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Before 2001, if you called an ambulance in New York City because your child was having an asthma attack, the emergency medical technician-basic (EMT-basic) who arrived had limited tools to help.

That has changed now in both the city and state, due to the findings of a study led by Dr. David Markenson, assistant professor of population and family health and pediatrics, who started his health care career as a teenage EMT on the Upper East Side of Manhattan. Dr. Markenson, who is also director of the Program for Pediatric Preparedness at the National Center for Disaster Preparedness in the Mailman School of Public Health, published results from the study in the January/March issue of PreHospital Emergency Care.

"Most EMS calls about kids are because of breathing problems, and more times than not, it's asthma," Dr. Markenson says. Still, before the new rules went into effect the EMTs who responded were not allowed to administer albuterol to those having asthma attacks. Albuterol is frequently effective in stopping an attack.

Janet Bentkowski, an EMT with the New York Fire Department (FDNY) who has been on the job for 16 years, says the situation was frustrating. "Before, we could only administer oxygen and get the person to the emergency department quickly so they could get more help."

"Albuterol is not only an important treatment for asthma attacks, it's time-sensitive. If administered quickly it reduces wheezing," Dr. Markenson says. "But if it's not given, then in just the time it takes to get to the hospital the attack can worsen severely and become harder to control." Asthma accounts for 1.5 million visits to emergency departments each year in the United States; 5,000 people die from severe asthma attacks each year.

"The problem in New York City and the rest of the country is that there are two levels of EMTs – EMT-basics and paramedics – and the difference between what the two are allowed to do is like night and day," Dr. Markenson says.

EMT-basics, who take a two-month training course, are limited to providing care such as bandaging, immobilizing, administering oxygen, and CPR. They cannot give medications like albuterol, which can only be administered by more highly trained paramedics, to people having an asthma attack.

But EMT-basics outnumber paramedics, sometimes 20 to 1, so scarce paramedics are usually deployed in cardiac cases, when someone is having chest pains or a heart attack.

Luckily, Dr. Markenson says, the state of New York has a provision in the public health law to allow researchers to test additional techniques to determine whether EMT protocols should change.

With the help of colleagues at New York University and the support of the Regional EMS Council of New York, Dr. Markenson designed a research project to see if EMT-basics, after passing a four-hour training course, could correctly identify an asthma attack and administer albuterol.

The protocol was approved by the New York State Commissioner of Health before EMT-basics from 29 area hospital, commercial and volunteer services were enrolled in the one-year study, which ended in 2001. The FDNY conducted a similar study at the same time with its own EMT-basics.

"In our study we found that EMT-basics correctly identified asthma attacks 85 to 90 percent of the time and that patients improved because the EMT gave them albuterol," Dr. Markenson says. "In many cases, the EMT-basics' actions stopped the patient from going into respiratory failure, a fatal condition if not treated adequately."

Even before Dr. Markenson's results were published, the study prompted New York to change the rules for administering albuterol. All EMT-basics could receive additional training and now all are allowed to treat asthma attacks with albuterol in children over age 5 and adults under age 59. Rural parts of the state may see the greatest impact of the rule, since many upstate counties are served only by EMT-basics. In New York City, all EMT-basics in the 911 system have been trained.

"The change has had a really positive impact on EMTs' job satisfaction and ability to care for patients," Dr. Markenson says. "EMT-basics now feel they're able to help patients more."

Ms. Bentkowski, the EMT, concurs. "This change is one of the best things Emergency Medical Services has done."

The research was supported by the Regional EMS Council and Regional EMS Medical Advisory Committee of New York City, the 29 EMS agencies who funded training for the EMTs participating in the study, and the EMS providers who enthusiastically gave of their time to support this improvement in health care.

—Susan Conova


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