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Quo vadis, rampart one?
EME~GRGENCYFORUM
Quo Vadis, Rampart One? Nancy L. Caroline, MD Pittsburgh, Pennsylvania
caroline NL: Quo vadis, Rampart One? JACEP 6:3763"79,August, 1977. mobile coronary care units; paramedical personnel; prehospital care.
INTRODUCTION Each week, millions of A m e r i c a n s sit r a p t l y in front of their television sets w a t c h i n g t h e Los A n g e l e s firemen/ paramedics wage t h e i r b a t t l e a g a i n s t disease and death. The highlight of a n y episode is u s u a l l y the cardiac a r r e s t scene. The firemen s t a r t c a r d i o p u l m o n a r y r e s u s c i t a t i o n and radio for i n s t r u c t i o n s to an e m e r g e n c y p h y s i c i a n c0de-named ~'Rampart One." W i t h furrowed brow, this exemplary doctor listens to t h e i r r e p o r t and issues instructions. He looks p e r p e t u a l l y worried, a n d w e l l he should. For R a m p a r t One practices in the no m a n ' s l a n d of medicine, the shadowy region of p r e h o s p i t a l e m e r g e n c y care, where p h y s i c i a n s must, by r e m o t e control, t r e a t critically ill and injured p a t i e n t s whom t h e y c a n n o t see, hear or touch_ This t e l e v i s i o n fare r e f l e c t s a r e l a t i v e l y n e w and rapidly b u r g e o n i n g p h e n o m e n o n in A m e r i c a n medicine, the paramedic-staffed mobile i n t e n s i v e care unit (MICU). The principle u n d e r l y i n g the MICU is to b r i n g - t h e emergency d e p a r t m e n t to the p a t i e n t , e n a b l i n g e a r l i e r stabilization of the critically ill or injured, for whom m i n u t e s may m e a n the difference b e t w e e n life and d e a t h . The success or failure of such a v e n t u r e depends, in t h e l a s t analysis, upon two variables: the p a r a m e d i c in the s t r e e t and the p h y s i c i a n at the o t h e r end of the radio. Both p a r a m e d i c and R a m p a r t One were born out of necessity to fill a v a c u u m in the e m e r g e n c y h e a l t h care system. E a c h h a s been s h a p e d by r e g i o n a l needs, resources a n d constraints, as well as by personal predilections a n d g o a l s . And the role of each has u n d e r g o n e swift and l a r g e l y u n p r e m e d i t a t e d 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.
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of such change m a y d e t e r m i n e w h e t h e r p r e h o s p i t a l emergency care becomes an exercise in mediocrity and ostentation or w h e t h e r it becomes an essential component in delivering q u a l i t y medical care. We shall first e x a m i n e the role of the p a r a m e d i c as it has evolved in t h i s country over the past ten y e a r s and t h e n t u r n our a t t e n t i o n to the physician who bears ultimate r e s p o n s i b i l i t y for the p a r a m e d i c ' s actions.
THE PARAMEDIC In western countries the first a m b u l a n c e s equipped to deliver a d v a n c e d life support in the prehospital s e t t i n g were the mobile coronary care units developed in Belfast in the e a r l y 1960s_ ~ F r o m the outset, they were physicianstaffed, a n d this p a t t e r n has r e m a i n e d c h a r a c t e r i s t i c of all MICUs abroad. However, since t h e i r inception in the mid-1960s, MICUs in t h i s country have been almost exclusively staffed by p a r a m e d i c s , a new breed of professionals who are still, to a large extent, searching for an identity. Indeed, t h e r e is considerable d i s p a r i t y among the ways p a r a m e d i c s view t h e m s e l v e s and the ways others view them. They have been termed, by the director of one large u r b a n M I C U system, "the new heroes of the street" (L. Lester, MD, p e r s o n a l communication). T h e y have been viewed by some as a n a t h e m a and by others as m a n ' s l a s t hope for salvation. The fact is t h a t t h e r e are c u r r e n t l y between 8,000 and 10,000 i n d i v i d u a l s in the United S t a t e s d e s i g n a t e d by t h e m s e l v e s or by local agencies as "paramedics" (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 communication). However, until the s p r i n g of 1976, t h e r e was no a g r e e d upon definition of this h e a l t h professional or his r e q u i s i t e skills. T r a i n i n g p r o g r a m s a r o u n d the c o u n t r y v a r i e d from 100 to 1400 hours in length. I n d i v i d u a l s called p a r a m e d i c s varied from basic e m e r g e n c y medical t e c h n i c i a n s trained only to i n i t i a t e i n t r a v e n o u s (IV) lines to those c a r r y i n g out p l e u r a l drainage, t r a n s t h o r a c i c cardiac pacing and cricothyrotomy in the field. In J a n u a r y , 1975, the P r e s i d e n t ' s I n t e r a g e n c y Committee on E m e r g e n c y Medical Services recommended t h a t a s t a n d a r d c u r r i c u l t i m for p a r a m e d i c training, h a v i n g the s a n c t i o n o f 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-
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veloped. Accordingly, in July, 1975, the U n i t e d S t a t e s 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 a w a r d e d a contract to the U n i v e r s i t y of P i t t s b u r g h D e p a r t m e n t of A n e s t h e s i o l o g y to p r e p a r e t h i s c u r r i c u l u m - - a n d t h e r e b y define the skill and k n o w l e d g e objectives r e q u i s i t e to the paramedic. The c u r r i c u l u m was completed in April, 1976 and received federal e n d o r s e m e n t as well as ratification b y a n u m b e r of s t a t e legislatures. The c u r r i c u l u m is exacting. It spells out explicitly the skills t h a t a p a r a m e d i c m u s t be able to perform (Table 1). F u r t h e r m o r e , in 1100 pages of I n s t r u c t o r Lesson Plans, the c u r r i c u l u m d e l i n e a t e s the level of medical knowledge expected of paramedics. Thus, the a s p i r i n g p a r a m e d i c m u s t u n d e r s t a n d the pathophysiology and m a n a g e m e n t of a wide v a r i e t y of medical, t r a u m a t i c , pediatric, obstetric a n d psychiatric emergencies. He m u s t be c o n v e r s a n t w i t h t h e p r o p e r t i e s of a p p r o x i m a t e l y 20 pharmacologic agents. He m u s t know the f u n d a m e n t a l s of radio comm u n i c a t i o n s a n d be a b l e to p r e s e n t a concise, wellordered r e p o r t on the p a t i e n t ' s h i s t o r y a n d p h y s i c a l findings. It is an impressive list. A n d t h e c u r r i c u l u m is designed so t h a t each e l e m e n t can be explicitly tested; knowledge a n d c o m p e t e n c y levels can be ensured. U n f o r t u n a t e l y , however, the c u r r i c u l u m has no built-in m e c h a n i s m for ensuring humility. The p a r a m e d i c does a few v e r y i m p o r t a n t things, and he does those well. He has skills t h a t m a n y p h y s i c i a n s do not possess. In general, he t a k e s pride in his competence and becomes comfortable w i t h his d e l i m i t e d a r e a of specific responses to specific situations. Things go t e r r i b l y w r o n g , h o w e v e r , w h e n t h e p a r a m e d i c becomes sufficiently intoxicated with his new knowledge t h a t he begins to s u b s t i t u t e his j u d g m e n t a n d a u t h o r i t y for t h a t of t h e p h y s i c i a n director. O u r e x p e r i e n c e in P i t t s b u r g h suggests that, when the p a r a m e d i c begins p l a y i n g doctor i n s t e a d of p e r f o r m i n g as a paraprofessional, t h e q u a l i t y of p r e h o s p i t a l e m e r g e n c y care declines. The very instrum e n t s for s a v i n g lives become d a n g e r o u s toys in t h e h a n d s of those who r e g a r d R a m p a r t One as a superfluous voice on the radio. CASE REPORT A call w e n t out over police radio frequencies t h a t t h e r e was an unconscious w o m a n in the street. The p a r a m e d i c who serves in an administrative position with the city MICU service elected to respond to the call in his own vehicle. R e a c h i n g the scene, he found the w o m a n in cardiac arrest. B y p a s s i n g the hospital frequencies, which were closely m o n i t o r e d by t h e medical director, the p a r a m e d i c called for a n M I C U over police frequencies. As it happened, t h e police frequencies were b e i n g m o n i t o r e d at t h a t m o m e n t in the medical c o m m a n d station, a n d the medical director radioed to i n q u i r e about the s t a t u s of t h e patient. "We have a n unconscious woman," the p a r a m e d i c reported. ~'What are the vital signs?" the medical director inquired. "There is no pulse and no blood pressure. The p a t i e n t is not b r e a t h i n g . " ~'You m e a n you have a cardiac arrest."
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Table 1 SUMMARY OF SKILLS REQUIRED OF PARAMEDICS =
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, pressure point control, tdurniquet and military antishock 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 extrication.
A t this point, radio contact was "lost." N u m e r o u s at, t e m p t s by t h e medical doctor to reach the paramedics in the field were unsuccessful. M e a n w h i l e , u n d e r orders from t h e i r a d m i n i s t r a t o r , t h e p a r a m e d i c s i n i t i a t e d an i n t r a v e n o u s line and a d m i n i s t e r e d v i r t u a l l y every cardiac d r u g t h e y stocked, i n c l u d i n g s e v e r a l doses of calcium, Radio c o n t a c t was r e e s t a b l i s h e d w h e n the paramedics called in to r e p o r t t h e y were l e a v i n g the scene. The patient could not be r e s u s c i t a t e d a n d was pronounced dead at the receiving hospital. L a t e r i n q u i r y r e v e a l e d t h a t the p a r a m e d i c administra" tor had felt h i m s e l f e n t i r e l y c o m p e t e n t to m a n a g e a resus ° citation and had not w a n t e d ~'meddling" from the medical director.
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It is not possible to d e t e r m i n e w h e t h e r this. case would :hove turned out differently h a d the p a r a m e d i c s not chose~ to take m a t t e r s into t h e i r own h a n d s . I n m a n y such cases, however, serious errors of j u d g m e n t are commit•od Furthermore, it is of more t h a n academic significance !~. '~ ~ r a m e d i c s in such i n s t a n c e s are clearly f u n c t i o n i n g ~,ba~ ~'~ the law. They are not h•c e n s e d to practme . medl-• ide They are p e r m i t t e d only to c a r r y out the orders of i~ulY licensed physicians, paramedics, in sum, have very i m p o r t a n t skills. But, :like all of us, the p a r a m e d i c m u s t l e a r n to recognize his limitations as well as the c o n s t r a i n t s t h a t the law imposes on his actions.
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THE pHYSICIAN The requisite skills of the p a r a m e d i c have been c l e a r l y identified, and a c u r r i c u l u m to i m p a r t those s k i l l s h a s been developed. What about R a m p a r t One, the p h y s i c i a n at t h e o t h e r end of the radio? He, too, needs a special c o m p l e m e n t of new skills in order effectively to deliver medical care by remote control (Table 2). These are not skills t h a t are learned in medical school or even in p o s t g r a d u a t e t r a i n ing. Indeed, most p h y s i c i a n s c u r r e n t l y fur~'ctioning as Rampart One acquired the n e c e s s a r y skills t h r o u g h a difficult process of t r i a l and error. Perhaps the most i m p o r t a n t aspect of R a m p a r t One's training is f i r s t h a n d field experience, a T h i n g s are s i m p l y not the s a m e out on the streets. It is one t h i n g to i n i t i a t e an IV'line in the controlled s i t u a t i o n of an e m e r g e n c y department where e v e r y t h i n g is c o n v e n i e n t l y a r r a n g e d a n d well-lighted a n d q u i t e a n o t h e r t h i n g to c r a w l into a mangled automobile at night, a m i d h y s t e r i c a l b y s t a n d e r s and i m p a t i e n t police officers, and s t a r t an IV on a p a t i e n t pinned behind t h e s t e e r i n g wheel. The p h y s i c i a n at the other end of the radio m u s t l e a r n to a p p r e c i a t e t h e s e unique aspects of p r e h o s p i t a l care and adjust his expectations accordingly. F u r t h e r m o r e , periodic field experience enables R a m p a r t One to a p p r a i s e the p a r a m e d i c s w i t h whom he works. It is his only o p p o r t u n i t y to see t h e m under fire, to assess t h e i r j u d g m e n t and clinical skills. Retrospective case reviews s i m p l y do not provide t h a t information. Back at the base station, 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 e a l i t y of the p a t i e n t on t h e s t r e e t . He is a i d e d in t h i s b y t h e p a r a m e d i c ' s s k i l l in c o m m u n i c a t i o n . T h e p a r a m e d i c should be able to supply a d e s c r i p t i o n sufficiently detailed t h a t the p h y s i c i a n c a n form an accurate picture of the patient. Nonetheless, t h e r e r e m a i n s an e l e m e n t of unreality in t h e situatiot~. A p a t i e n t one c a n n o t see, touch or a u s c u l t a t e does not h a v e the i m m e d i a c y of the patient in the e m e r g e n c y d e p a r t m e n t . It is e a s y in such circumstances not to t a k e the e p h e m e r a l p a t i e n t in the street seriously. Yet he needs to be t a k e n seriously. F o r Rampart One is no less responsible for the p a t i e n t he treats by radio t h a n for the p a t i e n t he t r e a t s in person~:~ F u r t h e r m o r e , the p h y s i c i a n ' s p e r f o r m a n c e in r e m o t e control care is subject to a k i n d of a u d i t u n p r e c e d e n t e d in r~edicine. In any given region, R a m p a r t One is l i k e l y to J~P
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Table 2 PREREQUISITES FOR RAMPART ONE 3 1. Insight into the unique aspects of field conditions 2. Familiarity with radio c o m m u n i c a t i o n s and telemetry 3. Ability to formulate protocols and standing orders 4. Knowledge of health facilities in the region, p a r t i c u l a r l y special care u'nits, and t h e i r bed capacity and staffing at any given time 5. Knowledge of the capabilities 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. Ability 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 frequency w i t h other R a m p a r t Ones at other hospitals. Thus, his a s s e s s m e n t of information and the a p p r o p r i a t e n e s s of his responses are open to i n s t a n t peer review by e v e r y p h y s i c i a n (not to mention nurse, p a r a m e d i c and a m a t e u r radio fan) t u n i n g in on the same frequency. It is like p r a c t i c i n g 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 t h e l i t i g a t i o n - c o n s c i o u s physician more t h a n a few sleepless nights. Nonetheless, such s c r u t i n y is, in the final analysis, necessary. It is easy for t h e p h y s i c i a n sitting by the radio to become complacent. U n a b l e to witness first h a n d the actions of the p a r a m e d i c s , R a m p a r t One is a p t to m a k e the most comfortable assumption, ie, t h a t t h e i r descriptions are accurate, t h e i r j u d g m e n t impeccable and t h e i r performance beyond criticism. But t h a t a s s u m p t i o n is not always w a r r a n t e d , 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 finished w h e n t h e p a r a m e d i c s complete t h e i r t r a i n i n g p r o g r a m and are dispatched out to the streets. R a m p a r t One is e q u a l l y responsible for the ongoing m o n i t o r i n g of those paramedics, for u p g r a d i n g t h e i r skills and reviewing t h e i r performance, for r i d i n g with t h e m in the ambulances now a n d a g a i n and debriefing t h e m on selected cases_ He is responsible for t h e i r every action for t h e y are his eyes and e a r s a n d hands.
SUMMARY When viewed in t e r m s of the E u r o p e a n model, it is clear t h a t the p a r a m e d i c m o v e m e n t in this country arose as the logical consequence of physicians' abdication of responsibility - - t h e i r failure to do the job t h e y were mandated to do: to r e n d e r care to the sick and injured wherever t h o s e p a t i e n t s m i g h t be. For w h a t e v e r r e a s o n s , A m e r i c a n physicians - - u n l i k e t h e i r E u r o p e a n colleagues - - will not w o r k on ambulances. So by default, the t a s k w e n t to p a r a m e d i c s . U n f o r t u n a t e l y , there has b e e n a 378)53
s u b s e q u e n t t e n d e n c y to forget t h a t the paramedic has no a priori a u t h o r i t y to function, let alone practice medicine. Unlike the nurse, he is not even i n d e p e n d e n t l y licensed. On the contrary, his function is wholly derivative. He derives his sanction entirely from the license of a physician for whom he is supposed to act as proxy in c e r t a i n clearly defined and strictly controlled activities. We have by default, assigned to the paramedic c e r t a i n aspects of care of the critically ill and injured. W h e t h e r it is appropriate to have delegated the care of this v u l n e r a b l e p a t i e n t group is a n o t h e r question. The fact is, we have chosen to do so. But this should not m e a n t h a t we also delegate the moral responsibility for the welfare of those patmnts. Somewhere in our retreat from the patient, we m u s t stop a n d retrench. We, as physicians, bear responsibility for w h a t h a p p e n s to patients out on the streets, they are our patients. And each of us should make c e r t a i n t h a t those p a t i e n t s are receiving the same q u a l i t y of care we ourselves would deliver were we physically present. This m e a n s t h a t e v e r y physician in the c o m m u n i t y m u s t be involved in the emergency medical services system, m u s t be informed r e g a r d i n g the policies, s t a n d a r d s and practices o p e r a t i n g on the streets of his city. And it m e a n s t h a t R a m p a r t One m u s t be w i l l i n g to m a k e a total com= m i t m e n t to q u a l i t y control of his system. He m u s t be w i l l i n g to go out on t h e a m b u l a n c e s a n d m o n i t o r f i r s t h a n d the a c t i v i t i e s of the p a r a m e d i c s ; to review every case report; to obtain follow-up i n f o r m a t i o n on pat i e n t outcome; to insist t h a t paramedic skills be periodically reviewed and recertified. He m u s t n o t trade off medical s t a n d a r d s for political e x p e d i e n c y or m a k e com-
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promises in the q u a l i t y of medical care in order to plata, special interest groups or to spare himself the Work~ constant surveillance. These are not hypothetical iso.,~l Regrettably, we are a lre ady a c c u m u l a t i n g ample°::li dence from m a n y MICU systems throughout the cou~t~ of what happens w h e n medical control falls to physicia~ who are too indolent or not concerned enough to moait~t closely what is h a p p e n i n g i n the prehospital setting. Ra~. part One is not a game. It has been said t h a t the i n d i v i d u a l lying in the stre~ is, u n t i l he comes u n d e r 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 A m e r i c a n medicine and its apath~ He is the victim of the c a r n i v a l atmosphere that c~ r e n t l y pervades so much of prehospital emergency ca~ He is the victim of every physician who would abdicai responsibility 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.
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Quo Vadis, Rampart One? Nancy L. Caroline, MD Pittsburgh, Pennsylvania
caroline NL: Quo vadis, Rampart One? JACEP 6:3763"79,August, 1977. mobile coronary care units; paramedical personnel; prehospital care.
INTRODUCTION Each week, millions of A m e r i c a n s sit r a p t l y in front of their television sets w a t c h i n g t h e Los A n g e l e s firemen/ paramedics wage t h e i r b a t t l e a g a i n s t disease and death. The highlight of a n y episode is u s u a l l y the cardiac a r r e s t scene. The firemen s t a r t c a r d i o p u l m o n a r y r e s u s c i t a t i o n and radio for i n s t r u c t i o n s to an e m e r g e n c y p h y s i c i a n c0de-named ~'Rampart One." W i t h furrowed brow, this exemplary doctor listens to t h e i r r e p o r t and issues instructions. He looks p e r p e t u a l l y worried, a n d w e l l he should. For R a m p a r t One practices in the no m a n ' s l a n d of medicine, the shadowy region of p r e h o s p i t a l e m e r g e n c y care, where p h y s i c i a n s must, by r e m o t e control, t r e a t critically ill and injured p a t i e n t s whom t h e y c a n n o t see, hear or touch_ This t e l e v i s i o n fare r e f l e c t s a r e l a t i v e l y n e w and rapidly b u r g e o n i n g p h e n o m e n o n in A m e r i c a n medicine, the paramedic-staffed mobile i n t e n s i v e care unit (MICU). The principle u n d e r l y i n g the MICU is to b r i n g - t h e emergency d e p a r t m e n t to the p a t i e n t , e n a b l i n g e a r l i e r stabilization of the critically ill or injured, for whom m i n u t e s may m e a n the difference b e t w e e n life and d e a t h . The success or failure of such a v e n t u r e depends, in t h e l a s t analysis, upon two variables: the p a r a m e d i c in the s t r e e t and the p h y s i c i a n at the o t h e r end of the radio. Both p a r a m e d i c and R a m p a r t One were born out of necessity to fill a v a c u u m in the e m e r g e n c y h e a l t h care system. E a c h h a s been s h a p e d by r e g i o n a l needs, resources a n d constraints, as well as by personal predilections a n d g o a l s . And the role of each has u n d e r g o n e swift and l a r g e l y u n p r e m e d i t a t e d 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.
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of such change m a y d e t e r m i n e w h e t h e r p r e h o s p i t a l emergency care becomes an exercise in mediocrity and ostentation or w h e t h e r it becomes an essential component in delivering q u a l i t y medical care. We shall first e x a m i n e the role of the p a r a m e d i c as it has evolved in t h i s country over the past ten y e a r s and t h e n t u r n our a t t e n t i o n to the physician who bears ultimate r e s p o n s i b i l i t y for the p a r a m e d i c ' s actions.
THE PARAMEDIC In western countries the first a m b u l a n c e s equipped to deliver a d v a n c e d life support in the prehospital s e t t i n g were the mobile coronary care units developed in Belfast in the e a r l y 1960s_ ~ F r o m the outset, they were physicianstaffed, a n d this p a t t e r n has r e m a i n e d c h a r a c t e r i s t i c of all MICUs abroad. However, since t h e i r inception in the mid-1960s, MICUs in t h i s country have been almost exclusively staffed by p a r a m e d i c s , a new breed of professionals who are still, to a large extent, searching for an identity. Indeed, t h e r e is considerable d i s p a r i t y among the ways p a r a m e d i c s view t h e m s e l v e s and the ways others view them. They have been termed, by the director of one large u r b a n M I C U system, "the new heroes of the street" (L. Lester, MD, p e r s o n a l communication). T h e y have been viewed by some as a n a t h e m a and by others as m a n ' s l a s t hope for salvation. The fact is t h a t t h e r e are c u r r e n t l y between 8,000 and 10,000 i n d i v i d u a l s in the United S t a t e s d e s i g n a t e d by t h e m s e l v e s or by local agencies as "paramedics" (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 communication). However, until the s p r i n g of 1976, t h e r e was no a g r e e d upon definition of this h e a l t h professional or his r e q u i s i t e skills. T r a i n i n g p r o g r a m s a r o u n d the c o u n t r y v a r i e d from 100 to 1400 hours in length. I n d i v i d u a l s called p a r a m e d i c s varied from basic e m e r g e n c y medical t e c h n i c i a n s trained only to i n i t i a t e i n t r a v e n o u s (IV) lines to those c a r r y i n g out p l e u r a l drainage, t r a n s t h o r a c i c cardiac pacing and cricothyrotomy in the field. In J a n u a r y , 1975, the P r e s i d e n t ' s I n t e r a g e n c y Committee on E m e r g e n c y Medical Services recommended t h a t a s t a n d a r d c u r r i c u l t i m for p a r a m e d i c training, h a v i n g the s a n c t i o n o f 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-
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veloped. Accordingly, in July, 1975, the U n i t e d S t a t e s 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 a w a r d e d a contract to the U n i v e r s i t y of P i t t s b u r g h D e p a r t m e n t of A n e s t h e s i o l o g y to p r e p a r e t h i s c u r r i c u l u m - - a n d t h e r e b y define the skill and k n o w l e d g e objectives r e q u i s i t e to the paramedic. The c u r r i c u l u m was completed in April, 1976 and received federal e n d o r s e m e n t as well as ratification b y a n u m b e r of s t a t e legislatures. The c u r r i c u l u m is exacting. It spells out explicitly the skills t h a t a p a r a m e d i c m u s t be able to perform (Table 1). F u r t h e r m o r e , in 1100 pages of I n s t r u c t o r Lesson Plans, the c u r r i c u l u m d e l i n e a t e s the level of medical knowledge expected of paramedics. Thus, the a s p i r i n g p a r a m e d i c m u s t u n d e r s t a n d the pathophysiology and m a n a g e m e n t of a wide v a r i e t y of medical, t r a u m a t i c , pediatric, obstetric a n d psychiatric emergencies. He m u s t be c o n v e r s a n t w i t h t h e p r o p e r t i e s of a p p r o x i m a t e l y 20 pharmacologic agents. He m u s t know the f u n d a m e n t a l s of radio comm u n i c a t i o n s a n d be a b l e to p r e s e n t a concise, wellordered r e p o r t on the p a t i e n t ' s h i s t o r y a n d p h y s i c a l findings. It is an impressive list. A n d t h e c u r r i c u l u m is designed so t h a t each e l e m e n t can be explicitly tested; knowledge a n d c o m p e t e n c y levels can be ensured. U n f o r t u n a t e l y , however, the c u r r i c u l u m has no built-in m e c h a n i s m for ensuring humility. The p a r a m e d i c does a few v e r y i m p o r t a n t things, and he does those well. He has skills t h a t m a n y p h y s i c i a n s do not possess. In general, he t a k e s pride in his competence and becomes comfortable w i t h his d e l i m i t e d a r e a of specific responses to specific situations. Things go t e r r i b l y w r o n g , h o w e v e r , w h e n t h e p a r a m e d i c becomes sufficiently intoxicated with his new knowledge t h a t he begins to s u b s t i t u t e his j u d g m e n t a n d a u t h o r i t y for t h a t of t h e p h y s i c i a n director. O u r e x p e r i e n c e in P i t t s b u r g h suggests that, when the p a r a m e d i c begins p l a y i n g doctor i n s t e a d of p e r f o r m i n g as a paraprofessional, t h e q u a l i t y of p r e h o s p i t a l e m e r g e n c y care declines. The very instrum e n t s for s a v i n g lives become d a n g e r o u s toys in t h e h a n d s of those who r e g a r d R a m p a r t One as a superfluous voice on the radio. CASE REPORT A call w e n t out over police radio frequencies t h a t t h e r e was an unconscious w o m a n in the street. The p a r a m e d i c who serves in an administrative position with the city MICU service elected to respond to the call in his own vehicle. R e a c h i n g the scene, he found the w o m a n in cardiac arrest. B y p a s s i n g the hospital frequencies, which were closely m o n i t o r e d by t h e medical director, the p a r a m e d i c called for a n M I C U over police frequencies. As it happened, t h e police frequencies were b e i n g m o n i t o r e d at t h a t m o m e n t in the medical c o m m a n d station, a n d the medical director radioed to i n q u i r e about the s t a t u s of t h e patient. "We have a n unconscious woman," the p a r a m e d i c reported. ~'What are the vital signs?" the medical director inquired. "There is no pulse and no blood pressure. The p a t i e n t is not b r e a t h i n g . " ~'You m e a n you have a cardiac arrest."
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Table 1 SUMMARY OF SKILLS REQUIRED OF PARAMEDICS =
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, pressure point control, tdurniquet and military antishock 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 extrication.
A t this point, radio contact was "lost." N u m e r o u s at, t e m p t s by t h e medical doctor to reach the paramedics in the field were unsuccessful. M e a n w h i l e , u n d e r orders from t h e i r a d m i n i s t r a t o r , t h e p a r a m e d i c s i n i t i a t e d an i n t r a v e n o u s line and a d m i n i s t e r e d v i r t u a l l y every cardiac d r u g t h e y stocked, i n c l u d i n g s e v e r a l doses of calcium, Radio c o n t a c t was r e e s t a b l i s h e d w h e n the paramedics called in to r e p o r t t h e y were l e a v i n g the scene. The patient could not be r e s u s c i t a t e d a n d was pronounced dead at the receiving hospital. L a t e r i n q u i r y r e v e a l e d t h a t the p a r a m e d i c administra" tor had felt h i m s e l f e n t i r e l y c o m p e t e n t to m a n a g e a resus ° citation and had not w a n t e d ~'meddling" from the medical director.
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It is not possible to d e t e r m i n e w h e t h e r this. case would :hove turned out differently h a d the p a r a m e d i c s not chose~ to take m a t t e r s into t h e i r own h a n d s . I n m a n y such cases, however, serious errors of j u d g m e n t are commit•od Furthermore, it is of more t h a n academic significance !~. '~ ~ r a m e d i c s in such i n s t a n c e s are clearly f u n c t i o n i n g ~,ba~ ~'~ the law. They are not h•c e n s e d to practme . medl-• ide They are p e r m i t t e d only to c a r r y out the orders of i~ulY licensed physicians, paramedics, in sum, have very i m p o r t a n t skills. But, :like all of us, the p a r a m e d i c m u s t l e a r n to recognize his limitations as well as the c o n s t r a i n t s t h a t the law imposes on his actions.
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THE pHYSICIAN The requisite skills of the p a r a m e d i c have been c l e a r l y identified, and a c u r r i c u l u m to i m p a r t those s k i l l s h a s been developed. What about R a m p a r t One, the p h y s i c i a n at t h e o t h e r end of the radio? He, too, needs a special c o m p l e m e n t of new skills in order effectively to deliver medical care by remote control (Table 2). These are not skills t h a t are learned in medical school or even in p o s t g r a d u a t e t r a i n ing. Indeed, most p h y s i c i a n s c u r r e n t l y fur~'ctioning as Rampart One acquired the n e c e s s a r y skills t h r o u g h a difficult process of t r i a l and error. Perhaps the most i m p o r t a n t aspect of R a m p a r t One's training is f i r s t h a n d field experience, a T h i n g s are s i m p l y not the s a m e out on the streets. It is one t h i n g to i n i t i a t e an IV'line in the controlled s i t u a t i o n of an e m e r g e n c y department where e v e r y t h i n g is c o n v e n i e n t l y a r r a n g e d a n d well-lighted a n d q u i t e a n o t h e r t h i n g to c r a w l into a mangled automobile at night, a m i d h y s t e r i c a l b y s t a n d e r s and i m p a t i e n t police officers, and s t a r t an IV on a p a t i e n t pinned behind t h e s t e e r i n g wheel. The p h y s i c i a n at the other end of the radio m u s t l e a r n to a p p r e c i a t e t h e s e unique aspects of p r e h o s p i t a l care and adjust his expectations accordingly. F u r t h e r m o r e , periodic field experience enables R a m p a r t One to a p p r a i s e the p a r a m e d i c s w i t h whom he works. It is his only o p p o r t u n i t y to see t h e m under fire, to assess t h e i r j u d g m e n t and clinical skills. Retrospective case reviews s i m p l y do not provide t h a t information. Back at the base station, 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 e a l i t y of the p a t i e n t on t h e s t r e e t . He is a i d e d in t h i s b y t h e p a r a m e d i c ' s s k i l l in c o m m u n i c a t i o n . T h e p a r a m e d i c should be able to supply a d e s c r i p t i o n sufficiently detailed t h a t the p h y s i c i a n c a n form an accurate picture of the patient. Nonetheless, t h e r e r e m a i n s an e l e m e n t of unreality in t h e situatiot~. A p a t i e n t one c a n n o t see, touch or a u s c u l t a t e does not h a v e the i m m e d i a c y of the patient in the e m e r g e n c y d e p a r t m e n t . It is e a s y in such circumstances not to t a k e the e p h e m e r a l p a t i e n t in the street seriously. Yet he needs to be t a k e n seriously. F o r Rampart One is no less responsible for the p a t i e n t he treats by radio t h a n for the p a t i e n t he t r e a t s in person~:~ F u r t h e r m o r e , the p h y s i c i a n ' s p e r f o r m a n c e in r e m o t e control care is subject to a k i n d of a u d i t u n p r e c e d e n t e d in r~edicine. In any given region, R a m p a r t One is l i k e l y to J~P
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Table 2 PREREQUISITES FOR RAMPART ONE 3 1. Insight into the unique aspects of field conditions 2. Familiarity with radio c o m m u n i c a t i o n s and telemetry 3. Ability to formulate protocols and standing orders 4. Knowledge of health facilities in the region, p a r t i c u l a r l y special care u'nits, and t h e i r bed capacity and staffing at any given time 5. Knowledge of the capabilities 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. Ability 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 frequency w i t h other R a m p a r t Ones at other hospitals. Thus, his a s s e s s m e n t of information and the a p p r o p r i a t e n e s s of his responses are open to i n s t a n t peer review by e v e r y p h y s i c i a n (not to mention nurse, p a r a m e d i c and a m a t e u r radio fan) t u n i n g in on the same frequency. It is like p r a c t i c i n g 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 t h e l i t i g a t i o n - c o n s c i o u s physician more t h a n a few sleepless nights. Nonetheless, such s c r u t i n y is, in the final analysis, necessary. It is easy for t h e p h y s i c i a n sitting by the radio to become complacent. U n a b l e to witness first h a n d the actions of the p a r a m e d i c s , R a m p a r t One is a p t to m a k e the most comfortable assumption, ie, t h a t t h e i r descriptions are accurate, t h e i r j u d g m e n t impeccable and t h e i r performance beyond criticism. But t h a t a s s u m p t i o n is not always w a r r a n t e d , 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 finished w h e n t h e p a r a m e d i c s complete t h e i r t r a i n i n g p r o g r a m and are dispatched out to the streets. R a m p a r t One is e q u a l l y responsible for the ongoing m o n i t o r i n g of those paramedics, for u p g r a d i n g t h e i r skills and reviewing t h e i r performance, for r i d i n g with t h e m in the ambulances now a n d a g a i n and debriefing t h e m on selected cases_ He is responsible for t h e i r every action for t h e y are his eyes and e a r s a n d hands.
SUMMARY When viewed in t e r m s of the E u r o p e a n model, it is clear t h a t the p a r a m e d i c m o v e m e n t in this country arose as the logical consequence of physicians' abdication of responsibility - - t h e i r failure to do the job t h e y were mandated to do: to r e n d e r care to the sick and injured wherever t h o s e p a t i e n t s m i g h t be. For w h a t e v e r r e a s o n s , A m e r i c a n physicians - - u n l i k e t h e i r E u r o p e a n colleagues - - will not w o r k on ambulances. So by default, the t a s k w e n t to p a r a m e d i c s . U n f o r t u n a t e l y , there has b e e n a 378)53
s u b s e q u e n t t e n d e n c y to forget t h a t the paramedic has no a priori a u t h o r i t y to function, let alone practice medicine. Unlike the nurse, he is not even i n d e p e n d e n t l y licensed. On the contrary, his function is wholly derivative. He derives his sanction entirely from the license of a physician for whom he is supposed to act as proxy in c e r t a i n clearly defined and strictly controlled activities. We have by default, assigned to the paramedic c e r t a i n aspects of care of the critically ill and injured. W h e t h e r it is appropriate to have delegated the care of this v u l n e r a b l e p a t i e n t group is a n o t h e r question. The fact is, we have chosen to do so. But this should not m e a n t h a t we also delegate the moral responsibility for the welfare of those patmnts. Somewhere in our retreat from the patient, we m u s t stop a n d retrench. We, as physicians, bear responsibility for w h a t h a p p e n s to patients out on the streets, they are our patients. And each of us should make c e r t a i n t h a t those p a t i e n t s are receiving the same q u a l i t y of care we ourselves would deliver were we physically present. This m e a n s t h a t e v e r y physician in the c o m m u n i t y m u s t be involved in the emergency medical services system, m u s t be informed r e g a r d i n g the policies, s t a n d a r d s and practices o p e r a t i n g on the streets of his city. And it m e a n s t h a t R a m p a r t One m u s t be w i l l i n g to m a k e a total com= m i t m e n t to q u a l i t y control of his system. He m u s t be w i l l i n g to go out on t h e a m b u l a n c e s a n d m o n i t o r f i r s t h a n d the a c t i v i t i e s of the p a r a m e d i c s ; to review every case report; to obtain follow-up i n f o r m a t i o n on pat i e n t outcome; to insist t h a t paramedic skills be periodically reviewed and recertified. He m u s t n o t trade off medical s t a n d a r d s for political e x p e d i e n c y or m a k e com-
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promises in the q u a l i t y of medical care in order to plata, special interest groups or to spare himself the Work~ constant surveillance. These are not hypothetical iso.,~l Regrettably, we are a lre ady a c c u m u l a t i n g ample°::li dence from m a n y MICU systems throughout the cou~t~ of what happens w h e n medical control falls to physicia~ who are too indolent or not concerned enough to moait~t closely what is h a p p e n i n g i n the prehospital setting. Ra~. part One is not a game. It has been said t h a t the i n d i v i d u a l lying in the stre~ is, u n t i l he comes u n d e r 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 A m e r i c a n medicine and its apath~ He is the victim of the c a r n i v a l atmosphere that c~ r e n t l y pervades so much of prehospital emergency ca~ He is the victim of every physician who would abdicai responsibility 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.
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