Originally posted at www.VoiceoftheOC.com. Reprinted with permission.
In dissolving its fire department, Santa Ana will wave goodbye to traditions steeped in 128 years of fighting fires and saving lives.
Santa Ana Mayor Miguel Pulido, however, pledged a continuation of quality when he signed the deal this month for the Orange County Fire Authority to take over emergency services: “Whenever they [residents] call, they’re going to get the same services they’ve always gotten.”
But under the new OCFA system — designed to shave $10.5 million from a $30-million city budget deficit — there will be significant changes from how paramedic services have traditionally been provided since beginning in 1974.
When OCFA officially takes over on April 20, there will be five single-paramedic teams serving the city’s 325,000 residents, who previously were served by two-paramedic teams only. There also will be nine two-paramedic teams in the new system.
Interviews reveal that single-paramedic teams can delay the application of maximum care, inefficiently tie up multiple teams at a scene, and disrupt continuity of care, since the members of a treating team constantly change.
Some departments — including Santa Ana’s in the early 1990s — have been displeased with single-paramedic teams and have or are planning to move back to dual-paramedic arrangements.
Yet OCFA leaders are advocates of the single-paramedic concept, utilizing them in each of their current eight battalions, which serve 22 cities around the county. The authority deploys 41 two-paramedic teams and 27 single-paramedic teams. In 2010, OCFA paramedics responded to nearly 61,000 emergency medical calls.
For Santa Ana’s new system, OCFA officials say there will be at least one paramedic in all 10 stations but three of the stations will have only single-paramedic teams. Two of the three single-paramedic teams are at stations also staffed with two-paramedic vans. In the current system, there are no paramedics assigned to four stations, which offer less-trained emergency medical technicians as first responders providing basic life support.
“Our goal is getting advanced life-support [paramedic] care there quicker for a higher level of assessment,” said Scott Brown, an 18-year paramedic who is OCFA’s emergency medicine program manager. A single paramedic on the scene can administer drugs for specific illnesses, set an intravenous line for fluids and insert a windpipe tube to ensure a victim is receiving adequate oxygen, he said.
Single Teams, More Delays
When single-paramedic teams are sent, another paramedic team of either one or two paramedics is also dispatched to join the first responding team. Then, if necessary, one of the later-arriving paramedics can combine forces with the initial paramedic to provide the full complement of life-support services via radio communication with nurses or physicians at hospitals. If the initial paramedic can handle the required services, the second team can be freed to handle other cases.
In some other jurisdictions like Fullerton and Fountain Valley, fire department leaders are not as sanguine about single-paramedic teams. Fountain Valley eliminated their only single-paramedic team this month, deciding to upgrade to a two-paramedic ensemble due to displeasure with the issues other departments also have seen.
Fire Chief Wolfgang Knabe, manager of both Fullerton and Brea’s departments, said he plans to adjust resources in July 2013 to eliminate the two single-paramedic units Fullerton deployed in November 2010. He said he would eliminate the single-paramedic teams this July were it not for a tight budget.
“The concept doesn’t work well,” said Knabe, a 27-year paramedic, citing delays in providing advanced life support.
The deployment of the single-paramedic teams caused “a domino effect” of delaying responses from 4 to 24 seconds across the Fullerton system, he said. Five of six stations have paramedics, who make about 9,000 emergency medical runs annually, he said. The exception was one single-paramedic team improved response times by 29 seconds.
For about four years in the early 1990s, Santa Ana also tried single-paramedic units, but they were eliminated because the department found dual-paramedics more effective, said Dave A. Thomas, Santa Ana’s current fire chief, who was a paramedic at that time. Also, the skills of paramedics declined on some procedures in the single-paramedic system because of lack of practice, he added.
Two-paramedic teams “are the Cadillac system,” said Thomas. “They provided the greatest services to one of the most needy populations.” As he was unfamiliar with the OCFA plans for Santa Ana, which he will manage, he declined comment on the new system.
By county standards, a first responder is to be on scene in five minutes and a two-paramedic team within 10 minutes in 90 percent of cases. While increases of seconds may seem small, Knabe doesn’t like the trend.
At a station in north Fullerton where paramedics respond to illnesses associated with the area’s older population, Knabe said, “There are a huge number of cardiac or difficult-breathing calls now covered by a single-paramedic unit; we want to get back to two-paramedic response.”
Examining single-paramedic team deployments in its current system, OCFA found that about 2½ minutes elapsed before a patient received advanced life support from two paramedics, Brown said. His agency is constantly evaluating such performance and adjusting resources accordingly, he added.
OCFA’s Biggest Job
Across Santa Ana, there are about 18,000 fire department responses a year, about 14,400 of them medically related. Santa Ana will become the Battalion 9, the largest component of the OCFA system. The city’s poverty, crime and related socio-economic dynamics can be expected to increase the overall intensity of emergency service compared to what the authority provides in Laguna Hills, Irvine or Placentia.
Providing emergency services in heavily populated Santa Ana also can be complicated by the overloading of hospital emergency rooms, which can tie up paramedic units that must continue to provide care while waiting for an opening for admitting their patient.
In January, the county Health Care Agency completed a report for 2010 showing hospital emergency rooms from Santa Ana through Anaheim experienced patient “saturation” for from 300 to 700 hours a year; thus delaying or blocking admission at peak times of need.
“It is a significant problem,” said Dr. Samuel J. Stratton, director of emergency and disaster services for the Health Care Agency and a UCLA professor. Santa Ana’s two base-station hospitals are Western Medical Center in the city, with 301 hours of overload in 2010; and UC Irvine Medical Center in Orange, with 443 overload hours that year.
Battalion Chief Rory Calhoon of Fountain Valley, which has paramedics at two fire stations handling about 4,400 emergency medical calls a year, said emergency room overload complicates the ability to get paramedics back into the field. And he said a single-unit paramedic team increased the likelihood his department would call for “mutual aid” from another jurisdiction, thereby shifting burden to another region.
Eliminating the single-paramedic team after four years of deployment, Calhoon said, “was the right thing to do;. It made sense, was better service for the community. The extra paramedic is cheap compared to the diminished service without it.”
Its also important to note that just as Santa Ana is shifting to the use of the single-paramedic teams, Orange County’s entire emergency medical system is undergoing substantial enhancements, giving paramedics more authority in the field and improving their communication systems.
New Rules Along with New Deployments
But paramedics will no longer be allowed to deliver patients to hospitals with overloaded emergency rooms, Stratton says, because they are considered “unsafe.” Overall, this could mean longer transports and reduced paramedic availability.
Asked about single-paramedic teams, Stratton said they evolved from putting two-paramedic teams on first-responder vehicles for quicker care, changing later because of budgetary restraints.
“Single-paramedic units now often are deployed to meet county-required response times in an economic way,” he said.
Dr. Bruce E. Haynes, now emergency medical director for San Diego County, who held the Orange County post prior to Stratton, said single-paramedic teams have “worked fine” in both San Diego and Orange County.
Yet, when asked to cite a peer-reviewed, published study on patient outcomes comparing single-paramedic to dual-paramedic deployment teams, Stratton said: “I don’t think there are any.”
Can anyone say the new Santa Ana system won’t reduce the level of paramedic service? “Nobody knows,” he added.
Rex Dalton is a San Diego-based journalist who has worked for the San Diego Union-Tribune and the journal Nature. You can reach him directly at firstname.lastname@example.org.