The Unneeded Ambulances

The Unneeded Ambulances

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San Diego ambulances respond to 120,000 medical calls a year, an average of more than 300 times every day.

Most of the time, said a high-ranking ambulance official, they didn’t need to go.

“Fifteen percent of those calls are really sick people,” said Wayne Johnson, general manager of the city’s ambulance provider, Rural/Metro. “The rest of them probably could have taken a car, in all reality.”

Rural/Metro’s ambulances go out so often, Johnson said, because they have to.

“We’re obligated under contract to respond to all 911 calls,” he said. “Regardless if they call up and say, ‘I need to refill my medicine.’ We can’t tell them, ‘No, we’re not coming.’ We have to go.”

Johnson’s comments reveal another facet of how the city responds to medical emergencies at a time when big changes appear to be on the horizon.

City officials are considering putting Rural/Metro’s ambulance contract out to bid, meaning the city could have a new ambulance provider for the first time in more than 15 years. The process could address how frequently ambulances need to respond and many of the other complex issues related to one of the city’s most vital services.

The Fire-Rescue Department, which typically serves as the city’s first responder, doesn’t meet its goals for getting to emergencies on time and the greatest risk for delays happens in some of the poorest and brownest neighborhoods. Rural/Metro’s ambulances do meet their goals, but the company has been struggling recently with more calls for service and is in bankruptcy. The company’s current contract calls for them to go every time someone dials 911 and requests assistance.

Right now, 911 dispatchers go through a detailed system to determine the severity of an emergency over the phone. The most serious problems, such as cardiac arrests, get a fire engine and ambulance with lights and sirens for the fastest response times. Other calls, such as a stubbed toe, get only an ambulance without lights and sirens and slower response times that come with obeying normal traffic laws.

The dispatch process is difficult, said Jim Dunford, the city’s emergency medical director. In less than a minute, dispatchers have to try to get information from someone who may be frightened, not know the sick person or otherwise have trouble communicating, he said. And the severity of potential injuries can change in an instant.

Because the city tries to figure out what’s happening before sending emergency responders to the scene, there’s always a risk of sending too many or too few, Dunford said.

Dunford recalled that the old “Nightline” news program had a recurring segment on 911 dispatch errors.

“Cities were barbecued left and right for failing to send resources quickly enough,” Dunford said. “Cities became afraid, adopted strict protocols and along the way it became clear that, at least statistically speaking, high sensitivity trumped high specificity.”

In other words, emergency response systems are now set up to send up to six people to respond to what could turn out to be a skinned knee. But six people will also arrive when grandpa’s breathing problems suddenly turn into a heart attack.

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Liam Dillon

Liam Dillon

Liam Dillon is senior reporter and assistant editor for Voice of San Diego. He leads VOSD’s investigations and writes about how regular people interact with local government. What should he write about next? Please contact him directly at liam.dillon@voiceofsandiego.org or 619.550.5663.

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16 comments
Aaron Klein
Aaron Klein

Mr. Dillon. As a citizen and firefighter of the City of San Diego, I very much appreciate the fact that you are investigating the problems we face in public safety. You have done an admirable job of looking at a number of different issues that we face. But I always finish one of your articles feeling just a little disappointed that you are not telling the full story. I admit that I am very passionate and opinionated about these issues, I deal with them most days of the month after all, so I am probably not the most impartial critic. One thing about this article that I believe could have been reported is the civil and criminal liability that I personally face on the job, and the liability that the City and Rural/Metro face (although you did touch on this), if I decide not to transport someone who wants to go to the hospital even if I believe they have no business clogging up EMS and the ER's. Firefighters and paramedics (I am both) have been sent to jail, and not just in California, for refusing to transport patients. Granted, most of the times they probably did not do a good job of assessing the problem, but in the back of my mind I am worried that I could make the wrong call at 4 am after working multiple days in a row and being exhausted so I do transport all patients who want to go (this is also a legal requirement by the way and I actually can not refuse to transport). As far as the dispatching of crews, hopefully you will ask to do a sit in with our dispatchers and listen to what they have to figure out over the phone, they have a very difficult job sometimes. As an example, my last day at work I had a number of difficulty breathing calls, a few were minor, one was BS and one was a life threatening cardiac issue that we, the ambulance crew and my crew, resolved before we got to the hospital. That patient I am sure was admitted and would have had a horrible outcome if he had even had someone drive him to the hospital instead of calling 911. And the problem is, the dispatchers can not tell which call is serious and which is minor. Only sending trained medical personnel to the scene to assess the patient can do that. Thanks again for your continued reporting and investigating of San Diego's public safety.

Aaron Klein
Aaron Klein subscriber

Mr. Dillon. As a citizen and firefighter of the City of San Diego, I very much appreciate the fact that you are investigating the problems we face in public safety. You have done an admirable job of looking at a number of different issues that we face. But I always finish one of your articles feeling just a little disappointed that you are not telling the full story. I admit that I am very passionate and opinionated about these issues, I deal with them most days of the month after all, so I am probably not the most impartial critic. One thing about this article that I believe could have been reported is the civil and criminal liability that I personally face on the job, and the liability that the City and Rural/Metro face (although you did touch on this), if I decide not to transport someone who wants to go to the hospital even if I believe they have no business clogging up EMS and the ER's. Firefighters and paramedics (I am both) have been sent to jail, and not just in California, for refusing to transport patients. Granted, most of the times they probably did not do a good job of assessing the problem, but in the back of my mind I am worried that I could make the wrong call at 4 am after working multiple days in a row and being exhausted so I do transport all patients who want to go (this is also a legal requirement by the way and I actually can not refuse to transport). As far as the dispatching of crews, hopefully you will ask to do a sit in with our dispatchers and listen to what they have to figure out over the phone, they have a very difficult job sometimes. As an example, my last day at work I had a number of difficulty breathing calls, a few were minor, one was BS and one was a life threatening cardiac issue that we, the ambulance crew and my crew, resolved before we got to the hospital. That patient I am sure was admitted and would have had a horrible outcome if he had even had someone drive him to the hospital instead of calling 911. And the problem is, the dispatchers can not tell which call is serious and which is minor. Only sending trained medical personnel to the scene to assess the patient can do that. Thanks again for your continued reporting and investigating of San Diego's public safety.

edwardg
edwardg

System overuse is endemic. It exist in all systems in all parts of the country. There are community paramedicine pilot programs throughout the US. Hopefully SD will get on board. Dispatchers need the training and latitude to redirect callers to other resources. Paramedics need the latitude to do the same. The paradigm where ambulances only transport to ER's has to change too. I would like to see a study that would show how many patients who are brought in by ambulance are actually admitted into the hospital vs treated and released from the ER. I'll bet Wayne is right, close to 15% A word about overuse. The ambulance is expensive. Those with skin in the came do not call as often. In other words, those who have insurances with co-pays or deductibles do not call unless they think they really need the ambulance. They know they will be sharing in the cost and decide accordingly. Those uninsured make a similar economic decision. Those on Medicaid (MediCal in CA) are not required to pay a co-pay, it is "free" 100% In these case, there is no economic reason to not call. It makes sense. Why use your own gas when the ambulance is "free". Not everyone thinks this way, but enough do to have a huge impact. In America there should never be something for nothing. There should always be a co-pay, even a small one. Economic consequence is a powerful motivator. I'm not saying deny service to those who don't have their co-pay. Just allow the ambulance service to charge it and attempt to collect it after the fact. If history is a predictor, this will reduce unnecessary ambulance requests. The private insurers knew what they were doing when they instituted co-pays. Even Medicare requires a 20% co-pay. Money talks. Just my 2¢.

Chris Brewster
Chris Brewster

In my view, this problem could be resolved if the State of California were willing. If dispatch protocols were codified such that certain specified circumstances receive a full crew including ambulance (lights and siren), certain circumstances receive an ambulance only (no lights and siren), and certain circumstances are directed to go to the nearest urgent care center (or call their doctor), dispatch centers could likely greatly reduce the number of unnecessary responses. State law could go further to say that if you summon an ambulance for something that turns out to be a clear non-emergency, your insurance company is not permitted to reimburse you. You pay. The Affordable Care Act is designed to increase the number of insured, with an ideal outcome that use of 9-1-1 and emergency rooms as primary care is lessened. However, this misbehavior will continue to some degree regardless. The problem may seem small, but if you have a true emergency and ambulances are tied up with someone else’s hypochondria, you may die for their abuse of the system. As well, costs to the system are racked up in the form of high mileage costs, accidents involving responding units, and a supply of ambulances above the real need.

Chris Brewster
Chris Brewster subscribermember

In my view, this problem could be resolved if the State of California were willing. If dispatch protocols were codified such that certain specified circumstances receive a full crew including ambulance (lights and siren), certain circumstances receive an ambulance only (no lights and siren), and certain circumstances are directed to go to the nearest urgent care center (or call their doctor), dispatch centers could likely greatly reduce the number of unnecessary responses. State law could go further to say that if you summon an ambulance for something that turns out to be a clear non-emergency, your insurance company is not permitted to reimburse you. You pay. The Affordable Care Act is designed to increase the number of insured, with an ideal outcome that use of 9-1-1 and emergency rooms as primary care is lessened. However, this misbehavior will continue to some degree regardless. The problem may seem small, but if you have a true emergency and ambulances are tied up with someone else’s hypochondria, you may die for their abuse of the system. As well, costs to the system are racked up in the form of high mileage costs, accidents involving responding units, and a supply of ambulances above the real need.

Tom Scott
Tom Scott

Thanks for doing this story. Here are some questions for your next few stories. How many patients that are seen by the paramedics and need care could be seen within a few hours at an urgent care center, but instead are transported to the overcrowded emergency room, taking the ambulance out service for another hour? Why is that the case? Some communities, Fort Worth, Texas comes to mind, are developing a "community paramedic" program that sends a senior paramedic without an ambulance to calls identified as non urgent. The paramedic assesses the patient and refers him/her to correct medical care AND makes sure they get there. Is San Diego planning such a program? The survival to discharge rate for witnessed cardiac arrest in Seattle is 50%. What are the outcome statistics for San Diego? BTW, the national response time standards are set based on Seattle's early research on what works for sudden cardiac arrest: bystander CPR and defibrillation (electric shock) with 5-.10 minutes.

Tom Scott
Tom Scott subscribermember

Thanks for doing this story. Here are some questions for your next few stories. How many patients that are seen by the paramedics and need care could be seen within a few hours at an urgent care center, but instead are transported to the overcrowded emergency room, taking the ambulance out service for another hour? Why is that the case? Some communities, Fort Worth, Texas comes to mind, are developing a "community paramedic" program that sends a senior paramedic without an ambulance to calls identified as non urgent. The paramedic assesses the patient and refers him/her to correct medical care AND makes sure they get there. Is San Diego planning such a program? The survival to discharge rate for witnessed cardiac arrest in Seattle is 50%. What are the outcome statistics for San Diego? BTW, the national response time standards are set based on Seattle's early research on what works for sudden cardiac arrest: bystander CPR and defibrillation (electric shock) with 5-.10 minutes.

Ken Platt
Ken Platt

I think that a study about Life Flight services should be done as well. It used to be that you had to severely injured and a considerable distance from the hospital in order to get transported by air. These days it seems like Life Flight responds to more and more less serious calls that are only 10 miles or so from the hospital. A $1,850 ambulance ride is a whole lot cheaper than a $10,000 helicopter ride.

Bill Bradshaw
Bill Bradshaw

Stubbed toe? Spooked by "Nightline"? There's got to be a better way. The dispatchers do a great job, but the idea that you MUST respond to everything needs some tweaking. How about contacting New York City, San Francisco and Seattle and seeing if they have different protocols.

Bill Bradshaw
Bill Bradshaw subscribermember

Stubbed toe? Spooked by "Nightline"? There's got to be a better way. The dispatchers do a great job, but the idea that you MUST respond to everything needs some tweaking. How about contacting New York City, San Francisco and Seattle and seeing if they have different protocols.

Liam Dillon
Liam Dillon

Hi Aaron- Fair point on the liability issue. The point of the piece was not to fault paramedics for taking people to the hospital when they're called, but to highlight the amount of times that ambulances don't turn out to be needed and the system that allows for that. I also wanted to try to get to the tradeoff. Like I mentioned at the end, we seem to have decided that it's better for emergency medical providers to overrespond rather than underrespond.

Liam Dillon
Liam Dillon memberadministrator

Hi Aaron- Fair point on the liability issue. The point of the piece was not to fault paramedics for taking people to the hospital when they're called, but to highlight the amount of times that ambulances don't turn out to be needed and the system that allows for that. I also wanted to try to get to the tradeoff. Like I mentioned at the end, we seem to have decided that it's better for emergency medical providers to overrespond rather than underrespond.

Aaron Klein
Aaron Klein

We already have a triage system in San Diego, something other areas of the County do not do. Each 911 call could get an engine and ambulance code (lights and sirens), a paramedic ambulance no code, or an EMT basic ambulance no code. The only thing we cant do is not send someone. There is even the possibility of transporting a patient to a facility other than an ER, but that is incredibly difficult to get done because we have to run that by an RN on the radio (and probably get the approval of the ER doctor at that ER as well) and they are not likely to allow it because that opens them up to liability as well. Also, as far as I know, most insurance companies do retain the right to refuse to pay for ambulance rides they feel were unnecessary.

Aaron Klein
Aaron Klein subscriber

We already have a triage system in San Diego, something other areas of the County do not do. Each 911 call could get an engine and ambulance code (lights and sirens), a paramedic ambulance no code, or an EMT basic ambulance no code. The only thing we cant do is not send someone. There is even the possibility of transporting a patient to a facility other than an ER, but that is incredibly difficult to get done because we have to run that by an RN on the radio (and probably get the approval of the ER doctor at that ER as well) and they are not likely to allow it because that opens them up to liability as well. Also, as far as I know, most insurance companies do retain the right to refuse to pay for ambulance rides they feel were unnecessary.

Bill Waugaman
Bill Waugaman

Something to consider Ken, is that the helo transports to the trauma facility, which for the North Coastal is Scripps La Jolla, which is a good haul when time is of the essence. Mercy Air has the sole service provider contract with the County of San Diego.

Bill Waugaman
Bill Waugaman

It's not Nightline, but the Lawyers in California that drive our protocols.