Seattle and King County Emergency Medical Services System

History

In 1968, motivated by the work of Frank Pantridge, cardiologist Leonard Cobb proposed to the chief of the Seattle Fire Department, Gordon Vickery, training firefighters to treat cardiac arrest. The department was attractive to Cobb because it already provided first aid and tracked its performance electronically.

In 1969, they trained fifteen firefighters and used a grant from the Washington/Alaska Regional Medical Program to convert a large motor home into a Mobile Coronary Care Unit (nicknamed “Moby Pig”) which would respond to calls with both the firefighter paramedics and a physician on board.

The first Medic One call was on March 7, 1970 and during the program's first year, 31 lives were saved. The following year the program was changed, replacing the on-board doctors with fire department paramedics given advanced special training and remote access to the doctors.

In 1974, TV news-magazine, 60 Minutes, profiled the success of Medic One, lauding the high standards of training and education provided by the Seattle training program. Correspondent Morley Safer declared, “If you have to have a heart attack, have it in Seattle.” A phrase still used frequently in conjunction with Medic One, due to its continued success which is reflected in the area's high survival rate for heart attacks and their comprehensive CPR training program.

That same year Medic One incorporated as a privately held, non-profit organization and established the Medic One Foundation, which works on behalf of both fund raising and the expansion of the program. The program is financed by local property tax levies, which are voted on by the public every six years, along with private and corporate donations.

Medic One had saved 655 patients from cardiac arrest by 1976 and this success was gaining national and international attention. Medic One service was expanded into the rest of King County in 1976 and, in conjunction with the Medic One Foundation, other counties in Washington State began paramedic programs to serve their communities.

In 1979, Cobb and UW professor Mickey Eisenberg began training fire department emergency medical technician - Basics (EMT-Bs) to perform the administration of defibrillation for patients in cardiac arrest since the EMTs were usually at the patient’s side several minutes before the paramedics. Eisenberg began training 9-1-1 dispatchers to provide instructions to lay-persons on how to perform CPR in 1982. With the introduction of automatic external defibrillators (AEDs) in 1984, EMTs were able to defibrillate patients in cardiac arrest even quicker.

Programs

There are five paramedic programs in the Medic One system.

Seattle Medic One

Seattle Medic One is the paramedic provider program serving Seattle. It is operated by the Seattle Fire Department. The paramedic medical director for Seattle Medic One is Michael Copass. The Seattle program conducts field internships for the University of Washington Paramedic Training Program.

King County Medic One

King County Medic One is the paramedic service serving all of South King County provided by Public Health - Seattle & King County. Its medical director is Peter Kudenchuk.

Structure

Founded on strong physician leadership Medic One is structured around response, training, and quality improvement.

One of the primary components to the success of Medic One is their “Tiered Response System” which begins with the citizen call to the 9-1-1 center. Emergency Medical Dispatchers are trained to rapidly triage the call to dispatch the appropriate level of assistance, while providing pre-arrival instruction of CPR. Firefighters, with EMT training, respond first to deliver immediate Basic Life Support (BLS), pending the arrival of the paramedics. Specially trained paramedics arrive within minutes to provide Advanced Life Support (ALS) and, if needed, can provide transportation to the nearest appropriate Medical Center.

The system is successful due to the blended cooperation between the fire department and paramedic/ambulance services, as well as, a strict policy of meticulous measurement of system performance and cardiac arrest survival information. Strong leadership and regional programs promote uniformity in medical care and response, regardless of jurisdiction.

Another critical element to the Medic One program is the comprehensive training program for the paramedics, one of the most stringent anywhere, making their paramedics some of the most thoroughly trained in the world. Only paramedics with at least three years of prior firefighter or EMT experience may enter the program. Medic One paramedics receive 2,000 hours of instruction, using both “book” studies and hands on field and clinical application through both the University of Washington and Harborview Medical Center. The national standard for paramedic training is just 1,100 hours. Medic One paramedics will have more than 700 patient contacts during their training, which is three times the national standard. Upon completion of training Medic One paramedics are considered to be an extension of the ER doctors and may perform advanced medical care, open airways and administer a variety of medications

The final component is an emphasis on community based CPR training, called Medic Two. The Seattle/King County area has the highest per capita number of citizens that are trained in the administration of CPR techniques, approximately 50% of its residents.

Leadership

Medic One is operated as a partnership between physicians and administrators. Medical directors review patient care by paramedics and can make recommendations including decertification and termination. Administrators act upon the recommendations of the medical director.

Response

The major components of Medic One's response system are universal access, dispatcher triage, basic life support services, advanced life support services, and transport to hospitals.

A medical 9-1-1 call is handled by one of the following communication centers Seattle Fire Department Alarm Center, Valley Communications Center, North East King County Regional Public Safety Communication Agency, Port of Seattle Police Department Communications Center, or Enumclaw Police Department Communications Center.

Medic One dispatchers use criteria based dispatch guidelines to send the most appropriate care providers. The three response levels are basic with advanced life support units, emergency BLS only, and non-emergency BLS only.

The first tier is basic life support provided by cross-trained firefighter emergency medical technician - basics.

The second tier is advanced life support.

Basic life support transports for 9-1-1 calls are provided by either a fire department or one of the private ambulance companies American Medical Response and Tri-Med Ambulance. Advanced life support transports for 9-1-1 calls are provided by paramedics.

Education

All paramedics in King County are graduates of the University of Washington Paramedic Training Program regardless of previous training. The training is 1,866 total hours consisting of 380 lecture hours, 120 lab hours, 466 clinical hours in the operating room and emergency department at Harborview Medical Center and critical care unit and labor and delivery at Seattle Children's Hospital, and 900 field internship hours with Seattle Medic One. Students see an average of 700 patient contacts.

Improvement

The paramedic medical director for the one of six Medic One programs that provided care reviews every resuscitation, intubation, and central-line placement attempt. That director provides both positive and negative feedback. For probationary paramedics a more rigorous review is conducted.

Funding

Medic One paramedic programs are funded by a property tax levy. Basic life support services receive partial funding from the levy. The levy passed in 1979, 1985, 1991, 1998, 2001, and 2008. The levy did not pass in 1997.

The Medic One Foundation is a nonprofit charitable foundation supporting paramedic training, research, medical oversight and quality review, and the purchasing of emergency medical equipment.

Cardiac Arrest

A change in the protocol of emergency response personnel is also credited as contributing to the high survival rate in the region. Guidelines set by the American Heart Association in 2000, recommend repeated shocks from a defibrillator and to check for a pulse prior to starting CPR. Medic One guidelines, established in 2005, are to provide a single shock from a defibrillator followed immediately by two minutes of CPR, beginning with chest compressions. This has dropped the average time between first shock to starting CPR from twenty-eight seconds to seven seconds, resulting in a near 50% increase in the previous rate of survival. For every one-hundred cardiac arrest calls, now an additional thirteen patients will live.

In King County outcomes of attempted out-of-hospital resuscitations are recorded, following the Utstein uniform reporting guidelines, in a cardiac arrest registry. In 2008 Medic One's survival rate for witnessed cardiac arrests due to heart disease prior to EMS arrival with initial rhythm of ventricular fibrillation or ventricular tachycardia was 49%.

The average response time for basic life support personnel for cardiac arrests from time of 9-1-1 being dialed to arrival is 4 minutes 40 seconds and for advanced life support personnel is 9 minutes 45 seconds.

In 2008, 58% (530/920) of EMS-treated cardiac arrests not witnessed by EMS in Seattle & King County CPR was initiated by a bystander.

Endotracheal intubation

Seattle Medic One's first-pass success rate for oral endotracheal intubation is 75% (years 2001–2005). Its overall success rate is 98.4%.

Research