with his new knowledge tha t he be- gins to subs t i tu te his j udgmen t and au tho r i t y for t ha t of the p h y s i c i a n d i rec tor . Our expe r i ence in P i t t s b u r g h suggests that , when the pa ramedic begins p lay ing doctor ins tead of per forming as a paraprofess ional , the qua l i ty of p rehosp i ta l emergency care declines. The very ins t ru- m e n t s for s a v i n g l ives become d a n g e r o u s toys in the hands of those who regard R a m p a r t One as a superf luous voice on the radio.

CASE REPORT

A call went out over police radio frequencies t ha t the re was an unconscious woman in the s treet . The pa ramed ic who serves in an administrat ive position with the city MICU service elected to respond to the call in his own vehicle. Reaching the scene, he found the woman in cardiac arrest . Bypass ing the hospi tal frequencies, which were closely moni tored by the medical director, the pa ramedic cal led for an MICU over police frequencies. As i t happened, the police frequencies were be ing moni tored at t ha t moment in the medical command stat ion, and the medical d i rector radioed to inqui re about the s ta tus of the pat ient . "We have an unconscious woman," the pa ramedic reported.

~'What are the vital signs?" the medical director inquired.

"There is no pulse and no blood pressure . The pa t i en t is not b rea th ing ."

~'You mean you have a cardiac ar res t ."

T a b l e 1 S U M M A R Y O F SKILLS

R E Q U I R E D OF P A R A M E D I C S =

1. History taking and physical examination

2. Assembly of intravenous equipment, vel ipuncture, and initiation of peripheral intravenou~ lines

3. Application and appropriate use of military a~ tishock trousers

4. Calculation and administration of correct doe. ages of intravenous, intramuscular and Sub,i cutaneous medications

5. Airway management with a variety of adjuncte, ~, including oropharyngeal and nasopharyngeal air.# ways, pocket mask, bag-valve-mask, demand valve and endotracheal intubation

6. Oropharyngeal, nasopharyngeal, endotracheal and tracheostomy suctioning, with sterile tecf nique where appropriate

7. Direct laryngoscopy

8. Electrocardiographic monitoring; recognition and management of 18 dysrhythmias

9. Cardiopulmonary resuscitation, including de. fibrillation and use of resuscitative drugs 10. Immobilization of an injured spine

11. Hemorrhage control by direct pressure, pres- sure point control, tdurniquet and military an- tishock trousers

12. Care of a variety of soft tissue injuries, includ. ing lacerations, impaled objects, avulsions and amputations

13. Care of burns

14. Immobilization of musculoskeletal injuries, with various commercial and improvised devices

15. Management of normal complicated obstetric events

16. Management of acute pediatric problems

17. Management of acute psychiatric problems

18. Proficiency in basic rescue, including vehicle stabilization, access, disentanglement and extrica- tion.

At this point, radio contact was "lost." Numerous at, t empts by the medical doctor to reach the paramedics in the field were unsuccessful . Meanwhi le , under orders from the i r admin i s t r a to r , the pa ramedics in i t i a t ed an in t ravenous l ine and a dmin i s t e r e d v i r tua l ly every cardiac d rug they stocked, inc lud ing severa l doses of calcium, Radio contac t was r ee s t ab l i shed when the paramedics called in to repor t they were l eav ing the scene. The patient could not be resusc i ta ted and was pronounced dead at the receiv ing hospital .

La te r inqui ry revea led t h a t the paramedic administra" tor had felt h imse l f en t i r e ly competent to manage a resus ° c i ta t ion and had not wan ted ~'meddling" from the medical director.

52/377 6"8 (Aug) 1977 U ~

It is not possible to de te rmine whe the r this. case would :hov e turned out different ly had the pa ramedics not cho- se~ to take ma t t e r s into the i r own hands . In many such cases, however, serious errors of j u d g m e n t are commit- • od Furthermore, it is of more t han academic s ignif icance !~. '~ ~ r a m e d i c s in such ins tances are c lear ly func t ion ing ~,ba~ ~'~ • . - • ide the law. They are not hcensed to practme medl- :°i~:.cJl~ They are pe rmi t t ed only to car ry out the orders of

i~ulY licensed physicians ,

paramedics, in sum, have very impor t an t skills. But , :like all of us, the paramedic mus t l ea rn to recognize his limitations as well as the cons t ra in ts t ha t the law im-

poses on his actions.

THE pHYSICIAN The requisi te ski l ls of the pa ramedic have been c lear ly

identified, and a cur r i cu lum to i m p a r t those sk i l l s has

been developed. What about Rampar t One, the phys ic ian at the o ther

end of the radio? He, too, needs a special complement of new skills in order effectively to del iver medical care by remote control (Table 2). These are not ski l l s t ha t are learned in medical school or even in pos tg radua te t r a in - ing. Indeed, most phys ic ians c u r r e n t l y fur~'ctioning as Rampart One acquired the necessary ski l l s t h rough a dif- ficult process of t r ia l and error.

Perhaps the most impor tan t aspect of R a m p a r t One's training is f i r s thand field experience, a Things are s imply not the same out on the streets . I t is one th ing to in i t i a t e an IV'line in the control led s i tua t ion of an emergency de- partment where eve ry th ing is convenient ly a r r anged and well-lighted and qui te a n o t h e r t h i n g to c rawl in to a mangled automobi le at night , amid hys te r i ca l bys t ande r s and impat ien t police officers, and s t a r t an IV on a pa t i en t pinned behind the s teer ing wheel. The phys ic ian at the other end of the radio mus t l ea rn to apprec ia te these unique aspects of prehospi ta l care and adjus t his expecta- tions accordingly. Fur the rmore , periodic field experience enables R a m p a r t One to appra i se the pa ramedics wi th whom he works. It is his only oppor tun i ty to see t h e m under fire, to assess t he i r j u d g m e n t and cl inical skil ls . Retrospective case reviews s imply do not provide t h a t in- formation.

Back at the base stat ion, R a m p a r t One's most difficult task is to m a i n t a i n a sense of the concrete r ea l i t y of the pa t i en t on t h e s t r e e t . He is a i d e d in t h i s by t h e pa ramed ic ' s s k i l l in c o m m u n i c a t i o n . The p a r a m e d i c should be able to supply a descr ip t ion suff ic ient ly de- tailed tha t the phys ic ian can form an accurate pic ture of the pat ient . Nonetheless , the re r ema ins an e l emen t of unreal i ty in the situatiot~. A p a t i e n t one canno t see, touch or auscu l ta te does not have the immediacy of the patient in the emergency depar tmen t . I t is easy in such circumstances not to t ake the ephemera l pa t i en t in the street seriously. Yet he needs to be t a k e n ser iously. For Rampart One is no less responsible for the pa t i en t he treats by radio t han for the pa t i en t he t r ea t s in person~:~

Fur the rmore , the phys ic ian ' s per formance in remote control care is subject to a k ind of audi t unpreceden ted in r~edicine. In any given region, R a m p a r t One is l ike ly to

Table 2 PREREQUISITES FOR RAMPART ONE 3

1. Insight into the unique aspects of field condi- tions

2. Fami l iar i ty with radio communicat ions and telemetry

3. Ability to formulate protocols and standing orders

4. Knowledge of health faci l i t ies in the region, par t icu lar ly specia l care u'nits, and the i r bed capacity and staffing at any given time

5. Knowledge of the capabilit ies and limitations of the paramedics, both in general and as applied to specific individuals

6. Ability to teach allied health professionals

7. Thorough familiarity with management of acute emergencies, ranging from airway control and emergency cardiac care to emergency childbirth

8. Abi l i ty to assess a patient one cannot see, touch, auscultate or question

9. Ability to render treatment through the skills of another whose actions one cannot observe

share his radio f requency wi th other Ra mpar t Ones at other hospi tals . Thus, his assessment of informat ion and the appropr ia teness of his responses are open to ins tan t peer review by every phys ic ian (not to ment ion nurse, pa ramedic and a m a t e u r radio fan) tun ing in on the same frequency. I t is l ike prac t ic ing medicine in a fishbowl, a s i t u a t i o n g u a r a n t e e d to give the l i t i ga t ion -consc ious physic ian more t han a few sleepless nights.

Nonetheless , such sc ru t iny is, in the f inal analysis , necessary. I t is easy for the phys ic ian s i t t ing by the radio to become complacent . Unab le to witness first hand the actions of the paramedics , Ra mpa r t One is ap t to make the most comfortable assumpt ion, ie, tha t the i r descrip- t ions are accurate, the i r j u d g m e n t impeccable and the i r performance beyond cri t icism. But tha t assumpt ion is not a lways war ran ted , and R a m p a r t One needs the prod of constant peer review to do his job properly. His job is not f in ished when the pa ramed ics complete the i r t r a i n i n g program and are d ispatched out to the streets . Rampar t One is equa l ly responsible for the ongoing moni tor ing of those paramedics , for upg rad ing the i r ski l ls and review- ing the i r performance, for r id ing with them in the am- bulances now and again and debrief ing them on selected cases_ He is responsible for the i r every action for they are his eyes and ears and hands.

SUMMARY

When viewed in te rms of the European model, it is clear t ha t the paramedic movement in this country arose as the logical consequence of physic ians ' abdicat ion of re- sponsibi l i ty - - the i r fa i lure to do the job they were man- dated to do: to r ender care to the sick and in jured where- ver those p a t i e n t s m i g h t be. For w h a t e v e r r easons , Amer ican physic ians - - unl ike the i r European colleagues - - will not work on ambulances . So by default , the task went to pa ramedics . Unfo r tuna te ly , there has been a

J ~ P 6:8 (Aug) 1977 378)53

subsequent tendency to forget tha t the paramedic has no a priori au thor i ty to function, let alone practice medicine. Unlike the nurse, he is not even independent ly licensed. On the contrary, his function is wholly derivative. He de- rives his sanct ion ent i rely from the license of a physician for whom he is supposed to act as proxy in cer ta in clearly defined and strictly controlled activities. We have by de- fault, assigned to the paramedic cer ta in aspects of care of the crit ically ill and injured. Whether it is appropriate to have delegated the care of this vu lnerab le pat ient group is another question. The fact is, we have chosen to do so. But this should not mean that we also delegate the moral responsibi l i ty for the welfare of those patmnts.

Somewhere in our retreat from the patient , we mus t stop and retrench. We, as physicians, bear responsibil i ty for what happens to pat ients out on the streets, they are our pat ients . And each of us should make cer ta in tha t those pat ients are receiving the same qual i ty of care we ourselves would deliver were we physically present. This means tha t every physician in the communi ty mus t be involved in the emergency medical services system, mus t be informed regard ing the policies, s tandards and prac- tices operat ing on the streets of his city. And it means tha t Rampar t One mus t be wi l l ing to make a total com= m i t m e n t to qua l i ty control of his system. He must be w i l l i n g to go out on the a m b u l a n c e s a nd m o n i t o r f i r s t hand the act iv i t ies of the paramedics ; to review every case report; to obtain follow-up informat ion on pa- t ient outcome; to insist tha t paramedic skills be periodi- cally reviewed and recertified. He mus t not trade off med- ical s t a n d a r d s for poli t ical expediency or make com-

promises in the qual i ty of medical care in order to plata, special interest groups or to spare himself the Work ~ constant surveillance. These are not hypothetical iso., ~l Regret tably, are lre we a ady accumula t ing ample°::l i dence from m a n y MICU systems throughout the cou~t~ of what happens when medical control falls to physicia~ who are too indolent or not concerned enough to moait~ t closely what is happening in the prehospital setting. Ra~. part One is not a game.

It has been said tha t the individual lying in the stre~ is, unt i l he comes under a physician 's care, a victim, ~ a patient . If this is true, it is because we have made hi~ so. He is the victim of Amer ican medicine and its apath~ He is the vict im of the ca rn iva l atmosphere that c~ rent ly pervades so much of prehospital emergency ca~ He is the victim of every physician who would abdicai responsibil i ty for the lives of others. He deserves rnu¢t better.

The author gratefully acknowledges the support of Peter Saf~ MD, who first plunged her, unsuspecting and unprepared, int~ the role of Rampart One and who encouraged the writing ofthit paper.

REFERENCES

1. Pantridge JF, Geddes JS: A mobile intensive-care unit in t~ management of myocardial infarction. Lancet 2:271-274, 1967,.

2. Adapted from work performed under US Department~ Transportation, National Highway Traffic Safety Administ~ tion Contract No. DOT-HS-5-01207, April, 1976.

3. Caroline NL: Medical care in the streets. J A M A 237:43-46; 1977.

54/379 6:8 (~,ug) 1977 , , ~ "