EMS Discussion on Athens News Matters

Last week, Athens News Matters featured a discussion on the uncertainty surrounding EMS in Athens. I joined Blake Aued from Flagpole and former Mayor Gwen O’Looney on the panel for this segment:

APN on Athens News Matters!

There was a lot I wanted to say on this program that we didn’t have time to get into. But before all that, if you haven’t seen my video on EMS in Athens, go ahead and watch that first.

The Debate about National EMS Response Times

There’s a lot to be concerned about regarding National EMS: closed-door oversight meetings, accusations of poor response times and the fact that they are owned by a private equity firm. What I’d like to focus on in this article is the debate over response times. Let’s see if we can’t resolve the confusion.

The issue, as Blake Aued points out at the beginning of the Athens News Matters show, is that there are two separate datasets, one which was obtained from the Department of Public Health, and the other which was created by National EMS itself. These datasets give very different pictures of National EMS’ performance:

Which is correct? Public safety activists Sam Rafal and Bob Gadd have been pushing for transparency for years so that we can make sense of these numbers. They distrust National EMS, and for good reason, since they have never shown their raw data to anyone outside of their company. At least not to anyone not bound by a non-disclosure agreement. National clearly has a profit motive to make their numbers look as good as possible.

However, it doesn’t follow that they are definitely presenting incorrect numbers just because they have a motive to do so. In fact, I assume both datasets are correct, since I have no reason to assume otherwise. But how can that be? Aren’t they contradictory?

A Theory to Explain Both Sets of Data

Before I can explain my theory, I need to give some basics on the types of calls National EMS gets on a daily basis. There are three different types of calls:

  1. Non-emergency calls (such as patient transfers)
  2. Priority 1 911 calls
  3. Priority 2 911 calls

Patient Transfers

Patient transfers are how National EMS makes its money. Operating a 911 service is not generally a profitable endeavor; it costs a lot of money and doesn’t generate much revenue. Being a for-profit company, National EMS has developed a business model that relies on moving patients around in non-emergency situations. Examples might be a hospital-to-hospital transfer or a ride from the hospital to the nursing home. It makes sense to me why National EMS would prioritize these calls and potentially spend a lot of their resources seeking out these kinds of business opportunities. Again, this is how they make their money.

Priority 1 911 Calls

Priority 1 911 calls are also clearly important — these are true emergency situations where every second counts, such as the case of a heart attack or stroke. It makes sense to me why National EMS would prioritize these kinds of calls. Even if they didn’t, I believe that the hospitals, who own National EMS’ contract, would most definitely apply pressure as needed to make sure that they did. Not doing so would be a violation of the Hippocratic oath and is hopefully unthinkable to most medical professionals.

Priority 2 911 Calls

That leaves us with the priority 2 911 calls. These are calls that are less urgent and less time sensitive, but it’s important to point out that these are all 911 calls and are all supposedly emergencies. These kind of calls might include broken bones, seizures and other serious medical situations (it’s hard to tell, because National does not give out this information). It’s becoming more and more popular with ambulance services to not run lights and sirens all the way to the patient in some cases like these. Why?

Even under normal conditions, we should recognize that cars are extremely dangerous machines. When speeding through crowded streets, the danger becomes extreme. The last thing any paramedic wants is cause an accident and potentially be the source of an emergency instead of the cure. With a well-run ambulance system distributed throughout the service area, not running red lights should only add one or two minutes to response times (according to the article linked above). For most 911 calls, speeding through city streets is not necessary and may be counter-productive, because the patient is able to wait an extra two minutes with no change in their condition.

Does National EMS Care About Priority 2 911 Calls?

The short answer is no, they clearly don’t. These calls don’t provide their Wall Street owners with profits. They also aren’t very time-sensitive — if the patient can wait two minutes, why not five or ten? National must decide every day whether or not to prioritize calls that will make them money or calls that will do nothing for them except drain their resources. I can’t imagine this is a difficult decision.

I spoke with a National EMS paramedic off-the-record for over an hour on two occasions, and from those conversations it is clear to me that National EMS considers these kinds of calls to be extremely unimportant. In their defense, they do get many 911 calls that are for “stubbed toes” or even just people wanting a ride to the hospital — I’m sure that happens on a daily basis. But in my opinion, that is no excuse. They are expected to respond to all emergency calls under 9 minutes, 90% of the time, according to common standards used across the country. Perhaps some flexibility should be given to priority 2 calls, but why should there be more flexibility than one or two minutes?

I’m getting us a little off-track, let’s get back to my theory:

Both Sets of Data Could Be Correct

Let’s take a look at a hypothetical scenario that I feel explains the difference between the two sets of data. Since non-911 calls (such as patient transfers) should not be included in the data from the Department of Public Health, let’s leave them out for now. I’m going to assume that priority 1 and priority 2 calls are about equally frequent.

Hypothetical Scenario

Let’s say that National receives 50 priority 1 calls and 50 priority 2 calls in a certain time period:

Priority 1: 50 calls, average response time = 6 minutes
Priority 2: 50 calls, average response time = 15 minutes
Total: 100 calls, average response time = 10.5 minutes

They respond quickly to most priority 1 calls, although unfortunately some are over 9 minutes. But that’s okay, because 90% are handled in under 9 minutes, so they’re meeting the official standards. This is the data that they show to the mayor and commission. Yes, there may be some outliers here, but generally this dataset shows that they are on-track and meeting their commitments.

On the other hand, they respond very slowly to priority 2 calls in this example. This can’t be explained simply by their not running red lights and sirens, which should add only about 2 minutes or so. They have many 15 minute responses and even some 20 and 30 minute responses in this part of the data. They don’t include these responses when they report to the mayor and commission. The hospitals are fine with this, and even support this decision because they know the priority 1 calls are the only ones that are truly urgent (also, because they know they would be asked to pay a larger subsidy to National if they were not supportive).

Athens for Everyone showed the entire data set, which is the reason why National appears not to be meeting their response time requirements in this case.

National EMS only presented one part of the data, which is why they were able to say that they are meeting their requirements. They feel they have a medically-valid reason for reporting it this way, and are resistant to any attempts to get them to be more transparent. The hospitals support them in this resistance for reasons I stated earlier.

This may only be a hypothetical scenario, but I feel that it both makes sense and fits all the available information that we have. It also allows us to assume that no one is making blatantly false statements. Personally, I believe this explains the difference in the datasets.

The Problem with Ignoring Priority 2 Calls

The vast majority of people who call 911 don’t understand the difference between priority 1 and 2. If their child is having a seizure, they would surely be unable to understand an ambulance getting there in 20 minutes. They would also be unable to understand that a profit-generating call took priority over their child.

When National ignores priority 2 calls, that causes the community to lose confidence. Even if there is no medical reason that would require an extremely fast response, people still expect it. And for good reason! We all benefit mentally from knowing that if we have an emergency, someone would be with us quickly. We don’t want to have to argue with the 911 operator that, no, our call is actually important, we should be priority 1! We also don’t want to be in the dark as the decision that de-prioritizes us is being made behind closed doors.

National EMS, supported by both hospitals, is operating in a way that causes mental pain and anguish to us and our neighbors. If they truly believe that their decisions are for the best — and they might actually be (I’m not a medical expert!) — then they should be able to explain that to us. We should demand that they at least try. They should be completely honest and open with us, because we are the community they serve. If they can’t, or if we don’t accept their explanation, then this system is in dire need of change.

Let’s get to that change sooner rather than later. If you are from one of the hospitals and are reading this — I’m begging you to stop being defensive and to start working with the community to come a solution for everyone involved.

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