Is This Right?

EMS Reruns is an advice column designed to address dilemmas you may have experienced in EMS that you did not know how to handle. But it offers you a luxury you don't have on scene: plenty of time to think. If you think of an example like the one that follows, send it to us. If we choose to publish your dilemma, we'll pay you $50. We don't know everything, but we do know a lot of smart people. If we need to, we'll contact just the right experts and share their advice with you. E-mail ideas to Nancy.Perry@cygnusb2b.com.

Sean Bennigan is a 67-year-old man who has arrived with paramedics in the ED of his local community hospital following an episode of non-pleuritic chest pain. The paramedics medicated him in the field with oxygen, aspirin, nitro and morphine and transported him essentially pain-free. The S-T elevation they documented in his anterior leads has disappeared by the time he arrives at the hospital. The hospital is 20 miles from a cardiac center. After evaluating him, the ED physician elects to have him transferred by helicopter. The weather is fine, traffic is light, the roads are safe and dry, and the transporting paramedics are available. The paramedics' district has plenty of ALS ground coverage.

According to protocol, an engine company receives the call for a "Chopper Go," indicating helicopter activity. They respond with lights and sirens to the hospital's helipad, where they land the helicopter. Mr. Bennigan's health insurance consists of Medicare, and the bill for the helicopter transport will be more than four times the cost of an ALS ground ambulance. The helicopter will be out of service for medical emergencies in excess of two hours, and there is no backup helicopter.

Q. Why did this patient require a helicopter? Hospitals in our area do this all the time, and it seems like they're just filling the air with choppers for no good reason. Isn't this subjecting patients to unnecessary risk?

A. Every situation is different, but there are good reasons why most medical choppers don't land or take off without an engine company on scene. All of those reasons are about risk.

Q. What about this man's bill for air transport? Won't he be expected to pay the additional costs himself? We were there throughout his ED stay, and to our knowledge nobody ever discussed that little detail with him.

A. Actually, it's not the best idea in the world for medical folks to discuss the specifics of health insurance with patients. Today's health insurance is extremely complicated, and even people who handle billing full-time aren't exactly sure how insurance companies will respond to their bills.

Q. It seems that too much of modern medicine is driven by money, rather than what's good for the public. We can get into so much trouble if we say the wrong things. How does one know when to say something and when to just shut up?

A. That's a question lots of people are grappling with. First of all, try to limit what you say to stuff you really know, and always consider the possibility that you're mistaken about something. That's probably the easiest way to keep yourself out of trouble. For instance, avoid speculating about what somebody's insurance company will pay and what they won't. When you discuss those kinds of things with patients and a giant bill comes in the mail, they tend to recall exactly what you say, believe you and hold you accountable for it.

Next, consider bringing potential ethical issues up not to patients, but to decision-makers (like the ED physician, for instance). None of us has all the wisdom in the world, so we all benefit from the observations of peers. Of course, it's important to breach those kinds of concerns inoffensively and with respect. Sometimes a person who's making a decision has information we don't, but sometimes they benefit from other perspectives about what's right and what's wrong. But do say something.

Fortunately, most agencies in EMS are intrinsically ethical. Bad ones tend to get into trouble all by themselves. If you find yourself getting involved in repeated ethical dilemmas, that's not a good thing. Maybe you should free up your future and find a new employer.

As for modern medicine being driven by money, well, you're absolutely right. Many institutions and individuals really are. That's why we all need people who care enough to ask the right questions and have the courage to insist on the right answers.

People just like you.