Medical Experiment

Should doctors run EMS programs? Louisville thought so--that's how Neal Richmond got there.
by | January 2006

Neal Richmond has a habit of making unconventional career moves. He trained in physics, then gave it up to pursue medicine. Now he's in local government, running emergency medical services in Louisville. That may not seem like an unusual thing, but it is. Although one might expect EMS departments to be in the hands of physicians, few of them are, for reasons that have more to do with history and bureaucracy than with practical needs. That's why Richmond's tenure is worth watching.

Post-Vietnam improvements in emergency medicine and cardiac care coincided with the beginning of the long-term decline in the number of fires. Fire departments, with less work to do than in the past, and with the skill and equipment to move around cities quickly, took on the job of responding to medical emergencies. For the average department, there are now more medical calls than fires.

But while they are doing the work, relatively few fire departments have embraced EMS as a primary mission. The percentage of people who survive heart attacks has improved in the fire-EMS era, for example, but rates vary tremendously among cities, meaning most could do better.

Reading about all this in a 2003 newspaper series, Louisville Mayor Jerry Abramson decided to try something different. He took EMS out of the fire department and put a doctor in charge. The fact that he was in the midst of reshaping city government after its merger with Jefferson County gave him the opportunity.

Abramson hired Richmond in 2004 from New York City, where he was deputy medical director for the fire department, felt "totally soaked in death-and-destruction scenarios" and wanted a change. In fact, though, Louisville is itself focused on disaster planning. It was recently selected by the federal Centers for Disease Control and Prevention as one of seven model cities that will test the ways emergency medicine can work with other public safety and health agencies in a crisis.

But Richmond, 51, says the best way to prepare for disaster is to get day-to-day operations running better. Over the past year, he's imposed many new procedures--both operational and medical--on a system that had been badly fragmented. He's redeploying units and working to end what he says was a traditionally lax response to medical calls late at night and on weekends.

The fire department doesn't necessarily like all the changes. "Our response times were better," insists Craig Willman, vice president of the firefighters' local. There's more of a consensus in favor of moves Richmond has made to improve care once personnel reach the patient. He's adopted protocols for defibrillators, ventilators and CPR that reflect medical knowledge fire chiefs don't have.

It's much too early to conclude that Richmond is revolutionizing EMS, but the results look promising so far. "I wanted someone who would drive the organization based on medical data and medical facts," Abramson says, "not just someone focused on the size of the ambulance fleet and the cost of gas."