The High Performance EMS website has been up for a year now and in review of all the topics we have visited, there are two that have stood out in particular both by the number of search terms as well as the number of page views. They are “dynamic system status management” and “EMS frequent flyers”. Since the first topic is based largely in technology, it has been fairly well covered (and developments will continue to be a topic of further discussion.) However, the social problem related to repeat, often non-emergency patient requests for transports continues to be a subject with few answers and it certainly deserves additional attention.
To many EMTs, the driving policy of most agencies (whether overt or not) seems to be “you call, we haul, that’s all!” That sentiment is often despairingly minimized even further as “just because you can’t afford a taxi, does not mean that you should call an ambulance.” These attitudes focus on the misuse, or even outright abuse of the Emergency Medical Services system in that they are assuming someone is routinely “crying wolf” for attention to some minor or even imagined problem. While these situations certainly do occur, and at some direct cost to your agency, it is important that we do not miss the occasion when the metaphorical wolf really is prowling at someone’s door.
So, how do we tell when a frequent patient has a real rather than an imagined need? The best answer is to simply do our job and assess the situation as well as the patient. And do it again every time. Will that waste resources in certain cases? Yes, probably so, but more importantly we won’t overlook the real emergency that we are always expected to address. However, it is the inefficiency of that way of doing business that bothers me.
Many agencies see the “haul ’em all” strategy as their best hope to avoid a mistake and are willing to pay whatever associated cost may arise just to avoid a single potential mistake. Is there not another way to be more effective and prudent in our use of resources? It is true that alternatives such as community public health screenings, planned paramedic home visits, and taxi vouchers – just a few of the many innovative solutions already implemented with varying success – have a cost too. But these programs become better options if we add a caveat to the simple definition of efficiency (which many would agree is “doing the most with the least”) in saying we also want to maintain a higher degree of control over our budget. When these programs are viewed as just interventions to stem the financial bleeding, they will not succeed in the long run. It requires a commitment to a systemic strategy of change that should be viewed more as a change in diet rather than as emergency care. It is only at this point that we begin to take control over the budgeting process through preventative community care in order to limit the need for uncontrolled – or even institutionally encouraged – personal misuse of emergency resources.
Healthcare in the United States is changing dramatically. To think the strategies of the past can be used to reform the system is just plain naive. We may not like the sound of it, but “field EMS” is increasingly becoming “prehospital care” by reforms tying the treatment which a patient receives en route to some definitive care received within the hospital and beyond with evaluation of the overall quality of the patient outcome. Think of an extension of the current trend in “evidence-based medicine” or treatment (that re-evaluates our skills and treatments based on outcomes) as “evidence-based payment” which would compensate based on the effectiveness of our overall service. While I am not suggesting that model or ever believe it would happen, I do believe that the thought is a potential motivator to change our behavior.
Unfortunately, one of the contradictory forces acting against the improvement of our practices is the failure of elected officials to recognize “field EMS” as an essential government service. As a citizen, I expect to flip the switch and see a light or turn the spigot to get a drink just the same as I want to be able to call 9-1-1 and receive skilled care in an emergency situation. We not only need to re-train the public what we do, we need to inform our political leaders as well.