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

A House Divided…

Not a political post, just thinking about firing up the EMS 2.0 machine again here in my home system.  This speech keeps coming to mind.

An excerpt from Senator Lincoln’s Speech to the Illinois Legislature in 1853:

If we could first know where we are, and whither we are tending, we could then better judge what to do, and how to do it.

We are now far into the fifth year, since a policy was initiated, with the avowed object, and confident promise, of putting an end to slavery agitation.

Under the operation of that policy, that agitation has not only, not ceased, but has constantly augmented.

In my opinion, it will not cease, until a crisis shall have been reached, and passed.

“A house divided against itself cannot stand.”

I believe this government cannot endure, permanently half slave and half free.

I do not expect the Union to be dissolved — I do not expect the house to fall — but I do expect it will cease to be divided.

It will become all one thing or all the other.”

 

A Comment on Typical Idiot EMS Managers by Burned Out Medic.

Burned Out Medic had a post up recently I thought I commented on, but apparently you have to hit ‘submit.’  Who knew?

The post is in reference to a Call the Cops story about an ambulance crew being reprimanded for going 90 MPH even though the vehicles govern out at 70.

Have a read and come back for my comments.

Well let me start by saying I agree 100% and that I’m going to have to disagree 100%.  Typical EMS Manager, right?

 

The trouble with the situation mentioned in the Call the Cops story is that there are no facts.  There does not appear to be any investigation policy or framework, nor is there any documentation confirming the speed of the vehicle, the exact location, time of day, etc.

Most field crews believe EMS Managers are sitting in the office hoping beyond hope that someone calls in a complaint so we can puff up our chests and assert the hair’s width of authority we have.

Let me confirm that that is not the case at all.  In between phone calls from hospitals, regulators, our own managers, chart reading, report filing and other mundane tasks involved with making sure you can still practice, citizen complaints are taken very seriously.

I used to get weekly calls from a fellow who swore up one side and down the other that a crew raped him*.  Same crew, every week. Seriously.  For over a year we were on casual conversation terms each time he called.  Heck one week he didn’t call and I was actually worried.  But the first time he called it was taken very, very seriously.

The conversation was recorded, run data was pulled, AVL signals gathered and only after confirming details from the caller was I able to conclude his complaint to be without merit.

The crew accused wasn’t even working that night but had transported this individual a number of times.  That same crew had recently been accused of other things by other members of the public and medical system.  Each time he called I’d pull the AVL map as we spoke to confirm the crew in question was in the clear.

You see my friends, complaints do not happen in a vacuum.  They are most often the result of someone getting a bill for service or just plain not liking EMS in general.

The example given by Call the Cops that Burned-Out references is hilarious because it can be easily disputed:

  • Obtain complaint in writing or verbally recorded.
  • Pull the unit history for the ambulance in question.
  • Pull AVL data for location.
  • Access maintenance data to ensure governing device installed and properly working.
  • Access previous violations for pattern behavior.

That’ll take maybe an hour.  The thing most field crews don’t realize is that good people can still do bad things.  If you’re a 5 star crew and get a complaint I handle it the same as a complaint about the crew that was in my office yesterday for what ever other frivolous thing the rumor mill says they were in for.

The tough call comes when the AVL data shows the unit traveling on the roadway in question, at the time in question, at the speed limit, but 3 hours earlier data show the vehicle traveling above the speed of the governor.

Now what do you do?  The crew has been proven to not be guilty of the accused offense, yet we now have data that show their defense is faulty.

It’s easy to sit in the rig and gossip about how the managers are out to get you after what happened to so-and-so but just remember it’s a lot of work to get you in trouble, and you know how we pencil pushing EMS Managers hate work.

If your managers are so bad at what they do, promote.  Nothing in EMS is easy, even sitting in a little room with a tie on reading charts and going to meetings.  The ultimate answer to bad leadership is to become a leader yourself.  Show me you can do it better than they can and your service will be the better for it and, as a result, your patients will have a better experience, which is all that matters in the end.

 

EDIT – *Forgot to mention, not the real reason he called, but just as unusual and hard to believe.