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The fire chief and the medical director from the City of D. spent the first day meeting with the Seattle Medic One battalion chief, visiting the alarm center, and riding all afternoon and into the evening with two paramedics. The second day they visited the quality improvement office to understand the data collection system and then had lunch with the Medic One medical director. Eventually the discussion came around to the issue of what makes the Seattle system work so well. The D. fire chief asked directly, “What is the secret of Seattle’s success?” The Seattle medical director was not surprised by the question. Almost every visitor to the Medic One program asked it. The visitors imperceptibly leaned forward anticipating the response . . . If you are going to have a cardiac arrest, one of the best places to have it is Seattle. So said 60 Minutes on a national TV broadcast in 1974. The claim was not just media hype —it happened to be accurate, and it remains accurate to this day. Seattle and the surrounding King County community, along with Rochester, Minnesota, have the nation’s highest survival rates for cardiac arrest. The latest data from King County and Rochester indicate that 46 percent of patients who collapse with ventricular fibrillation in the presence of witnesses walk out of the hospital alive. The survival rate in Seattle, at 45 percent, is virtually identical.1 So if you’re going to have a cardiac arrest, where should you try not to be? The obvious choices would be Los Angeles, New York, Chicago, and Detroit, cities with the nation’s lowest published survival rates for cardiac arrest involving ventricular fibrillation—7 percent, 5 percent, 3 percent, and 1 percent, respectively. What accounts for these drastically different survival rates? To begin to answer 120 six Location, Location, Location Best Places to Have a Cardiac Arrest this question, this chapter closely examines the communities with the highest survival rates—Seattle, King County, and Rochester. What are the elements of success in these communities? Do their EMS systems have a secret ingredient that is missing from the systems in other communities? Can successful systems like the ones in these communities be exported to other cities? the seattle and king county ems systems: history, foundation, design, and structure What are the elements of an EMS system’s success? What is it that makes Seattle one of the best places to have a cardiac arrest? I posed these questions to two individuals who are eminently qualified to answer it—Leonard Cobb (we met him in chapter 2), the cofounder of Seattle’s paramedic program, and Michael Copass, the program’s director of training for thirty-three years and its current medical director. History: Two Leaders, One Vision Leonard Cobb and Michael Copass have different, contrasting leadership styles, but in one area they are in total agreement—they refuse to accept anything less than full commitment to helping patients. Cobb and Copass, Copass and Cobb—these two complex, dedicated men made Seattle’s Medic One program what it is. It is difficult to speak of one without the other, since they are both so intimately tied to the program. And their strengths and personalities are perfectly complementary—Cobb is the professor, the thoughtful investigator who wants to know what works and how to make things better, and Copass is the enforcer, the one who gives orders and demands nothing less than 100 percent loyalty and effort. I’ve known Leonard Cobb since 1971, when I arrived in Seattle for an internship and residency in internal medicine.2 Cobb—he was “Dr. Cobb” to me at the time—was the attending physician on one of my first rotations, at Harborview Medical Center’s coronary care unit. I vividly recall seeing several patients who had been resuscitated after out-of-hospital cardiac arrest, and I remember Cobb explaining the workings of the Medic One system and the role that paramedics played in resuscitation. At the time, I assumed that every hospital had a number of such patients; only later did I learn how unusual Harborview was. As for Michael Copass, his gruff demeanor is legendary. I have heard him described many times, and some of those descriptions were less than kind, but my favorite saying about him is this one: “He’ll make you feel like you’re going to run out of ass before he runs out of teeth.” But beneath his harsh exterior shines...

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