Patients Define Their Emergencies (Part 2)

True Story…

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.

Comments

  1. I agree, but it leaves a question unanswered. Connecting resources to people is something we tried, and it worked, but how can we ensure that we’re not just leaving them a business card to be ignored?

    Some times the only way we can get people into social services programs IS to transport them. We did it just recently for an elderly lady that fell alone in her home and sat on the floor for 3 hours. She didn’t have any medical issues as a result and it was really only a lift assist, but the only way we could ensure her safety was taking her to the hospital.

    It seems that when we have no shortage of social programs to get people such as her or that addict that wants to connect to rehab, but there really isn’t a well established mechanism for ensuring those people utilize those resources.

  2. We responded today to a lady that could not find her meds and called 911.

    We are, in many cases, the “last line of defense.” We are the first ones people call when they don’t know who else to call. And we’re the last ones people call when they’ve tried everyone else.

    The benefits of being America’s most trusted profession.

    The general public believes that when EMS and Fire arrive, everything is going to be OK. That is the mindset that we’ve worked hard yo cultivate over the last 250 years.

  3. Getting better tools that you mention are a vital piece of the puzzle. I agree that doing PSA’s won’t do much. The people who call feel they have a need. But still, we need to start being able to tell people they don’t need an ambulance. If they want to go to the ED then we can give them other options and suggestions. But going by ambulance just because they called isnt the right avenue to travel and it sure won’t stop them or make them think twice the next time.

    However, people do learn to game the system and when the cut finger doesnt get them a ride they will fake chest pain, seizures etc. or stick to grave chief complaints because it’s what they think we want to hear or just to get that ride to the ED , for whatever reason.

    There must be a solution and I hope that discussions like this will bring that about. I dont have the answer either. But I think it needs to be a industry wide mission to start changing how we address the non emergent calls.

    I actually wrote a short article “Just Who’s Emergency Is It?” on how we can learn from any call we respond to a while ago at EMS House of DeFrance http://www.defrance.org/artman/publish/article_1476.shtml .

  4. Steve,
    Inspiring writing as always, Sir. We indeed agree about more than we disagree with, but I think you may be in a better place than me.
    My system offers no “outs,” no better options, no place to put Alan’s sick daughter, one who needs eye drops available at any local store. No, my system demands a transport or a refusal.
    That is my problem.
    I would also counsel Alan about his Daughter’s condition, explain to him the risks of her preparing food or emptying the dishwasher, then direct them to the pharmacy counter at the local Walmart and be back in service.
    However, my system does not allow that, nor do many.
    My rant was inspired by a supervisor who demanded a private unit transport a person for a reason we all knew was fraudulent stating, “It’s their emergency, not yours!” then going back in service, leaving my engine and the ambulance to carry them down the stairs to the ambulance.
    Our callers define their situation, but not AN emergency, something the dispatch system should discover, hence all the money we paid for it.
    Alan does not have an emergency, but a lack of knowledge and resources in his community…until you came along. Strong work Sir. If you see a blonde walking into a library looking hungry, do for her what you did for Alan and EDUCATE them.
    I find out tomorrow if I’ll have a chance to make my system that way.
    Justin.

  5. First-time poster here so be nice! My perspective from a newbie paramedic student who doesn’t hit the road for another year so doesn’t have a tainted view of the world yet (but spent enough time in ambulance comms to know the silly things we get calls for!)

    You’ve defined two types of calls there. One being the non-emergency (to us) medical condition, where our customer doesn’t know who else to turn to. The other being the person who is trying to game the system to get something (i.e. drugs, a lift closer to town, etc).

    I’d say one of these is abuse of 000/911/whatever your local number is, and should be treated as such. You can probably guess which. The question of how to deal with it probably isn’t so easy.

    The other type of call (didn’t know where else to turn) probably isn’t so bad. Okay, maybe they shouldn’t turn to EMS for something that’s not urgent, but do they know it’s not urgent? Given that the message we give is “if in doubt, call us out”, we should probably expect it. Unless we’ve given people other options.

    The rest of this probably isn’t EMS practice related so much as systemic, but I’ve seen some good ways of dealing with the problem here in Australia:

    1. We have a 24/7 telephone hotline known in various states as Nurse-on-call or Health Direct. Much as this service can be cynically known as “Health Redirect” amongst other things for their propensity to connect people to 000 for anything that sounds like it could possibly be related to a medical emergency (understandably, telephone triage is difficult!), it’s a good service that people can call for medical advice and recommendations on treatment, whether it’s something they need to worry about, etc. Often if the result isn’t to activate an ambulance the advice is “see how it goes for a couple of days and make an appointment with your doctor if there’s any more problems”.

    2. In the service I was doing IT for (before I caught the bug and moved interstate to head to university to be a paramedic myself) in Melbourne, any calls for low priority jobs (26A01′s and other similar codes for those of use using That System We All Know And Love) wouldn’t immediately go to dispatch, but would instead be sent to an area known as the “referral service”, where a paramedic or registered nurse (rather than an AMPDS phone jockey) would phone the caller back and run through some secondary triage questions (similar to those which would be asked by the service in point #1) and either send the call to dispatch, organise another service instead (such as a locum, home nursing service etc), send a non-emergency patient transport service instead of emergency paramedics if they just wanted a lift to the ED, or recommend other treatment.

    These systems worked well for getting rid of some of the obvious low priority jobs out of the system, while still ensuring the person at the other end of the line got their “emergency” dealt with to their satisfaction – both by giving them an option other than EMS in the first place, and by ensuring that if they call us, we might have the ability to find them more appropriate care.

    Doesn’t help with the person who knows to use the key words “chest pain, clammy, shallow breathing” no matter what their problem actually is, but I’d be happy enough to class them in the “deliberate abuse” category.

    But these are systemic responses to the issue, rather than anything that the paramedic on the road can do, and when the paramedic gets to the job that is obviously non-emergent, they still have to deal with it in the best way possible.

    How does any of the above apply to the USA context? My (limited!) understanding seems to be that over there EMS is more of a private industry, so any of these initiatives would potentially reduce a company’s profits because they’d be sending less trucks to jobs?

    Anyway, some thoughts from me! Love the blog by the way Steve! And sorry for the essay I’ve written!

    Jason

  6. Hello again, Steve! First of all, thanks for the diagram. As you’ll see on Twitter, it is now hanging up in our Ops Office.

    I just have a few brief observations about your post, and i thought I’d take a second to share them here:

    1. I agree 150% that we need more pathways to refer patients to. My boss is very ‘old school’ and is of the ‘shut up and take them’ opinion, which I disagree with. Not everyone belongs in an ER, but until we see some change to the structure of EMS, there is little we can do but continue to bang on every door we find, and share our position with everyone we encounter.

    2. So what do I think our BIGGEST road block is for change? I dont think its our medical directors. I feel that many of them would let us move forward with whatever treatments we can show evidence for, and lets face it, the evidence is out there. Just look at almost any other country in the world, and you’ll see it for yourself.

    Our BIGGEST roadblock is “For Profit EMS.” Now, dont misunderstand me, I’m not talking about all of the F&B Ambulance companies out there, I’m talking about any system that bills for service from its patients. That money is there to sustain positions and create improvements to the company/department as a whole. Until you find a way to show a Return on Investment on non-transport EMS, many of the bean counters out there (whether they wear a Chief’s Hat, a CEO’s Hat, or just a boss’s hat) will not get behind your cause.

    The answer, I feel, is to gather up the evidence that this system could work, and that we could be educated well enough to MAKE IT work, and then find some way to either knock out the profitability of EMS all together, or make a non-transport-to-ER business profitable and billable. Then, you will get all of those beancounters to come on board with you.

    I dont mean to say that our field is driven by the all mighty dollar, but its hard not to get that impression when you watch what happens with 911 systems nationwide. One company gets picked over the other not because of the quality of service they can provide, but because of the rates that they charge. Fire Departments take over 911 contracts (or at least the more profitable ALS Calls) because they “need to justify jobs.”

    Like it or not, we have created a monster with For profit health care, and its going to take more than just a sling and a rock to bring down THIS Golliath.

    Once again though, Steve, you keep me glued to my monitor, and for that I think you.

    Cheers!

    Scott

Trackbacks

  1. [...] Whitehead really gets to the heart of the matter in his post Patient’s Define Their Emergencies (Part 2). Steve asks us to challenge him, but I am totally on board with his views on the futility of second [...]

  2. [...] This month we looked at respiration. Then I took another run at the controversial phrase, “Patient’s define their emergencies.” After that we talked about doctors watching EMS care on cameras and we wrapped it all up [...]

Speak Your Mind