Ambulances & Vehicle Ops, Operations

Why EMS Shouldn’t Always Transport

Issue 4 and Volume 38.

I think our approach to EMS does a pathetic job of caring for many of the people we serve, Life-Saver. I think we need to work smarter than simply taking everybody to hospitals over and over again. We’re not robots, and I don’t think what we do is helping some of them.

My brother Greg, dead 20 years now, contracted tubercular meningitis in a world-famous hospital at the age of 6 while he was being treated for measles. As a result of his secondary infection, his right hemisphere was destroyed and he was rendered hemiplegic. Subsequently, he suffered recurrent, disabling, full-body seizures for the remaining 30 years of his life.

By the time Greg was 12, I, my parents and two of my next-oldest brothers had learned everything there was to know about the manifestation of those seizures. Their warning signs. Their physical features. Their regularity, frequency, intensity and duration.

We knew Greg’s dosages of Dilantin and phenobarb, and we knew how to shield him from the embarrassment of awakening publicly incontinent. We understood how to protect his head, his body and his airway. And before the world’s first civilian medic ever received a certificate, we knew a lot of things about Greg that his doctors didn’t know.

Today, I’m sensitive to diagnosed epileptics who awaken surrounded by EMTs after seizures that fit their normal patterns. Even today, after all we’ve learned, these folks are finding themselves responsible for expensive transports, ED visits, neuro consults, unneeded medical tests, thwarted responsibilities and the inconvenience of reinserting themselves into their normal routines. It’s all meant well. But it’s inflicted, not offered. And it doesn’t help.

Our existence depends on a health insurance industry that still thinks of us as ambulance services. They fund our activity with user fees, which are invariably linked to transport. But transport resources are thin, except in densely populated areas, and they’re scarce everywhere at some times of the day. Consequently, it’s difficult for most EMS crews to spend a lot of time on scene waiting for any kind of situation to resolve itself. And we’re constantly pressured to keep our fleets busy.

Furthermore, a common consequence of inappropriate non-transport is tort litigation. So, even the most reasonable EMS leader typically cringes at the thought of leaving sick people on scenes after being summoned for aid.

Think what you will about the Affordable Care Act. But fee-for-service EMS is a clumsy, inefficient, stupid way to serve sick people. For at least the past 40 years, it has forced us to escalate our charges to insured patients in order to address the needs of the poor. And it has subjected many patients (like diabetics and diagnosed epileptics) to preventable crises because they can’t access the meds and the routine care they need. Often, they don’t warrant transports to EDs. They call 9-1-1 because they have no other options.

EMS agencies should seize every opportunity to actively observe and document patients’ living situations. Our agency uses a system called PEAT, developed by Colorado medic/RN Chris Hendricks. PEAT is an acronym that stands for Physical Environment Assessment Tool. It incorporates a simple form that helps us evaluate the physical and medical safety of a patient’s living environment anytime we’re invited into a dwelling. PEAT can be used to trigger the involvement of social services, alert family caretakers, or prompt us to conduct return site visits (we call those Re-PEATs) to monitor the ongoing evolution of people’s living situations. Chris copyrighted PEAT in 2004, but he shares it graciously. You can reach him at [email protected] or 303/827-4025.

Sometimes we use PEAT to trigger the scant social services in our area. Several of them have disappeared in the past five years or so. And sometimes the remaining ones can’t handle the needs of all the people for whom we call. But we keep a current list of them, and we try.

We’re a small nonprofit, serving a poor community. We probably grapple with the same financial issues as you do. We receive no funding to support PEAT. Most often, our crews’ trips to pick up people’s meds, fix their toilets, install grab rails next to their stairways or even buy their groceries, are quietly handled by the crews themselves. So very often, we don’t hear about them.

Our next step, one we’re working on now, is to develop a system of medical preplans for high-risk residents—like the ones fire departments do for structures. I’ll let you know how that works out.

Meanwhile, there’s nothing to keep you from doing the same.