Why the Ambulance ComesToo Late

...The course itself had problems as well...

...As the regional council was originally constituted, the District had only four votes of the 30 total, although it has one quarter of the region’s population...

...Its officials, afraid of bungling or attracting criticism, have delayed the paramedic system for months with meetings and memoranda...

...By 1969, rescue squads in Miami and Los Angeles had begun using drugs, intravenous fluids, biomedical telemetry, and portable defibrillators to treat heart attack victims in the field...

...The paramedics finished their training three months ago, but they haven't yet started an intravenous line in the field or defibrillated a heart attack victim...

...Because they involve the fire department, the health department, emergency room doctors, and hospital administrators, as often as not the programs get lost in the cracks between the different organizations, or bogged down in interagency feuding...

...This all sounds like a horror story, but Washington is not an exception...

...They did watch surgeons in operating rooms for three weeks, four hours a day-time largely wasted, because paramedics won't perform any surgical procedures...

...If you’re bleeding from the mouth or throat, or vomiting (a common reaction), you’ll probably aspirate the liquid into your lungs, starving them of oxygen and causing eventual aspiration pneumonia...

...If you’re hit by a car in Seattle, or involved in a freeway crash, the ambu-lance paramedics will start intravenous lines to replace lost blood, and administer drugs to boost your blood pressure and forestall shock...

...HEW is trying to create its own political geography, and its officials have divided the country into 300 regions that don’t conform to existing state and county boundaries...

...Many patients who died hours after admission could have been saved at another hospital a few miles away...

...What’s going to happen is another Sirica, and then all of a sudden we’ll be running around two days later...

...The emergency room team will be working just to keep you alive...

...Sander Mendelson, another cardiologist, leaked the story of DHR’s bickering with the suburbs to The Washington Star, which crusaded against the agency in a two-part series and a scathing editorial...

...Once it admitted a patient, a hospital would keep him until he died, rather than quickly transferring him to a larger, more sophisticated facility...

...Here is how Marguerite Dalton, who once headed the emergency medical services branch of DHR, defends all the delays: “Things are very complicated in every field...

...No person can foresee all of them...

...Cardiologists had also developed car dio-pulmonary resuscitation to keep a trickle of blood and oxygen flowing to a victim’s brain until paramedics arrived...

...Nationwide, 340,000 heart attack victims a year die before they reach the hospital...

...He blamed the suburbs, ignoring the fact that HEW had done the cutting...

...If you’re badly injured in D. C., the ambulance attendants will splint obvious fractures, apply pressure to stanch serious bleeding, and administer oxygen...

...He then refused to appoint representatives to the regional council in the summer of 1975, preventing distribution of the $800,000...

...In neighboring Montgomery County, a paramedic starts at $12,000...

...If it weren’t enough for DHR to bungle money it already has, it also serves as the District’s representative on HEWS regional council, and is helping bungle that too...

...DOT’S not going to let their program fall flat on its face,” Dr...

...On the Friday before the paramedic course was to bsgin, the city corporation counsel's office ruled that city insurance did not cover the paramedics while they practiced on patients in the hospital...

...You’ll arrive at the hospital with dangerously low blood pressure and volume“shriveled up like a prune,” one surgeon says-and in deep shock...

...and 36 have begun paramedic programs...

...Some negotiated contracts guaranteeing them all of a company’s patients, even if another hospital was nearer and better equipped...

...In English, that’s a fancy radio network for paramedics, one that includes portable radios, telemetry between paramedics and emergency room doctors, mobile relay stations, and hospital base stationsvirtually all the hardware needed to start a system...

...From these disputes D. C. has acquired a reputation as a spoiler and earned the lasting enmity of several suburban 38 counties...

...by the time help arrives resuscitation will probably be hopeless...

...The FCC developed a face-saving compromise to assure compatibility: D. C. would develop its fancy system, but for the time being would operate within the suburban plan...

...Television reporters picked up the story, grilling DHR officials and providing a friendly forum for Gorfinkel, Mendelson, and other doctors...

...But D. C. still doesn’t have enough paramedics working on the streets...

...officials did essentially nothing about the paramedic system...

...Most of the others are “taxi-runs” for inner-city residents taking advantage of the free care and transportation...

...Hospital officials don’t like to admit that their facilities can’t provide some kinds of sophisticated care, or to lose the revenue from patients who would be transfered under the HEW system...

...But some D. C. paramedics, who are civilians rather than firefighters, are classified as GS-4 and GS-5 civil service employees, earning less than $9,000 a year...

...A fire engine usually isn’t dispatched until an ambulance unit requests help-even though it would arrive in three minutes...

...the District then submitted an application of its own...

...Nobody wahts to tell us what’s happening,” one says...

...When you arrive the emergency room team will diagnose your injuries, get X-rays and lab tests, and send you to the operating room...

...125 have received small planning grants...

...They’ll examine you thoroughly, straightening angulated fractures and splinting every possible break, before taking you to the hospital...

...You have to proceed very carefully to learn the various components and know what you don’t know...

...Six hundred people have been saved in the past five years...

...it just holds the purse-strings...

...indeed, District officials like the idea of a paramedic system...

...Ninety per cent of the ambulance attendants in the country have taken an 8 1-hour Department of Transporta-tion course in emergency care...

...It’s ‘We’ll worry about it and you just do it’ from all the brass...

...Half of the calls are dry runs, where a patient decides he doesn’t want to go to the hospital after all, or refuses to be transported...

...It’s a classic illustration of a problem that afflicts paramedic programs nationwide: nobody knows who’s responsible for them...

...Yet only 15 per cent of the country is covered by paramedic systems...

...Hospital administrators would threaten to cut an ambulance com-pany off from nursing home transfers, the lucrative part of an ambulance business, unless it brought its trauma cases to their hospitals...

...It can handle several simultaneous incidents and lets ambulances cross county lines without changing channels, but there’s a catch: it requires a central authority to regulate the channels, so that two units don’t try to use the same frequency at once...

...to midnight and eight in the early morning hours...

...The suburban scheme uses on-the-shelf, readily available components...

...It uses its grants to force hospitals to organize regionally, and to set up specialized centers for each of six kinds of life-threatening emergencies, like trauma, heart attack, and burns...

...DOT ridiculed the suburban plan as 40 primitive and claimed there would be no interference...

...This sort of petty regional feuding, more than anything else, has held up systems across the country...

...After the White House Office of Telecommunications Policy intervened and the quarrel attracted scathing newspaper editorials, the parties submitted it to the Federal Communications Commission for informal arbitration...

...The reason isn’t shortcomings in technology...

...The fire department also hasn’t yet decided how many paramedic units it will have, where they will be stationed, what calls they’ll respond to, and what hospitals will supervise them...

...s o th ings stood on February 5 , 1976...

...It has spent most of its time squabbling with the suburban representatives about how votes should be apportioned, how the HEW money should be divided, and whether the DOT-funded radio system will be compatible with a simpler system planned for the suburbs...

...Sam Hawken-the Georgetown resident in orthopedics who put together the course-ended up calling insurance brokers himself and arranged coverage...

...Yeldell screamed as if he had been robbed...

...It seems so simple-and then it all gets muddied up...

...In a series of stormy meetings, HEW said that D. C.’s radio system was poorly designed and unlicensable, and threatened to withhold its money if D. C. refused to accept the suburban plan...

...That slapdash approach has characterized the program ever since...

...George Hyatt, an influential advocate of the paramedic program, recalls that “we had to reassure DHR that, if it didn’t work, they wouldn’t be held responsible...

...At least 20 per cent of these people could be saved, and many of the eleven million disabling injuries a year alleviated...

...In the District of Columbia a system like Seattle’s could save 250 lives a year...

...Statistically, Washington is actually ahead of most of the country...

...But for some reason paramedic systems are spreading very slowly...

...The fire department asked Georgetown University to start it in a week...

...74 are upgrading their ordinary ambulance service...

...marshal1 guarding him, and then a D. C. ambulance crew, administered CPR, and doctors at George Washington University Hospital were able to resuscitate him...

...DHR got $102,00O-everything it had requested but the manpower allowance...

...As a result, Washington and the sub urban Virginia and Maryland counties that make up its region fought for months last winter over apportionment of the HEW money, and are still deadlocked about voting representation on the regional council...

...Patients in critical condition would theoretically be routed to the specialized centers, which in turn would mean better patient care at lower cost...

...As for DOT and HEW, they give out their money in different-indeed, conflicting-ways, and the combination of their disputes with the District’s attempts to play both sides of the game has resulted in an administrative chaos that has so far quite effectively stalled any moves toward a new ambulance service...

...He declaimed about the District’s “integrity as a state,” said the regional council “failed to protect D. C.’s geopolitical role,” and accused the suburbs of trying to take “complete jurisdiction over the D. C. government in emergency medical affairs...

...Within three minutes a fire engine will arrive, and firefighters will take over the external heart massage and mouth-tomouth breathing...

...You have to be thinking all the time and considering the consequences of your actions...

...It’s a political plum-a way for city officials to attract publicity and win votes as well as saving lives-and accordingly, it’s been endorsed by everyone from Mayor Walter Washington on down...

...Why are 100,000 people, most of them healthy and in their prime, dying needlessly each year...

...Pay is another continuing problem...

...The biggest bottleneck is the District’s Department of Human Resources (DHR), which administers the federal grants...

...The regional council prepared a grant application, with the cooperation of D. C. officials...

...DOT gives its money to existing local governments, so that the District of Columbia got its grant...

...After all, it had money...

...In the 1920s and 30s interns rode city ambulances, but s p e cialization - and suddenly ex p a n ding m e di ca 1 kn o w le dge removed physicians from emergency care...

...They meet most federal standards, but have torn upholstery, ripped-up flooring, loose fixtures, and the like...

...Trauma is the leading cause of death for children and for adults under 38...

...It’s operated by the fire department, which owns eleven ambulances that have to cover 80,000 emergency calls a year, more calls per ambulance and per 100,000 people than in any city in the country...

...The problem was simple: when D. C. unveiled its DOT project, the suburbs had already planned and begun implementing a paramedic-to-hospital radio network of their own...

...T h e logic behind all of HEW’S complexities is that its system will work out best in the long haul...

...If you’re unconscious they’ll slip a special airway directly to your lungs...

...In a small town it’s so simple,” Shelton says...

...In two years it has shuffled three people through the directorship of emergency medical services, and it’s now shifting the overall responsibility from one division to another as part of a department-wide reorganization...

...And the District hasn’t even begun to consider an educational campaign like Seattle’s, so its system will probably have a save rate of about five per cent, rather than Seattle’s 25 per cent...

...A 1966 National Academy of Sciences study found that half of the ambulance service in the United States was provided by morticians-a conflict of interest that must have been depressing to the patients they carried...

...Most ambulances meet federal specifications and carry adequate equipment...

...Dalton’s just another trimmer-she says yes to me and then does what she wants...

...The number of paramedic units now in the city’s ambulance service, and their operating budget, are still uncertain...

...But any wholly new paramedic system would have to live within the existing budget, because the city has not earmarked any extra money for the program...

...Everyone involved with the paramedic program is afraid of antagonizing DHR-renewed sniping could only bog down the program further-but their frustrations come out when they’re promised anonymity...

...It’s especially bad in metropolitan areas...

...The Washington region received $800,000 instead of $2 million...

...t i l l and all, it seems as if Washington could have made some progress toward getting its paramedical program off the ground...

...The course was thrown together fast...

...Judge John J. Sirica suffefed a near-fatal hiart attack while giving a speech at the Army-Navy Club...

...The two pioposals moved smoothly along side by side-DOT signed off on the suburban plan, and the suburbs approved the District plan-until an HEW c o m mu ni cat ions specialist realized that they would create “destructive interference” when D. C. tried to use a channel one of the suburbs was already on...

...What’s the problem...

...There’s no way to distinguish between what is and isn’t a genuine emergency over the phone, so ambulances must respond to everything...

...But few laymen know CPR, and few jurisdictions are developing paramedic systems...

...It has a staff of 100 Emergency Medical Technicians...

...the doctors bargained for time, and eventually began teaching it two months later...

...Since the foundation had a clear policy of denying duplicative applications, it rejected both...

...No one specialized in emergency medicine...

...In Seattle, one-quarter of the cardiac arrest victims the fire department tries to resuscitate live to walk out of the hospital...

...The situation is especially galling to the paramedics because most of them have extensive experience in the procedures they’re not allowed to perform...

...a D. C. fireman starts at $12,300...

...But then HEW decided to reject all requests for manpower expenses...

...However, DHR representative Dalton agreed to the arrangement, and DHR director Joseph Yeldell approved it, and the District signed the fiscal year 1976 regional application to HEW accordingly...

...it’s simple and cheap...

...that’s all well developed and relatively simple...

...The story behind the District of Columbia government’s non-delivery of something it ought to be delivering is a sad one both specifically, for the lives it wastes, and generally, for its broad typicality...

...The average response time is eight minutes, but during peak hours it may take an ambulance ten or fifteen minutes to get to a life-threatening emergency, and more than an hour to reach a minor case...

...In Washington, D. C., almost no one survives...

...Either by ignorance or perfidy, D. C. cost the region a half-million dollars...

...I think skilled paramedics deserve at least as much money...

...They did not have a chance to observe the delivery room, although obstetrical emergencies are common in the field...

...Since it doesn’-t have communications with the hospital, it doesn’t even carry drugs, intravenous fluids, or a defibrillator...

...An ambulance, dispatched simultaneously, will follow in a minute and a half, with professional paramedics who will try to restart your heart with an electrical shock...

...Politicans are reluctant to sacrifice their autonomy and carry out someone else’s guidelines...

...Poisoning, overdoses, drowning, and trauma kill more than 120,000 people a year...

...This miserable situation stood in stark contrast to the state of the art...

...A battle of consultants began, and DOT and HEW quickly joined in support of their respective clients...

...The District spends only ten per cent of it on emergency medical health care, and that goes to the maintenance of the conventional ambulance system...

...A good paramedic program would require well-trained, well-paid personnel and more than $100,000 worth of new equipmentmoney that D.C., already financially beleagured, just doesn’t have...

...Fire departmrn t officials decided not to wait for new equipment and rushed ahead with a training program for paramedics...

...DHR settled the radio disprite and dropped its tirade about the regional council...

...DHR has no connection with the fire department, which, you’ll remember, runs the city’s ambulances...

...Although his heart stopped, Sirica survived...

...Many were military corpsmen with field experience...

...They seem so frightened and demoralized-or so imompetent-that they can’t decide anything...

...Shelton says the fire department needs to develop a job classification for paramedics before it can increase their salaries, and admits he doesn’t know where the money would come from...

...emergency departments were staffed by interns and residents on rotation from other specialties, or by practicing physicians who worked occasional shifts in the E. D. Critical cases-victims of trauma, burns, heart attacks, and other life-threatening emergencies-were taken to the nearest hospital rather than the best one...

...Trained paramedics are in tremendous demand nationwide...

...But political promises can’t be redeemed in cash...

...You buy some equipment, make some arrangements with the hospital, train your people, go to the drugstore and buy some drugs, and go out and operate...

...The $2-million application allotted $410,000 to D. C., mostly for manpower...

...The root of the problem-and of quite a few other problems, for that matter-is that combination of petty politics and general ineptitude that is so common in American governments...

...They respond to calls in “Mobile 25,” which The Washington Post touted as a paramedic unit “just like TV...

...The situation in hospitals was as bad...

...The District applied for a grant from the Department of Transportation, and in June 1975 got $500,000 for a three-year “Medical Emergency Communications Coordination Assessment System...

...During most of the day ambulance attendants drop a patient off at a hospital emergency department, radio the dispatcher that they’re back in service, and are given another call...

...So you’ll wait eight minutes for an ambulance instead-or more, if you have the misfortune to collapse in the early evening, when calls for the city’s eleven ambulances often stack up...

...And the hospitals, prodded by the federal government, are beginning to identify local and regional centers for trauma, burn, poisoning, and cardiac cases, and to send critical cases to them...

...T h e situation in cities today isn’t as bad as it was in 1966...

...boosts their salary and develops a career ladder for paramedics, many say they will quit when their nine- m o n t h commitment expires...

...It’s partly money, of course, but even that isn’t the major obstacle...

...If you’re stricken in the District of Columbia, you might as well give up...

...All this is not to say that Washington doesn’t want a better ambulance service...

...Eighty per cent of the attendants had little or no training, and three quarters of the ambulances did not meet minimal design criteria...

...at least 75,000 of them could be saved by adequate emergency care...

...In fact it’s a glorified ambulance...

...In Korea and Vietnam corpsmen administered drugs and intravenous fluids to wounded soldiers in the field before evacuating them by helicopter to field hospitals, where surgeons were repairing trauma that would have been fatal a few years earlier...

...The U.S...

...If you go into cardiac arrest on the street in Seattle, a bystander will often start cardio-pulmonary resuscitation (CPR) immediately...

...It blamed “dilatory and arbitrary administration” in DHR for the delays...

...George Hyatt, chairman of orthopedics at Georgetown and head of the DHR EMS emergency medical services committee, paid for the insurance with a personal check...

...Fire department administrators have managed to protect the ambulances from the worst of the District’s budget crunch, adding one more unit and a few personnel while closing some fire stations at night...

...T h e 17 paramedics-enough to staff one unit 24 hours a day-are angry and demoralized...

...The DOT system’s designers rejected the suburban approach in favor of a more efficient system...

...There are still a lot of problems the District hasn’t even begun to grapple with...

...others have worked as cardiac technicians or licensed practical nurses in hospitals...

...Together, bystanders who know CPR and paramedics might save half of the people who now die before they reach a hospital...

...It has some special problems, but the country and officials at HEW say the bureaucratic delays, regional politics, and financial troubles that have delayed its system are similar to the problems in many other regions...

...F o r quite a while no funding was forthcoming, and D.C...

...The trouble in Washington began about 1973, when the Robert Wood Johnson Foundation was handing out $500,000 grants for communications and system development...

...when U.S...

...Washington, D. C. is one of the worst...

...The necessary equipment can be ordered from a catalog, and the medical protocols and training procedures have been proved and refined in 50 programs around the country...

...They’re taking a paternal interest in it...

...Emergency paramedical care is a classic example of something the government could provide, but doesn’t...

...Now this all sounds wonderful on paper, but in interaction with local politicians and doctors it causes problems...

...A well-trained ambulance attendant in 1965 could do more to save your life than a doctor in 1940, but ambulance attendants generally received no training at all...

...So conferring is what goes on...

...There was more money, too: $650,000 from the National Highway Traffic Safety Administration, and, from the Department of Health, Education, and Welfare, grants of $102,000 in fiscal year 1976 and $204,000 in fiscal 1977 for equipment and training...

...You can train a gorilla to hold a hose,” Fire department battalion chief Joseph Shelton says...

...Their plan costs more, and requires specially designed and manufactured components, but DOT officials say it will give D. C. the best communications system in the country...

...Emergency medicine became an accredited specialty in 1973, and more hospitals are hiring full-time emergency room physicians...

...You can’t make hasty decisions...

...The ambulance attendants won’t be able to do anything but administer CPR brain will begin to suffer irreversible damage after four minutes without oxygen...

...many were actually hearses with a reversible sign...

...The problems in the Washington ambulance system are obvious...

...They will also give drugs to stabilize the heartbeat, transmit an electrocardiogram to physicians at the David Thiemann is a reporter for the Washingtonian...

...Mortality statistics reflect the change: in World War I eight per cent of the soldiers who reached a hospital alive eventually died, compared to four per cent in World War 11, two-and-a-third per cent in Korea, and two per cent in Vietnam...

...The ambulance service operates eleven units from 8 a.m...

...This shrewd manipulation of the media (Mendelson has a “reliable source" sign in his office and says that "DHR is very careful about what they tell me now") worked remarkal le changes in DHR and the fire deparlment...

...HEWS grants go only to hospitals and cities that form regional organizations, so to get its HEW money the District has to cooperate with other nearby governments...

...DHR has never hired a supervisor for emergency medical services who has had any experience in the field, and has never kept anyone long enough for him to learn it on the job...

...But a few physicians had finally had enough of DHR’s casual progress toward a paramedic system, In press conferences and television interviews they linked the judge’s brush with death to the stalled program...

...The District, unwilling to spend its own money to pay them adequately, is still expecting to sponge off DOT...

...DHR has a staff of six working on emergency medical services, but all they do is arrange committee meetings, prepare transfer vouchers (to move money into fire department accounts), and shuffle papers between consultants, the fire department, and the federal government.’ It took DHR more than I year to hire a coordinator for its DOT grant, and he was the first DHR employee with experience in emergency care...

...Fire engines still don’t respond to life-threatening emergencies, so ambulances and paramedics will usually arrive too late...

...One person says of Emmett Banks, Marguerite Dalton’s assistant, “Emmett’s the ultimate bureaucrat-he won’t say he doesn’t have any background in this...

...Emergency medical care became a nationalscandal in the two decades following World War 11...

...The haggling brought both systems to a standstill from the fall of 1975 through the spring of 1976...

...Joel Gorfinkel, the cardiologist attending Sirica, lectured about DHR in a press conference on the judge’s condition...

...The attendants are jaded-it’s no wonder, since most of their patients are alcoholics, addicts, and psychiatric cases-and the ambulances themselves are grim...

...The expense isn’t prohibitive: it costs $15,000 to convert an ambulance into a paramedic unit, and $5,000 to buy a hospital base station radio...

...In its annual report on the emergency medical services program, HEW said that 65 regions aren’t receiving any money because they haven’t begun their programs...

...The paramedics weren't able to practice with a portable defibrillator and radio, because the city hadn't gotten the equipment yet...

...There are no statistics on trauma-that is, sudden injury-but experts estimate that Seattle saves at least 60 people a year who would otherwise die...

...The course ended as it began, with political opportunism: it was cut two days short so that the city could brag about its new paramedics on the Fourth of July...

...The problems go beyond that, though...

...Finally, in 1974, five years after other cities had proved that paramedic systems worked, an opportunity for outside money came along...

...The two consultants involved nearly came to blows, denouncing each other for shoddy work and professional incompetence...

...This occurred despite the fact that more critically wounded soldiers than ever before were reaching hospitals alive, because of better field care and quicker evacuation...

...There’s no effort to teach CPR to the public...

...Unless D.C...

...They're stationed at the Washington Hospital Center, so they can maintain their skills by observing in thee Emergency Department, starting IVs and administering medications...

...42 Hyatt says...

...So when the city worked toward a new paramedic program, it tried to get it with someone else’s money...

...Often they won’t notice some fractures, so the jagged bone ends may move when you’re lifted and, when the ambulance hits a bump, tear at your muscles, nerves, and blood vessels...

...Half of them are old Chevrolet vans, with rough sheet-metal work and plywood paneling installed to convert them into emergency vehicles...

...The system still lacks a full-time director with the medical credentials and political skill to push it through...

...Like any city, it looked to the federal government for the necessary funding...

...The next fight was over voting power...

...According to a consultant’s report, that coverage should be doubled...

...It takes a lot of conferring...

...A n o t h e r regional imbroglio, over the compatibility of two radio systems, began as a technical dispute between consultants for the District and the suburbs, but quickly escalated into a pitched battle between HEW, backing the suburbs, and DOT...

...The National Highway Traffic Safety Administration grant has had almost no effect...

...Seattle’s free three-hour course in cardio-pulmonary resuscitation, taught by firemen, has trained 120,000 citizens-at a cost to the city ,of $1.84 a person...

...The impasse continued until a new re-gional organization took over the grant in January 1976-and even now, DHR only sends observers to regional meetings...

...hospital, and obtain medical instructions by portable radio...