The day had finally come to start my first job as an EMT for a 9-1-1, emergency ambulance company. Before my first shift, I believed that most of the emergencies I would respond to were going to be serious and could be a matter of life or death. However, little did I know that many would end up being things easily handled in a primary care clinic.
First Day on the Job
After shining my black firefighter boots and putting on my uniform, I was ready for my first shift. Within minutes of stepping into the station, the alarm rang, and I experienced a rush of adrenaline. The first call of the day was for a 35-year-old male with right flank pain. This, in my opinion, was a potential emergent situation, as the patient was most likely experiencing a kidney stone and wouldn’t be able to drive himself to the hospital. After treating the patient and transporting him to the emergency department, I thought to myself, “Will I get any calls like the ones you see on TV?”
The next call, however, was for a 24-year-old female with a sore throat. While transporting the patient to the hospital, I wondered why someone would use 9-1-1 for a sore throat. In a polite way, I asked the patient, “Do you have a primary care provider you see?” She didn’t.
On another call later that day, the patient had uncontrolled hypertension. He had run out of his medication the week before. He told us that the reason he called was that he was starting to feel dizzy. He also said he did not follow-up with his primary care doctor regularly.
The more shifts I worked, the more I noticed that many patients who called 9-1-1 did not have access to primary care providers. Don’t get me wrong, some of the calls I responded to as an EMT were a matter of life and death and were serious emergencies. These included cardiac arrests, heart attacks and traumatic accidents, including motor vehicle collisions. However, a surprisingly large proportion of the patients we responded to could have effectively been treated outside the hospital at a primary care clinic. I kept thinking that if more of the patients I took to the hospital had primary care providers, then they very well may have never called 9-1-1.
One of the big issues with misuse of the 9-1-1 system is that when people call for low-acuity complaints, it reduces the number of ambulances available to respond to the high-acuity, potentially life-threatening complaints. It was not my job to judge whether someone called 9-1-1 for a legitimate reason. Whatever a patient’s complaint, we had an ethical duty to respond.
Fixing the 9-1-1 System
Where I currently live, the Los Angeles Fire Department has started a pilot program called the Advanced Provider Response Unit (or APRU). The unit is an ambulance staffed by a paramedic, along with either a physician assistant or nurse practitioner, and it functions as a mobile urgent care unit. The unit is dispatched to patients with complaints deemed low acuity. It provides on-scene evaluation, testing, medication, and immediate care. The APRU also gives patients follow-up information and resources on how to access primary care. In its first six months of service, the APRU treated more than 329 9-1-1 callers with low-acuity complaints. Furthermore, providers on the unit referred frequent users to Partners in Care, an LA-based community health and social services organization.
Community paramedicine is another potential solution. According to the Rural Health Information Hub, community paramedicine allows EMS providers to work in an expanded role by providing healthcare to underserved and rural populations. Community paramedicine, like the APRU, consists of paramedics and EMTs who make home visits to deliver primary-care services, post-discharge follow-up care, and integration with local public health agencies.
Ambulance providers often fund community paramedicine, but it has also been funded by grants, hospitals and even some Accountable Care Organizations (ACOs). ACOs contract with ambulance companies for the use of community paramedics and may even employ them directly. EMS agencies also can work with ACOs to determine if they will be reimbursed for community paramedicine services.
Misuse of the 9-1-1 system is a difficult issue that affects patients, providers, and our healthcare system as a whole. Not only are patients calling 9-1-1 for conditions that primary care providers (assuming they are available) are readily able to handle, but patients are visiting EDs for these conditions as well. Is it time to begin directing some of these emergency resources to expand the availability of primary care? And should we think about expanding programs such as those in Los Angeles and in rural communities nationally?
Vince Caserio