The dispatch information was updated before we had even rolled our rig out onto the pad. Eye injury, no serious symptoms. Jodie shut down the lights and I informed dispatch that we’d be responding non-emergent.
Up stairs and inside the small two bedroom apartment, Samantha, our patient, was waiting on the couch, holding a hot compress to her swollen right eyelid. Mom worked calmly in the kitchen finishing diner for her other two children. Alan, Samantha’s father sat on the edge of his seat next to his daughter in a state of barely containable anxiety.
He had recently arrived home from work and his wife had informed him of the apparent infection in Samantha’s right eye. One look and he was on the phone to us. Now he breathed rapidly as he fumbled through a list of questions. What caused it? Could it damage her vision? Could she lose her eye? Could she go blind?
I cleared the engine to go back in service and sat down next to him. Over the next ten minutes we both explained what pink-eye was and how to take care of it. We talked about hot-compresses and how contagious the bacteria was going to be. We reviewed the typical course for such and infection. How to prevent it in the other kids. How likely it was that one of them already had it. And we discussed his plan for morning. (It involved asking a neighbor to drive them to a near-by clinic.)
Alan called 911 for pink-eye. And…(This part is bound to be controversial, depending on what kind of system you work in.) I never offered to take him to the emergency room. And he never asked.
If he had asked, I would have most-likely obliged. I’d have put Samantha on the pram and given her a fun ride to the E.R. I do stuff like that frequently. I imagine most of us do.
So why am I telling you about Alan and Samantha now? What’s the point? The point is that Alan called 911 for pink-eye. He called because, in his book, a child with pink-eye was a medical emergency significant enough to warrant a response from the local emergency services. Alan defines pink-eye as a medical emergency. He’s wrong, but that’s beside the point. I don’t get to decide when Alan calls 911. Only Alan gets to decide that. I do get to decide how to respond. I decide how to respond with my apparatus. I decide what service to offer and I decide how I feel about it. That last part is important. I decide how I feel about Alan calling 911 for pink-eye.
The Happy Medic and Me
I bringing this up now because I got called out. (Well…sort of got called out.) I felt like I got called out anyway. The Happy Medic, Justin Schorr went off on a rant about blonds and library’s and patient’s and stubbed toes. And then he said this:
I hear from many corners of the EMS industry that we need to lose our “above them all” attitude and just take people in that want to go in. “It’s their definition of emergency, not yours” is something I am tired of hearing.
For the record, I never said “It’s their definition of emergency, not yours.” and Justin never mentioned my name in his post. But I did say that patient’s define their emergencies. Which is the closest thing I’ve ever seen to Justin’s quote in the blogsphere.
This isn’t the first time my words haven’t set well with Justin. He recently mentioned that he thought he resembled my 7th tragic EMS flaw. We’ve had a few lively discussions and we certainly don’t always agree on what’s best for EMS as we move in to the future. I’m glad I have Justin around. Sometimes I think that if it weren’t for him and Tim Noonan, nobody would ever disagree with anything I say. How boring would that be?
I also consider Justin a friend. He’s got a great blog, he’s a linchpin at the center of some of the coolest video projects in the history of EMS, and he once talked me out of punching an obnoxious dude in a bar who desperately needed it. We also agree on a lot of stuff. On the topic of non-emergent EMS System use, here are some of the things I think Justin and I agree on:
- People who call 911 deserve to be treated with respect.
- Our current EMS systems are an inadequate and flawed model for dealing with the complexity of prehospital medicine.
- Care providers should have more options in addressing the needs of our patients.
- Transporting everyone to the E.R. is a bad solution for non-emergent 911 use.
I could go on. The list of things we agree on is much longer than the list of things about which we disagree. We disagree on the usefulness of paramedic initiated refusal. We disagree on whether or not Alan should even get the opportunity to talk with a paramedic in his living room. And we disagree about how we feel when Alan calls for an ambulance when his daughter has pink-eye. So I’d like to put in my two cents as well.
Why do people call 911 for non-emergent reasons?
With all the information about dialing 911 in an emergency, why would anyone access the system for a stubbed toe, a cut lip or pink -eye? Are they, as Justin theorizes, just drastically misinformed? Do they think they’re standing in a fast-food restaurant instead of a library? Should we simply cater to their remarkable ignorance?
I think the idea that people call 911 out of ignorance is a flawed analysis. People call 911 inappropriately for two reasons.
1.) They have reached the end of their problem solving capability and need help. They don’t care if they are misusing the system. They care about getting help because they don’t know what to do. In their mind, that is an emergency.
2.) They are purposefully abusing the system for personal gain. Whether it is for controlled medications, in-home health care, a ride to somewhere closer to the hospital, attention, a warm bed or food, they want something that we provide and they don’t care if they have to game the system to get it.
Notice something about both of these types of people. They both have a basic understanding of the 911 system. Educating them further on the appropriate use of 911 will not prevent their next call. Even if you could stop them from calling, their problems are so common that their will almost certainly be a new person to call tomorrow instead of them. And the process begins again.
Neither of these types of people are standing in a library asking for a cheeseburger. They understand how the system is supposed to work. Most of the folks in category two understand the system far too well.
Here is my point:
System abuse isn’t about a lack of education or a lack of understanding. You could put billions of dollars into PSA announcements and it wouldn’t change things a bit because system abuse is about needs.
When Alan isn’t sure if his daughter is going to go blind he has a need. When Martha runs out of the pain pills that she’s addicted too, and she needs a fix, she has a need. When Reggie lives on the street and he wants a warm bed and some food, he has a need. All of them may turn to the 911 system. We get to filter it all. And we work in a system that gives us far too few tools to work with. Some systems only give their EMT’s one tool…transport them all to an emergency room…period. And that’s frustrating.
But we shouldn’t respond to that frustration with barriers that leave the need unmet. I just don’t believe that, “Sign here, it’s not my problem.” is the solution to the problem. I could have simply refused Alan my services and left him at home, scared and pissed off because the best we could do for him was reject his needs as unfit for our service. But the need persists.
If Alan asks for a hamburger, I’m not going to fire up the grill, but I can at least tell him where to find the local Burger King. I can even take the time to draw him a map.
So Why Is All This My Problem?
Because we gave everyone in the world our phone number. We created the system. We designed a system with virtually no barrier to entry. If you can remember three numbers and find a working phone, you can calls us and we’ll help you resolve your emergency. We taught this to EVERYONE.
And now we’re shocked when people call us for pink-eye.
The Way Things Are
I know what you’re saying. “OK smart guy. Then what’s the solution?” Good question. First, we need to drop the pissed off, “I can’t believe you called for this.” attitude. Of course they called for this. Reread the part about giving everyone our phone number. Drop the surprised look and let’s get real about the way things are. Then we can make peace with it and get on with the productive work. To start, allow me to draw you a quick diagram.
Line-A represents reality. The way things really are right now. Line-B represents the way we want things to be. The distance between line-A and line-B represents stress. The farther line-A gets from line-B, the more stress we experience. This applies to anything in life.
Sometimes that stress is good. If this chart is used to address your personal fitness, perhaps a good distance between line-A and line-B could lead to some very positive behavior changes. But when we apply this equation to something big and primarily out of our control, something like our 911 system designs, we’re better off keeping that distance in check.
One of the best things I ever did for the long term survival of my sanity in EMS was to recognize that patient’s will always be the ones who define their own emergencies. I can’t be there when they call 911 to guide them. They do it on their own. That’s the way it works. This is why patient’s define their own emergencies. They just do. It’s the way things are.
That doesn’t mean I don’t get to have my say. Once they call for my help, they’ve invited me to interject my experience and training and bring it to bear on their problem. This is where Justin’s analogy goes astray. The “..not you.” part of the equation. I would get pretty frustrated if I felt like I didn’t have any say in the process and had to blindly follow my patient’s whims. But who does that?
Just because you don’t get to tell your patient to pound sand doesn’t mean you don’t get to interject your experience and judgment. And that’s where the tool box comes in. I’d like to see the tool box filled with more useful tools. Pound sand is not one of those tools. Neither is, “It’s not my problem.” We invited them. They called. It’s our problem.
They Call We…Don’t Haul?
I consult with my base physician more than most paramedics in my system. Part of finding more useful solutions for our patients is having a rapport with the base hospital and feeling comfortable talking on the phone with your physicians and building their trust. A big part of that trust equation is doing a good job when you do transport patients to their facilities, practicing good, thorough physical assessments and performing good medicine.
The more the folks on the other end of the phone trust you, the more likely they are to believe you when you consult with them on the phone. When I call the local E.R. doctors on the phone, they tend to trust me. That helps a lot when I want to advise someone that they can go seek help from the urgent care down the street.
Fill the Need
Systems that aggressively pursue alternatives to emergency room transport have developed connections to the alternate resources that our patients need. Without these connections we leave a vacuum of need that will invariably lead to more use of the 911 system.
The systems that actually reduce the volume of non-emergent 911 use are the systems that connect people with detox facilities, substance abuse programs, urgent care clinics, food assistance programs, home health care providers and all the other appropriate resources that can fill the needs of the system mis-user / abuser much better than an emergency room can. In most large communities these resources already exist, we just haven’t partnered with them yet.
The system doesn’t need more barriers and gatekeepers, the system needs more resources and tools.
It also doesn’t need our anger, frustration or righteous indignation. That’s not to say that it isn’t OK to occasionally be upset, frustrated or even righteously indignant. But we need to recognize that those aren’t the things we need to change the system. To change the system we need courage.
We also need to fundamentally change the way we see our role in the big picture. We’ll talk about that next time. Until then, I’d like to know what you think about this. Leave a comment below and add your voice to the debate. What you think is important too.