As a wee lad, I loved watching Emergency! on TV. However, even as a child, there were aspects of the way paramedics were dispatched that seemed extremely wasteful to me.
On TV, our heroes John and Roy are firefighters with special paramedic training. They are dispatched on a variety of emergency calls to perform on-scene medical care and to rescue people from various predicaments. They roll out to calls in a truck dubbed a “Squad”. The truck carries their medical and rescue equipment, but has no room to transport patients. Instead, a private ambulance service is dispatched with two guys in white who load up the victim and haul him to Rampart General Hospital for care. This seems absurd. Why not send the paramedics out in an ambulance in the first place? They could find the victim, rescue him from his car wreck or the top of a crane or whatever, fix him up, load him in the ambulance, and head off to Rampart. Why the need for four guys and two vehicles?
Also, John and Roy have to contact the doctors and nurses at Rampart before doing so much as applying a Band-Aid. In my limited experience needing EMS care (in Texas), the paramedics arrive (in an ambulance) and have the autonomy to take action immediately without needing to reach out to a hospital. Do paramedic/firefighters in California still have to call in for every little thing?
Essentially yes, and it’s because the EMTs and the Ambulances are two entirely separate operations. The EMTs are (generally) part of the fire department, so they go out immediate for an emergency call. There are fire stations located all over the place, so they come quickly.
Ambulances are stationed only at a few central staging areas, not at the fire stations. They are often private companies with contracts with the municipalities. They take much longer to arrive than the EMTs.
EMRs are your basic First Responder/Wilderness First Responder certification trained in basic first aid (CPR, rescue breathing, immobilization, primary wound management, basic diagnostics, Focused Spinal Assessment) and can only provide over-the-counter medications (with a few exceptions for WFR under direction of patient or physician). EMTs and AEMTs are generally staffing ambulances, providing emergency and supplementary medical care under direction of a physician, and staffing first aid posts at public events; some fire departments require that all responders be trained to at least the EMT level. Many municipalities contract out basic ambulance services that are entirely separate from municipal fire and rescue, and these are almost exclusively staffed by EMT/AEMT because they are much cheaper.
Paramedic is the highest level of NREMT certification and is at the equivalent of an 2 year associates degree; most fire departments will have a staff of dedicated paramedics who are first responders to trauma and major casualty events, and yes, they do often use vehicles called “rescue truck” or “quick attack truck” like this which contains a lot of rescue gear such as hydraulic cutters and spreaders, SCBA equipment to deal with atmospheric hazards, et cetera depending on the environment they are working in which would not be practical to carry in an ambulance. They are intended to work in concern with fire suppression support but may also be called in for non-fire hazards and mass casualty events, and often have additional training beyond medical support.
Each level has a difference scope of practice with regard to emergency drug administration, intrusive and traumatic medical care, patient assessment, et cetera. As noted, a EMR level can generally only provide over-the-counter analgesics, antihistamines, and topical medications; an EMT will have a specific list of drugs that can be provided by nebulizer and intramuscular as well as pills; AEMTs have a longer list of drugs and delivery methods as well as IV an subcutaneous, while paramedics can delivery a large list of drugs with all methods including infusion pump and intraosseous infusion (ouch!). Similarly for airway management and breathing control, EMRs can only use non-invasive methods and facial oxygen mask, while EMTs can use oropharyngeal and nasopharyngeal devices with supplemental oxygen and positive pressure ventilation, AEMTs can use supraglottic airway devices and CPAP, and paramedics can perform endotracheal intubation through cricothyrotomical incision and treat tension pneumothorax by decompression needle or thoracostomy.
At the time that Emergency! (one of my favorite childhood shows, BTW) was in production, the protocols for EMT/Paramedic were not well established, and the idea of training “ambulance attendants” whose job was really just to scrape up patients and deliver them to the ER, was pretty novel outside of a battlefield context, as were non-physicians performing life saving medical interventions beyond basic wound care, so the paramedics are seen relaying diagnosis and being given explicit direction by a physician. However, advances in trauma care learned during the Korean and Vietnam wars were filtering into the civilian trauma medical community. As a result, agencies were cautious about giving too much autonomy to paramedics but as standards of practice and evidence of the value of prompt trauma care developed it became clear that trained emergency medical responders were just as crucial to trauma medicine as “Shock Trauma” medical centers and dedicated ER surgical physicians. Today all levels of EMS care can take immediate measures to preserve life and treat major trauma that are within their scope of practice autonomously, and generally speaking EMT/AEMT will give advanced treatment or assessment only under direction, and paramedics can perform many emergency procedures and assessment without direction.
In my area, the Fire Department is still dispatched on a lot of medical calls. They have EMT’s, who can assess the situation and decide if an ambulance is necessary. If you see a fire truck sitting outside a private residence, with its lights flashing, it’s more likely to be a medical call than a fire call.
If you ever get to see the first episode of Emergency!, you’ll see their main medical contact, Dr. Brackett, portrayed as being very skeptical–indeed, downright hostile–to the idea of firefighters “practicing medicine.” I imagine that there were any number of doctors at the time who felt the same way when the paramedic program was first introduced.
Wikipedia has an entry for Squad truck, whose description basically matches the “quick attack truck” that you link to. It took me a long time, watching Emergency!, to figure out that when the dispatcher said “Squad 51,” he was talking about the truck, not about the group of firefighters.
Where I live, 911 often results in fire, police, and an ambulance, mostly as a CYA measure, because people so frequently give incomplete information when they call, and/or things change for the worse in the few minutes between the call, and arrival.
BTW, “Emergency” was filmed 50-odd years ago. Nowadays, the big rivalry is between EMTs and nurses, and it sounds like they don’t like each other much.
Factoid: The name “Gage”, which has risen in popularity in recent years, came from that program.
If you watch episodes of other Jack Webb shows like Dragnet and Adam-12 it’s obvious that Webb was a strong proponent of public service employees staying in their own lane. In addition to the roles of detectives and patrolmen constantly being delineated in those shows, a common line from characters like Joe Friday or Pete McCoy was “That’s for the courts/social workers/doctors/psychologists, etc. to decide.” It makes sense that Webb’s technocratic philosophy would ensure that a hybrid character like a parametric should be kept on a short leash.
That’s still how the Los Angeles County Fire Department does it (though I think the private ambulance people have actual qualifications now). There are other fire departments in California that have their own ambulances, and places where the fire department is less involved with emergency medicine.
Stranger provided an excellent overview of the current state of EMS and the course of its development from its early days. Allow me to fill in just a few details, regarding how much it varies from state to state and from one locality to another.
This results from EMS being a very fragmented field, compared to nursing or physician level medicine. Or to firefighting, which has stronger national organizations and more consistent practices.
The result is that a basic EMT in a very progressive system with oversight by forward thinking medical sponsors may be allowed to do things that are forbidden to paramedics in neighboring regions. (This would be an extreme case, but I’ve seen situations very close to this.)
Depending on the system, initial emergency care might be provided by first responders, such as Johnny and Roy, while a private ambulance arrives subsequently and transports the patient. Or the local Fire Department may do both. Or the private ambulance service might be the one responding to the 911 call, only requesting Fire for special circumstances.
Or EMS might be a municipal third service (an independent agency, much like the Fire Department). Or another variation: ambulance transport may be provided by a hospital based service. And these are only some of the combinations.
Interestingly enough, there was an episode where Jim Reed basically espoused the philosophy behind “defund the police”, where he thought sending social workers or mental health professionals for some calls was smarter than sending cops. Webb was ahead of his time!
While I used to watch this show as a teenager (and had a sister that had a wild crush on Johnny Gage), it wasn’t until recently I caught the first season’s episodes on one of the “old folks’ channels”. In the first two or three episodes, they actually tell the story of getting the necessary legislation to allow paramedics at all and then setting up the infrastructure. Dr. Brackett is actually one of the people shown lobbying the California legislature.
(Second question first) No, EMTs and paramedics these days do not have to request a doctor’s order for most of the things they do in providing emergency care. They still need orders for anything that is considered advanced life support, but written standing orders have largely taken the place of calling in for these orders, especially for time-critical interventions like defibrillation.
Nevertheless every EMS system I’ve worked in has had some medications or procedures that required voice contact with a physician before being administered. If required for too many
Not sure why my post above was truncated. Curious!
To continue: If such contact is required for too many interventions, EMTs will speak scathingly of it as a "mother may-I " system.
(First question) Yes, it can be wasteful to send two vehicles and four responders to the scene. But in many other instances the four (or more) people and extra equipment are desperately needed. Since it isn’t always possible to tell this in advance, over-dispatch is preferred to under-dispatch.
Other times it is easy to tell, but extra responders are sent anyway. I’ll be cynical and bluntly honest: this is so that come time for budget allocations the Fire Department can say, “we assisted EMS 200-umpteen times last year.”
This isn’t just my own jaded opinion. I sat in an management course at the National Fire Academy where the instructor said multiple times, “EMS is where the money is,” and started one lesson with, “it’s important for Fire to keep control of EMS. Let’s discuss some strategies for doing this.”
Multiple factors influence the practice of dispatching first responders. Some are based on what’s best for the patient.
Thank y’all for the interesting discussion. As a tyke, the politics of starting the paramedic service totally passed me by. I was much more interested in recreating the rescues using my toy cars and trucks.
As an adult, I have seen the opening episode regarding the Wedsworth-Townsend Act that authorized paramedic service in California. In the Emergency! storyline, Brackett is quite skeptical of the program, but eventually comes around. One reason he ends up supporting the idea, though, was somewhat self-serving. John and Roy swung by the hospital to pick up Nurse McCall on the way to a rescue. A nurse was required on-site to authorize medical care. During the rescue, Dixie is injured. Brackett is, shall we say, quite smitten with Dix and is upset that she was injured performing a rescue. (Apparently, CA frowned on firefighters doing medical stuff, but was okay with nurses doing rescuing stuff!) Of course, the real Julie London was, at the time, married to the real Bobby Troup (Dr. Early) and the ex-wife of Jack Webb. The cast of the show was its own soap opera. I’m glad that the writers mostly dropped the Brackett/McCall romance. It was quite creepy in modern terms.
I also read somewhere that Governor Reagan signed the Wedworth-Townsend Act because his father had recently died of a heart attack. An ambulance service that was nearby could not respond to the call for help because the senior Mr. Reagan was in a territory covered by a different, though more distant, service. Reagan died while waiting for help. The Governor (and future President) liked the idea of bringing effective help to the victim more quickly without worrying about whose territory you might be in.
As seen in the episode where Gage, DeSoto, and Kelly encounter the aftermath of a head-on collision in the middle of nowhere while returning home from a fishing trip.
I grew up out there then. While in college I drove past the real station that represented station 51 every time I went between home & school. And a lot of times besides just banging around greater LA. As mentioned above, even then practice varied.
The Los Angeles County FD operated their paramedic service as shown on the show; the paramedics fixed people up enough for some other contracted company to haul the patient to the hospital. Potentially freeing the paramedics up to go do something else useful for somebody else while the ambulance did boring taxicab duty.
My college roommate’s dad was a big honcho at the Los Angeles City FD at the same time. The two agencies (mostly politely) hated each others’ guts. LA City paramedics did it the other way; their truck was an ambulance and after patching up the patient a bit they’d haul them to the hospital in their vehicle.
In my own hometown in nearby Orange County, we used the same system as LA City: integrated paramedic / ambulance teams.
What’s funny about that is Emergency!'s world seemed to be entirely within county islands. You’d never* see LAPD or LAFD, it was always LAC Sheriffs responding.
Even as a kid, I thought the paramedic should transport. They had to go to the hospital with the patient anyway (was it the law, or just practice?) and hand them off to the doctor. So the squad was always there, blocking the emergency entrance. What, they couldn’t park off to the side?
Emergency! was THE show that got paramedics widely accepted. There is a recent documentary about the show and its impact that is really enlightening. It’s humorous how the real life paramedics actually act like Johnny and Roy. They especially mentioned the “double thumb pop” of the injected drug, as seen in the credits. They all think that’s great!
* Except when they met Jim Reed and Pete Malloy at the hospital. Not to be confused with the episode where they were watching the TV show Adam-12. It’s Meta-licious!
