I get chided occasionally by Nancy Magee when I tell my students that 70% of EMS transports don’t need an emergency department, much less an ambulance to get there, and that EMS calls are 10% “oh, sh*t,” and 90% “bullsh*t.”
Nancy is right, of course. I should listen to my live-in conscience more. Most ED visits are unnecessary, hideously expensive and lack any semblance of coordination of care. Most ambulance transports need BLS care at most, and more often, just a ride. Those are facts borne out by myriad studies. They are indisputable.
But there is significant gray zone between “oh sh*t” and “bullsh*t” on an EMS call, and my hyperbole in trying to make the point that most calls will not be physically or mentally taxing ignores a simple fact: while the reason for the 911 call might not be an emergency to us, it is most certainly an emergency to the patient. Referring to it as otherwise only fosters the notion that some EMS calls are beneath us.
It’s just poor customer service.
We’ve been conditioning the public for two generations now to call an ambulance or go to the ED for every little ache, pain or sniffle. In our zeal to justify our own existence, we’ve fed, nurtured and carefully groomed the two-headed monster that is call volume and system demand. And now that people are following our advice, we have the nerve to call it system abuse.
Got numbness in your fingertips? “Call 911, it might be a stroke.”
Feeling tired and fatigued? “Call 911, it might be atypical signs of a heart attack.”
Feeling nauseous? “Call 911, it might be food poisoning.”
Got a headache? “Call 911, it could be a brain hemorrhage.”
Bitten by an insect? “Anaphylaxis kills quickly. Better call 911.”
All of those things are true, but lack the context of a thorough exam and history; things EMS professionals are taught to do, but patients are not.
COVID-19 impact on EMS call volumes
It took the COVID-19 pandemic to do what 20 year’s worth of billboards, radio and television PSAs could not: convince the worried well that maybe an ambulance trip and an ED visit wasn’t erring on the safe side. They finally had something they feared more than what their innocuous complaint might be.
They’re scared of catching the ‘rona, and they know that hospital emergency departments are just slammed full of those patients, and it’s hard to maintain social distance when you’re elbow-to-elbow with your neighbor, paging through old magazines, waiting hours for your name to be called. Never mind the fact that hospital waiting rooms have always been excellent places to catch the cooties. They are, by definition, full of sick people in close proximity to one another.
Around the country, while coronavirus cases have surged, hospital census and EMS run volume have dwindled, and it’s not just the cancellation of non-emergent or elective procedures, either. People are legitimately scared of going to the hospital for anything but life-threatening reasons.
In several social media posts, and community releases, Matt Zavadsky, MS, HSA, chief strategic integration officer for MedStar Mobile Healthcare in Fort Worth, noted that his system’s cardiac arrests in April were up 113% over last year, and patients pronounced dead on scene were up 164%. Overall run volume in many EMS systems has declined sharply in the past several months. Zavadsky openly wonders if patients in Fort Worth are waiting too long to call 911. In another post, he links to a “Wall Street Journal” article that highlights the financial burden that the COVID-19 pandemic has placed upon EMS systems. In following directives from local hospitals to only transport the sickest patients, EMS systems are doing far more treatment without transport, for which they do not get reimbursed.
https://www.facebook.com/MedStarMH/posts/3474415869243819
The irony here is inescapable, but the problem is concerning. We’ve designed entire deployment systems and staffing models based upon system demand and response time. Now that the system demand isn’t there – pandemic hotspots still inundated with calls notwithstanding – we can meet our response time standards, even with a significant portion of the staff out sick with COVID-19 themselves ... but we’re going broke doing it. The systems we’ve designed aren’t financially viable with the current demands (or lack thereof) we’ve placed upon them.
File that under, “be careful what you wish for.” MedStar was a pioneer in mobile integrated healthcare/community paramedicine, in large part as a means to ease system demand and reduce EMS superusers. Now they’re worried that people aren’t calling 911, and they’re not alone.
As the pandemic subsides – and this may literally take years – it’s clear that there will be a new normal; things will not return to exactly the way they were before. More to the point, should things return to the way they were before?
Proof of concept: ET3
They say that necessity is the mother of invention, and many EMS systems have devised innovative solutions to meet the demands of the COVID-19 pandemic. Those solutions are very much like mobile integrated health/community paramedicine. We’re seeing proof-of-concept writ large, even among agencies who aren’t officially participating in the ET3 pilot program.
Systems are discovering that yes, they can safely transport to non-ED destinations. Yes, they can safely do treatment without transport. Yes, they can do health screenings and testing in the home. Yes, they can terminate resuscitation in the field without fear of missing someone who could have otherwise survived. Yes, they can do all of the above without two medics on a truck. They can do it with medic/EMT, medic/EMR, EMT/EMR, medic/driver, heck, even medic that just came out of 10 years of retirement paired with a guy whose ink is still wet on his EMR card.
The question still yet to be answered is, can they continue to do these things after the pandemic is over? When our focus shifts from pandemic response to the more mundane aspects of out-of-hospital care, EMS systems and insurers are inevitably going to be paying closer attention to outcomes. Post-pandemic, the gray zone between “oh, sh*t” and “bullsh*t” is going to get wider. It’s going to take a more extensively educated provider to navigate it.
Now is the time to advocate zealously for stronger EMS educational standards, and government support in paying for it. They’re more receptive now to the idea than they’ve been since 9/11. If we can sell that, the new normal may see EMS in a stronger position than when we started.
Read next: What’s next? How EMS can survive the economic downturn
