Japan’s paramedics in a straitjacket

On April 1, Japanese paramedics will take a small but significant step toward catching up with their counterparts in the United States and Europe: For the first time in their brief 15-year history, they will be allowed to administer a drug, the heart stimulant epinephrine, though only in cases of cardiac arrest. Hopes are high among many ambulance workers that this will pave the way to the expansion of their role in emergency medical care. However, in the absence of any widespread public concern, the government has shown little sign of making further legislative changes or resource allocations in this direction.

The Japanese public, on the whole, is blissfully unaware of just how limited the scope of its emergency medical technicians is by the 1948 Medical Practitioner Law under which they operate. Recruited, trained and employed by fire departments of local governments, most Japanese paramedics were previously firefighters, and are still regularly rostered for firefighting duties. This accords with the fire authorities’ traditional view of the primary role of paramedics as being to provide an emergency transport service to hospital. “In principle, paramedics are firefighters,” in the words of a Tokyo Fire Department spokesman.

Yet today, emergency calls for ambulances far outnumber those for fire engines, as the incidence of fire has, thankfully, peaked. However, traffic congestion is causing ambulances to take longer to transport patients to hospital. In Tokyo, the average time taken is 40.4 minutes, well over the national average of 29.4 minutes — and this is after taking 6.3 minutes, on average, to get to the scene of an emergency.

Clearly, this is all the more reason for expanding the role of ambulance rescuers, re-establishing them as full-fledged medical technicians capable of performing a broad range of emergency medical treatment in order to save more lives.

This is the norm in developed countries, and doctors say Japanese paramedics were created in 1991 with this objective. Over the last 15 years, however, it appears, minimum efforts have been expended toward this goal. Until three years ago Japanese paramedics weren’t even permitted to use defibrillators without doctors’ supervision — via the phone. “I know of many cases where lives were lost while waiting for a doctor’s approval,” says an emergency physician at the Nippon Medical School Hospital in Tokyo. A one-minute delay reduces survival rate by between 7 percent and 10 percent, he says.

New legislation has removed such restrictions on using semiautomatic defibrillators and, from April 1, on administering epinephrine for resuscitation purposes only, and not for prevention of heart failure. Even if paramedics see the danger, current law dictates that “they must wait until the heart stops,” says the physician.

Insertion of a tube through the mouth of the patient is now allowed, without a doctor’s approval — but only when breathing stops, and not before. Resuscitation is all that emergency technicians are allowed to do. Anything more such as alleviating pain or discomfort or performing lifesaving preventive procedures is classified as “medical practice” under the 1948 law, and as such remains the exclusive domain of qualified doctors in Japan.

That same Medical Practitioner Law, which long predates the existence of paramedics, also prohibits anyone except doctors and nurses — and in exceptional cases patients’ families — from using a syringe.

In the July 7 London bombings, British paramedics were the first ones on the scene, injecting painkillers and feeding fluids through intravenous drips to critically injured victims as they lay in underground tunnels waiting to be evacuated. Japanese paramedics would not be allowed to do the same; nor would they presently have sufficient training to do so.

Retraining programs seem to be taking longer than expected. Nearly a year after the latest legislative change, only 51 of 1,500 paramedics in Tokyo are certified as qualified to administer the heart stimulant epinephrine starting April 1. Authorities say their resources are stretched. However, if the government’s aim is to have paramedics of international standard in this country, resources must be found — and quickly — to give all Japanese paramedics world-class training.

In the meantime, in order to maintain uniformly high standards, the recruitment and subsequent career paths of paramedics should be separated from those of firefighters. Clearly, the aptitudes and skills required for fighting fires and providing emergency medical care are poles apart. Currently, Japanese paramedics are wearing both hats — with increasing difficulty.