Company Officer Leadership: To Transport or Not to Transport, That is the Question

As a company officer or chief officer, have you ever heard your emergency medical technician or paramedic complain about a patient they transported to the emergency room when they felt transport was not medically necessary? As a lieutenant assigned to an ALS ambulance, it can be difficult not to join in and complain, especially when your crew believes the patient had an ulterior motive for wanting to go to the hospital.

Have the EMS system and ambulances ever been used as public transportation? If a person wants to go from the rural part of the city or town to the urban downtown area, how do they travel if they don't have a driver's license or a vehicle to drive?

Public transportation, including a bus or taxi, could be an option, but both of those usually cost money at the time of service. Those companies don't allow you to pay later or send you a bill.

Let me ask you this question: what public transportation service does allow you to pay later or will send you a bill? You guessed it: ambulances operated by a municipality.

Where are most hospitals located? Right again, urban populated sections of the city or town, where a lot of commercial businesses are located.

Has this ever happened at your department or to your crew? Is there anything that can be done to curb this abuse of the EMS system?

Part of me wants to say it's part of the job; some of us get paid to do it and some municipalities bill and collect payment from patients or insurance companies for treatment and transport. The monies may go into some type of municipal fund or used to purchase fire/rescue equipment.

Should we be transporting everybody to the ER no matter what the reason, chief complaint or lack thereof? This reminds me of a line by a helicopter pilot from the movie We Were Soldiers: "You call, we haul."

There's also a part of me that feels fire-based EMS can be improved. Could the EMS system develop no-transport parameters for EMS crews to follow when transport to a hospital emergency room isn't appropriate?

Most in the EMS field care about their patients and want to make sure they get the appropriate treatment.

For example, an EMS crew responds to find a patient with chest pain. The patient is of age (not a minor,) is not intoxicated and is alert and oriented to person, place and time. After a professional evaluation, the crew feels the patient needs ALS treatment and transport by ambulance to the emergency room. The patient states they don't want to go to the hospital.

The EMS crew will continue to discuss why the patient needs to be transported and attempt to convince the patient to go. They will even go as far as calling the doctor at the ER to explain the situation because sometimes patients listen to a doctor’s advice more than that of an EMS crew. If the patient still adamantly refuses treatment and transport, the patient and preferably a witness will sign a refusal form and the EMS personnel will document the call and submit the report.

Sounds like good patient care to me.

Here is some food for thought—some interesting questions to ponder:

  • How can public officials and chief officers make sure personnel, ambulances and fire apparatus are utilized in the way they were intended?
  • Should state EMS systems and fire/rescue departments look at purchasing passenger vehicles (SUVs) to respond to certain EMS calls when a three-to-four person ALS engine company or a two-to-three person ALS ambulance response may not be necessary?
  • If the above is changed, will a municipality or fire/rescue department lose revenue?
  • Will the municipality be able to bill and be reimbursed if they provide a nontransport type of service?

Have you heard about community paramedicine (CP)?

CP is a model of community-based health care in which paramedics function outside their customary emergency response and transport roles in ways that facilitate a more appropriate use of resources. Interest in CP has grown in recent years, especially in rural areas, based on the belief that it may improve quality of care while also reducing costs.

Here are some more questions to consider in this topic:

  • Is CP, which has already started in some areas, the next big thing for fire-based EMS?
  • What does the training entail and how much more training will a paramedic have to do in regards to CP?
  • If your personnel are covered by a collective bargaining agreement (a contract), will this have to be negotiated?
  • Is CP a change in working conditions?
  • Does fire-based EMS have a seat at the table?
  • Are chief officers being proactive and are they discussing this option with their municipalities and staff?

Again, just a few interesting questions to ponder.

With the ever-soaring cost of health insurance, I believe EMS has been and is continuing to take steps to improve services and curb spending. The government is looking and has looked at appropriate alternatives for patient's to be able to stay in their homes and for people that don't need an ambulance or an emergency room a more appropriate alternative. Will fire-based EMS change?

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