A quiet moment at the Bellevue Medical Center ambulance port (Photo: Joseph Stepansky)

Stephen Katz meets New Yorkers during their direst moments—times when the stakes are life or death. The lanky 28-year-old Emergency Medical Technician moved to Manhattan for exactly that type of high-urgency drama.

But Katz finds that most days are consumed by a slower, more pervasive crisis.

In New York he sees more cardiac arrests, strokes and seizures than he did in his previous post in Seattle. But Katz said he also has found many more low-urgency patients.

“It’s crazy, the stuff we train for is such a small part,” said Katz. “We’re a taxi half the time.”

To understand the problems created by these calls, said Katz, it’s important to understand the nature of emergency work. On slow or average days, non-emergency cases have little effect—they don’t lead to substantial delays for other patients.

On busy days, however, especially in the summer, low-need patients and repeat users can tie up the closest ambulances and create delays for patients facing actual crisis.

When responding to cardiac patients, “time is muscle,” said Joe Pataky, a Captain of the Fire Department of New York’s Emergency Medical Services, whose 4,000 emergency workers make up 60 percent of 911-dispatched emergency medical responses. (The other 40 percent work for private hospitals that send ambulances on 911 calls.)

On an average 12-hour shift, Katz will respond to anywhere from 10 to 16 calls and transport up to 10 patients. Two will likely be high-urgency, five will suffer from injuries or illnesses needing medical care but not necessarily emergency transport—broken arms, sprains, chronic illnesses—and three will be patients in need of a basic primary physician and remedies as simple as Tylenol.

“If there were more accessible non-emergency care, a lot of these people would see a better option”

Katz’s experience is typical. In 2011, 911 operators dispatched emergency services to more than 1.2 million calls citywide. Of these, nearly 800,000 were non-life threatening. In the eight-category rating system, one-fourth of the total transports ranked in the bottom three least-urgent categories, according to City of New York data.

When non-emergency patients are transported to the hospital by ambulance, they often join low-urgency patients waiting for treatment, said Marie Diglio the executive director of operations at the Regional Emergency Medical Service Council of New York City, which helps to coordinate emergency medical services across the city.

Although Medicaid reimburses ambulatory services if a patient is transported, the city or hospital must pay the costs of a patient without insurance.

“It’s not just using resources of the ambulance and hospital staff, but it takes time from the people waiting in the emergency room,” said Diglio. “A lot of times individuals don’t have insurance, and the hospital and the ambulance service have to absorb the cost.”

In 2004, uninsured New Yorkers were five times more likely to use the emergency department for primary care than were those with insurance, while Medicare and Medicaid recipients were four times more likely, according to a report put out by the department of Health and Mental Hygiene. In 2009, there were approximately 1 million uninsured New Yorkers.

On a Monday at 2 p.m. 50-year-old Barry Jordan of Manhattan squirmed in a green plastic-cushioned chair in the waiting room of the Bellevue Hospital Emergency Department. There were few empty seats around Jordan in the stuffy room. He tried to get comfortable. He repeatedly failed.

His wife, Diane, said that Jordan, a Medicaid recipient recently released from jail, had waited nearly seven hours to be seen for a pain in his calves she said was related to his diabetes.

“He has sugar, it’s really terrible,” said Diane. “We’ve waited all day.”

Mondays—or “Medicaid Mondays” as some more cynical emergency personnel call them—are notorious days for low-urgency patients who use emergency rooms in place of primary physicians, said an emergency worker who asked not to be named.

Low supply helps build the high demand for emergency departments. Fifteen hospitals closed in New York City over the last decade, increasing the pressure on surviving institutions. The most recent study, a 2009 report by the Press Ganey Consulting Firm, found the average wait time in a New York City Emergency Room was five hours, which was an 18-minute increase from 2008.

According to a 2011 study by the Journal of the American Medical Association, emergency care use has risen 35 percent nationwide since 2008—while one-third of hospitals have shut down.

Officials in charge of emergency medical systems, like Dr. Kevin Munjal, are seeking some way to reduce the pressure.

“The current role of EMS is to simply transport all patients to emergency departments,” said Dr. Munjal, the founder of the first Community Paramedicine Task Force in New York City, in a statement. “This paradigm is not patient-centered and raises costs to the healthcare system.”

That’s why on a Tuesday night after a meeting of emergency medical officials from across the city, Dr. Munjal invited several to a special meeting to discuss a dramatic rethinking of the role of emergency medicine in the city—a trend that has been spreading across the country.

Over the last year, Kevin Creek, a Community Paramedic in West Eagle County, Colorado, has been making house visits to high-need patients who often use ambulances. Every day he’ll visit one to three of these residents in the county to administer medication and basic health care.

The pilot program, one of the first of its kind, is funded by state and private grants, said Lisa Ward, the coordinator. Although the program is too new to show verifiable results, it offers a proactive approach to emergency care that has had success in connecting high-need individuals with social services and primary health care, while preempting their emergency calls.

A study conducted by the Baltimore City Health Department and the Johns Hopkins School of Medicine found a significant drop in calls when identified the 25 most frequent ambulance callers and preempted several with weekly visits.

Another study, conducted in 2003 by the University of California-Davis Medical Center and the Sacramento EMS, found equally promising results when emergency responders visited elderly residents at home and minimized tripping hazards.

Dr. Munjal and Diglio see the possibility for a similar program aimed at identifying and providing care for “frequent flyers,” the elderly, and those in need of primary care throughout the five boroughs.

“Community paramedicine would help decompress a lot of what is happening,” said Diglio. “If you could take care of these patients, they wouldn’t have to go to the emergency department.”

Bringing such a program to the city would have to be accompanied by a change in legislation. The Emergency Medical Services Act of 1973 states that EMS systems are primarily designed for care of emergency medical conditions—not preventative care, said Kurt Krumperman, the executive director of Albuquerque Ambulance Service, who is working on a dissertation on community paramedicine in North Carolina.

Another problem is that Medicaid does not reimburse for non-transport ambulance trips. As community paramedicine would likely encompass a practice of ”treat and release” for low-need patients, the coverage would have to be extended, Krumperman said.

Idaho is the only state to pass a revision to Medicaid that compensated ambulance services for non-transport responses.  A similar revision was proposed on the national level in 2002, but it did not pass.

“I think there’s momentum growing, but there’s a lot of inertia,” said Krumperman. “In days of economic constraints, people are focusing on immediate problems and not the long term.”

Dr. Munjal, in a statement, said a pilot program of community paramedicine might be possible in New York.

“While some small scale programs could be created within the bounds of existing regulations, there are several regulations in place that assume a narrow role for EMS,” said Dr. Munjal. “Some of these might be interpreted as prohibiting valuable community paramedicine programs.”

Standing outside of St. Luke’s Hospital on the Upper West Side, on the front lines of emergency care, EMT Katz said patients who now call ambulances for trivial problems might appreciate visits by community paramedics.

“If there were more accessible non-emergency care,” he said, “a lot of these people would see a better option.”

 

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