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EMS System Abuse

cj-beb-lores

I’ve been in EMS in one fashion or another since 1974, and like most of you, I’ve seen more than my fair share of EMS system abuse. In every system I’ve worked for, the prevailing policy was, “You call; we haul.” No matter how ridiculous the complaint, if you wanted to go to the hospital, we’d take you. And did we transport some ridiculous cases.

In my Fort Worth days, I carried everything from a patient wanting his prescription for Dilantin refilled to an ingrown toenail (seriously) to a woman who wanted her intra-uterine device removed. Back in those days it was common for hospital emergency department (ED) patients to be in the waiting room while ambulance patients went back to the treatment area without delay. Soon, these intrepid souls decided to go home, call the ambulance and be delivered back to the hospital and the treatment area ahead of the 10–15 babies with sniffles in the crowded waiting room.

I think EMS system abuse in Las Vegas is even worse. Not long ago, I was working the dreaded rapid medical assessment (RMA) position: One of the attending emergency physicians sees every patient who walks (or crawls) in and determines the treatment needed. Occasionally, when the beds in the back are full, the EMS crews are directed to bring the nonsense complaints to RMA where they’re offloaded from the EMS stretcher to a comfortable chair.

On one busy shift, an American Medical Response (AMR) crew brought an obese and talkative patient whose complaint was that she didn’t want to use her walker. I pondered the importance of her concern and dug into this medical conundrum. It seems she had been seen the day before by one of the physician assistants and given a walker. She decided that she didn’t want the walker and called 9-1-1 to return to the hospital. So after some investigative medical questioning, I told her to quit using the walker. (It still had the plastic wrapping, so I sent it back to central supply.)

She seemed happy that I solved her problem and then wanted me to call AMR so she could go back home. A free pass on the Las Vegas bus system was all I offered. It was an epic moment in my medical career.

Frequent Flyer Facts
Now, I’ll put the silliness behind and look the real problem of system abuse. Who are the EMS system abusers? A San Francisco study of elderly EMS patients (greater than 65 years of age) found that male gender, black ethnicity, homelessness and a variety of types of medical problems were associated with increased use of EMS resources. The single best indicator in this study was homelessness.(1) A New Mexico study found that repeated ambulance use by patients (five or more transports during the two-year study period) was most often associated with alcohol-related disorders, seizures and respiratory illnesses. In fact, although this group of patients accounted for only 4.3% of all patients, it accounted for 28.4% of all transports.(2)

Certainly, psychiatric conditions and substance abuse issues account for many EMS frequent flyers. Of course, there’s the absurd. There’s an interesting article about a 46-year-old male frequent flyer in Alameda County, Calif. who had more than 1,000 visits to the ED in a three-year period—sometimes coming (usually by ambulance) several times a day.(3)

Solutions
There have been numerous strategies to limit nonessential EMS transports—most to no avail. When I was a paramedic in Fort Worth in the 1970s, our colleagues 30 miles to the east at the Dallas Fire Department were allowed to refuse to transport what paramedics determined to be non-emergencies. Unfortunately, paramedics weren’t that good at determining non-emergencies, and ultimately, the Dallas Fire Department abandoned the policy. They did try nurse call screening in the 1980s, but that was also met with tragedy. Various other strategies—taxi vouchers, bus passes, referrals to physician offices—have been tried with little success. The use of advanced paramedic practitioners holds promise, but it’s still too early to tell.

The problems with EMS system abuse are just the tip of the greater problems with the U.S. health-care system. If you don’t believe it, come and spend a day with me when I work RMA. The sheer degree and volume of the nonsense that passes through our doors, or the doors of any big ED, will astound you.

Conclusion
We can never solve the issue of EMS system abuse until we solve society’s ills: poverty, homelessness, mental illness, substance abuse, domestic abuse, lack of primary care and education. Virtually all patients who abuse the EMS system have one (and often many) of these issues. As with all complex problems, there are no simple solutions.

The safest policy is to always transport, unless the patient refuses. Bring them to us. We won’t be happy, but we will provide a medical screening exam and any required treatment; it’s the law. That said, I’d love to hear your stories and experiences with EMS system abusers. This ought to be interesting!

References
1. Tangherlini N, Pletcher MJ, Covec MA, et al. Frequent use of emergency medical services by the elderly: A case-control study using paramedic records. Prehosp Disaster Med. 2010;25:258–264.
2. Brokaw J, Olsom L, Fullerton L, et al. Repeated ambulance use by patients with acute alcohol intoxication, seizure disorder, and respiratory illness. Am J Emerg Med. 1998;16:141–144.
3. Schaulis MD, Snoey ER. Three years, a thousand visits: A case study of the ultimate frequent flyer. Ann Emerg Med. 2001;38:87–89.

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