By Robert Davis, USA TODAY

Photo By Jack Gruber, USA Today

BOSTON — When Bobby Lie's heart stopped and he fell to the floor of his downtown high-rise office, Mayor Thomas Menino saved his life.

The mayor didn't rush to his side; a security guard did that. But emergency medical officials say Menino's leadership and his efforts to involve the community in saving lives changed the way Boston responds to such situations. Those changes saved Lie (pronounced LEE) and about 200 others over the past decade.

Powerful, proactive city leadership can turn a sluggish emergency medical system into a highly effective one, a USA TODAY study shows. The 18-month investigation, which included a survey of medical directors in the nation's 50 biggest cities, database analyses and extensive interviews and site visits, shows most big-city EMS systems are fragmented and slow, and as a result they lose about 1,000 lives a year that could be saved. (Related graphic: How 50 cities stack up)

But even an old city with complex problems can have a top-performing emergency medical system if city officials are forceful and committed. Boston is a case in point.

The best test of an emergency medical system is how many "saveable" victims of sudden cardiac arrest it actually saves. These patients must be reached and shocked with a defibrillator within six minutes, or they almost always die.

When Menino was elected mayor in 1993, Boston saved only 14% of these people. Menino was determined to improve that rate and make Boston's EMS among the nation's best. He tackled the system's performance on three fronts: He dealt with long-standing turf battles between the fire department and the ambulance crews; he hired a medical director to provide strong medical oversight to paramedics and insisted that EMS performance be measured meticulously; and he recruited the public's help.

Now, Boston saves 40% of cardiac arrest victims, second among the nation's biggest cities after Seattle's 45%.

The story of how Boston transformed itself is instructive, almost a manual that other big cities could follow to save more lives.

Dealing with turf battles

Boston has seen bitter disputes between firefighters and ambulance crews, the same kind of disputes that have undermined the emergency medical systems in major cities nationwide.

At the highest level, the debate in Boston has been over whether the fire department should take over the ambulance system, as other big-city fire departments have done. But on the front lines, where feuds have raged for generations, the disagreements boiled over about smaller issues.

"We had fistfights in the street" between firefighters and paramedics, Menino says. "There were real trust problems."

He saw the conflict firsthand as a city councilman in the mid-1980s. Menino sometimes would ride in the back of the ambulances on busy nights to see what the crews faced on a typical shift. He was struck by the friction between the two services.

One petty dispute, for instance, was over ambulance parking. Because ambulances carry intravenous fluids and medications that must be kept near room temperature, ambulance crews wanted to park their rigs inside the fire stations. Although the crews were not part of the fire department, they responded together to emergencies, so they had a relationship. But when fire department officers refused to allow some of the medics to park ambulances inside the firehouses, the ambulance crews were forced to run extension cords to heaters in the back of the rigs.

"Some places the ambulance would be outside, and they'd give the poor paramedics just a tiny table inside and no place for them to clean up after a run," Menino says.

That changed when he was elected mayor.

"We found them space," he says. The city converted spaces from many agencies, including the department of public works and the police department and local hospitals, to move the rigs and the crews inside, out of the cold.

Breaking down walls

Change did not come easily, particularly for the firefighters' union. The union and Menino bumped heads on more than one occasion, and not just over emergency medical services.

Menino found the union to be a powerful force. At one point in 2001 when the union and Menino were deadlocked over contract issues, firefighters protested outside the mayor's State of the City speech. Only one of the 13 city council members crossed the picket line to attend the speech.

But eventually, Menino and the firefighters made their peace. And the mayor put a stop to the debate about whether the ambulance system would become part of the fire department. It would not.

That decision went against a national trend in which fire departments have been taking over emergency medical services as the number of fire calls goes down and the number of medical emergencies goes up. Running more calls justifies more money, so Menino's decision to keep the two services separate in Boston has contributed to a steady decline in the number of firefighter jobs. At 1,600 firefighters, the department is at the lowest staffing level in 15 years, says Nick DiMarino, president of Boston Firefighters Local 718.

Though DiMarino is quick to praise the mayor and says the fire department will "support what the mayor wants to do," he also says, "I would be lying if I said I'd like to keep it this way."

Menino says that as long as he is mayor, the two agencies will remain separate, with the ambulance service an arm of the health department. Even so, the ambulance service works closely with the fire department. Firefighters carry defibrillators and respond to cardiac arrest calls, and often they are the first to reach and treat those victims.

Though an undercurrent of conflict still exists, the partnership that has been struck with the mayor's support is saving lives.

"The fire department first responders have greatly enhanced our cardiac arrest survival," says Peter Moyer, medical director of Boston fire, police and ambulance service.

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