Many lives are lost across USA because emergency services
By Robert Davis, USA TODAY
WASHINGTON Help came too late for Julia Rusinek.
The 21-year-old Yale sociology student, an accomplished runner, collapsed on
a busy street corner in the nation's capital on a summer evening in 1999 after
working out at a nearby gym.
Rusinek had more than a fighting chance to live: She was
healthy except for a hidden condition that caused a sudden electrical short
circuit in her heart. Her heart needed a zap within six minutes
from a common medical device known as a defibrillator. Bystanders saw her fall,
rushed to help and immediately called 911.
But Rusinek's life ticked away on the corner where she
fell. Twelve minutes passed before an ambulance crew connected a defibrillator
to her chest. Like thousands of others every year in cities across the country,
Rusinek lost any chance she had to survive because of an emergency medical system
that consistently fails to save as many lives as it should. (Related video:
of surviving cardiac arrest depend on where you are)
In post-9/11 America, where war and fears of terrorist
attacks have brought the need for effective emergency response into sharp focus,
a USA TODAY investigation finds that emergency medical systems in most of the
nation's 50 largest cities are fragmented, inconsistent and slow.
People die needlessly because some cities fail to make
basic, often inexpensive changes in the way they deploy ambulances, paramedics
and fire trucks. In other cities, where the changes have been made, people in
virtually identical circumstances are saved. Those sharp differences surfaced
in the 18-month investigation, which included a survey of city medical directors,
analyses of dispatch and response data; interviews with fire and ambulance crews
and on-site visits and ride-alongs with "first responders."
Rusinek's case illustrates the failures of the system:
She died of sudden cardiac arrest, a condition that serves as one of the truest
measures of an emergency medical system's effectiveness. Whether victims live
or die depends primarily on how fast they get treatment. For years, the conventional
wisdom was that help must come within 10 minutes. But new findings from the
Mayo Clinic show that lives actually are saved or lost within six minutes.
The USA TODAY survey and data analysis show that, of the
250,000 Americans who die outside of hospitals from cardiac arrest each year,
between 58,000 and 76,000 suffer from a treatable short circuit in the heart
and therefore are highly "saveable." Yet nationwide, emergency medical systems
save only a small fraction of saveable victims, and rates vary widely from city
The analysis shows:
- The chance of surviving a dire medical emergency in the USA is a matter
of geography. If you collapse from cardiac arrest in Seattle, a 911 call likely
will bring instant advice and fast-moving firefighters and paramedics. Collapse
in Washington, D.C., and as one EMS official suggests someone
better call a cab for you. Seattle saves 45% of saveable victims like Rusinek;
Washington, D.C., has no idea how many victims like Rusinek it saves. The
city estimates it saves 4% of cardiac arrests, but inconsistent record-keeping
makes it impossible for Washington to account accurately for its most saveable
- In the nation's 50 largest cities, about 9,000 people collapse each year
from cardiac arrest caused by a short circuit in the heart. Only an estimated
6% to 10%, or as few as 540, are rescued. If every major city increased its
save rate to 20%, as a number of cities have done, a total of 1,800 lives
could be saved every year.
Like Rusinek, those who could have been saved are often
young and vibrant: corporate executives who die at work, students who drop dead
in school gymnasiums, commuters who never come home from their jobs.
At the same time, Rusinek's case was unusual. At least
three people witnessed her collapse and the emergency response. Her family sought
answers from rescuers, and details of her death were reported in the media.
Most victims are hidden from public view by sealed medical records and a health
care system that routinely tells families their loved ones "died instantly"
and "we did everything we could."
What is not said and what families often do not
know to ask is precisely how, and how quickly, emergency services responded
to the call for help.
Over the next three days, USA TODAY will delve into three
major reasons that emergency services in most U.S. cities are saving so few
people in life-or-death situations:
- Many cities' emergency services are undermined by their culture. Infighting
and turf wars between fire departments and ambulance services cause deadly
- Most cities don't measure their performance effectively,if at all. They
don't know how many lives they're losing, so they can't determine ways to
increase survival rates.
- Many cities lack the strong leadership needed to improve emergency medical
services. Leadership by the mayor, the city council and community health
officials can make a dramatic difference. Boston, for example, more
than doubled its survival rate over 10 years under the direction of a strong
mayor who demanded change and enlisted city officials, businesses and many
residents in the drive to save lives.
Tackling turf wars
Of these three problems, turf wars between paramedics and
firefighters the focus of today's articles arguably are the most
The conflict has developed over time as rescuers' roles
have changed. Call for an ambulance today in a big city, and the first rescuers
to arrive are often firefighters. Most cities have turned their firefighting
teams into rescue squads as medical emergencies have become more common than
"The logic is obvious," says J. David Badgett, an assistant
chief with the Los Angeles Fire Department. "Geographically, fire stations are
close. There are a lot of us in the fire department. We're an emergency service
Every major city has more fire engines than ambulances,
and while both a fire engine and an ambulance are dispatched to the scenes of
most serious medical calls, fire engines often are closer and able to get there
Today's average fire department answers twice as many calls
for medical emergencies as for fires. The job of dealing with the sick has slowly
nudged aside the task of dousing flames.
The shift has been met with resistance in many fire departments,
USA TODAY found. Many firefighters said they were unhappy because they signed
on to fight fires, not to tend to sick people. Beyond that, fighting fires is
sharply different from delivering emergency care.
"The typical firefighter is a very linear person," Badgett
says. "They see a problem, they defeat the problem, they leave a winner. On
a fire you do that. Emergency medicine isn't like that."
It takes time and experience for firefighters to feel comfortable
using some medical equipment without paramedics backing them up. So even though
firefighters usually are trained to use defibrillators the portable devices
that shock a dying heart back to life some admitted in interviews that
they were hesitant at first to do it in a real crisis by themselves.
Jeremy Gruber, a Montgomery County (Md.) Fire Rescue captain,
paramedic and Washington D.C.-area defibrillator trainer, says delivering advanced
medical care is often most difficult for the veteran firefighters. "We have
people who have been on the job for 30 years, and they are used to doing it
one way and they have never really evolved with the technology and the changes,"
Fire departments that want to deliver medical care, he
says, should "hire people who are already medically trained so you know they
have an interest in that. You're not going to be able to force-feed somebody
who doesn't want to be there."
Failure in Washington, D.C.
The changing roles have caused resentment in many big-city
fire houses, and resentment can affect performance. Washington, D.C., exemplifies
First aid is part of a Washington firefighter's job. A
fire engine responds with an ambulance on serious medical calls. But the crews
don't always work well together.
Over 18 months, a reporter visited Washington crews on
the front lines dozens of times, sometimes scheduled, sometimes unannounced.
During those visits, emergency workers were more likely to be at each other's
throats than watching each other's backs.
Ambulance crews made it clear they view firefighters as
lazy; firefighters view ambulance crews as undisciplined. Every day in Washington,
firefighters and the paramedics who back their ambulances into the same fire
stations are likely to be quarreling over everything from where they park and
what they eat to whose job it is to care for the sick and injured.
In 2001, using stopwatches, city officials found that Washington
firefighters don't respond as quickly to medical calls as they should. Their
finding prompted the city to buy global positioning equipment so officials could
track the movement of rescue vehicles.
USA TODAY reviewed more than 85,000 emergency calls to
examine those delays more closely. The analysis of turnout time the time
it takes for firefighters to run to their rig and roll out the door toward an
emergency shows that Washington firefighters' median response time was
faster to a dumpster fire than to a report of a cardiac arrest.
The fire crew responding to a report of a structure fire
got rolling in 82 seconds, despite having to don protective boots, pants, coats
and breathing apparatus. In response to a report of a cardiac arrest, which
requires no special preparation, the crew took 124 seconds to reach the rig.
Kenny Lyons, who heads Washington's paramedic union, tells
his loved ones not to waste time dialing 911 if they face a dire medical emergency.
"If they can find someone to drive them to a hospital, drive them. If they can
somehow catch a cab, go," he says. The poor performance of the system, he says,
"is haunting to the providers, and it should be chilling to the community."
culture problems are not unusual. Most cities refused to answer USA TODAY's
question comparing response times on fires and emergency medical calls, but
a few cities, including San Francisco, Mesa, Ariz., and Wichita, said their
firefighters also are slower to respond to medical emergencies than to fires.
Medical directors, doctors hired by the cities to supervise
emergency medical care, are often aware of these delays, but many told USA TODAY
in the survey and interviews that they are viewed as outsiders by firefighters.
The directors can make suggestions to improve care, but the fire chiefs have
the final say about how money will be spent and how resources will be deployed.
In Los Angeles, fire department commanders and a powerful
firefighters union view fire suppression as the main focus of the department,
with medical services "a very distant second," says medical director Marc Eckstein.
He says many obstacles, including a "lack of attention
to emergency medical systems issues, overwhelming priority in terms of training,
and budget for fire-suppression activities instead," stand in the way of better
performance. Still, he says, "our department is much further along in merging
the two cultures than most."
In St. Louis, tension between fire suppression and emergency
medical crews results in fights over funds and misunderstandings about the other
side's jobs and concerns, says medical director Mark Levine. Within this embattled
system, efforts to monitor performance have been "poor but improving," he says.
Of the 28 medical directors who answered USA TODAY's question
about what forces in their systems affect performance and patient outcomes,
16 cited fire department culture or unions as key
Fernando Daniels, Washington, D.C.'s medical director,
was one of them. "The traditional thinking was bad: 'All we want to do is put
fires out,'." says Daniels, who is in his third year in the job. He has begun
an ambitious plan that includes mass CPR training, getting defibrillators into
more buildings and measuring the system's performance accurately.
But like the would-be reformers before him, Daniels has
struggled to see his fixes take hold in a culture resistant to change. "To make
the system work, you've got to get those barriers down," he says.
The firefighters union says the barriers go up in cities
when fire and ambulance services are merged poorly. Firefighters now provide
the vast majority of "pre-hospital" emergency medical service in the country,
says Harold Schaitberger, president of the International Association of Fire
Fighters. "And they do it with professionalism, commitment and esprit de corps
that is unrivaled by any other public safety sector."
Where ambulance services and fire departments are merged
"on a systematic basis with strong leadership, ample training and education,
and effective response protocols," the result is very successful, Schaitberger
says. "What creates confusion are those cities, like Washington, D.C., that
have EMS (ambulance service) under the fire department umbrella, but in actuality
EMS is still a separate service with a separate command structure, separate
training regimens, separate pay and benefit programs, and more transient employees.
"In these cases, firefighters often feel no affinity with
EMS. They wince when EMS is criticized by the public and the media because it
reflects on the fire department, yet they have no control and little participation
on the EMS side of operations."
Washington fire chief Adrian Thompson, who was named to
the post by the mayor last November, says he is taking steps to address this
problem. Over the next month, he says, the fire department will undergo a major
change of structure. All ambulance crew members will have to apply to be firefighters
to keep their jobs, a move aimed at establishing a uniform standard for all
employees of the fire department. And in the future, he promises there will
be a paramedic firefighter on all 33 of the city's fire engines.
"People don't realize that with firefighters and EMS workers,
one group seems to thumb their nose at the other group," Thompson says. "We
hope that this will bring some unity to the department."
Lyons, head of the paramedics union, has his doubts. Quality
emergency care, he says, requires "full-time dedicated paramedics and emergency
medical technicians that are committed not forced to provide patient
"While many will argue that dual-role cross-trained personnel
will provide a bigger bang for your buck, what it will provide is more firefighters
and few paramedics," he says. "This attitude has forced many paramedics out
of the profession and discouraged many others from pursuing EMS as a career."
From his 16th Street apartment window in Washington, D.C.,
Jonathan Agronsky says, he saw Julia Rusinek on the ground on the evening of
July 15, 1999. He rushed to the firehouse less than a block from where she fell.
The firefighters there said a fire engine from another
station farther away had been dispatched and was on the way. The ambulance crew
was going off duty.
"I was so mad I couldn't see straight," Agronsky recalls
now. "I could have throttled those guys."
He and a fire official agree that only after another man
ran into the station saying the woman down on the street corner was turning
blue did Truck 9 roll. Lt. John Desautels, the officer in charge on Truck 9
that day, says he and his crew were following protocol designed to send smaller
fire engines, not the long ladder trucks, to medical emergencies. "The initial
call was a woman down," Desautels says. "We get 100 of those a day," and most
are not life-threatening cases.
When it became clear the situation was more critical, he
says, they drove to the woman's side. But they did not use their defibrillator,
Desautels says, because his men reported that the woman had a pulse. Instead,
they called for Ambulance 1, still in the station.
Then the firefighters watched along with anxious
bystanders as the ambulance rolled down the fire station driveway, then
turned in the opposite direction and drove away, Desautels says. The crowd yelled
at the Truck 9 firefighters, who called the dispatcher to tell the ambulance
to turn around.
Desautels says Rusinek's heartbeat disappeared just as
the ambulance arrived and that the firefighters performed CPR, but they still
did not use their defibrillator. By the time the ambulance reached Rusinek,
she had been down for 12 minutes. The ambulance crew shocked her repeatedly,
but she was declared dead at a hospital a mile from where she fell.
Rusinek's mother, Roza, visited the fire station after
her daughter died to try to learn what happened. "Many people there were totally
unconcerned," she says. But, she says, "one fireman there dared to look us in
the eye, and he was crying."
That fireman was Desautels, who has been honored three
times for heroics at the scene of fires, including for daring, lifesaving rescues.
"I had to explain how sorry I was," he says.
But the mother, who immigrated from Poland, is still critical
of the ambulance crew that initially refused to attend to her daughter because
the shift was ending. "I can't imagine how good an evening that person had to
make up for our tragedy," she says.
Rusinek's father, Henry Rusinek, a New York University
Medical School radiology professor, says he wonders whether anything can be
done to improve Washington's emergency medical response.
Agronsky, an author who went on to write about the woman's
death in Washington's alternative City Paper, is still angry. "I could have
put her on my back and walked her to the hospital, and she would have had a
better chance of surviving," he says.
Rusinek's death should have been a wake-up call for Washington's
emergency medical system. It was an opportunity to study the flaws in the system
and make improvements.It's rare when a victim collapses so close to help, goes
so long without having a defibrillator applied and still is a candidate for
a shock more than 10 minutes after collapse. It is even more rare when such
an episode becomes public knowledge.
But her death didn't change things much. The city's average
response time for fire engines going to medical emergencies was slower in 2001,
the year studied by USA TODAY, than in 1999. Ambulance response times improved
only slightly in that interval.
And problems remain. Last December, for example, a paramedic
was dispatched to a report of a cardiac arrest at 6:01 p.m., but his shift ended
at 6, so he drove back to his firehouse to go off duty, according to news reports.
Firefighters performed CPR on the victim for 25 minutes until the new paramedic
crew climbed into the rig and drove to the scene from the firehouse about five
Unlike Rusinek, the victim had chronic health problems
and was not a candidate for defibrillation. He wasn't in the category of the
most saveable, so his death was not shocking. But the response which
made local headlines was.
Success in Seattle
In 2001, Seattle saved 45% of victims like Rusinek
those who are seen going down and who suffer from a treatable short circuit
in the heart. And unlike Washington, D.C., Seattle is able to provide a detailed
accounting of its victims.
One of the biggest factors contributing to Seattle's success
is its culture. There, the medicine delivered in the streets comes from firefighters
and fire department paramedics who have very different jobs but work on the
same team. Each has a well-defined role to play in the patient's care, with
firefighters reaching victims first and performing basic care until paramedics
arrive to administer advanced cardiac life support.
Paramedics grade the firefighters' care on critical trauma
calls. They fill out a "blue sheet" that details what the less-trained emergency
medical technicians on the fire department team have accomplished by the time
the paramedics arrive.
That accountability pushes first responders to deliver
rapid treatment and have the patient ready for transport. It gives critical
feedback on how they performed and what they can do better next time. It helps
the paramedics spot the firefighters with a knack for emergency medicine as
they look for new recruits. And the paramedics are scrutinized on every run
by their medical director, Michael Copass. Copass reads every run report, and
the paramedics know they will be called to task for any error. They say they
feel him looking over their shoulders as they make care decisions.
Seattle has led the nation's big cities in emergency medicine
research and provided the model that medical directors have followed in other
cities, including Washington.
Washington, D.C., Mayor Anthony Williams says his administration
is rebuilding city agencies that long have been in disrepair, including the
fire department. "We're improving," he says. "We're just starting from way,
way behind in so many areas. We're moving our way up, and I think you're going
to see that improve."
His medical director hopes that changes come quickly.
"These disparities shouldn't exist," says Daniels, who
vows that Washington one day will have an emergency medical system as good as
Seattle's. "Folks need more scrutiny. We are here to save lives."
Contributing: Rati Bishnoi, Tracey Wong Briggs,
Jacqueline Chong, Anthony DeBarros, Neal Engledow, Mary Grote, Erin Kirk, Jim
Norman, Paul Overberg, Emma Schwartz, In-Sung Yoo