At a time when advances in emergency medical care have significantly improved survival rates for victims of heart attacks, strokes and other traumas, Chicago continues to operate with an outdated emergency medical system, and city officials have ignored recommendations that would have brought it on par with others across the nation.
Only last month did the Chicago Fire Department put into service its first fire engine staffed with medically trained personnel and equipped with a defibrillator.
But even with this step, the EMS remains woefully deficient, a Tribune analysis of the system reveals, the apparent victim of politics, union infighting and inadequate funding.
Even as the number of emergency medical calls in the city rises and the number of fire calls declines, the city has not increased its supply of ambulances, nor has it trained more firefighters to become paramedics–a demand that paramedics have pushed vehemently for years.
The deficiencies become especially critical at this time of year, when poor weather and snow-clogged streets can further lengthen emergency response times.
Meanwhile, in Dallas, Los Angeles, New York, Philadelphia, Phoenix and San Diego, every firetruck is equipped with a defibrillator–a life-saving machine that helps restore the heart rhythm–and staffed with firefighters who can deliver advanced life support. In Houston, firetrucks have carried defibrillators since 1984.
Though there is no national standard to measure the effectiveness of an EMS, an examination by the Tribune of the systems in the nation’s eight largest cities shows Chicago falls dramatically short in many areas:
Chicago has the fewest ambulances compared to population; has the lowest percentage of firefighters trained in advanced emergency medical care; is the only city without a response system that matches the type of equipment and medical expertise to the call; and has a low survival rate for heart attack victims. Houston’s and Seattle’s rates are five times better.
And even though a 1987 blue-ribbon panel appointed by then-Mayor Harold Washington set 3,000 calls per year per ambulance as a reasonable number, today each of the 59 Chicago Fire Department ambulances responds on average to more than 3,700 calls a year.
“When you have ambulances that are working so hard that they are out of their district and it takes another ambulance twice as long to respond, I can say that not having optimum response times has probably led to some people dying who should not have,” said Dr. Stanley Zydlo, a pioneer in developing emergency medical systems and the man who headed two committees that looked into Chicago’s system.
Some Chicago paramedics echo Zydlo’s comments.
“When you are doing 15 to 20 runs a day, the chances are pretty good that someone who desperately needs an ambulance will call and you just can’t get there for 10 to 15 minutes,” said one 20-year veteran who asked not to be named because department rules prohibit statements to the media. “And that can make the difference between life and death.”
Only recently did the fire department say that it was considering training all new recruits as emergency medical technicians, a designation that requires far less training than paramedics but equips firefighters to provide some forms of emergency care.
Fire department spokesman Mike Cosgrove said that the cross training is a top priority of new Fire Commissioner Edward Altman.
Officials with other fire departments and national EMS consultants agree there’s no one-size-fits-all system for delivering emergency medical care.
“The bottom line is the EMS providers must utilize the personnel and the equipment wisely to get the best response times,” said Steve Athey, an EMS consultant based in Texas. “Maybe it means shifting people around or cross-training firefighters or buying new ambulances or using a private-public partnership.”
For more than a decade, Chicago officials have resisted such modernizations.
Among the roadblocks to change: city leaders who do not want to spend the money to add ambulances and hire paramedics; and union infighting between paramedics, who account for just 13 percent of the fire department’s work force, and firefighters, who control most of the jobs as well as six of the seven top union spots.
Chicago paramedics have long charged that the fire department brass–most of which has risen through the ranks of firefighting–fought change in an attempt to save the jobs of firefighters, who, over the years, have seen their workload decrease as structure fires in the United States declined dramatically. They say city and union officials had two choices, either get rid of firefighters or cross-train them.
Last year, the city’s 630 paramedics responded to more than 222,000 calls.
The city’s 4,200 firefighters responded to 171,000 calls: 29,000 fires, 71,000 non-fire emergencies such as gas leaks and 71,000 calls where they were sent to assist paramedics.
“The union doesn’t want more paramedics because then we would have a bigger voice when it comes time to vote (in union elections), and the firefighters just can’t bear to give up that power,” said a high-ranking paramedic.
Union officials could not be reached for comment.
Zydlo, who organized the Midwest’s first paramedic system in Chicago’s northwest suburbs, said the reluctance to change is, in part, a political power struggle.
“You have what the fire department wants administratively, what the participating hospitals want and what the fire department union wants,” he said. “It had nothing to do with right or wrong. It was a power thing.”
The push to upgrade the EMS began in 1986 when, after a series of scathing media reports, city officials appointed an expert panel to look into the city’s program. The group produced a report calling for 60 ambulances (based on an average 3,000 calls), training all firefighters as EMTs and switching paramedics to an eight-hour workday.
None of those recommendations has been implemented, and with the number of ambulance calls climbing from about 171,000 in 1987 to more than 222,000 last year, the city would need 74 ambulances on the street to meet the 1987 task force guidelines. Today, Chicago operates 59 ambulances, and 1997 calls already are 10,000 more than they were at the same time last year.
Though there is no hard and fast rule on how many calls paramedics should run each day, some in the industry say one every three hours is a good rule of thumb. Chicago paramedics run, on average, 11 calls per day, but some–specifically those in more depressed areas on the South and West Sides–often handle twice that number.
Fire officials in Phoenix, which has one of the country’s more advanced emergency medical systems, also use 3,000 as their target number.
“When you get much higher than that, you have to deal with the fatigue factor and then you have to worry about the kind of service you are delivering to the citizens,” said Capt. Bob Khan of the Phoenix Fire Department, which added more ambulances recently to ensure that paramedics keep their calls to a manageable level.
In 1993, Mayor Richard Daley appointed his own study task force. That group produced a report–which was never made public but has been obtained by the Tribune–that called for staffing each fire engine with an EMT trained in defibrillation and implementing what is described as a tiered response system.
Under the tiered system, basic life support ambulances are sent to less serious incidents, where a highly trained paramedic is not needed. About 53 percent of all Chicago ambulance calls are BLS.
Four years after Daley ordered the report, few things have changed.
Chicago officials toyed recently with the idea of putting 10 more ambulances on the streets. But when that proposal failed to win the support of Daley or the fire department’s top brass, the city decided instead to upgrade some fire engines to provide advanced life support.
After months of wrangling, the fire department put into service last month its first fire engine with a defibrillator. Since then, seven more have been upgraded, though officials had planned to have 25 in service by Nov. 1.
The fire department’s resistance to cross-training firefighters as EMTs or paramedics caused the delay. In fact, the city needed a waiver from the state to allow it to run the upgraded engines with firefighters.
In Los Angeles, Phoenix and San Diego, every firefighter is an EMT, and many are paramedics. In the other large cities, a high percentage of firefighters are EMTs.
“It’s just common sense that when the number of fire calls are declining and the number of medical calls are increasing, you should readjust your resources to meet that demand,” said Khan, of the Phoenix Fire Department, which, for 20 years, has required firefighters to be EMTs. “It saves money and it can save lives.”
Chicago also lags behind when it comes to instituting a tiered response system.
Every time a citizen calls 911 for medical assistance in Chicago, whether it be for a sprained ankle or a heart attack, a dispatcher sends an ambulance equipped for advanced life support and staffed by two paramedics. That procedure is not duplicated by any of the other largest cities in the country.
Instead, these cities have two levels of ambulance response: advanced life support, staffed by at least one paramedic, and basic life support, staffed by emergency medical technicians. EMTs have about one-tenth the 1,000 hours of training paramedics receive, and they cannot perform more invasive procedures, such as starting an IV.
“When (paramedics) are busy transporting people with broken arms, broken legs, those are things that can be handled by a basic emergency medical technician,” said Dr. Paul Pepe, director of emergency medicine at Allegheny General Hospital in Pittsburgh. “They are not available to respond to the type of calls where they can really make a difference.” Pepe is one of the nation’s leading authorities on emergency medicine and directed the reorganization of the Houston and Seattle emergency medical systems.
Some Chicago paramedics agree.
“Many of our calls could be handled by a taxi,” said a paramedic who works on the Southeast Side. “People are poor, they do not have regular doctors; if they have the flu or a headache, they call 911.”
A 1993 study of the Houston Fire Department published in the Annals of Emergency Medicine noted that when dispatchers asked a series of simple questions, they were able to send basic units to 40 percent of the 35,075 calls. A further examination showed that the arrival of a paramedic instead of an EMT would have improved care in only five or six cases.
Chicago’s single response level is a legacy of the late Mayor Richard J. Daley.
Initially, Chicago had a BLS service, but it began to change in 1972 after an Illinois Central train crash killed 45 people. Daley did not approve of the way things were handled, and he started to build an advanced life support service.
“It is nice to have a BLS unit when you have someone with a broken leg, but in terms of mass casualties, it is much, much better to have advanced life support,” Cosgrove said.
Chicago officials have not reacted to another national trend: adjusting the 24-hour workday.
Chicago paramedics work 24-hour shifts, often with little or no time to rest, and then have 48 hours off. Other large cities are trying more innovative means to staff EMS units.
New York paramedics work eight-hour shifts. In Philadelphia, they work two 10-hour days, followed by two 14-hour days, followed by a four-day break. In Dallas, paramedics work 24-hour shifts with 48 hours off, but they split their work time between the ambulance and less demanding chores on a firetruck.
Chicago’s 1987 blue-ribbon panel recommended changing to eight-hour shifts. The panel also recommended adjusting schedules to place more ambulances on the streets at peak periods.
Neither has been implemented.
