LIFESAVING DECISION; FIREFIGHTERS OPPOSE PLAN TO SPLIT UP TEAMS.

Byline: Deborah Sullivan Staff Writer

As the Los Angeles Fire Department makes plans to put one paramedic on every San Fernando Valley fire vehicle by splitting up the pairs that now ride together, medical experts disagree on whether the strategy would benefit or endanger the patients they treat.

Fire officials say the plan would get high-level emergency care to patients in the first critical moments, while sending a second paramedic minutes later.

``The benefit of the program will be that those patients who are in need of time-critical lifesaving interventions will be able to receive those interventions more quickly than under the current deployment model,'' said Marc Eckstein, the Fire Department's medical director and an emergency physician at Los Angeles County/USC Medical Center.

It would also ensure more consistent emergency medical service to the Valley's fire districts, some of which now have two paramedics and others of which have none, he said.

``In general, this plan will place at least one paramedic in every district in the San Fernando Valley,'' Eckstein said.

Paramedics, however, say it would overwhelm the first person on scene with myriad life-or-death duties and disrupt the smooth-running teamwork essential to saving lives.

``It's a total degradation of service,'' said William Ramsey, a firefighter paramedic at Fire Station 91 in Sylmar. ``The responsibility it puts on one guy is overwhelming.''

The Fire Department is moving forward with its planning for the new policy, although it has not yet received necessary approval from the county health department, which now requires paramedics to be assigned in pairs on fire vehicles. Fire Department officials hope to implement the new policy this year.

The issue ripples with political undertones: Paramedics accuse the department of devising the new program to cut costs, not medical response times, while advocates of the program say paramedics fear the new system will impact their comfortable work conditions, not harm patient care.

What is clear is that the program will affect the estimated 90,000 medical calls the Fire Department responds to in the Valley each year, about 10 percent of which are critical emergencies.

At this time, five of the Valley's 35 stations have no paramedic and must borrow from neighboring stations in a crisis, slowing response times and leaving gaps in coverage.

The average response time for paramedics is 7.1 minutes in the Valley now, compared to 6.9 minutes citywide, said Battalion Chief Emile Mack.

Under the new plan, the first fire engine or ambulance would arrive with at least one paramedic in less than six minutes, providing lifesaving care in the critical four to six minutes, fire officials said.

An emergency medical technician - a lesser trained medical worker - would be paired with single paramedics on the first vehicle, fire officials said. A second paramedic would arrive on another vehicle minutes later.

In critical cases, such as heart attacks or respiratory blockages, those first few minutes may mean the difference between life and death.

That's why two paramedics are needed to perform the dizzying sequence of lifesaving procedures, including restoring heart rhythm, opening airways, inserting intravenous tubes, administering medication and making radio contact with doctors.

Critical time

While EMTs can perform basic first aid and cardiopulmonary resuscitation, they can't administer drugs or perform advanced invasive procedures and have less diagnostic training.

``When you get on scene, it's real time-critical,'' Ramsey said. ``You have a lot of things you need to do. If you've got one guy who's not a paramedic, you're bogged down.''

Paramedics also worry that during large structure fires or brush fires, when firefighters are pulled off their normal assignments, the second paramedic may never arrive at an emergency scene.

Furthermore, paramedics say, their split-second responses depend on well-honed routines with long-term partners.

``This always having a different partner or not having a qualified paramedic when you get on scene will put kinks in the smooth-running machine,'' said Wendy Cummings, a paramedic at Fire Station 2 in Los Angeles. ``The job is full of adapting to a situation. And the fewer adaptations we have to make, the more beneficial it is to the patient.''

Fire Department Chief of Staff John Ware said the department shares some of the paramedics' concerns and is working on plans to assure that two paramedics are dispatched to every emergency and finding ways for paramedics in the same areas to work together regularly.

However, Eckstein disputed paramedics' contention that the first few minutes require two paramedics.

``In a cardiac arrest, the first several minutes are all EMT skills, like CPR and defibrillation,'' the process by which normal heart rhythms are restored through the use of electronic current, he said.

And fire officials point to the handful of ``assessment engines,'' in which a single paramedic works side by side with an EMT, as success stories.

Immediate care

When paramedic Randy Perez from Fire Station 106 in West Hills arrives on scene, his EMT partner and other firefighters prepare his equipment, setting up the IV bag and respiratory tube, hooking up EKG patches and defibrillating the patient. And the engine crew can get to the scenes in minutes, providing immediate care when the nearest ambulance is miles away.

``That is the benefit of redistributing the paramedics - that you have a paramedic on every engine company who has the medications that make the difference,'' Perez said.

David Schriger, an associate professor of emergency medicine and public health at UCLA, takes that a step further, arguing that in urban areas, paramedics' advanced skills might not be needed at all. A study he prepared for the city of San Diego showed no statistical advantage to employing paramedics on emergency vehicles rather than EMTs, he said.

``In L.A. where we have such a high population density and such a high number of hospitals with short transit times, we have never proven that paramedics save lives beyond what EMTs do,'' he said.

Demanding job

That sounds like ivory tower rhetoric to Brian Johnston, chairman-elect of the board of trustees of the Los Angeles County Medical Association and medical director of the Emergency Department at White Memorial Hospital in East Los Angeles.

``On this issue I side with the paramedics,'' he said. ``When you're dealing with a full cardiac arrest, even two paramedics isn't enough. Imagine yourself confronted with someone who needs to be intubated, who needs an IV line, who needs to be defibrillated all at once and get on the radio, alert the hospital, get orders, and all this at the same time controlling a crowd, perhaps. It's very demanding.''

He said the medical association opposed a similar Fire Department plan several years ago and would likely oppose this one as well.

The plan requires approval from the Los Angeles County Department of Health Services before it can take effect. Virginia Hastings, director of the county Emergency Medical Services Agency, said the agency hasn't seen a formal plan yet but approves of the program in concept.

``It's certainly been reviewed by us on a conceptual basis, and we think it's basically sound,'' she said. ``The plan puts more paramedics on engines and gets paramedics there faster.''

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Photo: Warren Glenn, an EMT firefighter, and Randy Perez, a paramedic, work out of the fire station in Canoga Park.

David Sprague/Daily News