Saturday, October 31, 2009

Flying Frequently

I'm sitting in the kitchen of a Frequent Flier and wondering what to say.
My main job is for a suburban service now. We're slower, but the patients tend to be sicker because they take their medicine, visit their doctors, take better care of themselves and thus, when they finally need 911, it tends to be because they are very sick.
This patient is the exception.
There is nothing remotely sick about him, at least not physically.
In my last job at a busy urban 911 system, Frequent Fliers were as common as streetlights.
They were an accepted part of the landscape. Only when they decompensated and became real players -- say, calling once or twice a day, every day, for a month or more at a time -- did they warrant comment.
But when they do get under your skin, well, there's NOTHING worse in EMS.
Some guys can handle taking the same Frequent Fliers shift after shift without a problem.
For others, it's sometimes enough to make them contemplate leaving the field entirely.
I'm usually in the former camp, but often in the latter -- much more so lately.
So now I'm in the kitchen of a guy who's called for nine nights in a row, each time complaining that his uclers are bleeding.
But he always has a twist to his main hemorrhagical complaint -- the ulcers are acting up AND a local gang has caused a rash on his forearm, or the ulcers are acting up AND the federal government has him under surveillance.
He's been rotating among the three nearest hospitals because each has identified him for what he is almost immediately.
Typically he's discharged and on his way home within a couple hours, depending on how much time and personnel the overworked EDs have to devote to a patient who darkens their door daily with a slew of bogus and bizarre complaints.
Tonight he is asking to go to a hospital 20 miles away. On a rainy Friday night. In a town with a single ambulance.
I have to measure my words.
These are not good times for telling it like is in EMS.
It's best if you don't think too much, don't worry about the system or allocation of limited resources or wasting public money on public nuisances.
The best thing for my career is to just forget the abuse this particular patient is heaping on the system, forget the tens of thousands of taxpayer dollars wasted on the meaningless carousel of transports, ED evaluations and ambulance rides back home this patient has created in order to exorcise his personal demons, and ESPECIALLY to not consider for a moment the possible patients we won't get to help while we are performing yet another fruitless transport -- the father of four who suddenly goes into cardiac arrest, or the 72-year-old CHFer woken from sleep by the suffocating presence of lungs filling with fluid.
Thankfully this nightmare scenario hasn't happened. But it's only a matter of time, I think.
But telling him so won't do any good and may in fact cause me significant grief.
So as much as I'd like to tell this patient exactly what I think of what he's doing, instead I smile.
We can't go to that hospital 20-miles away, I say. We are, though, more than happy to bring to the hospital of your choice in The Big City, about 5-miles away.
He is appeased, and within minutes we're on our way to the hospital once again, both of us certain in the knowledge that this won't be the last time this particular patient will make this particular trip in this particular ambulance.

Monday, October 26, 2009

In The Land of the Blind, The One-Eyed Man Is King

Think the health care reform debate is complicated?
Think the people making the policy that will result most likely in a government takeover of about 20 percent of the US economy give a flying fart about EMS?
I understand when laymen have trouble figuring out all the ramifications.
What does it mean when the "experts," people with PhDs who do nothing but ruminate daily on the health care reform debate, admit that they haven't thought even for a moment about health care reform's potential impacts on EMS?
And yet, this is exactly the case.
Last week I read a 10-page supplement to the Columbia Journalism Review written by a think-tank that philosophically stands squarely behind President Obama on health care reform.
The think tank advertises itself as "A private foundation working toward a high-performance health system."
When I read this group's piece I thought maybe I had found that touchstone, a group that made it's argument lucidly, plainly and convincingly.
Maybe, finally, I had found a way into the debate that made sense, could give me a reason to get behind reform.
But one nagging thought remained.
Nowhere in this 10-pager was there mention of EMS.
Nothing about how ambulance services would be re-paid for services rendered to Medicare/Medicaid patients despite the fact that almost every proposal for health care reform calls for Draconian cuts to the costs of Medicare/Medicaid.
How, I wondered, would EMS survive deep cuts to Medicare/Medicaid reimbursements if services to those folks were already burdensome financially at the current level of funding?
So I emailed the director of the think tank that wrote the piece and asked if she had any information on the subject.
She wrote back rapidly with the candid admission that she had no idea.
To her credit, this director spent part of her Friday night tracking down the contact information of people who might be able to answer my question, even though it was clear that I'm not a person of any particular importance and was asking the question mainly out of personal curiosity.
But it also points to the fact that EMS is NOT a part of this debate, and my fear is that when the entire US health system is overhauled and re-done, the EMS system could find itself with more demands and no way to meet them.