System abuse. That’s a term we commonly hear in EMS. And as soon as we start talking about system abuse, the talk invariably turns to EMS providers’ favorite solution for system abusers. Namely, the idea that EMS providers should be able to refuse transport to system abusers.
First of all, what constitutes a system abuser? We all know at least one of these creatures by name in our local service area. Yet, in my eleven years in EMS, I’ve yet to hear an agreed-upon definition of system abuse. It’s like the definition that former Supreme Court Justice Potter Stewart created for pornography — namely, that he knew it when he saw it.
Next, failing to provide treatment/transport to a so-called system abuser is a recipe fraught with peril. EMS medical directors, as a matter of risk management, have to write their protocols and policies to mitigate the risk of a poor decision being made by the worst provider in the EMS system. We’ve all seen or heard about “that guy” in our local system. The guy who missed a STEMI. The guy who doesn’t manage pain. The guy who took a trauma patient to a local community hospital. Bluntly, when the doctor (and the lawyers) think about it, the safest, easiest, least risky decision is to encourage every crew to transport (or at least offer to transport) every patient every time.
The average EMS provider has no idea of what they don’t know. Most EMS education programs excel at creating the impression that, by teaching a set of skills to “fix” some very acute medical emergencies, the average EMS provider is “doing everything that a doctor does.” After any period of time on the street working as an EMS provider and seeing the reality of our calls, we find our assessment skills in particular make us ill-suited for the reality of modern EMS — namely, the unscheduled delivery of primary care, urgent care, and the occasional emergency care.
I don’t have a solution for system abuse. However, I can tell you where the solution starts, at least in my eyes. To comprehensively address EMS system abuse, EMS providers need to work with EMS physician medical directors to develop a local protocol defining system abuse, providing alternative dispositions for these patients, and providing comprehensive medical oversight to mitigate the risk of deviating from the current accepted paradigm of taking every patient to the hospital emergency department.
My cynical side says that instead, one of two things will happen. One, we’ll just keep complaining and wishing that we had the ability to turn away patients. Two, some vendor will come up with some technological “solution” that just makes things more of a hassle than to just provide a ride to the ER.
As much as I love the practice of prehospital medicine, I sometimes think that the worst enemy of EMS is the average EMS provider. The solution to system abuse and almost every other EMS challenge is to raise the standard of what constitutes the average provider.