Thirty years ago, prior to the advent of the 9-1-1 system, EMS was very different. If you needed an ambulance, it was a simple process of finding your phonebook, flipping to the yellow pages, looking up ambulance, and selecting one of the three or four listed. If you’d lived in Portland for most of your life, usually you called Buck Ambulance on their seven-digit phone line. (Buck had been around since 1918 and everyone knew about them.) Your call would be answered by a couple of caffeine addicts who used to be ambulance “drivers” back before the advent of the paramedic program.
The dispatcher answering your call was tough, savvy, knowledgeable, experienced, and a master at multi-tasking. If you had a life-threatening emergency, dispatch would get an ambulance rolling your direction within moments. If it seemed like you needed an ambulance, but your need wasn’t life-threatening, these awesome dispatchers would send the ambulance without lights and sirens. It was deemed safer for the public on the streets, safer for the paramedics, and much less stressful for the people requesting assistance.
However, everything changed in the early-80s, when the 9-1-1 system was instituted in Portland. First the emergency dispatch call center was established in an old nuclear bomb shelter built into Kelly Butte, located in SE Portland. Then the public was asked to begin calling a central seven-digit phone number, instead of the local ambulance company. Eventually, as the Bureau of Emergency Communications (BOEC) developed and evolved, they were given full responsibility for police, fire, and medical dispatch.
The new call-takers and dispatchers were trained and certified as emergency medical dispatchers (EMD), the old guys who used to handle these calls at the local ambulance headquarters, or fire dispatch offices, were gradually phased out. The public was instructed to call 9-1-1 and everyone got phone stickers to help them remember. The best part about this is that now the closest ambulance was sent to your emergency, instead of one that could be across town, because you called a company that didn’t happen to cover your area.
In addition, dispatch began sending the closest fire unit if it was determined that this may be a life-threatening emergency. We told people to call 9-1-1, even if they’re not sure, we could roll the equipment and emergency personnel in their direction, determine whether we were needed, and help them sort through their emergency. We assured people that they are not going to send them a bill for showing up. We would only provide the services necessary.
In the 1970s, less than 5% of people suffering an out-of-hospital cardiac arrest would survive.
As the public became more savvy to the 9-1-1 system, more and more people began to access it. If your husband, or grandmother for that matter, were to have a cardiac arrest, you would have several highly trained, very capable people in your home within three to six minutes after you called 9-1-1. The advent of this evolved system was the right direction for the newly minted EMS system. Lives were being saved, and the paramedic program matured.
In the 1970s, less than 5% of people suffering an out-of-hospital cardiac arrest would survive. Currently, we are seeing and amazing 20+% save rate. That means that previously, less than one in twenty people would survive and out-of-hospital cardiac arrest, now one in four will. This is amazing.
However, there has been a great downside to this system. In the 1970s and 1980s, when you called for an ambulance, if it was merely an urgent situation (as opposed to a life-threatening emergency), you would usually have a two-person ambulance crew in your home, within ten minutes (or less), and your situation would be handled calmly and with great skill. Ambulances would use their lights and sirens less than half the time when responding to calls for assistance. Also, people didn’t tend to call ambulances unnecessarily.
Another unintended consequence is the overuse of the EMS System, for non-urgent calls.
Currently, ambulances respond Code-3 (with lights and sirens) at least 90% of the time – much more often than necessary. Also, for simple urgencies, you will often find a fire rig and an ambulance parked outside your home. Inside, three to four paramedics, and several EMT/firefighters will be crowded into your bedroom, dealing with your once-private, non-life-threatening, medical condition. This is overkill – and it happens far too often.
Another unintended consequence is the overuse of the EMS System, for non-urgent calls. People call for an ambulance because they don’t have bus or taxi-fare to get to the urgent care center. People call because they don’t have healthcare insurance, but they have an illness or injury that needs care. Some call whenever something abnormal happens, without first assessing if this really requires medical attention. It’s our own fault, we told them to call. We said, just call, we’ll come, and we’ll sort through it with you. But after three generations of telling people this, the threshold is very low on what constitutes a valid emergency.
The problem with this over-response is that we “cannot” recommend that people NOT take an ambulance. For reasons that are outside the scope of this post, Paramedics and EMTs have to recommend ambulance transport. Liability issues, quality of care issues, and other medical/legal issues prevent responders from recommending other transportation options to a more definitive care provider. Even if someone wants to refuse transport, the paperwork and legal issues, will take longer than an actual transport. In fact, the patient care report for someone who “refuses” transport, will be longer and more detailed than for someone who is actually transported.
Recently, an ambulance crew was dispatched to a call and they responded Code-3, with lights and sirens. The ambulance arrived simultaneously with the five-person fire truck crew. The “patient” was standing on the curb with her suitcase and kids. Apparently she had a sore leg and needed to be evaluated by a physician, so she called 9-1-1. The fire crew was cancelled and left the scene. As the patient and her children we loaded into the ambulance, the patient was asked why she called an ambulance. Her answer was classic:
“I need the cab-ulance, because I don’t have cab fare and it’s too far to walk to the bus stop.”
Unfortunately, many people in this situation don’t have healthcare insurance. They have learned that the EMS System will not refuse them – from the 9-1-1 call-taker, to the ambulance, and all the way to the hospital emergency department – they cannot be refused care. However, this is the most expensive way to provide routine healthcare to people.
Those who oppose universal healthcare, often overlook the fact that the uninsured are still receiving medical care, but it is very expensive care
Those who oppose universal healthcare, often overlook the fact that the uninsured are still receiving medical care, but it is very expensive care – and we are all still paying for it through higher insurance premiums, and higher healthcare costs. The fact of the matter remains, these folks have very few options. If they do have other options, they don’t know about them – but mostly, they are locked into spiraling cycles that cost everyone money. Our healthcare delivery system is obviously broken – especially for the less affluent in our society.
I’ve been wondering, upon my recent return to EMS, about some of the evolutionary changes that have taken place in my absence over the past 15 years. Primary on my mind is the incredible under-triage of calls, over-response of personnel, and over-use by the indigent population. It makes me wonder if this is a survivable business model – for public, or private, providers?
What I’m hoping is that with the advent of the new universal healthcare system, that people will begin to find and access healthcare outside of EMS. Not that I don’t want to care for them, but because there are better options out there for them. Hopefully, people will seek medical care before they need to call 9-1-1. Hopefully people won’t rely on hospital emergency rooms as their primary care center. Hopefully, we can lower medical costs, so that 30% (or less) of patients aren’t paying for 100% of those seen.
It’s time to stop blaming those that use the system for their everyday medical needs, and start taking responsibility to find a better way to handle those needs. The haves, have to take care of the have-nots – that’s the way it works. We can deny that responsibility, but ultimately, there is a price to pay – either in financial, or other social costs. Those that have the means, the resources, and the wisdom, need to work together to help redesign a system that provides the best quality care, to the largest number of people, for the lowest cost possible.
Or, as one sage once said:
If you keep doing what you’ve always done, you’ll keep getting what you’ve always got.”