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• EMS system abuse. The 900-pound gorilla in the room is this – the healthcare system in the United States is broken. Notwithstanding efforts to pass various pieces of legislation to fix the problem, the system is a problem and, at least for the pre-hospital care component, current laws will not provide the fix. For many Americans their first (and only) access to medical care is the hospital emergency room (ER). Thus, the EMS system is being abused. First responders are routinely summoned to take people to the hospital for a wide variety of non-emergency injuries and medical conditions. Some of the system abusers simply do not know any better. Some know EMS to be their only way to get access to medical care. Some know they are abusing the system, but they see it as their right to have an ambulance at their beckon call to take them to the emergency room any time they want for whatever reason they want.
Some system abusers are clever. They have learned what “trigger words” score them the automatic ride – “chest pain” being one. For some, they are simply seeking a ride downtown and the ambulance provides it. Once their care is turned over to hospital staff, patients sign themselves out of the ER or simply get up and walk out. There is no law that compels them to stay. In fact, there is no law that can compel the hospital staff to make them stay. And the next time they want a ride downtown, EMS will be there again to provide it.
Clearly, the system is broken and it must be fixed on a broad scale. Some EMS agencies have actually gone as far as providing taxicab tokens so system abusers can simply take a taxi to their desired destination instead of abusing the EMS system. Those with legitimate injuries or illnesses that are minor are also provided with taxicab tokens for rides to the emergency room. The real system abusers do not like this, however, because they do not get the express entry into the ER as they otherwise would when they arrive by ambulance. If they come by taxi, the wait in the ER can be hours.
• Response times. Some argue that response times are critical in medical emergencies. Indeed, for some emergencies every second counts. However, in some cases, time is not critical. One only need to take a trip to an ER for a minor emergency (e.g., suturing a lacerated finger) and see the people waiting for hours. While the ER waiting room is full, most of what is there are not emergencies. The same it true in the pre-hospital environment. Many, if not most, calls for EMS are not true, life-threatening emergencies. The caller may require medical care, just not emergency medical care.
However, for those with an emergency illness or injury, response times are critical and truly every second does count. Part of the problem is that first responders often do not really know what is an emergency until they arrive and assess the patient. Even in systems where dispatchers are trained to ask the right questions and provide pre-arrival medical instructions, the system is not perfect. An accurate patient assessment cannot be conducted over the telephone. Only a trained responder assessing a patient’s condition can truly determine the emergency need for medical care. In a litigious society, the risk is too great, so many systems default to treating every EMS call for service as an emergency.
• System demand. When assessing the impact on a fire-based response system, it is not abnormal to see EMS accounting for 70% to 85% of calls for service. Clearly, in some systems it is the vast majority of the services provided by the fire department. Some may contend that reducing or eliminating fire-based EMS would let a city significantly reduce the number of firefighters on the payroll. This conclusion may be premature if elected officials lose sight of the core mission of the fire department – to protect the lives and property of residents, businesses and visitors from the ravages of fire. In most systems, on-duty EMS responders are also cross-trained firefighters and when there is a fire, it is an extremely labor intensive activity. For example, a working fire in a single-family home could easily require 15 to 30 personnel, depending on the size of the structure and the complexity of the incident (i.e., the size and construction of the building, contents, extent of fire involvement, rescue of occupants and water supply). As staffing is reduced, so is the number of responders available for labor-intensive fires and complex rescues. While those happen far less frequently than medical calls, the consequences in relation to the loss of life and property are often exponentially greater.