In his self described musings Ambulance Chaser, both a Medic and a Lawyer, brings up some great topics we seem to kick around but never want to dive into.
Recently he wrote about system abuse in EMS:
"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." You can read more at the link above.
EMS providers should most certainly be able to refuse transport to system abusers, following a complete assessment, of course, but not in the way you think.
AC, as I'll call him, goes on to state what many already know, that EMS abuse is hard to identify and even harder to act on. He makes good points that we need to first raise the education standards, thus raising the quality of the average provider, but there is a real solution to EMS abuse when we finally pull the sheet off of it.
Trouble is, the sheet is different sizes and shapes in many communities.
We all know the EMS abuser who calls 911 when they want their window shut. No chief complaint, no medical condition, just an elderly woman living alone who can't reach the window. She calls 911, uses the buzz words and knows your refusal speech by heart. Is she abusing EMS?
Absolutely.
Do we refuse her care?
Absolutely not.
Should we refuse her transport?
If she asks and has no need of it based on our assessment, why not?
When responding to these kinds of calls we need to begin to assess the surroundings, not just the patient and yes, she is a patient until your assessment reveals otherwise. Is the milk in the fridge in date? Is there a decent amount of food? Are the bathrooms sanitary? Is it possible that there is a living condition we can improve on this brief stay that will solve her problem without a 911 activation next time? These are the questions we need answered, but too many folks will never consider it, they'll simply get upset they don't get to cardiovert someone and stomp away, leaving the problem right where they left it.
Chronic homelessness plagues my response district, with the most common call being "Man down, 3rd party caller."
An Engine and ALS ambulance are sent lights and sirens for a person sleeping. Is this EMS abuse?
Nope. Dude is just trying to get a nap in on the sidewalk when someone called 911 from a block away.
This is a flaw in the 911 system that values the call processing time over the information gathered on that call. This is also why so many calls here start with "...for the code 3 Medical, unknown..." Well, radio, just tell me what they told you and code it later.
The other side of the homelessness issue are those who call 911, lie to get a fast response, then seek out other services. This is EMS abuse. Knowingly activating the system without intent of care is EMS abuse. We encountered just such a patient when filming Chronicle of EMS back in 2009. She told 911 she had chest pains, got the fast response, then wanted to nap in the ambulance and the hospital, no medical complaint whatsoever. Should I have been able to refuse transport?
Absolutely.
Instead, because of policy and a misunderstanding of the word "liability" I was required, by law, to take her to a cardiac cath capable receiving facility. That bed needs to remain open for someone who needs it. AC mentions this trouble when he says he is afraid of the average provider messing up this privilege to refuse transport. I agree to a point. We let them drive the ambulance, right? I'd say that is far more dangerous than refusing transport to those who an assessment finds will not benefit from pre-hospital care.
And since we're big on the blame game in EMS, let me tell you exactly who to get upset with:
The mirror.
We are the reason EMS abuse exists and the #1 cheerleader for it to continue.
We focus on merit badge classes that rephrase the same information from 20 years ago with the occasional paragraph about a major change we all suspected anyways.
We sensationalize the rare and ignore the mundane. When was the last time your department held a ceremony with the 8 year old girl who used her inhaler properly, thus preventing the need for an ALS response?
We promise our young new hires lights, sirens and adrenaline, then get confused when they commit suicide following emotionally traumatic scenes.
Our training focuses on little boxes to fit patients into and rarely allows us to look outside those little boxes for solutions for fear of the Medical Director's rage and a loss of our 120 hour certificate from the local college.
Addressing EMS abuse must be a priority!
Our goal as EMS providers must be to answer calls for service and do everything in our power to identify the root cause of that call and take action to prevent it from happening again. It is the same for a choking, cardiac arrest, abdominal pain and, yes, the toe pain at 3AM.
Folks don't call 911 to get their meds refilled because that is what they WANT to do, they do it because someone, somewhere failed to teach them about what they are taking and how to get more. Be the solution.
The future of EMS doesn't have room for folks just running calls. We are on the front lines of medicine and, as such, have an enormous responsibility to prevent as many 911 calls as possible. Only with a reduction in non emergency calls can we begin to focus on advanced assessments and "respond, not convey" a remarkably successful program elsewhere in the world I saw first hand in England that flat out told people, "no, you're not getting an ambulance" then solved their problems in other ways.
So why won't it work? Why hasn't it worked?
Well, in some places it is, and very well, but when the service you work for calls you in because your refusal of transport is below the company average, their priority is billing, not health care.
Ambulance Chaser is right to bring up EMS abuse and commenters on the post have varying opinions on EMS abuse, but it is indeed easy to define and address. However, there can not be 1 solution for everyone, we need to pick and choose from other successful programs and see what works for our own communities.
We call it "Adopting best practices."
Recently he wrote about system abuse in EMS:
"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." You can read more at the link above.
EMS providers should most certainly be able to refuse transport to system abusers, following a complete assessment, of course, but not in the way you think.
AC, as I'll call him, goes on to state what many already know, that EMS abuse is hard to identify and even harder to act on. He makes good points that we need to first raise the education standards, thus raising the quality of the average provider, but there is a real solution to EMS abuse when we finally pull the sheet off of it.
Trouble is, the sheet is different sizes and shapes in many communities.
We all know the EMS abuser who calls 911 when they want their window shut. No chief complaint, no medical condition, just an elderly woman living alone who can't reach the window. She calls 911, uses the buzz words and knows your refusal speech by heart. Is she abusing EMS?
Absolutely.
Do we refuse her care?
Absolutely not.
Should we refuse her transport?
If she asks and has no need of it based on our assessment, why not?
When responding to these kinds of calls we need to begin to assess the surroundings, not just the patient and yes, she is a patient until your assessment reveals otherwise. Is the milk in the fridge in date? Is there a decent amount of food? Are the bathrooms sanitary? Is it possible that there is a living condition we can improve on this brief stay that will solve her problem without a 911 activation next time? These are the questions we need answered, but too many folks will never consider it, they'll simply get upset they don't get to cardiovert someone and stomp away, leaving the problem right where they left it.
Chronic homelessness plagues my response district, with the most common call being "Man down, 3rd party caller."
An Engine and ALS ambulance are sent lights and sirens for a person sleeping. Is this EMS abuse?
Nope. Dude is just trying to get a nap in on the sidewalk when someone called 911 from a block away.
This is a flaw in the 911 system that values the call processing time over the information gathered on that call. This is also why so many calls here start with "...for the code 3 Medical, unknown..." Well, radio, just tell me what they told you and code it later.
The other side of the homelessness issue are those who call 911, lie to get a fast response, then seek out other services. This is EMS abuse. Knowingly activating the system without intent of care is EMS abuse. We encountered just such a patient when filming Chronicle of EMS back in 2009. She told 911 she had chest pains, got the fast response, then wanted to nap in the ambulance and the hospital, no medical complaint whatsoever. Should I have been able to refuse transport?
Absolutely.
Instead, because of policy and a misunderstanding of the word "liability" I was required, by law, to take her to a cardiac cath capable receiving facility. That bed needs to remain open for someone who needs it. AC mentions this trouble when he says he is afraid of the average provider messing up this privilege to refuse transport. I agree to a point. We let them drive the ambulance, right? I'd say that is far more dangerous than refusing transport to those who an assessment finds will not benefit from pre-hospital care.
And since we're big on the blame game in EMS, let me tell you exactly who to get upset with:
The mirror.
We are the reason EMS abuse exists and the #1 cheerleader for it to continue.
We focus on merit badge classes that rephrase the same information from 20 years ago with the occasional paragraph about a major change we all suspected anyways.
We sensationalize the rare and ignore the mundane. When was the last time your department held a ceremony with the 8 year old girl who used her inhaler properly, thus preventing the need for an ALS response?
We promise our young new hires lights, sirens and adrenaline, then get confused when they commit suicide following emotionally traumatic scenes.
Our training focuses on little boxes to fit patients into and rarely allows us to look outside those little boxes for solutions for fear of the Medical Director's rage and a loss of our 120 hour certificate from the local college.
Addressing EMS abuse must be a priority!
Our goal as EMS providers must be to answer calls for service and do everything in our power to identify the root cause of that call and take action to prevent it from happening again. It is the same for a choking, cardiac arrest, abdominal pain and, yes, the toe pain at 3AM.
Folks don't call 911 to get their meds refilled because that is what they WANT to do, they do it because someone, somewhere failed to teach them about what they are taking and how to get more. Be the solution.
The future of EMS doesn't have room for folks just running calls. We are on the front lines of medicine and, as such, have an enormous responsibility to prevent as many 911 calls as possible. Only with a reduction in non emergency calls can we begin to focus on advanced assessments and "respond, not convey" a remarkably successful program elsewhere in the world I saw first hand in England that flat out told people, "no, you're not getting an ambulance" then solved their problems in other ways.
So why won't it work? Why hasn't it worked?
Well, in some places it is, and very well, but when the service you work for calls you in because your refusal of transport is below the company average, their priority is billing, not health care.
Ambulance Chaser is right to bring up EMS abuse and commenters on the post have varying opinions on EMS abuse, but it is indeed easy to define and address. However, there can not be 1 solution for everyone, we need to pick and choose from other successful programs and see what works for our own communities.
We call it "Adopting best practices."
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