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On April 1, Japanese paramedics took a small but significant step toward catching up with their counterparts throughout the developed world: For the first time in their 15-year history, they are 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 public 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 paramedics were previously firefighters, and are 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 hospitals. "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 longer than 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 and re-establishing them as full-fledged medical technicians capable of performing a broad range of emergency medical treatment to save more lives.
This is the norm in developed countries, and doctors say the nation's 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, paramedics weren't permitted to use defibrillators without a doctor's supervision — via the phone. "I know of many cases where lives were lost while waiting for a doctor's approval," said an emergency physician at the Nippon Medical School Hospital in Tokyo. A one-minute delay reduces the survival rate by between 7 percent and 10 percent, according to him.
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, the former law dictated that "they must wait until the heart stops," said the physician.
Also, insertion of a tube through the mouth of the patient is 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, prohibits anyone except doctors and nurses — and in exceptional cases patients' families — from using a syringe.
In the July 7 London bombings last year, 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 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. Authorities say their resources are stretched. However, if the government's aim is to have paramedics of international standard in the country, resources must be found — and quickly — to give all paramedics world-class training.
In the meantime, for maintaining 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. The nation's paramedics are wearing both hats — with increasing difficulty.
The Japan Times Weekly: April 8, 2006
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1日から法律改正により、日本の救急救命士は他の先進国と同様に、強心剤エピネフリンの投与ができるようになった。しかし薬剤の投与は心拍停止状態の患者に限られる。救急サービス問題について国民の関心が低い中で、政府はさらなる法改正、人員の配置について動きを見せていない。
救急救命士の行為は1948年施行の医師法により厳しく制限されている。救急救命士は地方自治体の消防本部に所属し、通常は消防活動や救急患者の病院への移送を行っている。
現在、救急車要請の電話は火事通報の電話よりもはるかに多いが、交通渋滞のため患者の移送に時間がかかっている。そのような事情から、より多くの命を救うため、救急救命士を広範囲な治療の行える本格的な医療技術者と位置づけることが必要だ。救急救命士制度が1991年に作られたが、3年前までは医師の承認・監督がなくては電気ショックを与える除細動器の使用は認められず、電話で承認を求める間に患者が死亡したケースも多い。
法改正で、半自動除細動器の使用制限は解除され、蘇生目的に限り、救急救命士によるエピネフリンの投与が可能になったが、心不全予防目的では投与できない。また、救急救命士は呼吸が停止してからでないと気管内挿管はできず、蘇生術以外の行為はできない。
05年7月にロンドンで起きた連続爆破事件では、救急救命士が地下トンネルで重傷者に対し鎮痛剤を注射し、点滴を行った。日本では救急救命士による同様の行為は許されていない。
東京都消防本部所属の1500人の救急救命士のうち、エピネフリン投与が許されているのはわずか51人である。政府は、国際基準に見合った救急救命体制を作るため、すべての救急救命士に必要な訓練を行わなければならない。
また、救急救命士と消防士の募集、配置は別に考えるべきだ。それぞれ異なる適性、能力が求められ、兼任するのは不可能だからだ。
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