Someone Failed… Is it the System? Everyday EMS Ethics

A tempestuous night is blowing outside the station walls. The cold night air is stirred wildly, blowing splatterings of rain against the glass window of my bedroom. The wind howls through the trees conjuring up fantastic images of the disturbed environs of the world outside my bunk room. Having gone to bed early, I cannot remember the dreams I must have been having but judging from the fact that my sheets were in such disarray when I awoke, they must have not been pleasant.

I awoke to a familiar but unwelcome voice, the night shift dispatcher coming from my radio. He spoke of a seizure in the next town over. The local ambulance service from that jurisdiction was calling for a paramedic to intercept and assist them with their call. I was due, it was my turn to be ripped from the warmth of my bed and respond to their aid.

I pulled on my clothes and zipped up my shoes. Since whomever controls the seasons in my area has decided to outright skip Fall and move straight to Winter I pulled on a jacket as well. Stepping out into the night air I halfway expected there to be a late September frost on the ground. As I started my truck and keyed the address into my GPS I cranked up the heat to stop my shivering. Hopefully this wouldn’t be too challenging for me in my sleep deprived, freshly woken up state. Hopefully I can wake up enough to safely drive. I shook my head violently to clear the sleep from my bleary eyes and keyed up the mic:

“Dispatch, Medic 84 is enroute to intercept Anytown”

The night shift dispatcher answered me and I switched to Anytown’s frequency:

“Anytown, Medic 84 is enroute to your scene”

With the red lights flashing over my SUV I pointed out into the deserted city streets. Anytown was about ten miles away from my station over country roads. The address was a few miles into their city limits. Curiously, the address they called me to was just a few short minutes from Anytown Hospital and it was strange that the EMT-Intermediate volunteer service had called me to an address where they would usually just scoop and run ILS to the ER. I figured that this must be one of those “Seizures” where the patient seized because of the fact that their heart stopped. People will oftentimes have a seizure when their heart does something funky, like stop, and blood flow is slowed or stopped to their brain. An old paramedic instructor I had once put it this way “Brains need blood flow to be happy, stop the blood even for a second, and the brain gets pissed off”. Everything seemed to get pissed off to that guy. An MI causing arrythmia was a “Pissed off heart”. Diabetes was a pissed off pancreas. A drunk at the bar was pissed off at his liver and so forth.

I wondered what this patient had that was pissed off for her.

The roads were open but the night was pitch black. The wind was blowing my small SUV in all directions but straight. Thinking that this was probably a bad call, I pushed the gas as hard as I felt was prudent with the driving conditions. I didn’t meet any traffic to get in my way. Just as I was coming into their town, a familiar voice crackled over Anytown EMS’s frequency:

“Medic 84. We still need you to respond but you can slow it down to non-emergent. We’re short an “I” and it’s going to be you”.

Ohhhh, so they couldn’t staff the truck fully and responded using me to make their full crew. Now I understood. Anytown EMS is a good service with dedicated people, but sometimes even the best volunteer service needs a hand. That’s what mutual aid is for. We have an arrangement with them in such circumstances so that our intercepting paramedic can make up a full crew for them by partnering with one of their EMTs.

I turned off the lights and just cruised silently through their deserted town. Yes, I popped the lights on momentarily to get through a couple of stop lights, but who’s counting, right? Arriving on their scene the EMT came out to me and said:

“You don’t need to bring anything. This is her third ambulance ride in 24 hours. She spilled a glass of water and (a family member) called because she thought she was “having a seizure” and needed to go back to the hospital”

Oh, now I remember this address. I don’t even work for this town and I’ve been here like umpteen times this year. The patient is one of their frequent fliers. Every community has them. I swear, without our frequent fliers we’d be short like a thousand annual calls. Think of the sleep time I could get.

Climbing up into the ambulance, I met the patient for the umpteenth time this year. She was in no distress and this is where her part in the story ends. My question isn’t about her. Honestly, the question here could be about any frequent flier in any community that has an ambulance response.

Why do we have them? Why do they depend on us so much?

The patient in this example had been to the ER twice already in the previous twenty four hour period, both times being transported by EMS and both times being taken home in a private car by family. Both previous times she had called her General Practitioner physician and had been referred to the ER because she said the word “seizure”. I can hardly blame the GP for recommending she call 911 rather than phone triaging her and suggesting she come into the office. But remember, it’s not about her. I can think of probably ten patients right now that I would consider to be among my personal roster of repetitive patients (I only have ten fingers) and their use of the emergency healthcare system for management of their chronic complaints is staggering in comparison to the use of it by the general population. Last year, every shift for two months we would respond to the same gentleman’s house to wake him up by popping in an IV line and giving him some D-50. We got pretty tired of it, as you can imagine. Most people with diabetes manage their illness pretty well and only occasionally need the assistance of an ambulance crew. This guy chose to manage it by drinking hard alcohol. I swear that I wanted to just leave the IV in place so that I wouldn’t have to start one the next day.
We fixed it by refusing to treat him on scene and release him anymore. It is common practice in my area to “sweeten up” a comatose diabetic with low blood sugar by popping in an IV and giving IV sugar (D-50), or in milder cases, by giving them high-sugar foods and making them eat until they regain full mental faculties. Once they regain their senses, all but a few of these patients sign a refusal of treatment form and do not wish transport to the ER. However, for this patient, we would find him unresponsive, so we would pack him up, move him into the ambulance, start the line and sugar him up while enroute to the ER. Once we were transporting, he couldn’t refuse to go and would end up at the ER for hours. Finally, he started managing his diabetes better because it was more convenient than waiting at the busy, urban ER we would take him to (yes, it was the closest. I work in many different jurisdictions).

However, the above solution just passed our problem we were having with the ambulance response onto the already overburdened Emergency Room. Yes, it “solved” the problem by increasing the patient’s level of personal inconvenience (although we still go to this guy about once or twice a month), but at what cost?
Who or what is causing the failure for these people? Who or what is causing the failure for this whole patient population? Is it the system that fails to adequately educate them on how to properly care for themselves or cure their ailment? Or is it the patient who is unwilling, or incapable of caring for themselves?

For both of the above named patients, socialized medicine already exists for them. They’re wards of the state as far as healthcare is concerned. One of them owns a house, one of them is in a free, government subsidized apartment, one
is in one state, the other is in another. You and I pay for their healthcare and almost their every need.

Is this the system’s fault? Is it their fault? Who should pay for the failure?

I’m writing this after coming back into my bunkroom and finding my sheets and blankets twisted into a ball. Everyone else in the house is snoring because of the abrupt weather change. (and DDex, if you read this YOU FREAKING SNORE WORSE THAN NACHO!) Whatever dreams I was having before this call came out must have been strange.

Until the next…

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Update:

My blogger buddies Happy Medic and Medic999 took off from this post and wrote their point of view on their respective blogs. Here they are. Join the discussion.

  • The Happy Medic

    CK,
    Rough night! To answer the question in your title, everyone failed. First and foremost the patient failed for thinking she can activate us whenever she wants. Personal responsibility is key. The family failed for going along with that same idea, the physician for practicing defensive medicine, the BLS crew for calling you to supplement their response and you for having to take her in.

    And the entire EMS community for not advancing ourselves into a position to end this kind of system abuse.

    I'll expand on this at HMHQ later today and see if we can get Medic999 into the discussion, but I wanted to point out one thing:
    These folks ARE NOT receiving socialized healthcare, just free EMS. Socialized healthcare encourages preventative care and education at little or no cost to the patient, allows doctors to stop defaulting to having family call 911, inserts trained caregivers to the call centers and allows EMS to interact with the physician to co-ordinate appropriate care. Socialized healthcare puts all resources into the same basket, meaning we can immediately connect our regulars with the services to get them healthy.

    It is not a perfect system, as 999 will tell us, but if the problem is abuse because people can not afford their meds or a visit to the doc, a socialized system will help.
    If the problem is people who don't care about themselves and don't take personal responsibility, there is no system imaginable that will help them.

    Just my first thoughts, hope tonight is quieter, HM

  • The Happy Medic
  • medicblog999

    Heres my point of view buddy!

    It was a little long to put as a comment!

    http://medicblog999.wordpress.com/2009/09/29/the-frequent-customer/

  • the observer

    Thank you for your thoughtful post. It would be easy to be really angry after being yanked out of a warm bed to take care of someone who should have not required your attention at that time. You were thinking about the event, the failure, and if anything could be done.

    You got me to thinking too and my thinkings turned into a blog entry:

    http://southkansascityobserver.blogspot.com/2009/09/80-20-rule-and-emergency-health-care.html

    Stay safe out there.

    A former EMT and present RN

  • http://www.bunkbedladder.net/ Chase

    It seems that bunk beds are a staple furnishing in any home. They can do wonders in maximizing the floor space of a very small bedroom. The problem is, if you don’t choose the right bunk bed, you may be putting your child’s safety at risk. There have been a lot of reports of accidents resulting from improper set up or manufacturing of bunk beds and it always pays to be very careful in selecting one for your children.

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Chris Kaiser aka "Ckemtp"

I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.

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