I read a recent article in the New York Times that disturbed me.

A Crash. A Call for Help. Then, a Bill tells the story of a 70-year old man in Chicago who was in a minor motor vehicle accident, not his fault, who was nevertheless forced to pay the local fire department $200 for their response. The article goes on to tell the larger story of the trend of first responder agencies billing victims for their services to help solve their departments’ budget woes.

I can understand rescue agencies billing people who do foolish or unlawful things such as hiking in dangerous restricted areas leading to massive search and rescue efforts, but sending a bill to a 71-year-old victim – a bill his insurance does not cover — is wrong.

What I initially loved about being in EMS (particularly coming from a recent background in government/politics) is that in EMS, we are the clear cut good guys, or at least we are supposed to be. People are in need, they call us for help, and we do the best we can for them. But as the years have past, I am coming to fear that we are not always doing the best for the public, and that in many cases, we are showing them our less munificent side.

I am not just talking about inappropriate billing. I see this with inappropriate use of helicopters (and sometimes ground transport for that matter), unnecessary RSI and other procedures because we can and not because we should, and in unrealistically portraying our abilities to try to increase our budgets.

Sure we are lifesavers and we sometimes actually do save lives. But to go in front of federal, state, city and town councils and swear upon the the every second counts, lights and sirens to the rescue, how dare anyone hold us accountable attitude is embarrassing.

We need to tell the truth about what we do and about why we are important.

The beauty and simplicity of EMS is that – whether we save lives or not — above all we about being there in the time of need. We are about community. No, the outcomes for cardiac arrests are dismal, but you can’t put a price on helping a family whose father’s heart has stopped. You also can’t really put a price on someone being there to give an elderly woman some narcotic analgesia instead of just picking her up on a board and jostling her all the way to the hospital. We are about doing right for the people.

What I am afraid of is in our desire to expand or justify our existing budgets we may be losing our way and becoming something that we were not.

We spend unjustified sums on the latest unproven medical technology. We respond to calls that we never went to before because it makes our numbers look better at budget time. (I’ve been on minor calls that have had five agencies responding). We change our staffing patterns to fit reimbursement rates. We shine artificial lights on our lifesaving myth and too few of us talk openly about our darker side. (For a truth-teller, read Rogue Medic’s Experts Debate Paramedic Intubation – JEMS.Com commentary in which he, without hyperbole, uses the term “serial killer” to describe a not unfamiliar type of paramedic.)

While these actions may seem to benefit us, the effect on the community is not always the same. Instead of being truth-tellers and true community advocates, we, in EMS, have become politicians, salesmen and marketers.

I don’t mean to be naïve. And I do not hold myself out as innocent in these issues (I acknowledge guilt of my own). I do understand that in these difficult economic times, to compete for diminishing dollars, we feel pressure to act more and more like every other interest group, business or political party. Perhaps it is inevitable. Hospitals went this route long ago. Why not us? Still it makes me uneasy.

Things aren’t so black and white in EMS land anymore.

And here is clear evidence of it:

A 71-year old man who didn’t need us in the first place and who did nothing wrong gets a bill for $200, and he ends up writing out a check because he is a stand-up citizen who has always paid his bills (and is perhaps afraid of what will happen to him if he doesn’t pay even though he knows he’s getting scammed).

Have we not gone astray?

(More on this in future blog posts).


  • Brad says:

    This kind of thing worries me as a young EMS provider, I don’t want to see patients that are scared of calling us when they really need to because of the worries of a bill they won’t be able to pay… The public model of the UK and Canada interests me a great deal, as does EMS 2.0

    How do we as the people on the ground get the message to those in charge?

    Brad Buckler

  • totwtytr says:

    This isn’t really about EMS, it’s about self serving fire departments unnecessarily responding to incidents and then dishonestly claiming that doing so is driving up their costs.

    90% or more of fire department first response is totally unnecessary. It’s make work for agencies that would otherwise not be able to justify their budgets.

    The fire department in Quincy, MA recently proposed this type of fee for MVC response. It was withdrawn after the public outrage.

    The post 9/11 luster is off the fire service, they are now being treated as just another municipal agency and have to justify their costs. Adding fees which will only infuriate the tax payers is not a winning strategy.

  • JV says:

    “90% or more of fire department first response is totally unnecessary.”

    It would be, if we could get the ambulance jockeys to do their jobs. I’ll remember this the next time we’re supplying all the manpower to access, remove, treat, and lift a patient, since the ambulance company isn’t there yet or the two girls on it can’t lift. No ambulance company in my area would last without all the “free” manpower provided by the FDs who do most of the ALS and lifting, not too mention providing the first response that hides their average 10-15 minute response times. Soon we won’t have the manpower left to go on EMS calls, and we’ll see how long your back lasts lifting all your patients by yourself.

  • medicscribe says:

    I did not write this to fuel a first responder versus ambulance or any provider against any other kind of provider war.

    There is truth in both of what TOTWTY and JV write about.

    I read a great quote recently the gist of which was “If you’ve seen one EMS system, you’ve seen one EMS system.”

    I don’t want to comment on any individual system other than what I have seen. I have worked in towns where there was no first responder and worked in towns where there were multiple first responders. I can say that it is a rare EMS system that involves more than one agency that does not have turf wars — some minor, other egregious. I think efforts by everyone in each individual system that has these wars best serves the public by working to coexist in the most efficient manner with the other services to best serve the public. Most of the onus of this effort is on the leaders of each service, but some also falls on the field responders to not let it interfere with patient care.

    I think the best solution is to have cities or towns form citizen commissions or committees or even just appoint one non-aligned individual to represent the people to inisit that the responders varied interests serve the public first and not their individual service agendas.

    I have witnessed towns struggle with creating efficient EMS systems and wanted to go before them and say, “Here’s the deal. Here’s what’s good and here’s what’s bad about each service’s role.” You never want to speak against EMS (and I include all responders in this umbrella), but I wish we could all speak first as citizens.


  • HC says:

    The flip side is going out on calls where we aren’t really needed. I went to a call for female abdominal pain, patient unable to walk. When we pulled up the teenage patient came out and walked to the ambo and climbed in with no sign of pain or difficulty. GrandMa told me we were free and quicker than a cab and she would be seen faster at the ER. They live 1/4 mile from a walk-in clinic. Buses available too. That’s why we’re short units when we need them. We can’t refuse and don’t charge. I’m all for helping people but people need to help themselves. When the service is free and compulsory it gets abused by some who feel they’re entitled. In contrast, I had a patient who apologizede for calling but he passed out 3 times getting in from the garden, his chest hurt and every time he sat up he passed out. His heart rate was 30.

  • JE says:

    The practice of double-billing is widespread and any Muny that collects taxes should not be billing its residents. Thats why they pay the taxes in the first place, to have the services of polic/fire/rescue. While I agree the response from multiple agencies ridiculous, I seriously doubt that sending a bill to someone will ever stop them from calling 911. In my experience its too widely abused for that to ever happen.

  • Matt says:

    Here’s my take. I certainly don’t suggest that I’ve seen all systems or the best way of doing things, but I have worked in several areas. I’m also not suggesting that any of these are politically feasible, just an ideal.

    1. There are only three types of single-patient calls that should have someone other than a (competent, JV) EMS crew initially respond: cardiac arrest, rescue required (including MVC), and known very obese patients.

    2. Fewer paramedics equals improved patient care. I tend to cringe when I see more than two paramedics on scene, especially when from different agencies, and most especially when there isn’t a clear, pre-established lead agency.

    3. For all but a very few calls, as Peter and many others have said we all know that seconds do not count. In the areas I have worked that have a paid FD response in addition to a separate ambulance response, the justification has been that seconds do count, FD is “strategically predeployed,” et cetera. This is poor patient care and demonstrates a lack of understanding of what the data supports. Side note: if fire departments must keep their numbers up with EMS response, another way to save money is to not respond with fire apparatus.

    4. Every public service agency wants a larger budget. Every private/billable ambulance wants larger reimbursements. In general, people are more willing to pay for what they can see value in, so we need to find better ways of educating the public about the proven and unproven value of EMS so that they are less likely to simply equate fast response or a lot responders with good service or care.

    5. We need to improve the service we provide. I think there is a wide range here in individual services and areas, but since a large part of procedures we do don’t help patients (or are unproven), we can step back and develop more strategies about how to problem solve for people who call 911 with something other than a clearly defined medical emergency. This includes alternative disposition options, medical advice lines (that include something other than a nurse telling them to call 911), treat-and-release, alcohol detox, and so on.

  • totwtytr says:

    JE, the funny thing is that even if the patient didn’t call for the fire department, he’s going to be billed for it. I’ve responded to any number of calls where the patient or family has specifically told the fire department they wanted an ambulance, not a fire engine. I think at some point the taxpaying public is going to stop buying the hype that a fire truck has to respond to all medical emergencies.

  • Chaz says:

    In my town, fire responds to every medical call. This means even calls out of nursing homes or assisted living centers that are essentially transfers have an engine assigned in addition to the ambulance. In many cases, the caller specifically requests an engine not respond as the patient is stable, and the call simply could not be coded as a transfer for some reason. Each time fire arrives on scene, the patient receives a bill.

  • Rogue Medic says:

    I have worked in Radnor, which is one of the places in the article that tried billing people for responses, before Pennsylvania banned it. I enjoyed working with their FD/EMS, but that is one of the wealthiest communities in the country. Money problems?

  • Medic 14 says:

    The article was good, but all I really came out of it with as a paramedic student was the line that it’s a myth that we save lives 🙁 Gave that dream a good kick… what am I here for (“community”?) and why am I spending all this money to get these skills if veteran medics are calling us on our “life-saving myths”?

  • Being in the UK, the thought of charging patients for transport to hospital seems very strange to me. Having said that, we do get some imbeciles who will call an ambulance for transport when they could actually walk there in 20 minutes – and are fit enough to do so.

    Our fire service(s) do not usually attend calls for illness/accident unless there is an additional reason – a patient needs freeing from a crashed automobile, the pt is grossly obese and two ambualnce personnel would not be able to carry them safely or there is actually a fire as well!

    Ambulance crews are part of our (much maligned but generally very effective) National Health Service.

    At some times, the professional ambulance trusts will request assistance from one or more of the voluntary agencies such as St John Ambulance (England, Wales and, I believe, Northern Ireland) or St Andrews Ambulance (Scotland) and British Red Cross.

    I’m a volunteer member of St John Ambulance (SJA) but am not a uniformed ambulance “Johnner”. I only attend illness rather than accident and am non-uniformed (apart from a yellow vest and ID) but I attend from home. I’ll sign on with Ambulance Control and then get on with my work or recreation. If there is a suitable call where I may be able to arrive before the ambulance, I’ll be sent. I have no blue lights and must obey the rules of the road.

    My arrival on scene stops the waiting-time clock. I carry a defib, O2 and (now) salbutamol, along with a selection of dressings etc, just in case.

    The main calls I get are for “difficulty in breathing”, “collapsed” (can mean anything from a faint to cardiac arrest!), “not responsive” (similar to me after a good saturday night in the pub!) and similar. Yes, we get cardiac cases and I’m told I do mean CPR. I’ve only been practising for 40+ years!

    We can sometimes give early life-saving treatment.

    For this I get paid very litt… er noth.. er absolutely sod all! I’m happy to do this voluntary work as I appreciate the FREE (paid through taxes) service available to me, should I ever need it.

    Our Unit raises cash from public donations to buy our kit, and gets consumables from the Ambulance Service. We pay for our our own fuel. I have a pulse oximeter because I bought one.

    We’re Amateurs; we do not think of charging. In return, many employers allow staff to be on duty during work time and most of these do not dock pay for responders who are called out.

    I will never criticise our professional colleagues simply because they get paid – I’d quite like to join them – and we don’t. They are true colleagues as well, explaining to us why they are doing what they are doing, and often including us in discussions about treatment once they know we are not morons.

    Sorry you guys in the US; I reckon our “free” (but paid for via tax) service is the one to go for, though I’d like to see the ambulance service start charging for the “called an ambulance because our company insurance says we must” calls that waste time and could deprive a genuine patient of an ambulance.

    I love volunteering (but I’d love a paid job even more!).

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