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?

When Does Intoxication become an Emergency?

Drunk Girl - Crossfirecw
Drunk Girl – Crossfirecw

I’ve been having a number of jabs on Facebook (2 or 3 comments in 2 or more places) about the all too common intoxicated patient.

There are those in our ranks who believe they have the ability to determine when a person is “just drunk” implying that no assessment is required.

We need to make a clear delineation on our terminology before moving forward.  First, notice in this post title that I do not use the term “drunk” but instead intoxication.

Drunk is the extreme form of intoxication.  Drunk refers to one affected by alcohol to the extent of losing control of one’s faculties or behavior.

While certainly not an emergency, a person who meets the definition of drunk is in no way, shape or form able to assist in an assessment for other mimics to intoxication such as stroke, hypoglycemia and sepsis, just to name a few.

A drunk person is likely to be semi-conscious or unconscious.  These folks are horrible at maintaining a clear airway and can get into trouble fast if not properly taken care of.  That may not always mean a hospital, however.  More on that in a moment.

How many times have you been called out by PD for the “alcohol poisoning” only to find someone alert, ambulatory and smelling of alcoholic beverages?  Is this person drunk?  Only after a complete assessment will we be able to determine if their level of intoxication meets the definition of drunk.

Here’s a quick tip: Your local protocols probably don’t have a section for this.  There’s an altered mental status section, but no, “He doesn’t need to go to jail but we can’t let him drive home, so take him to the hospital” section.

PD is adorable on these calls, often telling a patient they can either go to jail or to the hospital.  I often cal their bluff, when appropriate, and tell the patient they can still refuse transport (After my assessment finds them able to do so under local policy).

Intoxication is, technically, a poisoning.  All levels of alcohol ingestion constitute alcohol poisoning if you want to get down to the nitty gritty.  The key is going to be determining to what extent the intoxication is impacting your patient’s ability to make sound decisions regarding their care.  Plain and simple.

My local policy states that, among other elements, the patient does not appear to be under the influence of drugs or alcohol in order to be able to refuse care.  That’s a big gray area.  They may be intoxicated, but able to comprehend my questions, weigh their options and have a plan for decreasing the level of intoxication in the near future.

These folks should have a sober adult with them and not operate a motor vehicle, but they seldom need an ambulance ride to an ED.  Think about it.  What will the treatments be?  Fluids?  If they are able to sit in triage long enough they could drink more water than any IV could run in in the same amount of time.

Now, before you go running off to your next drunk call and leave someone lying in the street because of something I wrote, let me ask you this:

How do you know they are merely intoxicated and not drunk?

Remember the definition?  Losing control of one’s faculties or behavior.  We all have that one friend that overindulges and becomes an idiot, but are they drunk or intoxicated?

Stop looking for zebras.  Sometimes drunk is just drunk but you won’t know until you assess.

Unconscious people are unable to make sound decisions.  Semi-conscious people are the same.  Ambulatory people who have been drinking may still be able to understand their situation.  Only after a complete assessment will you know for sure.

 

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?

It’s OK to Not Be OK

As many calls as I’ve shared in this forum, there are still those that won’t make the cut.  Not because they’re “gruesome” or “funny” or even filled with heroic actions or memorable scenery, but because of the little things.  Little things that are mine and mine alone.  Frozen moments in time that impact me to this day.

On a recent call one of my most memorable calls came back.  Not like a wafting scent or a slowly rising tide, but like a slap to the face and a punch to the gut, taking all my breath away.

The dispatch was a simple fall in the bathroom.  A bread and butter call.  Likely someone with one too many drinks and not enough sleep.  As I walked towards the restroom, donning my gloves and admiring the large artwork in the lobby a woman came running out covering her mouth in fear.  She was hunched over and moved erratically as she exited the restroom.

In half a heartbeat I was taken back over a decade.  My pace quickened, my heart in my throat.  The little things were there.  A glimpse of broken mirror.   The faint smell of bleach long mopped up.  The first drop of blood.  I was afraid.  I went to work doing what we do.

All I’ll say is that I didn’t sleep much that night.

Then or now.

We deal with things that most folks fall apart after seeing.  Trouble is, so do we.

If you experience something and need to talk about it please reach out.  It can be a friend, clergy, co-worker, even drop me a line.

You don’t have to keep what we do inside.  You don’t have to make sick jokes or make fun to get along in EMS, all you need is an outlet.

We all have calls that wake us from a sound sleep like a clown in an old horror movie.  The trick is finding someone to help you through it before it eats you away from the inside.

It’s OK to not be OK.

It’s not OK to let it get worse.  Everyone feels like you and I feel, some are simply too scared to share it.  You’re not the problem.  If this job doesn’t shake you to your core, chances are you’re doing it wrong.

I’m reminded of that every time I see a handful of calls from my past.

I’m reminded of that when I read Kelly’s story about the swing set.

I’m reminded of it when I see a young EMT freeze up at a scene and wonder if I’ll be in their nightmares in 20 years, a simple bystander on their worst day.

I wonder if they know they’re in mine.

It’s OK to not be OK.

 

See also: CISD with OK GO, a 5 part series on addressing trouble using the music of OK GO

Up to and including death

This is a phrase I see a lot in my line of work.  There are a number of variations including another favorite “seizure, coma, death” that are designed to cover the hind quarters of the author in some half cracked attempt at documentation.

For you folks out there who will swear up one side and down the other that you were told by an EMS Anchor that if that phrase isn’t included you’ll goto court and get sued for malpractice, just take a deep breath and relax, Sparky.

Your local policy likely includes guidelines for patients to be eligible to refuse transport, care or a combination of both in certain circumstances.  For example, the patient must be alert, oriented and not under the influence of alcohol, understand the risks involved with refusing an assessment or transport and sign acknowledging that they understand…you know, the basic stuff.  When I see so many less than EMT-Basic calls being completed and the risks of refusing transport for a hand abrasion include “patient advised of all risks including seizure, coma, death” I have to shake my head and laugh.

Funny part is that this blanket statement calls into question the rest of your document most times.  Do you really believe the hand abrasion will lead to death?  In what fashion?  If it is such a risk, why isn’t the patient being transported?

A more accurate statement could be “patient advised of risks of infection and advised how to avoid repeat injury.”  BAM!  That simple statement covers you far more than the giant heavy blanket of death.

So dial back the drama and have an honest discussion with your patients, otherwise get ready to explain to me or someone like me why you were worried this was a possibly mortal wound.

Halloween and Christmas rolled into one

In all the EMS debates over BLS vs ALS, evidence based vs anecdotal, public vs private is the real reason we do what we do.  I like to say that we make bad days better.  More often than not we ride the bench.  Sometimes we get the grand slam in the bottom of the ninth to win the game.

I got a facebook message from a reader who was looking for a spark to get out of a rut and gave the best advice I could.  My response included examples where we find joy in this work: The smile from the woman who’s hand we hold when nothing is wrong, the man who half smiles at his wife when he sees her as we unload him at hospital having a massive stroke.  There are so many small victories in this world sometimes we miss them.  If you are looking for medals or public recognition in EMS I have bad news for you: It will be a long, lonely wait.

 

But sometimes that wait pays off.  I had no idea that the best motivation to be a good Paramedic or EMT would come in my email inbox early this morning.

8 months ago today a man died.  Dead.  Asystole.

Then some of my co-workers showed up.

This morning we got an email with a photo.  The photo showed our patient dressed up for Halloween with his young daughter.  He was Obi Wan Kenobi and she was Princess Leia.

His smile made me smile.

Her smile made me forget all the bullshit.

Although I keep a running tally of cardiac arrest saves on a white board in my office, this is my first photo of a smiling child.  And hopefully not the last.

Righty tighty…

Being back in the field is a wonderful thing.  The smell of week old urine on a regular, the thrill of getting the line on the recus patient and even just sitting in the buggy at a street corner catching up on QA.  But I was not prepared for what happened today.

THE EMREGENCY

A local clinic has called in a code 3 transfer for an asthmatic patient.

THE ACTION

Well, this sounds like a good one.  With at least one MD and a scattering of RNs in the office for them to call 911 before 5PM means it must be something serious.

Stop giggling.

I add myself to the run and head over the few blocks to the well known clinic as the engine company pulls up.  We head inside and are led, rather swiftly, to an exam room where our patient is working on sucking a non-rebreather bag back through the tiny hole in the mask.

“Hi there, what seems to be the trouble today?” I ask seeing a look of panic on the patient’s face.

“His sats are dropping and the albuterol isn’t helping!” a pajama clad medical office worker is telling me as she’s fumbling with the tiny O2 sat monitor on his finger.

“Well, let’s switch this to one of ours to start” the Engine Medic and EMT have prepared a mask on 15 liters with a well filled bag and the patient drinks in the fresh air, the look of panic quickly receding and relief taking it’s place.

“Thanks guys, the albutrol must have finally kicked in” the pajamas tell the room, hoping it will cover up the look on her face that she is still completely dumbfounded as to what happened.

“Here’s your trouble” the Engine officer says as if noticing an oddly shaped cloud, “Yer tank ain’t on.” And as soon as I can turn around to see the EMT still holding the clinic’s mask the officer turns the key on the top of the clinic’s O2 tank and air begins to flow.

“Beginner’s mistake I guess” he says as he shuts it off and looks to me barely holding my professional pose. “Unless you need us Cap, we’ll be on our way.”

I cleared the Engine and comforted the patient who’s “low sat” of 94% had risen to a comfortable 96%.  The ambulance arrived to take him in to Saint Farthest, per his request, and I relayed the situation.  The pajama clad person had left just after the engine and now came in with what was clearly an experienced RN.

“I think the tank is faulty.” She told the older RN.

“I don’t think it’s the tank, Dear.  Thanks, guys.” And down the hall they went.

“What was all that about?” the ambulance EMT asked as we wheeled the now calm patient to the elevator.

“She didn’t know how those tanks worked.  Can you believe that?” the patient chimed in with not a hint of distress.

And to their credit the crew kept a straight face as the doors closed.

Hate Firefighters that complain about EMS? You might be one. I was.

It is no surprise that anyone working in the Fire Department who hates EMS is in for a rough career.

I have met many a “Basic for Life” who groans everytime the bells ring and it is not a fire.  Some even groan at building alarms.

I was talking with a colleague recently and we stumbled into the problem most in EMS struggle with and one I built this platform on:  BS calls.

You might be thinking “Justin, calling them BS calls isn’t respectful.  It’s that kind of attitude that encourages less than Professional actions by our low information voter EMS types.”

But they are BS calls.  The scraped knees, the MVCs without injury some passerby called in, the headaches after slurpees and stomach aches after a seafood dinner, all BS calls.

And if you agree then you still have a lot to learn about modern, and I’ll argue future, EMS.

If you argue that you only exist for emergencies and the other calls waste your time, your argument is no different than the firefighter claiming they are there to fight fire, not wipe asses.

So let’s rename BS calls as Basic Service Calls.  Not EMT Basic, but Basic care.

You exist to assess.  So many in EMS list their abilities to treat as their claim to fame when we have all known for a long time that treatments are useless without a complete assessment.  That headache, stomach ache, every call you go on deserves a complete assessment to determine possible solutions to you patient’s chief complaint.  If your main reason for assessing is simply whether this will be a transport or not, perhaps we should get you an application at Dairy Queen.  I can say that, I used to work there.  If all you d is check your boxes on the ePCR and exclude the patient from your box of tricks are you even addressing their concerns?

Every single call you are sent to is someone who didn’t know what else to do.  What an amazing opportunity to help them.  Not with a 12-lead most times, or albuterol even, but listening to their concerns and reacting to them.

If the guy on 3rd street keeps calling every time he runs out of meds, can we possibly help him figure out why instead of getting upset he called again?  In case you haven’t noticed, getting mad and yelling at him only makes him call and complain in between calls for 911 to refill his meds.

Getting upset isn’t working.  So instead, get involved.  It will take just as long to complete a transport or refusal helping him or ignoring him so why not make the time you have with him useful?

You don’t need Advanced Practice, Community Paramedicine or (I can’ believe I’m about to type this) Integrated Mobile Healthcare (ewww) to make a positive impact while still acting within your scope of practice.  There is no law that keeps you from being a patient advocate.  Since he called you for medical care you are now able to access his medical record (as much as he gives permission for) to determine what may be the trouble.  Call his Doctor’s office and mention to the clerk who answers that you are on a 911 call and need to speak to his Doctor.  Dude will be on the phone in a heartbeat.  If the van service from the managed care service is always late or keeps skipping the house, make a call.  If the home care nurse isn’t doing what they are supposed to be doing, ask for their agency’s contact information and follow up with your concerns.

All of this can be done in the same time frame as your frustrated conversation with your regular that will end the same way it always does unless you change your perception.

He IS the reason you are here.

Like the Fire Service before us we are doing a great job at preventing major medical issues and because everyone seems so intent on getting to any scene as fast as possible, we see many conditions far earlier than before, meaning they’re not as dire as our 20 year veteran colleagues remember.

We are the safety net these people need when their insurance company fails them.  We are the number they call when Medicare can’t cover everything.  We can make a difference if we try and we don’t even need to try very hard.

These calls will frustrate you.  They frustrated me so much I wrote about them.  As I did I realized I was getting frustrated for no reason at all and that I alone had the power to help these people.  That’s where EMS 2.0 became a reality for me.  That’s when Chronicles jumped off and my perceptions changed forever.  Had I kept stewing in my frustrations there is no telling where my sanity would be.

If you disagree with me and believe the first word in EMS is more important than the last word in EMS give up ever becoming a Professional.  You’ll burn out in a few years and I hope you don’t hurt anyone between now and then.

It’s time to take the extra step so many think is not their job, not their responsibility or not in their power:  Help people.

 

EMS Flashmob

Eli Beer formed an all volunteer First Aid/EMS group when he was 17.  In the process of developing the program he volunteered on an ambulance and was always upset when they would get stuck in traffic.

Eli attributed his dying patients’ demise on the extended response time and wanted to do more for them in the time between when they needed help and when help arrived.

This video goes directly to the core of the Response Time argument and it is important to make a clear distinction between first response and ambulance response times.

We can all agree that getting someone in the door quickly can help guide the rest of the system’s response.  This can be a fire department engine, an EMT Police Officer or perhaps a third service handling first response.  What we don’t need is to send a reclined cot van on every call, nor does it need to get there in 4 minutes most of the time to make a difference.

In this TEDMED talk, Eli talks about how he came to found United Hatzalah and send motorcycles he calls “Ambucycles” to the scene of an emergency to help until an ambulance can arrive.  He touts a 3 minute response time to over 207,000 incidents last year and is using mobile technology to achieve it.

The phone app broadcasts the medical incident to the 5 closest volunteers in the same way CPR needed apps do so in the states.  When he mentioned it was kind of like an EMS flash mob he had my attention.  We’re locked into some old ideas and this one breaks the mold.

 

Why aren’t we as communities encouraging this kind of organization?  Sure there are volunteer First Aid Squads all over, but this is far far simpler than that.  And don’t wave the liability flag here, those folks would have to be trained to get access to the app and with the right kind of basic QA program built in you’re golden.

What do you think of the various things mentioned in this video?

  • Motorcycle first response
  • Volunteers
  • Phone App dispatching

 

Response Time or Patient Outcomes – How do you measure your EMS system?

I know it’s been quite around these parts lately but a recent article caught my attention this morning.

High Performance EMS posted “Does Response Time Matter?” and it got me thinking.

The author states an example of a patient being “treated” by fellow citizens at an airport and having to wait 20 minutes for an ambulance to arrive.  The author goes on to describe how we need to arrive quickly to save the public from themselves.  After 30 years of telling them to call 911 for anything and convincing them that “seconds count!” what did we expect?  While I agree that a delayed response to certain patient presentations could result in an adverse outcome, that points out a glaring omission from the story.  Missing from the story is the patient outcome.  The outcome will allow us to marry all the data from the response to determine the answer to the author’s question in the headline.

The short answer is no, response times don’t matter.  And no, I don’t have to pee.  I have data that does not have any correlation between quality of treatment, outcome and response time.  From my perch here at the data hub of a quite busy EMS system we have been trying to determine the quality of our EMS system and we rarely look at response times.

Don’t get me wrong, we look and our Department statistician collects, quantifies, qualifies and reports to regulators the 90th percentile of all code 2 and code 3 calls to meet their requirements.  We report it, they receive it.  The document says nothing about the quality of care or patient outcome.  The reason being that we can not guarantee a positive patient outcome, but can measure when we left and when we arrived.  Imagine if we had to treat 90% of symptomatic asthmatics with oxygen within 5 minutes of arrival and document an improvement in condition.  Can your system guarantee that?  Why aren’t EMS systems measured by the quality of their care instead of the quality of their response?

Apply this metric to any other industry and it fails.  Industry is measured by their quality and efficiency, not the speed in which they complete their tasks.  So long as we only look at one metric with any regularity we will continue to shuffle ambulances 2 blocks at 5 minute intervals to meet an average instead of realizing just leaving them still would bring the same outcome.

That’s where I come in.  My Medical Director and I, unhappy with the lack of actual patient care quality metrics, created our own in an effort to determine the quality of care being provided.  We learned very quickly that our ambulances do not respond in a vacuum.  Each patient receives a call taker, dispatcher, first response, ambulance response, assessment, treatment and some get transported.  Once at hospital they receive a whole new level of care and review until they are finally sent home.  It is hard to argue that the time it took to get an ambulance from point A to B has an impact on this outcome without any review of the call taker’s coding of the call, the dispatcher’s assignment of the ambulance all the way to the destination hospital capabilities and location.

We can all sit at the Pratt Street Ale House in Baltimore and discuss short times that had a bad outcome and long times that had a good outcome, but the worst part of all of this discussion is that so few systems measure anything more than response time.

If you consider response time your metric of success you have already failed.  You have failed the patient who improves when you arrive “late” and discounting that response as a failure, yet trading high 5s when a 2 minute response yields a call to the Medical Examiner’s Office.

We all know the stories of companies staffing ghost cars near the end of the month to bring down the monthly response metric to meet guidelines.  It happens.  But I also wonder if that flood of ambulances to help more people had any other impact.

The complication in tracking outcomes is the relationship your agency has with local hospitals.  We may never have a seamless transfer of data but what we can do is pull data from the PCR to determine if the patient received the indicated treatments for the recorded chief complaint and observed complications.  By reviewing your policies and protocols as well as your patient demographics you can quickly spot your core performance indicators and design tools to track them.

It may be nice to know that we make our 90th percentile in 8 of 10 districts on a regular basis, but what if those 2 districts happen to have the highest number of cardiac arrest survivals to discharge?  Are they still a failure?

Widen your view to include more than how quick you can put the ambulance in park.  This goes far beyond the lights and sirens System Status Management debate and speaks to the core of the reason we’re out there to begin with:

To make someone’s bad day better

Delays can hurt, but not unless you look deeper into your system to find out if that is the case…or not.

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