Just Like Riding a Rigged Bicycle

This video swam into my feed recently and the click bait was well written.

“See why no one can ride this bicycle!”

OK, internet, what’s the catch?

 

Smarter Every Day

Not only is it fascinating that the welders threw this bike together, but watching the host try to ride it, and everyone else try to ride it, really hit home for me.  There is the old saying that you can’t teach an old dog new tricks.  I’ve always hated that phrase but in many respects it is true.

Most times we are so engrained in the way we learned something that learning a new way of doing it is not only difficult, but could be impossible.

Training and education can challenge the old ways.  Heck it should, but we need to use caution in moving forward with new ideas that change the way we’ve operated in the past.  For whatever reason we think changing the system may be better, there will be those who will need time to adapt to the changes.

Indeed it is easier to change your ways when they are fresh in your head, hence why the child in the video was able to learn in a few days what took the adult 8 months.

While riding a bike is a great metaphor for EMS (We train, rehearse, drill and train again until we can’t get it wrong) it is important to remember that there are those in our field who still ask for Lidocaine on an arrest, reach for the MAST or go for a pulse check after a shock.

They are still riding the way they were taught, wobbling unsteadily trying to adapt to the new settings in front of them.  Some things can’t be unlearned, simply archived and new pathways used for new concepts.

However, just like in the video, when challenged we will revert back to what we have known the longest.

 

Hey, it happens.  Just be ready to admit when you’re wobbling and don’t be over confident in your ability to suddenly be able to adapt to change.

After all, it is just like riding a bike, right?

Informed Customers and the Irrational Medical Marketplace

Leonard Rodberg PhD, penned an article in July of 2013 discussing why Healthcare in America costs so much.  His take on the system boils down to an often overlooked glitch that is required for a market to thrive the way we are told the Healthcare market should:

The customers have no idea the cost, the options or the necessity of the products they are being sold.

Imagine you are going in to buy a television.  The clerk in the store has only 1 and there is no price listed.  He tells you there may be other TVs, but this one is the best fit for you.  You’d be out of that store in a heartbeat looking for a store with more choices, pricing information and make an informed decision.

Healthcare overall is still being treated like a product to be sold instead of a service to be delivered.  The Marketplace set up to handle payments for service can not work if the end user is purposefully being kept in the dark about pricing, options and alternate methods of care.

I’m not talking about healing crystals, but instead trying to focus on the actual end game for healthcare:  Healthy people.

A healthy population is more productive and costs far less in the long run in regards to care so why aren’t we making a difference?

Shouldn’t our goal be to prevent larger problems early?  What ever happened to an ounce of prevention being worth a pound of cure?

Turns out an ounce of prevention means a loss of billable services later on.

Jeffrey Brenner, Physician and co-founder of a group researching new methods of delivering care called the Camden Coalition of Healthcare Providers, was recently a guest on Freakonomics, a show about the hidden meaning of everything.

On that program he discusses his group’s efforts to find high users of healthcare and address their problems head on.  By making them healthier, they use less of the system.

From the show:

“So we learned that 1 percent of the patients is 30 percent of the payments to the hospitals, and that 5 percent of the patients is about 50 percent of the payments to the hospital. So a very small sliver of patients are driving all of the revenues to the system. … And you know, the question really is this the fault of the patients or is this a system failure? And I think our journey over the last couple of years has really demonstrated to use that it’s a system failure and that we could be doing much, much better for these patients.”

If we suddenly improve the health of 5% of the people visiting the hospital, just 5%, that hospital will lose 50% of their revenue.  There is no incentive to cure these people.  The same can be said for EMS.  If we actually start telling people they don’t need an ambulance we lose our revenue stream and can’t operate when someone does need it.  Of course that logic only holds if you consider EMS a product and not a service. (Here’s a hint…the word Service is actually in EMS.)  Until EMS is considered a service just like police, fire, animal control and the courts it will be driven by profit and profit alone.  New methods of care will be challenged with “What is the reimbursement model on that?” instead of “How many people do you think we can reach and improve?”

Sounds a lot like some programs sprouting up recently, doesn’t it?  Community Paramedicine needs to be that tool for EMS, but may get cornered into simply visiting folks post discharge.

In the meantime we need to change the way we deliver care.

We need to start educating our patients.

Ever been told by your managers or Chiefs not to discuss billing, costs or any other financial aspects of care?  Why do you think they do that?  Could it be that finding out the cut finger will be billed $1700 may impact the patient’s ability to make a good decision or is it that the manager and Chief need the $355 State payment for the transport to keep the system afloat?

You know it’s the latter but will still tell patients, like I used to, that worrying about money should be the last of their worries.

Or should it?

If patients knew the cost of the service they requested, were given options at various levels of cost that fit the situation and were able to choose a solution that met their needs, that would be a true marketplace and the cost of healthcare would fall dramatically while maintaining the same levels of care to those who need it.

We operate in a marketplace that hides cost, reduces choice and intentionally restricts access to services.

That is an irrational medical marketplace indeed.

Cash on Delivery – American Healthcare from the Outside

Those of you following along know where I work and why I can no longer mention them.  For you new people, I work at one of the busiest airports in the Nation and the world.  I meet all types of people, from the college kid traveling home on the puddle jumper to the executive boarding early for champagne on the A380.

I meet them all at one time or another because of a tight travel schedule that didn’t leave time for lunch, a few too many $12 mugs of beer at the terminal, a bag falls from the bin or, on the rare occasion, their pilot isn’t able to bring the aircraft in for a controlled stop.

Most times we encounter a person dehydrated, intoxicated or suffering from a minor traumatic injury.  Like any other EMS service we respond, assess and offer treatments and transport options as appropriate.

It was the summer of 2009 when my discussions with Mark Glencorse, then a Paramedic in England, turned towards the American and NHS systems of care.  In the US we were being told the British were being turned away at over crowded emergency rooms and old women were laying in the street to die.  Mark was being told that in America if you didn’t have cash money the ambulance would not take you.  This opinion was confirmed on multiple ride alongs with Mark in England and, most recently, at my current job.

THE EMERGENCY

A pilot has contacted the tower declaring a medical emergency, person unconscious and they are on final descent.  ETA to terminal, 5 minutes.

THE ACTION

My crews are at the jetway as it lurches to life to approach the aircraft that appears to be pulling into the gate rather quicker than most.  Sometimes the pilot will call in CPR, other times you are met with a door opening and the sound of “three and four and five…”

Meeting us at the door the crew informs us that the patient merely fainted at the rear of the aircraft after getting up from their seat after the final descent began.  She’s in good spirits, embarrassed, but in need of further physician evaluation and she agrees to it.

As the local ambulance company arrives she is digging through her purse rather intently.

“We have your passport if that’s what you’re looking for,” I mention to her, softly toughing her arm to distract her from the task.

“Oh, I know, but I need to pay for the ambulance.”

The looks that flashed around the room were of disbelief on all faces but one.  Mine.

I crouched down into her line of sight and held her hand.

“You don’t have to pay right now.  I wouldn’t be surprised if NHS picks up the tab, but they’ll take you in and get you well for no fee up front.”

Her face was considering my words when I realized some background was in order.

“I had the chance to serve a week in Newcastle Upon Tyne with the Northeast Ambulance Service and heard folks from that region concerned about American medical access.  Rest assured, you can get care without cash in hand.”

She sighed heavily as the cot finally reaches her side.  As she was covered with a blanket and my business card tucked neatly behind that of the airline supervisor in her purse I heard her tell the ambulance Paramedic very softly “He told me not to give you any money now.”

To his credit, the medic quickly whispered back “I’ll make sure the hospital knows to contact the NHS for you.”

Her smile likely reversed the condition she was suffering from while the rest of us packed up and headed back to get ready for the next call.

Preconceptions can cause trouble.

Remember?

Response Times Discussion Continues

While I expected Scott and I to get into the ALS vs BLS first response debate a lot faster, we seem to have trouble moving on from the response times discussion.  Or, I keep getting distracted by great questions and comments.

Reader Florian commented on my original post regarding a large American City struggling to meet response times with a question about unit deployment and availability:

“WHY there are not enough units available? Cost, ageing fleet, retired staff etc were touched upon, but what are all the available transport units up to when they are unavailable for other calls? Are they on actual emergency calls? Or calls that could have, and should have been dealt by other services, e.g. community nurses, GPs etc? Should that unit have been dispatched at all, or could they have been given home help advice over the phone?”

Excellent points all Florian and you were right later in your comment that your views are skewed to the UK version of healthcare: Actually getting people the care they need.

When I visited Mark Glencorse in the UK my eyes were opened wide to a new model of delivering care – Respond Not Convey.  This simple program allowed medics to divert reclined cot 2 person transport units away from ambulatory patients and those who did not need transport via a reclined cot.

The system allowed for single paramedic resources to relocate patients to their GP, local clinic or even local A&E (ED) depending on severity of condition.

Because of the American system of health insurance those options are almost impossible.  While many communities are adopting Community Paramedicine with great success they may also still be locked into a rigid transport model that does not allow single practitioners to transport.

And all because of billing.

You can take someone to the hospital in a horse drawn wagon if you wanted to.  Perfectly legal.  Just don’t label it “Ambulance” and don’t try to bill for it.

But back to Florian’s comment in regards to the American City noted in the news story.

It is likely that those reclined cot 2 person transport units are busy taking folks to the ED who neither need the cot or the ED.  Most 911 calls require only BLS intervention following an ALS assessment.  So why keep those practitioners, equipment and units committed?

Billing and a warped definition of liability.

I can’t speak to the municipality mentioned in the story but it is likely that any system seeing an increase in call volume without an increase in patients who require intervention needs to address their patient population with alternate services.

Homeless outreach, community prevention programs, asthma programs and community paramedicine can all do a fair job at decreasing the calls to 911, but offer no help when a crew is on the scene of the cut finger who demands an ALS 2 person reclined cot van ride to an ED while the choking down the street gets no ambulance.

Florian, I would bet that this system could benefit from diverting appropriate patients to single unit resources for transport to clinics, urgent cares and EDs but the lawyers would never go for it.

After all, they would want to try to bill for it and you can’t bill unless you meet the requirements.

Is an ALS front loaded system with those options more efficient than throwing BLS fire engines at every call?  Most definitely, no question about it.

But what would we do with all the BLS resources in the community?

 

Great question, Florian.

Should Response Times Matter? A discussion with Medic SBK

I’ve been discussing THIS story with good friend and fellow EMS 2.0 believer Scott Kier on the book of faces.

Since I can not mention the Department name here, just read the story and come back.

Disclosure:  I am a trained Firefighter/Paramedic.  I am a second generation Firefighter.  I am a card carrying member of the IAFF and my Local.

That being said, let’s move on to the meat of Scott and my discussion.

The story references a municipality struggling to meet increasing demand for ambulance responses under a state mandated market share of 80% responses shared with 2 local private providers.  To reach that target the municipality made funding available to replace an aging fleet (some stories reported over 200,000 city miles on some ambulances) and hire new EMS staff.

The Municipality operates an EMS transport tier within its Fire Department, a decision made in 1997 when the municipality’s public health ambulance group was folded into the fire department.  If you’ve been awake for more than an hour you know that never goes over well.

Skip ahead to about 2006 when single function EMS crews are sent back out from 24 hour assignments in the firehouses on a “1 and 1″ deployment model.  That means one EMT and one Paramedic per unit.  AKA the norm.

The 24 hour medics were reassigned to the municipality’s fire engines to increase the capability of ALS first response.

The local EMS Agency sets response times for all ambulances in the system and has magically chosen 10 minutes for code 3 calls and 20 minutes for code 2 calls.  The determination of code 2 or code 3 is made by the call taken and caller discussing the patient’s condition, weather and who knows what else.

The times are averaged using an approved statistical model and reported to the EMSA and State.

Now that that’s out of the way, let’s talk about response times.

Response times are solely to determine if a contracted agency is meeting contract parameters.

See, wasn’t that easy?

It would be a challenge to hold ABC Ambulance Company or Random Municipality to actually treating illness and injury to a certain level.  Imagine if the contract to earn a service area required an agency to treat all asthma patients with a bronchodialator or ensure that all patients with a revised trauma score less than 5 are being transported to a level 1 facility.

EMS needs to be held accountable for the assessments and treatments they provide not how swiftly they can arrive or how many people they can haul away in a day.

Trouble is we’ve spent the better part of 40 years telling people that “seconds count” when in fact they only count in groups of about 200.  Add to that that reimbursement is tied to transport, not treatment and the service simply looks to turn over calls as fast as possible.  Armed with the belief that a 10 minute response time is required for chest pain, ankle injuries, drownings and sleeping street people, the entire system must be built for the smallest community of patients: the critically ill.

EMS 2.0 is about stopping the band aid fixes and overhauling the EMS system in each community to meet the needs of that community.  For some that means EMS based EMS or a third service while others will need to lean on fire and PD to take up the slack when staffing levels can’t be filled.

Scott and I agree that a tiered approach is necessary, however, based on discussions we’ve had online and in person we are on opposite sides of that discussion.

Perhaps Scott can pick it up here over at EMS in the New Decade?

An EMS Expo Blogger Scavenger Hunt!

Here is a pic of a bunch of EMS Bloggers (and our ZOLL hosts) from 2011

Can you find them all in Baltimore this week?

If you find them, tag them and me (@thehappymedic) in a pic and throw it up on twitter.  Whoever finds the most gets bragging rights for at least a year and special perks at EMS World in September!

 

And if you are in this photo and don’t want to be found, better get to hiding!

Run.

It was cold when they left the house.

In the early morning hours they gathered a bag from the trunk of the car and walked to the end of the icy block.

At the stop sign was a friend idling, waiting.  Waiting to run.

Climbing into the warm car they felt a glimmer of hope for the first time in years.  The drive to the airport was silent, the younger one in the back seat falling asleep almost immediately.

It wasn’t until the plane finally left the ground that she took a deep breath, confident in the decision she had made.  4 year old asleep on her lap she allowed herself a drink to calm her nerves on the first flight to Anywhere But Here, USA.

Unfortunately the stress, lack of sleep and drink caught up to her when they arrived and the gate agent was concerned.  Medical assessment finding nothing of concern rescuers turned to the events leading to their arrival without bags or a ride anywhere.

“We are trying to get to Anytown*” she said through teary eyes.

The 4 year old seemed curious about the tiny fire engine outside the window.

“We have a connecting flight but I think we missed it because of…” she pointed to the rescuers, the gate agent, the airport and broke down crying.

The agent confirmed the flight had been missed bit because of circumstances causing their delay and the next flight was being arranged.  That flight was tomorrow morning, a good day away.

After the ambulance ride had been refused and the airline snacks consumed, the gate agent approached with wonderful news.  He had arranged for a hotel room and a shuttle for the woman, her child and their grocery bag of earthly belongings.

As she was assisted to the shuttle stop the reason for their sudden departure crashed awkwardly into the conversation.

“It just wasn’t safe for us anymore,” she said to the 4 year old boy.

“Not for me, not for him and not for who he’ll turn into if we stay,” she mentioned casually over her shoulder.

They were on the run from an unsafe home or telling the most believable cover story ever known.  Violence and intimidation had turned fear into action late the night before.  She had a plan, a friend she could trust and took the next opportunity to run.

“Do the local police know about the father?” I asked looking for the shuttle van.

“He left three years ago.  Decided he didn’t want a kid after all.  His replacement didn’t know what he wanted most days.”

We stood in silence for a good 10 minutes.  I wanted to go straight home and hug my family.

After the van pulled away from the curb local law enforcement was notified of their physical description, origin and location for the night just in case the story didn’t hold water.

A week later I was informed an officer had followed up at their location and confirmed they had arrived safely with family in Anytown.  Hopefully the little guy only remembers the little fire engine outside the window and not the reasons they had to run.

 

 

image credit Shanon Wise via creative commons

Inspiring our Peers

Ambulance Chaser, Driver and friend of the blog Wes Ogilvie has an inspiring post up today I just had to share.

“But if we, those of us who consider ourselves to be ‘good’ providers, motivated by the right things in emergency medicine, don’t make ourselves available as mentors, resources, or peer support providers, then someone else surely will.   These may be the the Low Information Voters who chant the shopworn phrases of low EMS standards.” – Wes Ogilvie

Go read the post HERE.

So many folks in EMS focus on patient care, training or licensing.

So many folks in EMS focus on QI, vehicle design or discipline.

But how many are looking around their immediate area:

The driver’s seat.

Chances are the biggest positive impact you can make as a Paramedic is to mentor or inspire another provider, starting with the grunt taking you from patient to patient.  That person we often think of as simply a means to an end was once us.

Think back to the moment you realized you wanted to be a Paramedic.  It wasn’t watching Emergency! or Mother, Juggs & Speed, there was someone in the right hand seat that made you want to be better.

I’ve told you about my inspiration to do better, but instead of thinking back to your own glory day of inspiration, Wes reminds us that we have an obligation to inspire others.

If you don’t someone else will and there’s a possibility that person believes in EMS Anchor myths of kidnapping, starting large IVs on combative patients, ridiculing the under-served and wants nothing more than to pass along their bad habits.

Perhaps one of the problems in EMS is that we’ve forgotten to inspire while spending too much time looking backwards?

Not a medic? What about inspiring a young beat cop or firefighter instead of just hoping they run into the right folks in the future?

We are the future we’ve been waiting for.

-HM

Community Paramedicine doesn’t belong in EMS

Community Paramedicine, or what some would rather call Integrated Healthcare, is a fantastic concept.  Why not take basic medicine and evaluation skills to the patient recently recovering from a procedure instead of making them visit the MD’s office?

Why not follow up with Mrs Jones on how her medications are doing?

Why not have a Paramedic check in on Mr Thompson and his blood sugar levels?

My first paying gig in EMS was for a system that did just this.  We visited our list of clients based on the schedule and checked their blood sugar, blood pressure, medications and checked the fridge for food.  I hated it.  I hated it because it wasn’t what 18 year old me wanted to be doing.  I didn’t see the value in the program until I was about to finish my employ there and noticed we never ran a 911 call on any of our home visit regulars.  We weren’t providing Emergency Medical Services (EMS), we were doing something completely different.  Call it by any name you like, but don’t call it EMS.

Today I’m a huge supporter of decreasing the demand on 911 by focusing on reducing the number of people who call.  One of the proven tools used to combat 911 calls is making people healthier before they need 911.

Community Paramedicine is just the thing each and every community in America can use to reach out to a niche that needs to be addressed.

When I was in England all those years ago Paramedics with only 1 year experience were out on their own making recommendations, referrals and taking people directly to what they needed, not just a 2 person cot van to an ER (Or AE for those who favourite that term.)

The concepts have been proven over and over again and some systems are even carving out revenue streams to make it profitable or, at least, not at cost.

I applaud their efforts and if the opportunity ever comes along for me to get involved…

…I’ll pass.

In my opinion Community Paramedicine is too important to be trusted to the 911 crowd.  We need folks more interested in sitting and talking than squeezing a few home visits in between calls for service.  Some systems have adapted schedules and providers to respond only on the Community cars and that’s great, but a greater separation is needed.

Yes, I’m advocating splitting EMS even further than we are now.  A split that will allow this new sub specialty to thrive.

Community Paramedicine needs to be a specialty, a half brother, not a spin off hoping to get picked up for a second season.

It will not succeed if it is tied to the chaos that is 911 for profit and must succeed if 911 for profit has any chance of surviving another 10 years.  We’re approaching a cross roads to possibly finally squeeze our little patient care machine into the main stream of medical professionals.  Do we want to squander that opportunity by having Community Paramedicine as a side project of EMS or as a full fledged community service independent of the lights and sirens?

I know 18 year old me had a different reason for having this opinion, but the opinion remains:  911 and community care shouldn’t mix.  They should each focus on their strengths and excel at the service they provide the community instead of stretching us so thin only our merit badge classes hold us above water.

The 3 Real Reasons EMS isn’t Ready to Refuse Care

Sean Eddy from Medic Madness, and fellow Uniform Stories contributor, has a new post up titled “3 Reasons EMS isn’t ready to refuse care.”

Go have a read, then come back for my comments.

Well, you’re either ready to storm Sean’s gates with your sharpened pitchfork or ready to defend him from what I’ve got to say on the subject.

Sean brings up some great issues that have been bouncing around EMS circles for decades.  With the recent introduction of Community Paramedicine and the concept that we can, gasp, leave people at home in certain situations, EMS providers are looking to build on the outdated “Transport them all and let the ED sort it out” mentality of the 1970s.

Sean’s 3 reasons are certainly worth discussion but I think he was very careful to sidestep the elephants in the room.

l’ll address Sean’s reasons 1 by 1, then give you the 3 real reasons we’re not refusing care.

Sean’s Reason #1 We’re not trained for it.

I’ll agree with Sean here on a handful of cases.  I would argue that leaving a hyperventilating patient at home simply telling them “It’s just anxiety” without addressing the symptoms we aren’t ready for, nor should we be ready for.  However, this skips over the other 99% of our calls.  When a person has an injury or illness (or nothing assessed) and asks us “Do you think I need to go?” we should not be bullied into transporting by a management who only gets paid if the wheels turn and a nurse signs the chart.  Honestly answering that patient’s question and giving them the information they need to seek the care the need should be job #1.  We are trained for that.

Sean’s Reason #2 No Legal Protection

This is one of the urban legends of respond not convey, that somehow, somewhere, we’re simply going to pull up, roll down the window, tell the person to just go to the ED and drive away.

There is not added liability in obtaining a refusal for a stubbed toe after telling the person that they don’t need to go in an ambulance than there is in obtaining a refusal after telling them they should.  Zero.  It is simply changing the amount of accurate information available for the patient to make an informed decision regarding their are.

Sean’s Reason #3 – We aren’t designed to be the end point in care

Sean brings up an interesting point that we are not meant to be the definitive treatment for patients, that that is only done by MDs.  Then I would call into question each and every refusal of service ever collected in the history of EMS.  We should be, and currently are, the end point when necessary.  Again, we’re not talking about chest pain, stroke, abdominal pain of unknown etiology, those patients are all obviously in need of evaluation and we are not their end point.  For the finger smashed in the door of the car we are also not the end point in care but that is no reason to REQUIRE ambulance transport to an Emergency Department.  I can’t fix the finger, surely we can agree, but there is nothing I can do beyond splinting and supportive care.  In addition now we’re sending an urgent care level patient to an ED, grossly over triaging “just to be safe.”

 

Sean is a friend and don’t take my comments about his concepts as disagreeing with him.  He and I have discussed this topic repeatedly, as many of us have, and it is of course far easier to comment on ideas than come up with them.  But we all need to be realistic about the REAL reasons EMS is not ready to refuse care.

Real Reason #1 – There’s no profit in it

Oh, there’s reduced cost in it, but no profit.  Spending 30 minutes on scene for a refusal is not nearly as lucrative as a 30 minute transport.  There is no increased liability, no increased training required, no fancy advanced classes or licenses, we just have to do what is right and allow the patient to make good decisions and seek out appropriate care in the community.  But so long as insurance only covers transport, it won’t happen.

Real Reason #2 – We don’t understand liability

Leaving Erma Fishbiscuit at home isn’t the problem, it’s transporting her for no reason to an ED for no reason “Just to be safe” that is the liability.  We remove needed resources from the system to satisfy decades of urban legends from the anchors about so and so who broke the rules and left someone home to die, but never about how no rigs were available for Mr Johnson yesterday.  If the rules were broken and something bad happened, it isn’t the rule that is the problem.  We shouldn’t be scared about letting patients make decisions.  We inform, they decide, we do our best to get them what they need, we complete a chart and go away.  Just like we do now.

Real Reason #3 – Adrenaline and turnover

No EMT wants to sit in Erma’s house for 30 minutes making sure she knows where her medications are and when they should be taken.  No Paramedic wants to sit with Mr and Mrs Jones and explain how their daughter’s nebulizer works.  They’d rather hit the lights and sirens, break hearts, save lives and take’em all and let the Doctor’s sort them out, after all “We don’t diagnose.”

 

EMS is having a real problem taking itself seriously recently.  I applaud Sean for making his list and putting it out in the public.  We have a decision to make in the very near future and that relates to the future of EMS and I see it will divide us even further and I think it’s a good thing.

Yes, I said dividing EMS is a good thing.  More to follow.

-HM