The Cost of System Abuse

I have only been hauled in an ammalance twice. Once for a violent football-related neck injury, and the other when I mangled my spine, spent a few hours crawling toward my car in amazing pain, eventually deciding that it would be better to let somebody scrape my decrepit ass off the floor and give me a ride to the hospital.

Do I get a cookie?:D

From your description it seems unlikely that health care payment reform would have changed the outcome for the patient in either the short or long term. An individual who is an addict isn't going to suddenly turn into a responsible adult because of legislation passed by the Federal government. Are you really advocating the idea that there is Federal law that if passed would solve this issue?

Addicts in your community should be an issue for local (city, county/parish, state) legislators, community organizations, religious leaders, educators, and health care providers work together to solve. If you are aware of the legislation that needs to be written to enable individuals who are to incompetent, ill, mentally unstable, poorly educated, addicted to narcotics or alcohol, inexperienced (read young people), then by all means walk into the office of your local legislator with your petition.

Recent societal and medical history seems to point in the direction that there will always be a proportion unable or unwilling to take care of themselves, and that they rely on the benevolence/charity of society, and that every society must determine how benevolent/charitable they want to be.

Popular lore is full of fables like the Grasshopper and the Ant that are designed to encourage individuals to take the necessary steps to survive in the lean years, but it seems as though there will always be humans who have underdeveloped or damaged amygdalas. Economist love solving the "free rider" problem, but you've suddenly removed the medical providers from the equation and handed it over to bureaucrats.

The fact that your EMS district charges $500 per call seems to indicate that they believe in double taxation. They collect disproportionate amounts of revenue from the wealthier members of your community, and then bill their insurance providers for the call as well. These excessive fees are used to subsidize the patient care for those that are unable or unwilling to pay. Maybe resource management should be based upon the actual taxes paid by each neighborhood, with 20 stations in the richest part of the city, and just 1 station in the poorest. Want to cut to the front of the line in the ER, slip the triage desk $50.

"From your description it seems unlikely that health care payment reform would have changed the outcome for the patient in either the short or long term."

There is probably nothing that will keep this guy from attempting to abuse the system. However, reform that requires Medicaid recipients pay some sort of cash copayment for unnecessary visits or ambulance rides might discourage it quite a bit.

"An individual who is an addict isn't going to suddenly turn into a responsible adult because of legislation passed by the Federal government. Are you really advocating the idea that there is Federal law that if passed would solve this issue?"

Nope, what we need instead are repeals or revisions of the currently existing Federal laws that enable such behavior.

"Recent societal and medical history seems to point in the direction that there will always be a proportion unable or unwilling to take care of themselves, and that they rely on the benevolence/charity of society, and that every society must determine how benevolent/charitable they want to be."

Unable to take care of themselves, I have no problem with helping. Unwilling to take care of themselves, I shouldn't have to pay for. Current laws do too little to address the former, and the health care bill before Congress will only serve to encourage the latter.

Fact: Medicaid and Medicare reimbursement is less than the cost of actually providing the services rendered. It's for that reason that increasing numbers of physicians refuse to take such patients, leaving them effectively without access to health care unless they seek the most expensive and inefficient routes - liking calling an ambulance to take them to the ER for their minor ailments.

Increasing the subscriber rolls without addressing the payment inequity and without making the current and new subscribers responsible for using their benefits wisely is only going to make that problem worse. Massachusetts has already tried the "free healthcare benefits for everyone!" thing, and it's failing miserably for the reasons I just mentioned.

"Economist love solving the "free rider" problem, but you've suddenly removed the medical providers from the equation and handed it over to bureaucrats."

Nothing will SOLVE the free rider problem, but we can at least hope for laws that won't encourage it. And are you actually trying to say that the current healthcare reform bill leaves the medical providers with some say in how their services should be delivered, and not the bureaucrats?

"The fact that your EMS district charges $500 per call seems to indicate that they believe in double taxation. They collect disproportionate amounts of revenue from the wealthier members of your community, and then bill their insurance providers for the call as well."

Horse shit. The Borg does not receive any taxpayer monies. They bill Medicare/Medicaid and private insurance, as does every other for-profit EMS provider in the country, and the majority of the taxpayer funded ones as well.

"These excessive fees are used to subsidize the patient care for those that are unable or unwilling to pay."

Currently, the government reimbursement (Medicare/Medicaid) for such patients is well below the cost of providing the services, so yes, the private insurers and individuals get hosed with higher rates to help subsidize the shortfall.

"Maybe resource management should be based upon the actual taxes paid by each neighborhood, with 20 stations in the richest part of the city, and just 1 station in the poorest. Want to cut to the front of the line in the ER, slip the triage desk $50."

Nice bit of populist trollery right there, but I ain't biting. You're the one trying to make this a rich vs poor argument, not me.

AD,

Thank you for making the time to reply. I forgot that the "Borg" was a not a municipal entity, thanks for reminding me that everything is a little spicier in La.

Have you ever been at the ER, with a patient, and asked one of the on duty physicians to write you a prescription for medication for you or a family member? Did you pay the full cost of that request? Could you have taken care of that on your own time and through your primary care physician? The number of EMT-B,I,Ps who treat the ER as their primary care provider is shocking. And I bet we can even find medics who have had toothaches and had the script written by the staff of the ER. Maybe you aren't guilty of this, but there is some irony in accusing patients who behave in a similar way to the medics who make very similar demands. I don't mean this to be an attack, but merely a chance for honest self-reflection on human nature.



A plan as outlined by you, of requiring the patient/victim to make a cash payment at the time of service might indeed cut down on the unnecessary visits. It seems unlikely that patient who is unwilling or unable to secure the funds as outlined in your example would somehow secure those funds in the future scenario, but that doesn't mean the idea is without merit. And this is where pilot programs would come into play to test out the economics of your model.

Under this example the patient wouldn't be treated for the toothache (because he had no intention of paying), and the disease might be allowed to progress and result in a more invasive and costly procedure at taxpayer expense at some point in the future. There does seem to be a link between tooth decay and cardiac injury. So at some point your MICU will respond to this patient's home.

Many of the problems you describe are related to public health issues, and maybe some of the focus should be on compensating health care providers for dealing with these issues in a prophylactic manner, rather than an emergent one. It is cheaper to have a school district have PE that is taught everyday and enjoyable than it is to pay for diabetic children. It is better to have more parks and open spaces that are safe and accessible for all children than it is to have obese children.

Employers should encourage their employees to lead healthier lives through economic incentives and disincentives, since in the long run they cost less. Don't hire and fire employees who smoke. Set weight and height restrictions to receive employer provided health insurance, and enforce said restrictions.

Provide elementary school children with a toothbrush for their classroom and encourage them to brush their teeth during the school day. Eliminate sugary, high fat and salt foods from their lunchroom menus. Get rid of all drinks in schools but milk and water. Plant fruit trees on school properties.

Advocating that medicare and medicaid patients who can't/won't pay the additional cost for medical treatment should, or demanding that the Federal government increase the compensation to health care providers still doesn't seem to lower the costs of treatment.

A real problem with health care is that the pricing model is a mystery. I can check online for a flight to anywhere in the continental United States, and in a matter of minutes I can compare the cost of the flight, the time/connections required, the type of aircraft, even the class of service and amenities I want. I can even bundle that with hotel and car rental reservations to lower my costs. But I can't tell you what the cost of an MRI at various locations is in my major Texas city that has the largest medical center in the world.

A doctor wants a patient to get an MRI done. They go online and check out the costs, locations, and times available. It turns out that AD's MRI offers a 50% discount on MRIs after 9 PM. They choose to go there, because it matched the services with their own personal economics. A free market system in medical pricing wold do much to reduce costs.

You may choose to fly in coach with Southwest or on Singapore Airlines Royal Service, but you make the selection based on a more accurate economic model. You can choose to get your MRI done in a seedy part of town after 9 PM, or you can choose to visit your Harley Street physician in his walnut paneled surgery.

Ben Franklin advocated a system of national government where the number of representative grated to each member of the union was based on the amount of their percentage of taxes they paid. Members could elect to pay more or less, and their ability to control legislation at the national level was based on their contributions. Under our current system we already have a health care system where wealthier individuals can cut to the front of the line for medical treatment. Poor people can't do that, and although that seems unfair, it isn't necessary that needs to be corrected.

Please continue to address the issues of health care in this nation. It doesn't seem to be a one recipe solution, and in fact like many problems, it will probably be solved best at the local level. Each city and state must do what works for their population. In that sense we certainly agree.

All my best and a happy New Year to you and your family.

Actually, I couldn't really support requiring a cash payment before services are rendered, if there is no other means for that patient to seek the care needed. If there is no physician or clinic locally that treats indigent patients or accepts Medicaid, the ER is their only recourse.

However, they don't need a friggin' ambulance to get there.

What I think would work is that, for those patients who also receive other forms of public assistance, take the cash copayment out of their benefits if they utilized the ER or ambulance for a non-emergent complaint.

If a person who pays insurance premiums has to decide between groceries and an ER copayment, why not require the same level of diligence from people who get their benefits for free?

Got chest pain or difficulty breathing? Fine, call the ambulance and we'll treat you on the way to the ER, where likely as not you'll go to the front of the line, and the cost will be billed to Medicaid.

Need a pregnancy test, or choose to call an ambulance for the earache you've been seen for twice already? Fine, we'll take you to the ER, where likely as not you'll go to the very end of the line. And if you insist on treatment in the ER once your turn comes, also fine.

But also know that your welfare check or food stamp stipend will be $50 lighter next month because of it.

I think that's an equitable and common-sense approach.

AD,

Like everything in our great Republic, there will need to be compromise from all parties involved. Your plan is a good first step into helping educate adults (who need the education) about personal responsibility, and addressing the duality of personal/societal cost and need in health care.

Again, thank you for bringing up the issue, and a forum for it to be discussed.

So true. I'm an ER nurse and totally unerstand how people needlessly abuse the system...both on your end and mine. If it wasn't for the damn EMTALA laws that 'protect' everyone from being refused treatment or being dumped somewhere else I think alot of people wouldn't go to the ER. If they knew you guys or us could turn them away they may actually take some responsibility for their health!

911 non-emergencies a growing problem nationwide
http://www.denverpost.com/ci_14084125

Finally, someone who told it like it REALLY is....Thank You!!!!!!! I am an RN and see this type of abuse of the Healthcare system every day I work......and it is getting worse than ever....I agree there needs to be Healthcare PAYMENT REFORM.........People wake up, before it is to late to change this BILL sitting in Congress.....we are gonna go broke treating these type non-compliant people, who visit the ER bec. they know they CAN for BULLSHIT minor complaints.....

"While the paramedics were treating a mother. fucking. ear. ache"

Really?!?

I remember a call we got one time not too long ago for a tooth ache. Yes, a mother. "f"ing. tooth. ache. Can you believe the gall of someone to call for that of ALL things.

Well, thanks to my training and the fact that I actually give each and every patient a through assessment from top to bottom now, thanks to some screw ups I've made; I found out by doing a 12-lead that it wasn't a mother. "f"ing. tooth. ache. It was a mother. "f"ing. MI. Remember that damn little nuisence called refered pain?

This guys only sign or symptom was the classic jaw pain that he interpited as a tooth ache.
Don't be so quick to judge. Treat EVERY request for service as that...a request for service.

As for the code that was happening at the same time; we are not gods or father time and we certainly can not control the timing of these events. What if "Toothache Boy" was a code and the other code still happened? That's right; the other ammalance is STILL three minutes away!!

"While the paramedics were treating a mother. fucking. ear. ache"

Really?!?

I remember a call we got one time not too long ago for a tooth ache. Yes, a mother. "f"ing. tooth. ache. Can you believe the gall of someone to call for that of ALL things.

Well, thanks to my training and the fact that I actually give each and every patient a through assessment from top to bottom now, thanks to some screw ups I've made; I found out by doing a 12-lead that it wasn't a mother. "f"ing. tooth. ache. It was a mother. "f"ing. MI. Remember that damn little nuisence called defered pain?

This guys only sign or symptom was the classic jaw pain that he interpited as a tooth ache.
Don't be so quick to judge. Treat EVERY request for service as that...a request for service.

As for the code that was happening at the same time; we are not gods or father time and we certainly can not control the timing of these events. What if "Toothache Boy" was a code and the other code still happened? That's right; the other ammalance is STILL three minutes away!!

I too have had the patient with bilateral jaw pain that turned out to be an inferior wall MI. HAd that one a couple of times, in fact.

In the case of Earache Boy, I was convinced that it wasn't REferred pain (what is deferred pain, by the way? Something that shows up after the event?) by the redness and purulent drainage from his right ear, and the antibiotic scrip in his pocket.

Why do you assume we didn't assess our patient?

Not trying to get into a pissing match with you on this, but your recounting of the incident left me with the impression that the patient was not getting your best due to a pre-conceived notion as to what he did or did not need.

Until our system has some other options made available to us to offer patients like yours, we'll just have to deal with them. That doesn't mean we have to demean them in the process. Remember, any one of us could find ourselves in that position one day. Some choose that condition, and some may find themselves there through no fault of their own.

And for the record, I am very aware of what REfered pain is. My proof reading was obviously not up to par. I will also rearrange my keyboard and put more distance between the R & D keys to ensure this does not happen again...my bad.

Gate Keeper, I've no wish for a pissing contest either. Sorry if it gave you that impression, or if I took that impression from your comment. I didn't detail the assessment we did because I felt it was a given that we'd assess our patient, and it wasn't germane to the point I was trying to make anyway.

And you're right, we'll have to deal with them until our system changes. However, it's not going to change until we make it obvious just how much abuse is going on out there. The health care policy makers are shamefully disconnected from the realities of prehospital and ED care, and it's up to the people on the sharp end of the spear to make these issues known.

And I know all about fat fingers and small keyboards. They really need a sarcasm font on here. ;)

it is sad that this happens i was in the local e.r. last night listening to a lady complain because she was having to wait while the e.r. treated people with real problems that were life threatening all because she had chest pain after i told the lady i took in a joke the crazy lady laughed and passed some gas but in her thoughts her gas deserved a trip to the er and she should go ahead of those in real need of care i hope the caradiac victim lived and that the earache guy learns his lesson

I want my non first responder friends to read this article. My first responder friends will confirm that the system is overloaded with people like this. I've picked up a person 4 blocks from the hospital that greeted us at the curb and did't want to pay for a taxi. Went to a house because the person had no minutes and could only call 911 for a ride to the ER for her minor cat scratches. Every shift brings more stories like this, the cost of a system with no consequences.

Seems like business as usual. We in healthcare know exactly how to fix the bill. This person should have been turfed with no consequences to anyone. We see this allll the time.

The whole system is broken. We need to reevaluate how we treat and transport patients. Every patient should not have the ability to be transported where they would like to be transported. If this patient would have called a taxi cab he would have only been transported to a facility that was within the boundaries in which he could pay for cab fare. If a person needs an ambulance it should be for emergent situations. Calling an ambulance should trigger an assumption that the person requesting transport believes that their situation is an emergency. At that point, the medical professionals who are assessing the patient should be the ones who decide where the patient is transported. Transport should be to the closest most appropriate facility, not one that dispenses the best medications. Transporting to the closes most appropriate facility will get units back to their coverage area quicker and the patient will receive a level of care that is appropriate for their situation.

Why do we have to always transport to hospitals? Why can’t we transport to clinics that can better treat certain patient complaints? Why do we have to transport? What is keeping our profession from progressing to the point where we can treat and not transport on the scene? Especially in a situation where the patient was just seen less than 24 hours ago for the same complaint and they have not taken the measures prescribed by the emergency room physician. What is holding back telemedicine? Obviously, the profession is young and we are moving forward, but we need more people moving forward. This profession is not just about lights and sirens, driving fast, and emergencies. It is about delivering compassionate care to people regardless of their situation.

Please, if you are progressive keep moving forward. If you are not involved in shaping our profession please get involved.

"Why do we have to always transport to hospitals? Why can’t we transport to clinics that can better treat certain patient complaints? Why do we have to transport?"

Because Medicare doesn't pay for transport to clinics or doctor's offices, and private insurance is also weighted far more toward transport than treatment. The people who pay the bills place more value on the ride than the care provided.

And yeah, that's stupid. Yet another thing crying out for reform.

Like I said we need to change the whole system. Payment should be attached to the care provided, not the mileage traveled to the hospital.

Also, please remember that individuals on the street are not the only ones that abuse EMS. This goes for ground and air transport. Hospitals and other health providers abuse EMS providers by falsely documenting reasons for ambulance transport from one facility to another. I have transported many patients that could have been transported by other means but because there was a wait, the physician documented that it was an emergency. When is it an emergency to transport a patient to a medical bed without any telemetry? The industry is abused from many angles. Patients, Hospitals, Physicians, tax payers, politicians, and ourselves. Where does it end and how do we choose who is allowed to abuse EMS?

What kills me is that no matter what kind of service you work for, fire, private, district, this is a problem that plaques the system.
T 4 wrote: " I hope this kind of crap won't reach us here on the other side of the ocean. I don't work in an ambulance, but if I did, I'd quit the moment I couldn't tell this patient to stop bothering me for such nonsense."
You would have left your job with-in HOURS!
I dare someone to tell that patient that this is not a medical emergency and it would be cheaper to call a cab. Sir, it'll be 5 dollars for a cab, or 500 dollars for an whambulance ride. I would dare to guess that you would be crucified by your agency when the phone calls start coming in.

Only if you get caught. But if you do get a complaint, which this is just the kind of asshole that will place that complaint, then you just explain to your boss what the "valued customer's" crisis was, and what a legitimate opportunity to positively intervene in someones true emergency in an expiditious manner was missed by wasting your time on him. Prob get a slap on the wrist and a headshake when you leave the office because your boss knows the truth, wether you can get them to admit it or not. I have told 'em we are just gonna give you an expensive ride. They don't give a shit. They know they don't have to pay, like they would a cab. BTW our base fee is $1500 here...LOL helluva write-off huh? Wonder why there is no money for raises?

Are you lying to the patient by telling him the cab is appropriate and cheaper? No? Then why not tell him so?
Maybe these folks expect the level of service they so because we've all been afraid to tell our patients the truth.
I just recently told a man he didn't need an ambulance but one was coming for him if he wanted. When I explained that his sore wrist would not be seen right away but end up in the waiting room, he signed the refusal and took the bus.
I didn't lie or refuse care, just answered his questions honestly. But if we did the right thing all the time our private services would crumble without all the transport fees, even though they don't cover the cost to begin with.

It amazes me that with all the advances we have made in modern medicine, all of the billions of dollars spent world wide in research, we still have not figures out a cure for stupid.

25 years ago, we had an old country doctor who was called into the ER one night for such an ER abuser. I looked him over then wrote him out a $100 bill for services rendered and made the dude pay him in cash before he left the ER. We never saw the dude again! Until we as a society stop coddling these folks and start making them pay for the services we render up front, the abuse will continue.

that is so true i would tell the earache pt to get the drug precpetion filled and follow up with his doctor in the moring. and the new health care will be the same as now no change.

You sound like you work where i do! fucking trash all day long. 90% or greater of my 15+ calls a shift are jittney rides. Fuck um!

im getting ready to start the medical field and i think people like that shoul be in a home just for situations like that it is bs that ur not allowed to turn away people like that their should be a law for that

If you are just getting into the medic field you had better learn to spell, and learn the rules of grammar.

I think I had this same guy. The problem, aside from him not taking any responsibility for his own actions, is the current system writing him the $4 script, then not giving it to him. If we can tell him to go to the walk in clinic and get seen, and he does and gets what he needs, not wants but needs, then he never calls you back.
Of course everyone has access to "health care" via EMS, 911 and the EDs. That just happens to be the absolute most expensive manner of providing it. Without a change in the way we deliver care, he will continue to walk up to your station and expect somethign different to happen. imagine the power in first telling him no to an ambulance and being able to arrange a ride to the clinic, then a clinic that assesses, treats, prescribes and follows up with him. THAT is health care.
The current bill is so watered down it actually increases profits while restricting care. But when you have people determined to see it fail, it will fail.

The solution for regulars is to stop taking them, plain and simple. and it won't take improving education or fancy new techniques, but systems trusting their people to make the right decisions and backing them up. that's what i was in the UK firsthand. It works, people. We just have to want it to work here.

Happy, that would work except for a few major flaws:

1. What if there are no 24 hour urgent care clinics in your area? The majority of their clientele is Medicaid and uninsured patients, and the reimbursement isn't enough to keep the doors open. In many parts of the country, it costs more to treat a Medicaid patient - even in a doctor's office - than it pays. Ergo, increasingly fewer doctors take Medicare or Medicaid patients. That's only going to get worse once they expand the Medicaid rolls while not reforming the current reimbursement model that heavily favors specialty procedures over primary care.

2. Trusting your people to make good decisions is a nice theory, but the sad fact is, there are way too many medics who can't be trusted to make those decisions. I've worked with them, and chances are you have, too. Not to mention the fact that educational standards are extremely variable across this country. In my experience, the really good medics who can be trusted to make those triage decisions aren't the norm. In fact, they're the outliers. Barely competent is the norm. And until education improves - nationwide - that's not going to change. And it may never change even then, unless reimbursement improves to the point where we can afford to pay them what they're worth.

My impression is that it works in England because a) the medics there are generally better educated than their U.S counterparts, and b) the patients don't have the "big white taxi" sense of entitlement ours do.

As much as I hate giving people stuff funded with tax dollars, I think I have to agree that it would have made sense to give the jerk the antibiotics instead of a script that he had to fill for money. If nothing else, the $4 in antibiotics is cheaper than the second $500 ambulance ride.

You b) point is spot on, as for a) Mark's entire Paramedic course was as long as my cardiology section. We are by far "more" educated, but never trusted to do anything right. I have worked with crappy Medics, burnt out from system abusers and long hours, they don't care anymore. The solution to that is beyond me.

What levels of EMT or medic do they have in the U.K.? I have a couple of friends who are medics with London Ambulance Service, and from my understanding, their education was roughly comparable to mine - which is to say, not terribly extensive, but more so than many places in the U.S.

I think the best way we could reform this is very simple. Take a co-pay, even if it's like $20 directly from their benefits the next week.

That, and Triage to Taxi would be the way forward

For TOTWTYTR: AMEN!

Maybe he thought that EMS squads carry the "special" (read "free") antibiotics that make the pain go away instantly?

No common sense is involved... My daughter (PM in NORCAL) and I were talking last night, they get the same thing- walk ins to the station saying you GOTS to transport me... Because they 'know' if they come in by ambulance they are "in" the system and will get drugs/treatment even for a two week old toe ache (ingrown toe nail)... sigh...

Say it brother! Can I get an Amen from the EMS Choir? Seriously.

Last night we took a guy from one of the local homeless shelters, whose staff had called because of his "Severe difficulty breathing." After we woke him up, he refused to answer any questions and didn't even want to go to the ED. However, refusing to answer questions disqualified him from a refusal. This, during a shift while every truck was running straight out.

Oh, he had left the nearby ED less than three hours before, he still had their wristband on.

As usual, it's not about heAlth, care, or reform - it's about power and control.

Rampant waste, fraud and abuse is a feature, not a bug...

B I N G O ! ! ! !

When I was doing clinical time in an ER in East St Louis, we had a patient come in via EMS 2 nights on the trot for the very same complaint as your ammalance guy. She was drug seeking and according to her, she HAD to be given narcotics for her earache because she'd called 911 and had come in by ambulance - apparently ghetto rules state that as long as your conveyance is an ambulance the hospital is legally obliged to fuel your addiction with copious quantities of Vicodin, Dilaudid, Fentanyl or Percocet. I think it's the same set of rules that say if EMS bring you in you don't have to sit in the waiting room. Oddly enough, she said she had "insurance" - she had Medicaid. Imagine that, huh?

It's people like that that make me second-guess being a medical professional.

Just trolling: instead of giving him a tour around the city in an ambulance, wouldn't it be a lot cheaper to just give Earache Boy the pain meds he's craving for? ;)

On a more serious note, I hope this kind of crap won't reach us here on the other side of the ocean. I don't work in an ambulance, but if I did, I'd quit the moment I couldn't tell this patient to stop bothering me for such nonsense. Surely, if he really needs an ER, the nearest ER capable of handling his problems is quite fine? Did you actually take him to the other ER (probably on the other side of town) for a simple aching ear?

On a side note, I learned a few weeks ago that (mostly left-sided) ear pain might be referred pain from a MI. In everything solely left-sided, you'd better call the paramedics! Pain in the left ear, left buttock, left toe, who knows what kind of ischemia might have hit you ;)

Hey T4 - if by "other side of the ocean" you mean the UK (as opposed to Oz / Asia), then go take a look at a couple of AD's opposite numbers:
http://randomreality.blogware.com/blog
http://theparamedicsdiary.blogspot.com/

Both these guys work in the London Ambulance Service - Random is Tom Reynolds, who works in an ambulance, and Paramedic is Stuart Grey, who works on a fast response vehicle. Both show the huge abuses that go on against the NHS, requiring ambulances and paramedics to be taken away from those who are genuinely in need.

T4, if there is any doubt in my mind that it's a legitimate complaint, I err on the side of giving the pain meds. I'd rather enable an occasional drug seeker than risk denying analgesia to someone genuinely in pain.

Problem is, this guy wasn't angling for pain meds. He had an ear infection, and wanted it cured instantaneously. And he considers an ambulance his personal, free taxi.

You know, I do not know which is worse. I want to agree with AD about being able to tell this particular person to 'piss off'. There are a couple of similar individuals around these parts with one in particular that can get as many as FOUR ambulance trips in one night because his 'feet hurt'.

But then, I am thinking about a good medic around here that went to a really busy ED recently with chest pains. He was sent home. And woke up dead the next morning. I have to ask if they really gave him a really good check-over, or did they cut a lot of corners because the ED was overrun with so many people using the ED as their only means of healthcare?

I admit, I don't know the answer. Teach responsibility? I think we have missed out on a couple of generations. And unfortunately, it's not just the 'ammanlance' crowd these days. Even the members of 'the greatest generation' have caught on to the MTV/I want it now/I am entiltled mentality.

And no, from what I have read and heard, this new healthcare bill is not going to fix anything.

OK - please tell me how someone "woke up dead"?

It's a saying around these parts for "died during their sleep". In this case six or so hours after being discharged from the ED as being "OK".

One problem with limiting repeat customers is that these are sometimes the patients where the doctor missed something. Nothing about this guy tugging on his ear suggests that is the case, but there are plenty of cases, where the return of a patient leads to a more accurate diagnosis. A repeat visit is certainly better than having a visit from a lawyer.

Point granted, but in this case, the followup should be, "Get out of my ER, and go fill your prescription."

And the current system discourages such common sense.

I have no problem with being critical of this patient. The problem is that some medics hear that this is a repeat trip to the ED, bypass all thoughts of assessment, and assume that it is abuse.

We need to try to make EMS encourage common sense, such as assessing a patient, before jumping to conclusions. While you don't base your treatment/lack of treatment on hunches, there are plenty who do. One of the things many old timers will rag on others about is being fooled by a faker. This generates an environment of never threat something that might be bogus, rather than act as professionals and perform whatever assessment is appropriate to the situation - in this case, a brief targeted assessment should be more than adequate.

The problem is discouraging medics from making those front door diagnoses of, This is obviously nothing, even though they have not even come close to performing an appropriate assessment. This is something that is as legitimate a problem as system abuse, and the two are connected.

You have a great point rogue, but I think AD's taking issue with the system that fosters both repeat idiocy offenders and lazy medics...

Oh, I'm not advocating refusals for patients like these, at least not without some serious increases in provider education.

But there ought to be some means of making these kinds of patients responsible for their decisions. Heck, if the current health care legislation is empowering certain types of review panels, how about doing something useful, like a utilization review panel? Tie their welfare or food stamp benefits to their Medicaid. Go to the ER or call an ambulance for something silly like this, fine... but the deductible comes out of your food stamps or welfare check.

I mean, if people who pay for their insurance premiums have to make a decision as to whether an ER visit is worth the copay or not, why not require the same for people who pay nothing for their healthcare benefits?

There are supposed to be some rules with some insurance, that if the ED doctor does not write that the ED visit was necessary, the patient is responsible for a larger out of pocket payment. Sounds like a great start at dealing with abuse, but many doctors have stated that they do not want to do this, because they are afraid of receiving negative Press Ganey scores. why does the opinion of a system abuser allowed to have any influence on this? Because the hospital administrators have become so caught up in the Press Ganey and JCAHO/TJC nonsense, that they believe it actually makes sense. The hospital administrators encourage this abuse.

Of course the health care bill isnt going to do shit......its going to be written and run by the government, which has been the downfall of medicaid and medicare. And as for earache boy, I have been told idiocy can not be cured (but I did meet his brother who took an ammalance to the hospital for his long toenails!)