Fast, Good or Cheap

I was recently reding a blog post on Too Old to Work Too Young to Retire about a Swedish report detailing the lack of an EMS response to an emergency situation due to their over the phone triage. I was intruiged both by his story as well as hers which you can find here: The Local.

Rebecca Ahlfeldt wrote the initial story and in the response to her two things stood out to me. The first is when Ahlfeldt makes this claim:

While an emergency operator undoubtedly has a tough job, one piece of it sounds fairly straightforward: if someone asks for an ambulance, in most cases, they probably need it.

The response is:

Obviously, she never read this blog, Ambulance Drivers, or many other EMS and Emergency Medicine blogs. The problem in our country the opposite of what she describes here. We send ambulances, often with lights and sirens, to trivial problems. The difficulty is in knowing what is going on. Nor is there much evidence that EMTs and paramedics are all that good in deciding if someone really needs to be in the hospital. That doesn’t count the blatant system abusers, of which there are many. The problem is that if we miss ONE patient and that patient dies, the entire system comes under scrutiny. So, we are incredibly risk averse. While that might be good, it’s incredibly expensive. Plus a lot of people get free health care, including EMS, and have no incentive NOT to abuse the system. (She misses the point)

I have talked to medics from many different states in the US and read many different blogs and articles about EMS and it seems many different people from many different areas agree that many calls we get are non-emergent. 

 Now I am not talking about elderly patients or non-emergency transfers. We understand that as the population ages more and more of our calls are going to be for the elderly (have you heard that EMS now stands for Elderly Management Service?). We also know that transfers are a fact of life for many in EMS. Not only does it provide a sometimes life sustaining function when transporting a patient to a facility that has the resources to service that patient, the income, however little it might be, is vital to many EMS companies. Some city services are starting to see this and are working to get reimbursements for their efforts. 

 What I am talking about are the calls to 911 that are a blatant disregard for what 911 was meant for. In the past few weeks alone there have been calls for a little girl who drank her water too fast and had a coughing fit, so obviously she needed a pair of paramedics to check her out. A baby who coughed up some milk, yup that was a medicaid transport because the mom said, “I have medicaid so they will pay you to take me.” A woman with a splinter she couldn’t get out of her finger, a Veteran who was fighting with his sons so a few hours at the ER should do the trick, you guessed it he said, “I’m a Vet so the government will pay for the trip.” Abdominal pain on a 45 year old male after he ate spicy food and drank beers with a history of GERD, “it happens all the time I eat spicy food, it feels exactly the same as before but I don’t want to risk it.”

 And the ever classic, “I called 911 because we get seen faster at the emergency room that way.”

 The question that occurred to me is how much are these 911 calls that are unnecessary costing? How big of a burden are these abuses putting not only on the individual EMS company or system but also on taxpayers in general? Has there been any real study into what is more wasteful, the financial risk with denying transport to someone that doesn’t need transport or the burden of having to transport the same frequent flyer to the ER some 10 times a month?

 Any thoughts?

 The second thing that got me, and this one really got under my skin was the last line of Too Old To Work, Too Young to Retire blog, 

You can have it fast, good, or cheap, pick two.

This is the Holy Grail of truth right there. Why is it that a city will understand that a police force needs funding that it cannot expect to recuperate, a fire department will require funds for it to function and yet an EMS system will sometimes be auctioned off to the lowest bidder. Of course the greed of some EMS companies will make them push their bids down as low as they can go, only to then suffer when trying to make ends meet. 

There is a city locally to where I am that is going to go out for bids, again. They switched from one provider because that provider was costing too much. Not because that provider was not performing well, not because that provider was not showing up to calls, not because that provider was behind in technological advancements in emergency care, they switched because a group of commissioners looked at the budget and had to shave off a few percentage points. 

The first service that came in did well in the beginning, and then steadily began to lose their grip on financial situations. Late responses and lack of resources infected the entire system.

A second company came in, after a few months they began to have trouble responding in a timely manner to calls. People died, calls with CPR in progress waited 20 minutes before an ambulance would arrive. Sometimes longer. Commissioner meetings became circuses where people would line up protesting the EMS service. 

So of course they were replaced, with someone that obviously could do the job, for a quarter of what the other companies were doing it. Really, does this seem feasible? Instead of realizing that maybe, just maybe, your getting what you pay for your going to risk more lives and your citizens safety on yet another private provider that is promising the world on a platter for next to nothing? 

The time has come for another set of meetings in that town, once again they are having massive delays on 911 calls. Other EMS systems in the surrounding areas are going into that city to help. Solutions are called for, something must be done. 

A request has been sent out and all potential EMS providers are to submit their lowest bid to the city. 

You can have it fast, good, or cheap, pick two.

You can have it fast, good, or cheap, pick two.

This should be chanted to anyone that complains about EMS. Imagine if that city did the same thing for their fire service, imagine their police department being run like that! 

Never, no way! Why? Because those are necessary services! Guess what, EMS is a public service that in the time of a real emergency is just as vital, if not more so than those other two. 

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