System Abuse

Over the years some great ideas to change how we care for our patients have come from street level providers and their day to day encounters and insight to the challenges that they face.  Others, however, either fall flat on their collective faces or are proven at a larger scale with the use of evidence to be ineffective.  One of the most frequent discussions that comes up on many EMS related internet destinations is the effects of system abuse on our industry.  Some feel that it is the crippling factor that renders urban systems ineffective however I disagree.  While I do not dispute the presence of system abuse, and while these calls might stand out as being memorable, I think that it is less of an issue than we make it out to be in our own heads.

But how show we deal with it?  One popular internet author suggested that something needed to be done, but has not present a plausible example of what that should be.  When the concept of increased education for providers to be trained to make non-transport decisions or recommendations for alternative ways of entering a patient into the health care system, he went as far as to state that I was being “negligent” for advocating for more education for EMTs and paramedics because he felt that this was refusing to address the problem.  While he can try and hang his hat on the anecdotal experiences of his career, I will instead choose to rely on evidence which tells a different story.

How can we expect EMTs and paramedics to perform assessments and make treatment decisions when our training tells us to stabilize to the best of our ability and deliver a patient to definitive care?  Giving EMS providers the blessing to deny transport or to recommend alternative destinations or treatment options is something that we have received no training to do.  While there are some instances where our assessment can be spot on where we would tell a patient “you don’t need to go to an emergency room, and you certainly do not need an ambulance” this decision making power would need to be universal if granted at all.

The problem is that people’s opinions whether right or wrong about who should and should not be transported to the hospital are based largely on their experience, comfort level, and anecdotal encounters that they have had with patients.  For example, in my system I have the option to release a patient to a BLS unit for transport to an ER if I feel that they do not require ALS care.  It’s a huge responsibility and something that is largely left to the discretion of the paramedic and their partner to make the decision.  Even as a fifteen year paramedic there are patients that I see other providers releasing and I say to myself that I would have at least ridden that patient in to go down a few additional avenues with my assessment.  Others I scratch my head at because cutting the patient loose seemed like a no-brainer.  The comfort level of the paramedic, whether they have been on the road for a week or for 29 years dictated the decision making.  Neither paramedic is wrong and neither is right.

Releasing patients to another provider is a huge responsibility.  If given the option to release the patient without treatment or to deny a patient transport based on their complaint, you need to multiply that responsibility significantly.

When I look at national systemic problems such as this one, I usually turn towards high performance systems and The Gathering of the Eagles for answers.  MedStar, for example, took an aggressive approach to dealing with their high volume users and have been pioneers in mobile integrated health care because of it.  Some presentation titles from the 2016 Gathering of the Eagles include “The LAFD Nurse Practitioner Response Unit,” a profile of London’s community treatment team and a look at Grady EMS’ MIH program.  The presentations about “when to leave the patient behind” and “decision making without education” were once again left out this year.  The systems that have started to address the EMS super users have done so with specialized units and more education.  While it might not address the “I need a ride” cases that frustrate so many of us, it is a start, and I feel that the answer to the “sick” calls is a larger issue than the impact that EMS has.  The problem there is access to the healthcare system and EMS can certainly be a part of the solution to that problem but it must be done the right way.

When it comes down to it, we have nobody to blame for all of this but ourselves.  This nation chose a response model that is driven by response times and the mythical 8:59 number that we all measure ourselves by.  I will never argue that there are certain emergencies that require a rapid response, and I will spare you all the list of putting them down here, but an emergency in many of these systems is an emergency with no means to differentiate between emergent and non-emergent.  We are also so fearful of failure and litigation that we opt to treat everything like an emergency instead of triaging calls and realizing that in medicine there will be mistakes made.  The important thing is that when mistakes happen, we learn from them and fix what we can as a result.  If we operated in a police model where the low priority calls became the barking dog complaint of the EMS world, we would be much better off.

If people want the power to deny transport and they feel that having this authority would really alleviate much of the system abuse that EMS in America currently experiences we will need to revamp how we are educated.  Want an example of what that will entail?  Look no further than the training that paramedics in England receive that can take as long as five years to obtain.

There are some really smart paramedics and EMTs rendering care in this country.  They are easily some of the best in the world.  There is a need, however, to recognize what our limitations are, and when we are trying to be innovative in problem solving, we need to get creative when trying to overcome the obstacles that we face.  Let’s solve the problem by utilizing the strengths of our industry not chastising the under/uneducated populace.  Stop blaming the patients.

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