Thursday, June 4


Sometimes the obvious is difficult to comprehend.
Why can't my system make common sense choices like this from Medic999:

"Its obvious that something is bothering her sufficiently to call 999, and in all likeliness, a further GP would just send her to the hospital anyway. I told her that I would run her up to the hospital myself, in the car, to get her checked out further. "

He can cancel the ambulance and transport appropriate patients in his car.

Am I the only one stateside thinking this is the right way to do it? A scaling system that can adapt to the changing call as it develops?
The American model is locked into a BLS before ALS mentality and it is hurting the system.

Benchmarks set to reach BLS patients faster than ALS patients simply because more of your resources are BLS is just silly. Yes, I said silly. We should be striving to reach the ALS patients within 6 minutes or less and let the scratched fingers and sick evals wait a little longer. They waited all day to call anyway.

My system has these same benchmarks and they were set in place when a BLS system was augmented with a smaller than curent day ALS force.

But now the volume is catching up and demand for ALS resources by BLS units is overwhelming the system everyday.

What is the solution, though? Adding ambulances is just like parking tow trucks near a problem intersection and waiting for the accidents to happen. We know what is causing the increase in call volume, why not nip it in the bud, where it starts?

The "patient."

Patient is defined by Webster's as both a noun and an adjective. But today, the two couldn't be more opposite.

As an adjective, patient means enduring difficult situations with an even temper; Capable of calmly awaiting an outcome or result; not hasty or impulsive.
That is most certainly not the modern clientel of EMS services. They call demanding a level of service they do not need or understand, only so they can seek attention from an advanced system, the hospital, which they may or may not need. And all of it has to happen right now, no question, no delay, let's go.

But the noun, patient, means one who receives medical attention, care, or treatment. "Receives," not requests, or identifies with, but "receives."

Does that mean I have not made patient contact until they receive care? Is calling 911 legally, technically, recieving care? Yes, unfortunately.

Why can't I rely on my training and ability to assess people for illness and/or injury and define them as something other than a patient? Could that cut down on our call volume?
Absolutely. Would it spark a tidal wave of legal questions? Most certainly.

So where does it leave the average American EMS professional? En route to the hospital, that's where.

WAKE UP friends! Our systems are about to be swamped with baby boomers hitting retirement and expecting the level of service they had to maintain for 40 years. If you thought we're busy now, just wait 10 years.

Reading Medic999's stories and then reading mine, I keep seeing distinct differences in the level of care provided by the systems. Medic999 is able to cancel an ambulance and refer the patient directly to the appropriate service, based on his professional assessment. That's what we're already doing, except the hospitals hold the keys to the services our clients need. We just move them from A to B, sometimes intervening.

If appropriate, again based on a professional assessment, they just need a ride, Medic999 can put them in the car and take them, leaving the ambulance available for a more serious call.

It makes so much sense it hurts to think about it.

So what is standing in the way? Profit. I can't refer patient #1 to the rehab unit at St Farthest because they have a different insurance, who needs to have a referral from the patient's primary care, who isn't at St Closest either, but in a completely different HMO. And I can't refer patient #2 to their general practitioner because, surprise, they don't have one. Their only access to medicine at all is me, as a ride to a doctor, who is legally required to listen to them, clogging up a bed in an EMERGENCY room.

There needs to be a complete re-thinking of the way EMS is delivered in the US if any of it is going to survive the rapid increase in volume that is coming.
We can't keep adding ambulances, we need to look for other ways to address the issues we face.

Help. We need help. We need a solution that can deal with the expectations of our clients, while still providing a competent, professional service that meets the needs, not the desires, of that client.
The UK system isn't the answer, it can't be so long as insurance companies can restrict access to services. But what about the fast car model?
Wake County EMS is having success with a variation of the FRU with their Advanced Practice Paramedic role, a design that interets me a great deal.

But in the end it really comes down to liability and cost. 2 things a Paramedic and EMT in the field have no control over. Sure if I can tell someone who doesn't need an ambulance to take the bus I can save money, but increase liability. We can take everyone who summons us, regardless of the reason, which eliminates liability, but increases cost.

Enough. The fire based model won't last long if it relies on an ever shrinking fire system and can't survive in the private sector with the increase in volume and decrease in benefits.

Enough. We are no longer a group of certificate wielding drivers, we are licensed professional Care Givers.

Enough. The EMS systems can't be governed by organizations that refuse to adapt to the changing landscape that is the modern patient, or citizen with a medical complaint.

Enough. We need those ambulances to stay in service for when the call comes in, the rare call, where we can actually use our advanced skills to make a difference.

"I'm sorry," I had to tell the woman lying on the floor of the grocery store after fainting, "We don't have anymore anbulances to take you in right now."
After not 10 minutes prior being forced to summon an ambulance for a man who skinned his finger, who demanded transport.

We're better than that. Now let's get out there and do somethign about it, before it's too late.

Humbly submitted,
Your Happy Medic


The Road Doctor said...


Pedro the Paramedic said...

Wow- very powerful, thought provoking article... too bad dinosaurs don't read...

Connie said...

Your description is interesting. I must live in an area (near DC) that has looser rules than yours. My husband had a kidney stone attack (no previous history) when I was at church one Sunday and he was unable to reach me. The pain was so severe that he almost passed out, so he eventually called 911. Just after he did I saw he had called me and called back. I returned home to find the paramedics monitoring him on the front porch. They assured us that he was not experiencing anything life threatening, but that he did need to be seen and did say his symptoms were consistent with kidney stones. They then suggested I drive him to the hospital and left after I assured them I would take him immediately. He did have kidney stones and all was taken care of.

This seems the type of scenario you are suggesting as a model. Do I live in an "enlightened" place or am I misunderstanding the point of your blogpost?

The Happy Medic said...

My trouble is when the man on the porch refuses to wait for his wife to drive him or refuses for anyone to drive him except the ambulance.
Like those medics told you, he didn't NEED an ambulance, he just called because he was concerned for his life. I would call too.

Had he insisted on an ambulance they would most likely be legally required to take him.

You and your husband sound responsible and chose an option proper for your situation. You are indeed the exception.

Anonymous said...

Happy, I think the best solution to our crisis is similar to Wake County's Advanced Paramedic Program. Gary Wingrove is advocating the Community Paramedic, which operates like a PA that makes house calls, in conjunction with the 911 service already provided. We cannot change our current health care system as a whole. We need solutions that work with in the structure. I believe Community Paramedic could be the direction we need. Nova Scotia is using this model and do is a service in Wisconsin. Google Community Paramedic.

Anonymous said...

Another great post HM.

You know, we really should get together sometime and change EMS for the better!!!

Ive just added some more info on my blog regarding this. Just being honest and discussing a couple of the negatives too.

Have a look when you have a minute

Connie said...

Thanks, Happy. I understand now. Guess common sense isn't quite so common. :(

Ckemtp said...

Excellent post Happy. Although, you didn't sound so "Happy" with this one.

Ya know, "Enough: EMS 2.0" Sounds like a great slogan.


TheNanny said...

Although not a medic myself, I've been on multiple ridealongs with medics for a large city's 911 response, and have also heard many horror stories. Nothing beats the call for "severe head trauma" which ended up being a headache from drinking. While we were out, a man was stabbed 5 times two blocks from the station. The next medic was 10 minutes out. Guess what happened to him.