A continuing recurring theme in EMS social media and in EMS in general is that we believe there’s a such thing as “EMS system abuse.” Usually, this manifests itself with some meme or catchy saying that 911, EMS, and/or the emergency room are reserved for “true emergencies.” Allow me to just say one thing – WRONG.
Let’s take it piece by piece. First, even for non-profit or government organizations, medicine is a business. Businesses exist to make money. When’s the last time you saw McDonald’s or a law firm tell you not to use their services? Does a lawyer tell you that your routine, uncomplicated will could be done with will-writing software? No lawyer would do that and remain in business. What makes emergency medicine so different? Why do we feel it’s in our best interest to turn away patients? And let’s face it – patients are another name for customers.
Next, imagine the worst EMS provider you work with. Would you trust them to be the “gatekeeper” that decides whether your family gets EMS treatment or whether that EMS provider gets to go back to his station and return to his Xbox? Take an average EMS provider instead. How many of us know enough medicine, pharmacology, pathophysiology, and assessment to make a good, informed decision about sick or not sick? While my blog isn’t meant to be a journal review, the current evidence shows that the majority of EMS providers don’t have the clinical sophistication, knowledge base, or good judgment to make the right call as to not transporting (or transporting to alternate destinations). As an attorney and medic, I can tell you the risk of allowing the average EMS provider to function as a gatekeeper to emergency care is too great. Yes, there are clear-cut cases of abuse of 911, but the temporary satisfaction that an EMT or paramedic gets from refusing to transport one specific patient is not going to address the underlying pathological issues that patient is dealing with – and the best place, under ourcurrent model of emergency care, to begin that process is the emergency room.
In my opinion, what we are really dealing with is the failure of modern medicine to meet the needs of a modern society that functions 24/7. I recently had a medical issue that took several office visits to my physician’s group practice, ranging from urgent care, to my primary care physician, and multiple specialists. Each of these visits (save the urgent care visit) took me away from my work and had multiple co-payments. Factor in the cost and convenience factors, especially with referrals and imaging, and it’s hard to say that I’m actually the intelligent user of medical care. Meanwhile, someone goes to an emergency department, and even if they wait, there’s access to an exam, lab work, at least some imaging, and the ability to consult/refer to a specialist.
The so-called “abuse” of emergency care may be a problem. Belittling those who use our services is 1) not the way we should treat our fellow man; 2) financially counterproductive; and 3) clearly not working. Maybe it’s time to adjust our medical care to account for after-hours availability and the need to meet unexpected/unscheduled healthcare problems.
Until then, it’s my personal belief that if your office phone number is 911 and/or the sign says “Emergency” on your workplace, then you’re first and foremost in the problem solving business. Let’s solve the problem of availability and access to quality care. We can do this – and do it without belittling those we see as beneath our expertise as emergency clinicians.
A a couple of retorts. 1) There are system abusers. The guy who spends his disability on alcohol and then has no money for food and then calls 911 to take him to the ER so that he can get a cheeseburger or a turkey sandwich is a system abuser. 2) Transports that are not considered a true emergency by the prudent layperson are not reimbursable. Attempting to generate revenue from such transports is called fraud. 3) While you wouldn’t want the village idiot making the gate keeper role, the average medic can identify bullshit when he sees it.
While I have personally experienced your frustration in situations identical to the scenario you described above, there are a couple of issues at play here that never seem to come into the equation. I am only going to address one for the sake of brevity.The alcoholic does need help, but we are unable to give him the help he needs. This creates a perpetual cycle. He calls, we pick him up, we drop him off, and he storms out of the ER after getting his sandwich. Then it happens again, and again. Why? Because the man needs help with his addiction, but we can’t give him that. All we have to offer is a ride to hospital in this case. This cycle repeats itself and in the case of many EMS providers it does so in the wee hours of the morning after they have been up working for 18 to 20 hours. This is a whole other problem I like to call system deficiency that plays a role in, but is not entirely responsible for provider apathy. Something you have clearly displayed here Steve. Not that I’m pointing fingers, we have all been guilty of it at one time or another to varying degrees after all.
So, a couple of retorts myself. I think it’s this kind of defensive, dogma based, anecdotal medicine that we have been reduced to in this country. I recall a time, I know revealing my age here, when you could have an honest discussion with your physician and no one was scared of a lawsuit as long as it was dealt with honestly and openly and saying “I’m sorry” wasn’t the equivalent of a four letter word.
Secondly, I take umbrage with your statement that “Does a lawyer tell you that your routine, uncomplicated will could be done with will-writing software? No lawyer would do that and remain in business.” I think that both the continued presence as a lawyer and the success of Robert Shapiro and his business Legal Zoom turns your assumption on its head. Yes, I really he may be quite the exception to the rule, but your statement didn’t allow for that and made quite a sweeping generalization. And if there’s one thing I’ve learned over the years is that you shouldn’t just lump a whole group or class of people in together based on said group or class. Maybe you didn’t hit that gold mine quick enough, or haven’t figured out a way to do that and beat that and other services at the game. Maybe you have absolutely no desire to even try, and that’s fine. But saying you can’t do something and stay in business because it’s not been done before is stifling to the spirit of creativity and thinking outside the box that best of EMS, and I believe legal as well, professionals should excel at to best help their patients/clients.
And now that I’ve scorched the earth, I’ll retreat to my hobbit hole.
I believe the author takes a narrow view of “systems” abuse here and neglects to incorporate the same focus most EMS managers look at the problem with. The problem is with the authors use of the term abuse, whereas most managers equate abuse with high-frequency-avoidable-utilization. In this regard, systems abuse can include the traditional narcotic seekers “shopping” from hospital-to-hospital. It can include patients who (as is the law in some states) call 911, get an insurance check cut to them, and then never pay a cent to the EMS agency, rendering that whole “paying customer” concept moot. It can include patients lacking access to proper care, lacking healthcare literacy, or lacking social/emotional support services that would reduce their likelihood of contacting EMS in the first place. Hand-in-hand with any talk of “abuse” reform in most serious systems is an integrated healthcare strategy that addresses all unnecessary utilization- from the patient-initiated abuse to the systems-failure of our present healthcare system. I do not think that this article fully recognizes that systems abuse management via EMS is much more involved than simply identifying patients our crews don’t like and bullying them away from the hospital. As boomers age, EMS pay stays stagnant while other wages rise, and enrollment in EMS programs continues to shrink, these types of unnecessary utilization volume management strategies will pay big dividends.
The argument you use to start is highly flawed. You say it is about making money, and that a lawyer or McDonalds wouldn’t refuse customers. You left off 1 tiny word that makes a huge difference in this comparison. A lawyer and McDonalds would not refuse service to “PAYING” customers. The system abusers do not pay. Many of the chronic alcohol callers o not want help for the underlying problem of their alcoholism, and many of the he less ones, at least in my area, don’t want to go to shelters. So instead they call 911 for a free ride, and take up space in am already crowded ER, all so they can have a couch and a bed for a few hours at their convenience.
You say that you don’t believe many EMS providers can determine whether someone needs an ED or an alternate destination. I believe the model they have in London may prove that wrong. If we need more education, then we should get that education. Instead, EMS continues to play the role of an over priced taxi, at the expense of tax payers, while continuing to feed an overcrowded hospital system with people who choose not to take care of themselves or are ignorant of alternative options.