No Longer a Taxi: the Australian Non-Transport Proof-of-Concept

On the top floor of a bleak apartment block a woman complains about her blood pressure. There’s a history of hypertension and her BP is up again. She checked it with a machine she bought from her chemist. It read 154/90. All her other vital signs are normal; she is asymptomatic, with no pain or deficits or dizziness. She is alert and orientated, if just a little anxious.

She insists on being taken to a hospital to manage her blood pressure. However, after a full assessment, we tell her that her blood pressure is not dangerously high at the moment and she would do just as well to see her own doctor down the road. We offer to call her son, who lives nearby and owns a car, to take her there, and we book her an appointment. Then we wish her a quick recovery and leave the scene.

To many paramedics outside Australia, this scenario may seem inappropriate, or a recipe for disaster. Media coverage of the NSW Ambulance announcement about a pilot program allowing paramedics to officially refuse transport of patients who request it and refer them to general practitioners has gone viral around the world.

Reactions to these reports have ranged from alarm about potential legal repercussions, to well-worn discussions about the very role of paramedics.

The truth is, Australian paramedics have been finding alternative solutions for their patients with non-urgent problems for years. The Extended Care Paramedic (ECP) program, which also exists in the United Kingdom, is one example. ECP involves a supported portfolio of skills including on-scene suturing, urinary catheter placement and antibiotic prescription that helps patients avoid the hospital. Indeed, it’s been almost a decade since transport was a given outcome for all those who request an ambulance, and this is because, as most paramedics well know, not everyone needs to go to a hospital and not everyone who does needs to go there by ambulance.

The word ‘refusal’ is misleading, however. It implies that paramedics simply stand there, arms crossed, stubbornly opposing a direct request. Instead, patients will be treated and discharged from paramedic care with advice, or referred to non-hospital medical facilities if appropriate. If a patient can be reasoned with, most will be satisfied with a referral if it is sold well. ‘I know you want to go to hospital, but let’s talk about other options that might be more appealing.’ Abandonment has never been on the agenda.

So what drives the incredulity coming mainly from the U.S. after getting wind of the new Australian proof-of-concept? Why does it seem so radical? Judging from both the online comments and my own experiences riding on American ambulances, reasons for these reactions seem tied up in the organizational and cultural differences of Anglo-American prehospital care between Australia and the U.S.

In Australia, EMS is considered an essential service that state governments are obliged to provide to the people and nowhere is a private EMS contracted for emergency work. While patients are charged for call-outs and transports, the fees are not exorbitant. And because EMS provision is a government responsibility, regardless of whether users pay, there is zero pressure on paramedics to elicit transports. On the contrary, unnecessary conveyance to overloaded hospitals is discouraged, because ambulance services are part of the health department and play an important role in easing strain on the system.

Last year I rode with AMR in Las Vegas where paramedics were under enormous pressure to make transports. I was taken aback to hear one medic tell me he had a ‘70% transport target’. As we conveyed a young, walking/talking drunk man to the hospital after a single vomit—a patient I would have left in the care of his friends back home—I pondered the nature of paramedicine as a ‘business,’ something quite foreign to me.

Is it ethical, as a highly qualified, critical-thinking paramedic, to transport a patient you know needs nothing more than a good night’s sleep in their own bed, all for the sake of making money? Best practice does not necessarily mean transport. While the very survival of private EMS companies relies so often on profit, it is disappointing when profit hijacks best practice.

Despite the liability insurance held by ambulance services, fear of litigation is the other major concern expressed by paramedics in the U.S. about the Australian proof-of-concept. But these fears are mostly unfounded. Very few paramedics in Australia have ever made it to the Coroner’s Court. Moreover, the expertise of Australian paramedics is widely respected. Most universities now offer three-year, full-time paramedic Bachelor’s degrees, or four-year paramedic/nursing combined degrees, as well as critical care post-graduate studies. The majority of new recruits to state ambulance services in every state are degree qualified.

Medics Down Under have long been encouraged to think as 'clinicians' rather than 'technicians,' and finding non-hospital solutions for patients, where appropriate, comes with the clinician’s territory. If a highly-qualified medic conducts a comprehensive assessment and has an acceptable rationale for referring patients to alternative care, and then if the occasional patient has a poor outcome, negative legal consequences are extremely unlikely. If mistakes do occur, they will attract the standard Root Cause Analysis (RCA) investigations that have applied to previous cases of negative outcomes.

Politely refusing a patient’s request for transport when there is no clinical indication for it may seem to many like a step too far, but it’s a logical step for a profession still desperate to be taken seriously. Quality paramedic education and experience is highly valued in Australia and the clinical wisdom of paramedics is finally being supported by employers. We’ve moaned too long about our ambulances being treated like taxis, but until we stop acting like taxi drivers, the confusion will continue.

Benjamin Gilmour is the paramedic, author and filmmaker behind Paramedico: Around the World by Ambulance, available for purchase at EMSWorld.com/store. Watch 'Paramedico' the film now at www.paramedico.com.au.