EMS FAIL or Client FAIL?

Our Pal CK had a rough night recently, not just with some hellish weather and unsound sleep, but encountered one of the glaring issues of modern Emergency Care, the frequent flier.

For those of you not in the industry, frequent flier refers to clients who activate 911 for non-emergent conditions or situations that the normal responsible person would simply take some tylenol or decongestant. These persons call 911 when they run out or lose their albuterol inhaler, have their seizure medication "stolen" or didn't listen when the pharmacist told them not to drink alcohol when ingesting these medications.

Another kind of frequent flier is the basic care seeker. These clients call 911 and use code words like "chest pain" and "seizure" and "difficulty breathing" to get their response bumped up to a priority dispatch. Then, when the crews arrive and find no life threat, they know the law and demand a transport to the ER, which they know we can not refuse.

You see, the laws were written back when companies would refuse to take those who could not pay, or, for whatever reason, the attendants didn't want to take in. That was back when we were a trade.

Now those laws tie the hands of professional care givers who care not only about the patient at the scene, but the next patient who may actually need that ambulance, instead of the client demanding care they do not need.

These folks are not responsible citizens. They demand others care for them, even when there is no care needed. It goes without saying that we treat those who need it, right? So why can't we be honest with those who don't need it? If she calls 911 3 times in 24 hours and got transported, seen, released and brought home twice, why the hell are we there a third time? This issue needs to be solved at EVERY level of the health care ladder, from the patient all the way up to the CEO of the insurance company she may or may not have. So let's break down where the system fails our friend CK, respecting that I don't know the specifics of his system model, so I'll try to be generic in my solutions.

The "patient," or client as I like to call them, is the single biggest share holder in their own health care decision making. The patient needs to seek out information about their medical history, health care options and basic interventions. This can be as simple as listening to the tylenol ads on TV in between episodes of Walker: Texas Ranger and as complex as making an appointment to see their doctor to discuss different interventions. Most folks can't take the time out of their busy schedule of sitting to be bothered with caring for themselves, besides, "Isn't that your job?" No, Ma'am, that's your job as a responsible citizen and proactive member of your community. Not every person can step back and see how their personal life effects their community, we are in the middle of the most selfish generation of people who don't care what happens to their neighbor, only to them.
In CK's example, the client was the first part of the system to fail. She refused to listen to the care takers already put in her path from the prior transports and thinks the ambulance is her personal taxi. PATIENT FAIL.

The family needs to be informed decision makers and understand the conditions which their family suffers from, if at all. Don't tell me she has seizures but you don't know how often, or why, or if she takes meds for them, or if it's just "DTs" (Which I am observing less and less, I think even the alcohol abusers are getting too lazy to fake seizures). If you care for your family, then CARE for them. If they fall and hurt their elbow, maybe take them to a clinic or their doctor's office. Don't call 911, demand a transport, then follow in your car. Tell you what, you get in with her and I'll drive your car, how's that? The family needs to also recognize abuse and nip it in the bud. Huh, third ambulance ride today? Maybe nothing is wrong if they keep sending her home. FAMILY FAIL

The General Practitioner who was called and defaulted to a 911 response is playing CYA with local resources. I am not your insurance policy Doctor, I am a Paramedic. My profession is not your car service and can not respond to cover you should you decide to actually see your patient. I know you are overbooked and understaffed, but that nice Audi I saw in the parking lot is coming from somewhere. Get off the phone and get in the Audi and tend to YOUR patients. House calls are a thing of the past? How about a thing of the future? If there was a component of your practice that allowed this patient to access you or your staff at all hours, she would not be calling 911 3 times in 24 hours and bothering you at all hours. If she is healthy she doesn't need to call you and you actually have more free time for cruising in the Audi. And if you think that simply activating us gets you off the hook and we can do a better job, then let's see you put your credentials where your mouth is and step up as a Medical Director and give your Paramedics authority to refuse care to folks who don't need it. DOCTOR FAIL

The 911 EMS system. You fall, they call, we haul is funny, yet true. Why can't our friend CK take in all the facts, do a professional assessment, determine no need for the ambulance transport and call the doctor back, informing them of the situation? Why? Lawsuits. Our services are afraid someone will actually be refused a transport because of their nationality, sexual orientation or ability to pay, but they ignore the fact that if I wanted to stick it to people I didn't like I would simply not treat them properly. Well, I think it's obvious we're past that part of EMS history, let's get up and actually move past it. Medical Directors need to be proactive in giving their systems tools to guide people out of the water slide that is defaulting to ALS to a hospital. Why was an entire town's EMS system activated 3 times for this client? EMS RESPONSE FAIL.

Does this woman have medical insurance? Is she on disability or perhaps in the VA system? If she is in a private system, has she called the nurse advice line and if we reached that far, did the dial-a-nurse default to telling her to call 911? In my experience with the dial-a-nurse lines, they should be replaced with a recording that says, "Hang up and call 911." In the rare instances where the information is valuable and followed, the clients calling are honest about their symptoms and are clearly responsible citizens, proactively trying to stay healthy. In this situation, again assuming she has some sort of policy, the company must now reimburse the ambulance service, the ER docs and whatever specialists may be activated, instead of spending $100 to get this person into the office sooner. INSURANCE FAIL

The emergency room is the most expensive form of preventative care. I once transported a woman who demanded a pregnancy test. When I offered her the $12 to buy one she refused and told me to do my job and take her in to get the test. "That's what my insurance is for." she told me. No, Ma'am, it's not. And even worse, I know for a fact that the Docs that night gave her that test and anything else she wanted simply to avoid the possibility of legal action should our client decide she didn't get what she wanted. We give these Physicians powers to save lives and end them but tie their hands when it comes to rationing (ooooh buzz word) treatments they know, from being doctors, clients do not require. Let Doctors practice medicine, not constantly defend themselves from what could, possibly, maybe, one day, be a law suit. ER FAIL

So there we have it, CK's situation broken down and the failure found. That's the easy part, unfortunately. The difficult part is finding the solution that fits to make sure our client, remember her, is healthy. That is what this whole giant medicine thing is about, healthy people.

So do we ditch the whole for profit thing and go single payer socialized medicine? It might change a few aspects fo the system, but it will not make our client responsible for her own care. It will give doctors and paramedics more options for diverting her away from the ER, but in he end, CK is still right there in the middle of the night for the third time.

Can we tweak the way insurance companies bill, maybe have everyone pay a little? Still not changing our client's desire to be proactive and there is CK, sleepy and at her home.

Tort reform will surely change the way physicians treat, right? Maybe, but how can solving the problems in the penthouse fix the problems in the foundations? Insurance for the Docs will cost less, but will they pass along the savings back into the system or will there be His and Hers Audis? Not to mention our client is still calling the first time, even if we can convince her no to call the second and third times.

Advanced Care Paramedics and ability to refuse transport could help, right HM? That's only part of the picture and we're still going out there for the initial call and, likely having to return multiple times if they don't get what they want. How many times have you had someone wave you down demand meds and when you refuse they call 911 thinking someone else will return for them. Refusing transport only works if there is a framework we can plug people into instead of the ER.

The solution has to be wide ranging, sweeping and take into account every single aspect of health care from inoculations and birth control to advanced surgery and experimental treatments for advanced conditions.
There is no solution that solves all our troubles, but there is one solution that goes the farthest towards helping to take the pressure off the rest of the system.

Personal Responsibility. Taking control of our own lives and inspiring others to do the same. Get in the faces of your clients and impress upon them how they impact the system. Follow your protocols, do what is right, but point out to your clients the truth about what they are doing and remind them of ways they can access healthcare that isn't running red lights, putting lives on the line for a hurt foot. Be honest about the cost of your response, that if someone nearby is actually sick or actually hurt, they will suffer as a result of this abuse of the system. Nothing in the laws says you can't tell the truth. When people say "Sorry to bother you with this, but I didn't know who to call" take the extra 5 minutes, grab a phone book and show them who to call, where to go and how to get help. Then do what the law requires. Be nice, be supportive, but be honest.

Next time, if we can get people proactive about their care and encourage them to do the same for their neighbors, maybe our call volume starts to go down.

Lofty dreams of an overly optimistic Paramedic, sure. Ramblings of an EMS blogger, certainly. A simple first step towards positive changes in our profession...if no one else will, then I will.

Will you?

Hope you have a better night CK, and if it gets to busy, I'll bring 99 over and we'll cover in. I'd love to have a little chat with your client.
This post started as a simple response...sorry I got long winded. And Medic999 and my UK friends, I'd love to get your responses to CK's situation.