Back in the mid-1980s when I walked uphill to work both ways and watched television by candlelight because there was no electricity, there was a patient well known to our local EMS system. Homeless and alcoholic, he had developed a penchant for calling 9-1-1, saying, "Man down, 12th and Main," and promptly lying prone upon the pavement, awaiting rescue. After passing the night in the warm confines of his favorite ED (ours), he'd stroll off into the crimson glow of sunrise.
One day, however, he was so infused with "two-carbon fragments" that he forgot to tell the medic his hospital of choice before slipping into the sleepy night. Alertly noting that the patient had a tattoo suggestive of Navy service (I won't go into detail here), the paramedic surmised that the local VA might be an appropriate destination. As the radio control physician, I heartily endorsed this course of care. After all, he wasn't coming back to see me. We had thwarted the wants of a system abuser. We had scored a victory at least until tomorrow.
We've been discussing the idea of EMS as a right and as a luxury. (See Part I and Part II of our discussion so far.) Intimately tied to this concept is the vision of EMS access as a privilege. Worldwide, the trend is that people of different status have access to different levels of EMS. Fee-for-service or subscription-based EMS organizations are quite common in most parts of the world and, in some cases, may represent the only possible means to deliver prehospital care. But in the United States, we've entrenched the existence of EMS as a societal luxury. We've further established as precedent that everyone should have the privilege of equal access to EMS care.
The question that arises is whether we really believe that everyone should retain this privilege. We all know patients like the one described. We know he's misusing the system, potentially taking resources from those who need them. More than this, he's misusing and annoying us, demolishing our mental and emotional constructs of what we should be doing in the field. Left to our own devices, most of us wouldn't hesitate to terminate EMS access for that person.
I'm certainly not immune to these feelings, but trying to find a solution has led me to a less vindictive view. While a liberal in many ways, I do believe that everyone bears primary responsibility for their own conduct. I recall a project in my MPH course where we had to indicate those factors that lead to medical noncompliance. One of my classmates raised a strong objection when I suggested free choice played a role. But when someone goes out every Friday and gets his head repeatedly whacked with a pool cue, you have to admit that at some basic level he has the option to decline such an adventure unless an armed gang of street thugs dragged him from the house.
"Even with better triage, the variability inherent in clinical medicine means that the privilege of EMS response can never be withheld. "
(I should probably note that a unique trait shared by both liberal and conservative politicians, policymakers and commentators is that they really never know the problems they bemoan. How many senators, radio talk show hosts or news analysts are living from day to day, working two jobs to make ends meet, raising a family in an unsafe neighborhood with no health insurance and kids who can't afford to go to college? At least when we develop our views of society, it's because in EMS and emergency medicine we see, touch, hear, feel the best and worst of humanity. It's easy to be conservative when you never meet poverty; it's easy to be a liberal when you have money to burn. I'm no exception here, either. While I consider myself a liberal in the best sense of the word, I also recognize that I have the luxury of being one.)
The belief in free choice as a driver of health-care decisions started my thinking about EMS as a privilege. There are a host of situations where we, as a society, legally restrict someone's privileges. We require people to act responsibly, and, if they don't, they are subject to penalty.
But responsible behavior does not encompass letting your child have a cold for three weeks before calling an ambulance at 3 a.m. It does not condone being on disability and then injuring your back lifting a transmission. It should not permit a patient to request a prescription for Tylenol on the basis of poverty when there is a pack of cigarettes in a shirt pocket or a cell phone glued to the hip. A patient with COPD who continues to smoke should pay some price for not helping himself. It was especially galling that many of these patients whom I was required by law to see paid nothing for the services rendered or paid with my own tax dollars. And despite the fact that they gave me nothing for my efforts, they could still endanger the well-being of my family through a lawsuit. I reasoned that if someone appeared to consciously and willfully abuse the health-care system, they should lose their right to access that care.
Once I formulated this theory, however, I instantly discovered a host of practical and logistic problems. Initially, I thought that health care could be rationed on a compliance system: We'll give you all the care you want as long as you're compliant with care. If you have COPD and you quit smoking when the doctor tells you to, we'll take care of you forever. You did what was required, and gave it the old college try. But if you don't follow our advice, we're sorry, but the meter's expired and you're out of change.
This concept fell apart in fairly short order. Suppose you're a noncompliant patient with COPD, but now you've fallen and broken your leg. Should you be denied care for an unrelated problem? That didn't seem quite fair. And how do you know before evaluation that the dyspnea you have is due to the chronic COPD and not a new, superimposed pneumonia? The next request for help may not be related to the primary problem. How many chances do you give someone to change their noncompliant ways, and how do you accurately measure compliance with care in the absence of 24-hour surveillance? Finally, my theory implied that all the advice given to patients by the health-care system was necessarily correct. Indeed, the only ethically appropriate and clinically safe approach seemed to be to keep the floodgates open.
What about multiple visits for visits for the same problem? Was there a point at which the number of repeat visits should be terminated? I had felt that if you abuse the system a set number of times, you forfeit the privilege of care. I tried to think about "three strikes" sentencing guidelines as a precedent for this view. But persistent criminal behavior that endangers society is on a different plane than behavior that inconveniences society. (We tolerate a lot of annoyance under our freedoms of speech and assembly. We tolerate it in every adolescent we know.) Clinically, I recognized that this design would not take into proper account the fact that clinical status ebbs and flows and that patients may require more intensive and more frequent care over time.
Could we restrict access in patients who continually present with nonemergency problems? Again, I was faced with the idea of missing the true emergency when it happens. And early on I abandoned the idea of limiting any access to care of children, no matter how minor the problem. There is absolutely no justification whatsoever in punishing children for the inappropriate actions of their parents. (To me, the saddest thing in medicine is to look at a happy, smiling, bright-eyed child and then to look at the parent and realize the child doesn't stand a chance.)
Eventually, it all seemed to boil down to a bizarre twist of The Boy Who Cried Wolf. You'll recall that in the tale, the boy gave so many false alarms that the true danger, when it came, was ignored. In EMS, there are a lot of bogus cries. But somewhere, sometime, the problem will be real. As emergency health-care providers, we cannot ethically refuse any cry for help, no matter how much that privilege may be abused. Any cry may be the real one.
There's a further kink in this knotty tale. Subjectively, most of us would consider that those who use EMS in an inappropriate fashion are of lower educational and socioeconomic status. I don't know whether that's actually true. I've personally never done an analysis to match "true" EMS need with income or payer mix. But we need to be very cautious about linking EMS abuse to any specific group of people. We also need to recognize that there are other factors involved in what might be considered "inappropriate" use of EMS. A poor family where both parents work during the day and use public transport may have no other way to seek care for a minor illness than to call an ambulance at night when the buses stop running. In this situation, use of EMS is not abuse. It's the only resource they have. And we need to recognize that to some extent, when people call EMS for everything and anything, they're only following directions. We've told the public for years that we were there for any reason, just a phone call away. We made accessing the system easy and consequence-free. It seems hypocritical for us to now be angry with those who are simply doing what we told them to do.So I think we're stuck with the concept of "you call; we haul" (or at least "we respond"). We've already discussed the issue of patient non-transport. The use of a truly accurate triage system at the dispatch level may ameliorate some of these issues, but the legal climate must also change to allow dispatch contact to represent a patient care evaluation. Even with better triage, the variability inherent in clinical medicine means that the privilege of EMS response can never be withheld.