The Uberification of Emergency Response

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Trek Medics International has developed an uber-style mobile-based dispatching platform that alerts taxi drivers trained in basic emergency care about medical emergencies in their vicinity. The SMS-based technology has been successful in low-resource countries, but its utility is evident right here at home.

We’ve all seen it before: a 35-year old male is brought to the emergency department by ambulance, complaining of mild flu-like symptoms – most notably, a stuffy nose and sore throat. As the paramedics give their report to the triage nurse, they quote the patient as saying, “I was going to drive myself here, but I didn’t want to wait for hours in the waiting room, so I called 911.” The nurse takes the patient’s vitals, asks a few follow-up questions, and then directs the patient to take a seat in the waiting room.

Scenarios like this happen countless times each day in emergency departments across the globe. Whether it’s blatant abusers or others who are forced to utilize ambulances and emergency departments for lack of a better access point, it’s becoming increasingly hard to justify the “emergency” aspect of most emergency medical systems. Paramedics routinely refer to themselves as taxi drivers, nurses regularly reduce their job responsibilities to those of a glorified babysitter, and emergency physicians often consider themselves under-appreciated and over-worked as compared to their physician peers. Is it any wonder “burnout” is such a prevalent topic among emergency medical professionals? Whatever it is we thought we were signing up for is not what we’ve found ourselves doing. So perhaps it’s time to reconsider what it is we’re actually doing, or at least how we’re doing it, and acknowledge it for what it really is: a high-volume entrance point into the larger healthcare system, with a mix of routine and acute conditions.

When I worked as a paramedic in a busy urban system, I often found myself questioning the sense of what we were doing. Every time we got a call, overzealous policies obliged us to respond with lights and sirens, whether it was for a cardiac arrest or a stubbed toe. We were also usually accompanied by a 5-ton fire engine, which I never once saw transport a patient. Back in paramedic school, we were often taught to treat the patient’s attorney, and not the patient – a mentality that was reinforced by reimbursement policies only allowing ambulance providers to bill when the patient’s been transported. “How do you expect us to be able to pay you if you’re not taking patients to the hospital?” was a question I heard on more than one occasion.

For a long time, I just accepted these counter-intuitive policies: I was a small cog in a big machine, and could be easily replaced. But then one shift I had an epiphany: it was 4:30am and my partner and I had just transported a 15-year old female who had had a mild panic attack, and I was back in the ambulance, venting. My partner, equally tired and frustrated, didn’t want to hear any: “If you don’t like our EMS system, why don’t you go back to Central America and start your own?” It seemed he was on to something.

Fast forward seven years, and today my organization, Trek Medics International, is building EMS systems in developing countries where they never previously existed. A major component of our programs is a mobile phone-based dispatching software we’ve developed called Beacon, that was designed specifically for communities that can’t afford (or don’t need) advanced “911” dispatching technologies. Beacon is very similar to Uber, the taxi-sharing mobile phone app, except instead of calling for a taxi, our software sends text message alerts to taxi drivers who’ve been trained in basic emergency care so they can treat and transport the patient to the hospital. This isn’t an entirely original idea as it’s what taxi drivers are already doing – or pretty much anyone with a vehicle in a resource-limited setting, for that matter. But the novelty of our approach is that we’re simply strengthening what already exists. Through this process, we’ve been learning a lot about what makes emergency medical systems effective and what doesn’t, and we’ve also been gaining new insights into how fully-functioning EMS systems in wealthier nations could be greatly improved. The good news for us is that we’ve found we’re not alone in our thinking.

Whatever your position is on the role of non-clinical providers in prehospital emergency care, I hope there’s one thing we can all agree on: what we’ve been trained to do has little bearing on what we actually do in the field. This has become especially apparent as our software has improved. On a weekly basis we’re being approached by emergency physicians, paramedics, hospital administrators, and public health practitioners from across the nation who have their own ideas for how we can use our software. And though they may seem a bit disparate, two common themes seem to prevail:

  1. Most emergency providers inherently understand that our “orthodox” 911 systems are very limited in their ability to reach everyone at any time, and
  2. Even when orthodox 911 systems can get the job done, they don’t necessarily do it very efficiently

For this reason, we’ve started looking a lot more into distributed prehospital emergency response networks at the community level, and how they could outperform traditional services. Here are a few ideas:

  • Rural EMS – An off-duty paramedic (or nurse or doctor) that’s 20 minutes away is always preferable to an on-duty paramedic 60 minutes away. People living in rural communities are often more inclined to help their neighbors than city folk, and saying that only an official ambulance can transport patients to the hospital after calling 911 is just asinine.
  • Focused Interventions – Just because someone needs emergency medical assistance, doesn’t mean we need to send the cavalry out – and especially if that’s the exact reason they won’t call in the first place. By de-centralizing 911 response into distributed, community-level networks, many premature deaths could be averted, and at a fraction of the cost, for example:
    • Community Access Naloxone – Despite the fact that more public safety personnel are now carrying Naloxone, and many states are passing good Samaritan laws to protect witnesses who report an overdose, the reality is that most drug abusers don’t want to call 911 – i.e., “good Samaritan today, heroin junkie tomorrow.” If any layperson can be trained to do CPR, use an AED, or jab someone with an Epi pen, than Naloxone should be in every first aid kit – and taxi.
    • Peer-to-Peer Mental Health Support – A veteran from Wyoming explained to us how other vets suffering from PTSD were not inclined to call 911 because they didn’t want lots of official vehicles with bright lights on their front lawn, waking up the neighbors and further complicating their reintegration into civil society. His idea was to form a peer-to-peer support network for vets, by vets, to be accessed during mental health crises.
    • Domestic and/or Sexual Violence – This idea was presented to us by a university group looking to prevent date-rapes on campus, though the application to the larger society is evident: sign up a group of your closest friends, and when a situation starts getting dicey, a simple, discrete text can alert the nearest friends to come and intervene before it goes any further
  • House Calls – Oscar, a new private health insurer, offers physician consultations via Skype, and many others are following. Taking the community paramedicine model a step further, what if that physician were able to dispatch a paramedic in a private vehicle to the patient’s home to carry out the physician’s assessment in person and maybe run a few other tests or draw blood? In the UK, Australia and other countries, paramedics are routinely used in this fashion, and even have the added bonus of being able to refer patients to general practitioners and primary care physicians.

As for liability, by now I think it’s safe to say that it comes with the territory: Every time a paramedic gets on an ambulance, or a patient enters an emergency department, there’s significant liability. Adding more highly trained specialists and advanced technologies only seems to increase liability, not lower it. And despite our seemingly inexhaustible preoccupation with liability, including every nonsensical measure we’ve taken to limit it, insurance rates still seem to go up every year. Is that our fault?

In case anyone missed it, we’re witnessing a complete overhaul in the organization and management of emergency medical services (EMS) systems. While the usual suspects are re-doubling their efforts to remain entrenched, their efforts will likely prove impotent: this overhaul is so complete that the EMS systems we see today will likely be a shadow of their former selves before the end of the decade. Everywhere you look, the status quo is changing: Tectonic shifts in healthcare reimbursement brought about by Obamacare; the advent of free-standing emergency departments and the growing support for community paramedicine programs across the nation; the cruel fiscal realities imposed upon insolvent municipalities who, for years, have taken for granted policies that mandate sending out a 5-ton fire engine every time someone calls 911; and, of course, the “Uber-ization” of modern society. In each case it seems like the EMS community is finally coming to a majority consensus that the systems we developed in the 1960s and 70s are no longer appropriate, much less sustainable, and that plenty of new, exciting, and effective innovations in emergency care delivery are at our fingertips.

However this overhaul happens, putting more ambulances on the road is not the answer. Ambulances are for transporting patients and having the full range of supplies and medications at hand. If we can get past the well-entrenched traditions we’ve been raised on, and quite literally start to think outside the box (ambulance) we might see that tradition is a euphemism for a lack of vision. If medicine is constantly changing, why are our modes of delivery still so antiquated?

ABOUT THE AUTHOR

Jason Friesen, MPH, EMT-P is a paramedic who has been working in international development since 2003. He is the Founder of Trekmedics.org

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