May I have the definition please?

A funny video has been making the rounds on the interwebs machine, an ad for Mercedes Benz.

In this video a woman walks into a library and tries to order lunch:

It’s funny, right?

Now imagine she wanders into an ambulance station and asks to be transported for a toothache.  Is it still funny?  She’s still in the wrong place asking for what she wants.

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.

What if I told you it’s her definition of library, not yours?

We are not Jim’s Emergency Medical Services, or Sally’s or even Justin’s.

Responders have been trained to handle specific situations using specific tools, medications and techniques.  If you can not be aided by those things, then perhaps we need to find another resource for you. Most communities do not offer these services on demand, but arrangements need to be made ahead of time. They either wait or call 911 and get immediate service.  In still other communities EMTs and Paramedics are discouraged from or worse, disciplined, for accepting refusal of transport.

I’m not advocating leaving the sick and injured in the streets, but adding some realism in addressing our current problems.  We do not face a shortage of ambulances in America but an overpopulation of “emergencies.”

When you get on scene of the young woman who bit her lip and didn’t know what to do so called 911, no matter how you dice it, that injury is not worth placing responders lives at risk to respond to, not to mention who might be told “We have no ambulances available” while you’re trying to nicely tell your patient how minor the injury is.  Add to that that some private services do not allow refusals, now they’re generating a bill for the bit lip and taking up a spot at the ER.

Rogue Medic reminds us that our concern when at the scene with a patient is that patient and not the next one.  I completely agree that when on scene we need to focus on the needs of that person and not what might happen.  But when looking at the system as a whole, someone needs to be thinking about the next run.  Supervisors, managers, Chiefs, EMS Educators, SOMEONE needs to be looking out for who might need those supplies, skills and equipment your patient is asking about while getting that ride.  In the back of the ambulance is not the place to theorize about EMS.  That place is here in online forums, at conferences and when meeting with your Medical Director, System Managers and Chiefs.

There are things we can and can’t do for our patients.  If all you can offer is a ride, is it still an emergency?  Think about it for a minute.  If it’s just the speakers not working, do we really need to call a tow truck “just to be sure?”

Awhile back I had a good back and forth with David Konig about comparing McDonald’s, Starbucks and Dunkin’ Donuts to modern EMS.  He mentions the way Starbucks outdoes Dunkin not because of superior product, but because of superior customer service and a better customer experience.  It was in response to a series on Liability.

But those companies are still limited in the experience they can provide.  As I mentioned, when someone calls 911 for a reason I can not help with, nor any of my equipment, training or experience help with, do I still have to give them a positive experience?

Absolutely.

And that means not transporting those who do not need it.  The same way Starbucks will not make the girl in the video a hamburger, or arrange for one to be delivered.  They’ll likely smile, ask her if she meant a venti Americano, and remind her she is asking for a service Starbucks can not provide.  Then a good employee will make sure the customer can find what they are looking for, leaving them a positive impression of the company.

“This is a Starbucks.”

“This is a library.”

“This is an ambulance.”

We’ll just load her in the ambulance and take her in because after all, it’s not our definition of emergency, it’s hers.

Should the librarian stop her work and fire up the grill? After all it’s her definition of library, not yours.

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26 thoughts on “May I have the definition please?”

  1. In my opinion there needs to be an explicit criteria for who should be transported by ambulance. One study concluded EMS-initiated refusal is risky because ten patients given a taxi voucher were admitted to the hospital and one was admitted to the ICU. Is that a good criteria for ambulance transport, “likely to be admitted to hospital”?

    What I don’t understand is why agencies can’t refuse for at least “patient requests prescription drugs.”

  2. Most people have no idea what an emergency is and when they should call 911. I think it is time to spend some money on advertising, in both our countries, to explain when you should call 911 and when you should seek other forms of medical help. They should use detailed examples of when to call. You may need to go to the ER, but it doesn’t necessary mean you need an ambulance to get you there when a taxi or a friend driving you will work just as well.

    In Ontario we have a service provided by the Province government called Tele-Health. One phone call puts you in touch with a Registered Nurse 24/7. You can call about any type of medical problem. They are able to answer your questions and direct you to the most appropriate type of medical service, and probably help you locate it if necessary. Depending on your problem, their advice can range from telling you how to deal with the problem at home and what to do if it worsens or they may tell you need to call 911 immediately.

    I think some well spent advertising money informing the public in such a way that they will remember in an emergency when to call for the paramedics would go a long way.

  3. Thank you for addressing one of the most pressing issues for our dept, like many others. We are a small rural community with one ambulance, 17 miles from a hospital from our town center – but our district is 70 sq. miles. If we transport a patient, during the approx. 90 minutes our ambulance is out of service, any other emergency would have to draw from a neighboring community, possibly a 20 minute wait for an ambulance to respond, plus transport time. So we must consider “the next patient” as well as “this patient”.
    Something like what TBChick describes would be wonderful. How do we make that happen here?
    On the other hand is a lady I just spoke with who told me about her mother-in-law’s death from anaphalaxis, while they drove her to the hospital. I couldn’t bring myself to ask her why the He11 they didn’t call 911?!?

  4. In my opinion there needs to be an explicit criteria for who should be transported by ambulance. One study concluded EMS-initiated refusal is risky because ten patients given a taxi voucher were admitted to the hospital and one was admitted to the ICU. Is that a good criteria for ambulance transport, “likely to be admitted to hospital”?

    What I don't understand is why agencies can't refuse for at least “patient requests prescription drugs.”

  5. While I agree that we have an issue here, maybe I disagree with where the solution lies. What about changing the way we are dispatched. If the dispatchers can filter out the “real” emergencies from the “toothaches” we would spend less time en route dealing with these types of calls. I am not saying anything bad about our dispatcher co-workers, they do a fantastic job in a rough environment but if they had the resources and training to “strongly advise” personal vehicle transport, it would prevent the risks associated with the callout all together.

    That said, I do understand the liability issues with encouraging refusals. I know that is against our policy although the PT can refuse on their own.

    Great point and I appreciate not only you reminding us of this but also for getting me thinking at the end of a long day!!!!

  6. Most people have no idea what an emergency is and when they should call 911. I think it is time to spend some money on advertising, in both our countries, to explain when you should call 911 and when you should seek other forms of medical help. They should use detailed examples of when to call. You may need to go to the ER, but it doesn't necessary mean you need an ambulance to get you there when a taxi or a friend driving you will work just as well.

    In Ontario we have a service provided by the Province government called Tele-Health. One phone call puts you in touch with a Registered Nurse 24/7. You can call about any type of medical problem. They are able to answer your questions and direct you to the most appropriate type of medical service, and probably help you locate it if necessary. Depending on your problem, their advice can range from telling you how to deal with the problem at home and what to do if it worsens or they may tell you need to call 911 immediately.

    I think some well spent advertising money informing the public in such a way that they will remember in an emergency when to call for the paramedics would go a long way.

  7. “It’s their definition of emergency, not yours”?!

    What a load of crap.

    I’m sorry if that offends, but that’s my stance on that comment. When a suitably trained, professional medical person (paramedic, doctor, nurse, etc) arrives on scene with a patient and makes a clinical decision based on evidence gathered that the patient is not suitable for emergency transport to the hospital, then why on earth should *any* EMS system transport them to the hospital?

    I truly believe in patient choice and patient education but at the same time, patients need to understand that there are numerous pathways to receiving the treatment they need and that the medical person that is attending to them is giving them the best advice that they can and that they should damn well take it. Transport to hospital is expensive, much less the hospital care itself, and as such is limited in availability – no medical system in the world has an unlimited budget. So why are we wasting resources on those that patently don’t need it?

    Please note that I’m not advocating anyone neglect a patient. If the person-on-scene is unsure, concerned or cannot gather suitable evidence to convince themselves that the patient does not need emergency treatment, then by all means take them in.

    Transporting every patient just because they want it? That’s the product of an over-litigious society and it’s costing us dearly.

  8. Thank you for addressing one of the most pressing issues for our dept, like many others. We are a small rural community with one ambulance, 17 miles from a hospital from our town center – but our district is 70 sq. miles. If we transport a patient, during the approx. 90 minutes our ambulance is out of service, any other emergency would have to draw from a neighboring community, possibly a 20 minute wait for an ambulance to respond, plus transport time. So we must consider “the next patient” as well as “this patient”.
    Something like what TBChick describes would be wonderful. How do we make that happen here?
    On the other hand is a lady I just spoke with who told me about her mother-in-law's death from anaphalaxis, while they drove her to the hospital. I couldn't bring myself to ask her why the He11 they didn't call 911?!?

  9. I’m a respiratory therapist in a hospital on the outskirts of a major metropolitan city. We are not the largest hospital in the area, but we are located in an area with a very high percentage of people with no insurance (nearly 20%). Recently, I was called to the emergency room to administer a breathing treatment on a child with an asthma exacerbation. When I entered the patient’s room, mom and her 5 children (all under the age of 8) were all in the room. I asked what had brought them to the ER today and mom said that two of the kids had colds and one of the others had a heat rash. They arrived in an ambulance. They live 4 blocks from the hospital, along the bus route, and across the street from a drugstore. They have state health insurance.

    I would have loved to have been able to redirect this mom to another choice. Instead, her mass of children was occupying one of our trauma rooms, because the other rooms were too small. The other trauma room was occupied with someone having chest pain. The gunshot wound had to be redirected to another hospital (5 extra transport minutes, but still) because we were full.

    Explain to me how this is better than “everybody goes if they want, whether they need it or not”.

    LadyHavoc

  10. While I agree that we have an issue here, maybe I disagree with where the solution lies. What about changing the way we are dispatched. If the dispatchers can filter out the “real” emergencies from the “toothaches” we would spend less time en route dealing with these types of calls. I am not saying anything bad about our dispatcher co-workers, they do a fantastic job in a rough environment but if they had the resources and training to “strongly advise” personal vehicle transport, it would prevent the risks associated with the callout all together.

    That said, I do understand the liability issues with encouraging refusals. I know that is against our policy although the PT can refuse on their own.

    Great point and I appreciate not only you reminding us of this but also for getting me thinking at the end of a long day!!!!

  11. “It’s their definition of emergency, not yours”?!

    What a load of crap.

    I'm sorry if that offends, but that's my stance on that comment. When a suitably trained, professional medical person (paramedic, doctor, nurse, etc) arrives on scene with a patient and makes a clinical decision based on evidence gathered that the patient is not suitable for emergency transport to the hospital, then why on earth should *any* EMS system transport them to the hospital?

    I truly believe in patient choice and patient education but at the same time, patients need to understand that there are numerous pathways to receiving the treatment they need and that the medical person that is attending to them is giving them the best advice that they can and that they should damn well take it. Transport to hospital is expensive, much less the hospital care itself, and as such is limited in availability – no medical system in the world has an unlimited budget. So why are we wasting resources on those that patently don't need it?

    Please note that I'm not advocating anyone neglect a patient. If the person-on-scene is unsure, concerned or cannot gather suitable evidence to convince themselves that the patient does not need emergency treatment, then by all means take them in.

    Transporting every patient just because they want it? That's the product of an over-litigious society and it's costing us dearly.

  12. I'm a respiratory therapist in a hospital on the outskirts of a major metropolitan city. We are not the largest hospital in the area, but we are located in an area with a very high percentage of people with no insurance (nearly 20%). Recently, I was called to the emergency room to administer a breathing treatment on a child with an asthma exacerbation. When I entered the patient's room, mom and her 5 children (all under the age of 8) were all in the room. I asked what had brought them to the ER today and mom said that two of the kids had colds and one of the others had a heat rash. They arrived in an ambulance. They live 4 blocks from the hospital, along the bus route, and across the street from a drugstore. They have state health insurance.

    I would have loved to have been able to redirect this mom to another choice. Instead, her mass of children was occupying one of our trauma rooms, because the other rooms were too small. The other trauma room was occupied with someone having chest pain. The gunshot wound had to be redirected to another hospital (5 extra transport minutes, but still) because we were full.

    Explain to me how this is better than “everybody goes if they want, whether they need it or not”.

    LadyHavoc

  13. “In still other communities EMTs and Paramedics are discouraged from or worse, disciplined, for accepting refusal of transport”

    Yep, work for one of those. Still not sure why a refusal counts against me.

  14. I say 3 cheers for some of the US cities that have empowered 911 dispatchers to tell someone “NO”.
    Risky, sure , but isn’t everything?

    Perhaps if the industry didn’t feed off such time-driven goals, like call processing, and allowed better trained 911 dispatchers [the REAL first responders] to TALK with 911 callers, we might filter out calls that should go no further than the telephone call.

    If Mr/Mrs/Miss ObligatoryCellPhoneUserChatterboxDoGooder drives past an individual on the sidewalk, and at a passing glance decides that that individual ‘needs help’, calls 911, says ‘You need to DO SOMETHING’, to the 911 operator, do we collectively drop what we’re doing and race over to help, or slow the process down and have a short conversation with this caller?

    If this same person, driving down the road, sees an individual doing synchronized cartwheels with his/her motorcycle in the opposite lanes, it seems likely we will be needed, and the ‘interview’ could be shortened.

    ‘You call, we haul’ seems to be an unfortunate reality for too many in this industry.

  15. “In still other communities EMTs and Paramedics are discouraged from or worse, disciplined, for accepting refusal of transport”

    Yep, work for one of those. Still not sure why a refusal counts against me.

  16. I say 3 cheers for some of the US cities that have empowered 911 dispatchers to tell someone “NO”.
    Risky, sure , but isn't everything?

    Perhaps if the industry didn't feed off such time-driven goals, like call processing, and allowed better trained 911 dispatchers [the REAL first responders] to TALK with 911 callers, we might filter out calls that should go no further than the telephone call.

    If Mr/Mrs/Miss ObligatoryCellPhoneUserChatterboxDoGooder drives past an individual on the sidewalk, and at a passing glance decides that that individual 'needs help', calls 911, says 'You need to DO SOMETHING', to the 911 operator, do we collectively drop what we're doing and race over to help, or slow the process down and have a short conversation with this caller?

    If this same person, driving down the road, sees an individual doing synchronized cartwheels with his/her motorcycle in the opposite lanes, it seems likely we will be needed, and the 'interview' could be shortened.

    'You call, we haul' seems to be an unfortunate reality for too many in this industry.

  17. Hey Justin, just wanted to drop a quick line and let you know that this specific post was printed out and has been floating around the EMS office here…getting much feedback but by far the funniest was “maybe we should put a mini grill in the ambulance!”

  18. Hey Justin, just wanted to drop a quick line and let you know that this specific post was printed out and has been floating around the EMS office here…getting much feedback but by far the funniest was “maybe we should put a mini grill in the ambulance!”

  19. if we say it’s not emergency and you don’t like it, take a cab. the cab won’t turn you down. unless you pee in the cab.

    i’m not entirely certain where this phenomenon of non-professionals insisting they know better than the professionals comes from. and it’s pervasive both in ems and outside of it. look at politics.

  20. if we say it’s not emergency and you don’t like it, take a cab. the cab won’t turn you down. unless you pee in the cab.

    i’m not entirely certain where this phenomenon of non-professionals insisting they know better than the professionals comes from. and it’s pervasive both in ems and outside of it. look at politics.

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