EMS: A Primer

Ok, judging by the recent news story I feel it's again time to discuss the basics of my job. The news story I'm referring to is about the high cost of ambulance bills, and can be found here:

http://www.thedenverchannel.com/news/23557782/detail.html

EMS stands for Emergency Medical Services. Most commonly, this translates into ambulances. There are a number of different ways of providing ambulances to the public. One way is through a private company. This may be a for-profit or a not-for-profit endeavor. Alternatively, the service may be hospital-based, and the profit standpoint depends on the hospital. As an aside, these hospital-based systems don't "only" transport to their own hospital. The most common solution to providing ambulances in Colorado is in fire-based EMS. In this system, the fire department cross-trains its firefighters in EMS and run ambulances as well as engines and trucks. At our department, there is no difference beween who works where--I may work on an engine one day and the ambulance the next. It is a non-profit endeavor.

Now, onto who works on an ambulance. There are three levels of certification. EMT (Emergency Medical Technician)-Basic, EMT-Intermediate, and EMT-Paramedic. EMT-Intermediates are found mostly in rural areas, so I will focus on EMT-Bs and Paramedics. EMTs provide BLS (Basic Life Support). They take vitals, perform exams, provide oxygen, and perform techniques ranging from CPR to IV cannulation to artificial ventilation.

Paramedics are the most advanced form of pre-hospital EMS. They have all the skills of an EMT plus some. They go to school for a longer period of time, and perform more detailed exams. They have a number of drugs they can administer to treat respiratory problems, allergic reactions and cardiac dysrhythmias. They can intubate, perform synchronized cardioversion and defibrillate, among other things.

At our department, an ambulance consists of an EMT and a paramedic, or two paramedics. Some things we can't do: kidnap people against their will, diagnose diseases, make your decisions for you, provide parenting advice or parent your children.

Now, what happens when 911 is called? For a medical emergency, the nearest fire engine and ambulance are dispatched to your location. Why two rigs? There are more engines than ambulances, so an engine will usually reach you first to provide care (remember, EMTs and paramedics are on all the engines). Also, on a seriously ill patient, more hands can help the call run more smoothly. We aim for a response time of under five minutes, and have to be out of the station in under a minute after receiving tones. Want to try it out? Here are two fun ways at home. First, get into the shower. Lather up. Relax. Then start the stop watch and make it out of the shower, dressed and sitting in your car. Don't want to soak your seats? Get into bed. Fall asleep. Deeply asleep. Have your alarm go off at 0230, in the dark. Again, get dressed, out to your car. One minute.

So, we've arrived where you are. A number of things can happen. Usually, you describe your complaint, we evaluate you, and off we go to the hospital. However, there are times where the "patient" isn't the one who called 911. They may not wish to go with us to the hospital, preferring to have someone take them, or they may not wish to go at all. Sometimes this is reasonable, sometimes they are making a poor health decision. Either way, we can't kidnap them. They can refuse, against medical advice and after consultation with our base physician at the emergency department. What we can't do is "paramedic initiated refusals;" that is, refusing to take you to the hospital. If it is a minor injury, we can explain that it may be a better decision to seek care at an urgent care, your personal physician, or have someone drive you to the emergency department. But if you want to go to the ED, we'll take you.

This brings up the question of cost. Yes, it does cost for us to take you to the hospital. Sometimes a lot. No, I don't know how much it will cost. Administration won't tell us. And we've been told that if we do know, we can't tell you. So someone gave you an estimate? Well, it's not based on anything. Your bill is higher? Sorry--it was uninformed. Here's the deal though. When you call 911, you get the jurisdiction covering your area. It's not a "shop around" type of deal. The services that respond are paid by your tax dollars.

So, you ask, if I pay taxes for these services, why isn't my ambulance ride free? Good question. It turns out taxes pay for the stations, salaries, rigs, rig maintenance, keeping our training up to date, etc. It doesn't cover the wear and tear on ambulances, fuel costs, drug costs or other supplies. So we have to charge. Again, we're not making a profit. Additionally, there are health insurance companies to deal with. Some reimburse us only pennies on the dollar. The last average ambulance reimbursement figure I heard thrown around was 30%. This is why fire-based EMS is popular in Colorado. The fire department is supported by a consistant tax base, not by ambulance fees. This is also why so many private ambulance companies go out of business. Imagine running a business where you took up to a 70% loss on every transaction.

Abuse of the 911 system adds to these costs. Think of the number of people, with or without insurance, that take the ambulance frivolously (yeah, there's a lot of them). There's the ones with a cold for three weeks that call at 3am for an ambulance ride. The drunk on the street who we will transport twice in one night. The minor cuts and scrapes, not to mention the "neck pain" patients from car wrecks hoping for an insurance payout. There's people that are "frequent flyers," known to EMS crews and ED staff by name. These aren't unusually sick people, just drunks or those with imaginary illnesses.

These patients spill over into overcrowding in the emergency department. In a place that is supposed to be reserved for life threatening illnesses, nowadays you find a majority of patients that should be seen instead by their primary care doctor. This brings us to another problem--many people lack health insurance to have a primary doctor, and thus use the emergency medical system as their primary care.

As you can see, this is a problem that quickly grows in size and complexity as it is unwrapped. I don't foresee a simple solution--my goal is to educate you to the issues at hand.

Please, just remember a few points.

-We're not "ambulance drivers."
-We're not gunning for a profit. We are healthcare workers concerned about your health.
-Please use common sense before dialing 911. If you have no common sense, please consult someone with some.
-For those of you against healthcare for everyone, remember that next time you or a loved one is waiting for hours in an overcrowded emergency department waiting to be seen.
-If you insist on calling 911 from your cell phone for a car wreck or a person "passed out" in the grass/bus stop/alley and you DON'T stop to render aid or wait for us to show up...I will hunt you down and you will lose phone privileges.

Thanks for reading.