System Abuse. Yet again.

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.


  1. I agree with you on many topics and this is another one. However, system abuse can easily be described as activating 911 for a chronic condition not warranting emergency care after being assessed and advised as such. We can curb abuse by addressing the reason they are calling. It’ll take an extra few minutes but save hours in the long run. Blog post to follow.

  2. CMS will soon write a policy for us. EMS is soon to become the gate keeper for the ED as a cost control measure. Without a doubt, one of the Key Performance Indicators to which ambulance reimbursement will soon be tied will be a reduction in unnecessary ED transports.

  3. The moment we become “gate keepers” for the ED, malpractice premiums will soar and stock in BMW and Mercedes will skyrocket because the plaintiffs’ lawyers will be ordering them by the dozens. We are in no way qualified to serve in such a role. Sure, there are times when abuse is obvious and no transport necessary, but as my friend Dr. Bryan Bledsoe has said, even for a board certified ED physician the scariest time can be when it comes time to decide whether to discharge or admit a patient. Community paramedicine programs may be able to help us reduce unnecessary transports, but the minute we allow bureaucrats and bean counters to practice medicine, and that is exactly what they will be doing if they influence us to deny transports, mistakes will be made. Who will pay? Surely not CMS or the other insurers. Bean counter medicine already runs hospitals and medical practices. We must resist allowing that to happen in EMS.

    • Steve Pike says:

      The guy in a city I used to work who drank all his SSI money and never had money for food, so he would call an ambulance saying he thinks he might have a seizure, knowing that the ER staff will give him a cheeseburger out a jab and cheese sandwich is a system abuser.

  4. Wes, the first step in solving system abuse is to realize there is no such thing as system abuse.

    People call Fire, EMS, and Police for help, sometimes because of fire, medical emergencies, or crime.

    If you want to stop “system abuse” all you have to do is realize your system is not designed for the help people need and choose to help anyway.

    • theambulancechaser says:

      Exactly. Hence why I’m asking for people to define system abuse. Because in all honesty, what it comes down to is identifying those patients you don’t want to treat. Which is the very antithesis of medical ethics.

  5. I’m a student in the UK – here it is common for us to refer back to primary care through our single point of contact. After ruling out any red flags we can ask SPOC to arrange the out of ours GO to consider the case and either visit, phone back or pass on to the patients GP when it’s open. Our frequent flyers are assessed when they reach a certain level of calls. Plans are normally put in place either through mental health, restricting the number of visits they can receive in a time period or addressing their underlying needs. We do still have system abusers but it is satisfying to do something useful rather than cart them down to A&E pointlessly

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