John Bowman was 74 years old when he died for the first time.
That was on the afternoon of July 13. Bowman (not his real name) and his wife were in their southeast Seattle home when he suddenly collapsed and slumped to the floor, the victim of acute cardiac arrest. His wife's first action was to rush to the phone and dial 911.
Today, Bowman is alive and well.
What happened between the time Bowman's wife dialed the number and the time he walked unaided from the hospital is testimony to this city's emergency medical system and, more specifically, to its paramedic program, known as Medic One.
It was 12:21 p.m. when Mrs. Bowman's call reached the fire department dispatch center downtown. Within four minutes, a fire engine manned with emergency medical technicans was at the Bowman home. Five minutes later, a two-man paramedic unit arrived and, for the next hour and a quarter, administered advance medical treatment.
Bowman had been clinically dead, but by the time the paramedics delivered him to the coronary care unit at Cabrini Hospital he was alive and they were able to enter into their written report that they "definitely" were responsible for saving his life.
Bowman's case, while not typical because the response time was almost double the average is yet another in a growing number of success stories that have earned the Medic One program literally worldwide acclaim during its first decade of operation.
What is it about the Medic One system that has made Seattle, as one observer put it, "the best place to have a heart attack?" The answer seems to lie in a number of factors, the overriding one being the manner in which the program is run. Those same people who praise Medic One as excellent and "the best in the world" also refer to its organization as paramilitary and to its administration as "one of the few dictatorships left in this country."
If Medic One is dictatorial in its administration, then the benevolent dictators are the program's director, Dr. Leonard A. Cobb, 53, known as "the father of Medic One," and Dr. Michael K. Copass, 41, who was appointed deputy program director and director of paramedic training by Cobb four years ago.
Both men are faculty members at the University of Washington's school of medicine and Cobb also is director of cardiology at Harborview Medical Center, Seattle's major hospital. Niether is paid for his role in the paramedic program, but their authority is absolute. "Our program is run by two physicians, by Dr. Cobb and Dr. Copass," explained Lt. Ralph Maughan, a former paramedic now in the fire department's research and development section. "There isn't a board, there isn't a committee, there's two people, period. They run the program and they make the decisions. I think that't the real key to how it works."
Neither Cobb nor Copass will argue the point, although there are elements in Seattle's medical and political hierarchy that would prefer to see a more broad-based and democratic administrative system.
"There is a contention that there should be a board, that decisions should be made by a group," Copass said in an interview, adding, however, that he believes this would lead to vested interests becoming involved in the Medic One program and to "dissemination of the responsibility for action."
As it now stands, the lines of responsibility are clearly defined. While the city's 49 paramedics and more than 400 emergency medical technicians are all firefighters they report directly to Cobb and Copass in all medical matters. A little historical perspective is necessary to appreciate the close ties that have developed between Seattle's fire department and the medical community.
The five department, now with 958 sworn personnel, has provided some type of first-aid care for as long as anyone can remember, and certainly since the 1930s.
When state law in the mid 1960s permitted, and in fact encouraged, the training of firefighters in cardiopulmonary resuscitation, Seattle took advantage of this by establishing a system of aid cars, fire units manned by firefighters trained in cardiopulmonary resuscitation. A few years later, Seattle joined Los Angeles, Jacksonville, Fla., and Columbus, Ohio, in pioneering the paramedic concept and the paramedic program was simply grafted onto the existing aid car program.
It was out of this merger that Cobb devised and instituted Medic One. The fact that the 911 emergency call system already had been instituted made it that much easier.
Today, the city's 500,000 residents are served by four two-man Medic One units; one is based in the northern portion of the city, one in the south and two at Harborview Medical Center, home of the paramedic training program. In addition, there are eight emergency aid units staffed by medical technicians, and, because almost half the firefighters in the city have such training (the goal is to have the entire fire department trained), every fire unit in the city has at least one, and usually two or three medical technicians on hand when it answers an alarm.
This has led to what is known as a "tiered response." When a citizen reaches the fire department after dialing 911, one dispatcher will ascertain the location and nature of the emergency, while another, also monitoring the call, will determine where the nearest engine company, aid car and paramedic unit are and will send them to the scene.
Naturally, the dispatcher's task is a difficult one because he has to determine the extent and acuteness of the emergency to know whether or not a paramedic unit really is needed. Copass describes the dispatchers, all of whom are highly trained and some of whom are former paramedics themselves, as both "the strongest and the weakest links" in the operation.
When in doubt about the seriousness of an emergency, dispatchers will play it safe and send the paramedics. Because engine companies are the most numerous, they are the first to arrive on the scene, followed closely by the aid unit. If the emergency is less serious than first believed, the medical technicians in the aid unit can "code green" the paramedics, notifying them while en route that they are not needed and allowing them to return to base.
Response times, of course, are crucial, and for that reason, use of a computer enables the dispatcher to tell immediately which available fire, medical technican and paramedic units are nearest to each of the city's more than 14,000 intersections.
"The average response time by an engine company to any intersection is 2.6 minutes," according to the fire department. The average aid car response time is 3.07 minutes and the Medic unit average is around five minutes.
Under ideal conditions, the longest response time any paramedic unit would log is nine minutes. Depending on weather and traffic conditions, that could be lengthened to as much as 14 minutes in the extreme northern and southern portions of the city.
Part of the reason for the success of Seattle's paramedic program is the geographic make up of the city itself -- the city covers only 96 square miles, being roughly 12 miles long and eight miles wide -- and in the nature of its half-million residents.
Copass sees "a sense of self-reliance permeating Seattle" and this is reflected in the fact that no fewer than 227,000 of its residents have cardiopulmonary training, the result of a highly successful campaign by the medical community in the early 1970s.
That residents' concern about the paramedic program was evidenced early in its history when the federal and city funds supporting the program ran out, and the local politicians apparently were willing to let it die. A well-orchestrated public relations campaigns by the fire department generated $225,000 in public donations, most of it in $1 to $10 contributions, Copass said.
"This was enough to keep the program going and also told the city fathers that this was a popular public service which the citizens themselves would not tolerate monkeying around with," Copass said. Today, the program remains relatively inexpensive, taking just $1.3 million of the fire department's $26.5 million budget.
Seattle residents have become so familiar with and so confident in the system that roughly 75,000 to 80,000 requests for medical assistance come in via the 911 number each year. After screening by the dispatchers, about half of these actually require an emergency medical technician response, while roughly 10,000 to 12,000 require the dispatching of paramedics.
While the number of calls for help has risen, so has the success rate, as measured by the number of cardiac arrest victims treated.
"The number of people who leave the hospital has literally tripled," since the first year or two of the program, Copass said. "It's gone from roughly 8 percent or 9 percent to roughly 33 percent. We have a sort of standard saying: you have one out of two chances of being resuscitated and one out of four chance of going home. No one else in the United States can match that."
Although there have been those who have questioned the figures, most members of the medical community -- at least in Seattle -- support them.
"Their evaluation is detailed and very professional," said Seattle surgeon Dr. Jay M. Kranz, whose involvement in emergency medical care was focused more on the state and national level. "I would be pretty confident about their figures."
According to Kranz, the program's success is due not only to the close connection between all components of the emergency medical technician system but also to its operational management.
"It's paramilitary, it's very tight, it's very closely supervised, a physician is on top of every move these guys make," he said. "Their reports are reviewed every day and I don't know of another paramedic program in the whole country in which every run is reviewed every day by the medical adviser."
The man who reviews the highly detailed reports that the paramedics have to fill out is Copass, who said the report forms "were designed by physicians to generate physician-type information."
By almost any measurement, Seattle's Medic One program is an unqualified success, but there is disagreement over whether a similarly successful system could be established elsewhere based on the Seattle model. Kranz thinks not.
"The visitor may get the idea that Medic One is an off-the-shelf item where you can take a lot of notes and go back to say, Tulsa, Okla., and put this kind of system in place," Kranz said. "I don't believe that's possible because there are many local peculiarities that make this particular method and these particular operational techniques appropriate here and they would not be appropriate anyplace else."