In the 1960s, when EMS was beginning, Dr. Eugene Nagel set some of the standards of physician involvement in EMS. At that time, he was the medical director forthe Miami Fire Department (MFD), where he introduced many of the early techniques used in EMS today. He was so confident firefighters could perform these new techniques that he was willing to go to great lengths to convince others.
One of those people was MFD Chief Larry Kenney, who was worried that his department was getting too involved in medical treatment, specifically in starting IVs. He asked Dr. Nagel to present the idea before the Miami Commission, where Dr. Nagel had one of the paramedics insert an 18-gauge needle in a vein in his arm and began a drip of fluids. Dr. Nagel then said he would rather have a trained paramedic performing emergency treatments like that than a passing physician. The commission passed the measure unanimously, and IV therapy for emergencies in the street formally began.
Read what Dr. Nagel had to say about the past, present and future of EMS.
Question: What gave you the vision to create the fire-based paramedic?
Answer:In the early days, [it was called]Miami Fire Department "Rescue." Ú Many of the chiefs had ridden rescue in the early days ('40s and '50s) and so to them nothing had changed. Miami Fire only had one rescue truck, an ancient Gerstenschlager that felt like it had solid rubber tires and carried about a ton more[about] rescue equipment than the rating of the truck.
Lt. [William] McCullough and I met in 1963 over a cardiac arrest in our building, and after I pronounced the victim dead, he said, "No matter what we do they all die." That's what got me started because in the hospital we would occasionally save one. So, we tried to do in the street what had worked in the hospital and to do it as simply and safely as possible. In those days, there were no ICUs, no emergency physicians, no emergency department nurses, and a few avaricious lawyers waiting to make millions on every supposed mistake.
Question:How did you employ the invasive paramedic skills to the fire department?
Answer:In order to get Chief [L.L.] Kenney to agree to allow us to start IVs, I had to go before the Miami Commission Ú and allowed a fire paramedic to start an IV in my arm. We used 18-gauge steel needles because the catheters had not been invented yet. The intubation was strictly prohibited by Chief Kenney, but I trained six officers using cadavers, then dogs, and then one night a resident, Harry Heinitsch, and I sprayed 4% cocaine spray in each other's throats, and we intubated each other and then each officer intubated each one of us. The next morning I presented this to Chief Kenney and he offered a few choice words and then OK'd the use of intubation, provided the officer get one try and that was it.
The medical direction for any procedure had to be OK'd via radio link before it was done. So my cardiology friend, Jim Hirschman, and I had to be on the radio 24/7. In later years a standard protocol could be used. We would meet monthly in the union hall and review our progress, or lack of [it].
Question:What do you think the current status is between the relationships of fire departments and physicians both then and now?
Answer:Then: The relationship was extremely difficult and time consuming. One of my jobs was to answer the media, victims' families and other doctors. There was a very poor understanding of our job, our limitations and expected outcomes.
Now: The Brass expects the doctor to protect the department from criticism. Along the way teach the teachable and unteachable, provide Q/A, be reasonable on budget request, make the department look good and support fire combat operations.
Question:How can the "traditional" fire department better embrace EMS delivery?
Answer:By understanding EMS expectations and limitations. This requires understanding how we got there and where we are going. Not an easy task.
Question:How did you tap into the culture?
Answer:By trying to bring some of hospital medicine to the streets.
Question:What advice do you have for the 30 year-old emergency department resident coming out of training?
Answer:I would have themspend time teaching in a paramedic prgram, preferably.
Question:Where do you think it [EMS] will go?
Answer:More regulations, more legality, more protocol, more unnecessary expense, bookkeeping, billing and understanding government-ese. Along with that may come better emergency care than at the present, but it is not inevitable.Click here to read the article, "Have You Seen Your Medical Director Lately?"