My agitated response appeared in Ambulance Driver the same day as the Whistleblower report.

Whistleblower has a follow-up today in which Erica A. Brix, senior plant manager at the Post Office, refuses to throw away the shovel.

She essentially gives two reasons for denying the request. The first is the 3.5 minute reponse time for EMS to arrive at the scene. This is a bogus response time. She is referring to the average time it takes for an ambulance to pull up to the curb, after the call is received by the ambulance. It does not take into account the amount of time  to actually place the call to 911 after the patient collapses, for the call taker to process the call, for the call to be transferred to the ambulance dispatcher, for the dispatcher to determine where the closest ambulance is located and the amount of time for the medics to load their gear on the stretcher (after they pull up to the curb) and walk into this large facility and to the patient’s side.

Now don’t get me wrong – all this happens fairly quickly. But to assert that EMS can arrive at a patient’s side in 3.5 minutes after a person suffers cardiac arrest shows just how clueless Ms. Brix is about this issue – even after months of study.

Cost is the second factor, it is contended. They claim they are going to need 18 AED’s to adequately supply the facility. Now think of that. The Postal Workers asked to place ONE DONATED machine in a central location and the bureaucrats said, “Nope, we can’t afford 18.”  What does that tell us about bloated federal programs? Government thinking if I ever saw it.

Ms. Brix also indicates that the facility already has a CPR and First Aid program. As far as I know, any CPR training that I am aware of requires training for AED use.

I don’t know where the National Medical Director of the Postal Service came up with his numbers for cost, but if the device is donated, all you need is an extra set of batteries, which have a life expectancy of several years ($200 bucks) and an extra set of pads for $20 – which need replaced every two years.

They admit the training program is already in place,  they have at least one machine donated, and their understanding of response times is flawed.

Give these folks their AED, you look like a bunch of fools.

We were called to a “Wet House” (which I will describe below) and found an intoxicated individual lying in his bed. There were stool and urine all over the floor and his bed clothes were soaked with the same. He was awake, spoke in a monotone and had just awful color. He gave us a history of pancreatitis and GI bleeds that were associated with his chronic alcoholism. His main complaint today was black stools (indicating the presence of blood) and abdominal pain probably caused by the pancreatitis.

He had been having pain, diarrhea stools and vomiting for several days. He admitted to a 2 week binge of drinking a liter of vodka a day, though it is likely the time frame was closer to 2 months.

We got him on the stretcher without getting “dirty” ourselves – which was quite the trick considering that he been rolling around in soiled bedding, fully clothed for quite some time.

We then asked him about any medicines and he pointed to a couple of bottles on a bed side table. On reentering the room, I found that it was going to be impossible to reach the bottles without stepping in stuff I’d rather leave behind. It was then that I noticed a few boxes, plastic garbage bags and paper sacks at my feet. Inside were found at least 200 prescription bottles, every one of which appeared to be full.

Now we frequently see folks that are non-compliant with their meds, but never have I seen so many medicines left untouched.

 My immediate thought was: “I don’t care what the Department policy is, I’m not going to write all these down.”

We were left with three options:

1. Declare a hazardous materials emergency and call in the Fire Department.

2. Pretend we didn’t see the bottles and just leave them behind.

3. Bag everything up and take them with us.

 I asked the staffer if she had a garbage bag – a Big garbage bag. She soon returned with a bag the size you would use to rake leaves into in the Fall. We filled it up beyond half-way. As my partner slung it over his shoulder, I swore he could’ve passed for Santa Clause, except Santa has more hair on his head.

 To make a long story short, we got him to the hospital.

 ”Wet Houses” are facilities for the destitute chronic inebriates who have failed time and again to dry out. The purpose is to give them a safe place to drink. In fact, this place has a sign posted by the elevator that reads, “Drink if you want to. Stay sober if you have to.” 

They are assigned to a space about the size of a college dorm room. There is no meals provided. There is a staff that oversees the operation. If memory serves, the cost to state government is about $1300/mon. They are also provided a type of bank card in which the state deposits about $150 a month for food. In addition, they are provided a little over $200 in a monthly payment.

But the $20,000 a year described above does not yet cover their expenses. Folks like this are huge consumers of health care services. The program that this patient and the one described in the last posting has over 30,000 enrollees that have incomes of less than $7500 a year. They incur health care costs to the state of over $1000 per month per person. But that still isn’t the whole story. The reimbursements the state pays to the providers of this care is significantly less than the total cost of the service.

So how does the provider make up the difference? They charge everybody else more. That’s you and me folks. Our insurance premiums are higher and our out of pocket expenses are higher due to care given to those who cannot pay and depend on government.

 I’m not claiming that every one of those 30,000 people are drunks and beyond help. But I will assert that a significant percentage of them are and it is costing a fortune. In this instance there were several thousands of dollars of medicines in that bag which will be simply thrown away – paid for with taxpayer money.

The cost of this particular program is rising at a rate of 18% a year. Simple math tells us that the cost will double every 4 years with that level of yearly increases – and it already is a $1 billion item in the state budget.

What we are doing here is not working. The sad part is that society has tried every reasonable (and unreasonable) way to try to help people like this and none of it works. We simply end up enabling behavior and calling it compassion.

I want to talk about the Hall of Famers, the chronic inebriates, those who have not seen a sober moment in years and attempt, if they have found themselves sober, to do everything they can to remedy the situation.

Two patients in recent weeks stand out in the annals of drunkedness and merit some discussion. The first will be dealt with in this posting

This was a fellow that was found unconscious lying on a sidewalk.  He reeked of alcohol. His best response to hard pain stimulus was to raise his head and grunt. Despite this, his blood pressure, pulse, ventilations and oxygen saturation were normal. He had no sign of trauma and the blood sugar was normal. Given that my partner and I have over 70 years experience, we were able to quickly diagnose the patient’s problem.

He was drunk.

Now I know what you’re thinking – “Those medics are sharp as tacks.”

Well, its not quite that simple. Yes, he was drunk, but this is where a little discernment is required. This patient is not one of those who can just be taken to a facility where he can sleep it off. His level of consciousness was so decreased that he was in a potentially dangerous situation. It is also possible that my partner and I had completely missed something obvious – although we try not to let that happen, as a rule.  At any rate this patient needed to be taken to an emergency room where he would be monitored closely.

And I’m not talking about just any emergency room. Patients such as these need a place where the personnel are used to dealing with those deeply intoxicated and understand the need for close monitoring. Not all ER’s can be trusted with this in my opinion.

A lot of things can happen as they detoxify. They could vomit and aspirate at any time. They are in danger of hypoventilation, where they are so neurologically depressed that their breathing becomes so inadequate that they stop altogether. They can awake in a 2-3 hours and not fully appreciate why they are lying on a hospital bed and start throwing things around – like nurses.

So what we did was to initiate our protocols for an unconscious patient of unknown origin and transported to an appropriate ER. Once there we were asked if the patient could go to the area where the less intoxicated go to sleep it off.

Our answer was “no”, not until he is evaluated by a physician. The Doctor soon appeared and agreed that the patient was too “down” and needed admission to the main ER.

Up to this point, all of this is fairly routine. It’s what we found out next that makes this a little more interesting.

I don’t know how many of you have seen how a breathalyzer works but here is what they look like:

What you need to do in order to get an accurate reading is to blow HARD into that little plastic tube until the operator tells you to stop.

Well, for this patient, having him to blow hard was not going to happen, so they merely stuck the tube in his mouth and obtained a “passive BAC.”

Which resulted in a measurement of 0.419%.  This is the mark of a true professional.

But that’s not the end of it. A nurse walked in and shook her head stating, “He was in here 2 days ago with a blood-drawn BAC of 0.80%.”

Now over the years I’ve found that 0.50 isn’t all that rare. I’ve had several patients over 0.60 and even one who measured 0.65 who was standing erect, swinging his arms around and loudly telling everyone he was going to kick my ass.

I’ve heard of 0.75% at my hospital – but I’ve never heard of 0.80% BAC.

Think of it. First of all this guy had to drink enough to get to 0.80, which is quite an accomplishment in and of itself, but then he had to live through it. In addition to that, he had to sober up in the hospital, (and I’m sure that was an all-day thing)  gather his wits, get discharged from the hospital, get outside and say, ” Ya know, that was fun. I think I’ll do it again.”

Now, my readers not in the medical profession may chuckle and shake their heads. My colleagues may shrug their shoulders. What we all need to think about, however, is the impact of folks like this on our health care system and the costs incurred in taking care of this patient over a course of years.

It ain’t a pretty scenario. It is also something that no one wants to talk about.

My next posting will drive this point home.

Kinda like how Medicaid is and how ObamaCare would be.

I urge you to follow the link Mitch provides to the NPR story (where you can read the transcript or listen to the playback) and then read his thoughts.

Across the nation, in metropolitan areas, one sees a great many folks standing along the road holding signs speaking of their desperation. I’ve often thought of Mr. St. Clair and wondered just how much money they were taking in during their day’s work.  A few months ago, the Ambulance Driver was given an inside glimpse at a panhandler’s life style.

We responded to a call on the near south side of the city for a man who had fallen. There we found a fellow that was bleeding from a badly lacerated hand. He was mid-forties, but could have passed for a younger man. He had good teeth, erect bearing, passable grammar and was sober. The reason these attributes stood out was that he obviously was a “street person.” He was grimy, but not filthy. He carried a backpack stuffed with most of his worldly possessions, one of which was a sign that read, ”Desperate Please Help.”

As I bandaged his hand, I thought of Neville St. Clair and decided to see just how talkative my patient was going to be on the trip to the hospital.

He responded to my inquiries as follows:

He had been panhandling on the Nicollet Mall for several months. His reserved spot was near the entrance of a well known department store. Apparently there is some sort of unwritten rule that no one dare panhandle in his spot as long as he was around. He is there Monday through Friday, appearing sometime just before lunch time and staying until he makes his “mark.” He has become a well-know fixture. Certain people never fail to drop some money in his “cup.” Women who work in the area often buy him a sandwich and soda for lunch and drop it by.

His “mark” is his collection goal. It was disappointing to hear that it was a mere $10.  Collections, oddly enough, come quicker in poor weather than when the sun was shining. Whether it comes as quickly as ten minutes or as long as a couple of hours, as soon as the mark is made he packs up and heads for the nearest liquor store for a cheap bottle of vodka and a pack of smokes.   

He is enrolled in the state’s General Assistance Program where he receives $203 a month in cash benefits. He doesn’t eat free at Mary Jo Copeland’s Sharing and Caring Hands because her rules are too strict. Instead he uses his state provided EBT card (like a debit card) to buy cheap food at a local convenience store. I’m not sure how much the state puts in his EBT account every month but $150 is a pretty good estimate, I think. He also is a General Assistance Medical Care recipient, where medical care is all but free.

He is married and his wife is also a General Assistance enrollee with an EBT card. She, however, has a state subsidized apartment where he can’t officially live, “because the state won’t let me.” He sleeps there anyway. (Ambulance Driver has a pretty good idea on why the state won’t let him live with his wife. As a married couple they are only eligible for a single GA payment of $260, not two separate payments of $203).

His long term goal is to qualify for several Federal Programs due to his chemical dependency.

We had just enough time for him to tell me about the “Heroin Bitch” who has a  spot was just a block down from him. She is the leader of a band of four that panhandle six to eight hours a day. He claims they earn $2000 a week, total, and spend it on street drugs.

I didn’t have the heart to tell him that a bunch of dopers had more ambition than he had.

Since that encounter, I’ve often thought about this life style and the culture that enables this type of behavior. This guy is perfectly able to work but has chosen, instead, to live off the generosity of the state and those of us who supply the money for his booze.

I’m not done with this subject.  The Neville St. Clair’s of this world fascinate me. Stay tuned.

• My bio, which only appeared for a very few days, has been removed.
• My employer is not named on the blog
• In the 911 Update series, the reader cannot trust the day of service, the patient’s age, sex, or location. The order in which the runs occurred also cannot be trusted.

What remains could be described as a “fictionalized” account of a typical day in the life of an urban Paramedic. Were the runs actually made and was the “essence” of the calls preserved?  The answer is “yes.”  Will the reader be able to track a specific call to a specific patient?  My answer to that is, “I don’t see how anyone could.”

In addition to all of this, it has come to the Ambulance Driver’s attention that many of his co-workers are using MySpace, Facebook and Twitter in a manner that has not been as circumspect as this writer has attempted to be

Be forewarned.

However, it is equally obvious that the health insurance plans are not convinced of the efficacy of this method of health care delivery.  Julie Brunner, executive director of the Minnesota Council of Health Plans, has this to say:

“That’s a really expensive use of a physician’s time,” she said. As a practical matter, home visits by nurses or other caregivers are much more common and affordable, she noted. “We would all love to be seen by a physician in our home, but we’re being killed in health care costs in this country right now. There’s a crisis, so we may not have [that] luxury.”

Once upon a time the health plans would not reimburse EMS providers for on-scene treatment of hypoglycemic patients with no transport. Their reasoning was that it would not save health care costs. The fact is that paying EMS $175 for scene treatment, including a physician consult by phone, saves money by eliminating the ambulance transport, the ER visit and the physician charges. The Plans didn’t have a leg to stand on and eventually started to pay – but the lesson is instructive.

What the Plans don’t want (or any other provider, for that matter) is to lose a revenue stream. With regulations and reimbursements the way they are, providers have learned how to “make it” with volume. High volume, even though accompanied by low reimbursement, is doable. Cut into the volume, however, and the system begins to be stressed.

So it is not at all surprising that health plans are leary of physician house calls. It has the potential to cut volume.

The chase after reimbursements is one of the biggest problems in health care and its genesis has been due to over-regulation, chiefly by government.

The Health Insurance Portability and Accountability Act, or HIPAA, however, was not one that had immediately come to mind.

Soon after this website’s beginnings, a reader forwarded an anonymous email voicing the concern that Ambulance Driver, in its 911 Update series, was violating HIPAA laws as it pertained to patient confidentiality. This was rather surprising given the care given not to disclose personal health information and the efforts made not to link data to a specific patient.

Since this subject has been dropped in the lap of Ambulance Driver, and it does directly relate to the goal stated above, we may as well talk about it.

The first call was made to the Ambulance Department manager requesting to have this blog’s content reviewed by the hospital’s HIPAA compliance officer.This request was made March 3rd and, in what may very well be a

bureaucratic world record, a reply was sent the very next day.

Permission has not been granted to disclose the reply but a fair synopsis would be:

• A policy on this subject is in the works
• Providing dates of service is a problem
• Providing location of service any more specific than a state is a problem.
• Blogging on the course of your work is not advisable
• Blogging on the subject of patient care is not advisable

Ambulance Driver is unconvinced that a patient’s identity could be gleaned from the information provided on its 911 Updates. However, after reviewing a legal summary of the law, one has to admit that the employer’s reasoning does have merit. HIPAA is a morass. For a health care agency to be cautious is just being prudent. The employer did not write the law, they are merely trying to comply.

HIPAA law seems to indicate that one may state, “I picked up a patient in Illinois last week with a broken leg.” On the other hand one may not say, “On March 2nd I picked up a patient in Chicago with a broken leg.” Seems silly, doesn’t it?

While not discussed in their response, the employer probably has some other thoughts on this topic. They have thousands of employees, hundreds of which may use social networks such as Twitter, Facebook and My Space. A few may be blogging. In this context, protection of patient confidentiality would be

a concern.

Ambulance Driver will do its best to alleviate the employer’s concerns over this website’s content and is confident that the situation can be worked out to the satisfaction of both parties. This has been submitted to an attorney familiar with HIPAA law and inquiries made to my Congressman in an effort to obtain a definitive answer to this question. All material will be shared with this blog’s readers and with the employer.

If any of my millions of readers have any comments, please feel free to share.

Since shown the door in the November 2006 elections, I haven’t spent much time at the Minnesota State Capitol but that does not mean my interest in public policy has waned.

Recently,  the Department of Public Safety was making their budget presentation in front of the House Public Safety Finance Division, the archives of which can be found online. The Department’s presentation was very good and the questions asked by committee members were on-point and probing. Representative Debra Hilstrom (pictured here)  was particularly well prepared and her questions reminded me of something that captured my attention in 2004 while a member of that same committee.

That year I stumbled upon some information that seemed to suggest that the Department was appropriated monies from 911 fees under pretenses that no longer applied. When asked privately about this, the response of Department officials was to tug at their collars, look down at their shoes and try to change the subject. At the time it was safe to conclude that I was onto something. However, after the 2004 elections, I moved off the Public Safety Committee and let the matter drop.

After listening to that committee hearing twice, and spending some time confirming that the situation had not changed since ‘04, I called Deb’s office and left a short message basically saying, “Saw the hearing – got an idea – give me a call.”

For Republicans like me, Rep. Hilstrom can be thought of as  a “Good Democrat.”  She is pleasant, thoughtful, hardworking and easy to work with.  But knowing the pressures and load she was carrying, I did not expect a prompt reply – and none was forthcoming.

Fast-forward to last week. For the third time since leaving office, I ventured to the Minnesota State Office Building. Wandering around for three hours, meeting old friends and sticking my head into places that the public does not know about was both enjoyable and fascinating.

On the Ground Floor level, heading towards a hearing room where I spent hundreds of hours, I saw Deb Hilstrom speaking with a group of people -I lingered.

Deb turned around to head back into the hearing room and saw me. It was obvious that my presence was not a pleasant surprise but she did manage to mumble, “I owe you a phone call.”  About that time Rep. Michael Paymar burst out of the room and asked for the whereabouts of a person whose name I did not catch.

Deb immediately blurted, “Sheisatthecafeteriahavinglunch,I’llgogether.” – and off she went. She did not lope, she did not trot, she wasn’t even merely running. She sprinted, and I mean SPRINTED, down the tunnel towards the MN-DOT cafeteria with her shoes slapping the marble like a drum roll by the U.S. Marine Corps Band .

With my hands in my pockets and watching her rapidly fade off into the distance, I had two thoughts -

• Look at that girl run
• Don’t waste any time sitting by the phone waiting for her to call you back

All of this only goes to prove that my close personal friend, former State Representative Ken Wolf, was right when he said, “There is nothing more useless than a former state legislator.”

Insuring that a patient’s protected health information is kept private has been my greatest concern. It is my understanding that as long as the information presented here cannot be linked to a specific individual patient, then there is no HIPAA violation.

To protect a patient’s confidentiality, I have set up some rules for myself which include:

• No ages – just a general description, such as elderly.
• No addresses – not even the city.
• If the patient does not speak English, they are described as non-English speaking. No nationalities are reported.
• Specific hospital destinations are not given
• If I am on a scene that will probably make the 6 o’clock news, I will simply say, “I was there.”

It seems to me that if any personal information is to be linked to a specific patient,  it would have to be released by my employer. There is no way it can be gleaned from the stories told on Ambulance Driver.

It must be said, however, that the rules are arcane and can be interpreted in some very odd-sounding ways. Two examples come to mind.

1. At the scene of an auto accident, I can tell the police that the patient has a broken leg but I cannot tell them that I suspect the patient has been drinking. They have to figure it out themselves.
2. Cell phone cameras are great for bringing visual images from the scene to the hospital. Vehicle damage from wrecks, height of a fall, or the length of a knife that the patient was stabbed with are just some examples of information that is valuable to hospital staff. Our medical director will not allow this use due to HIPAA concerns.

I am asking several individuals and entities, whose job includes HIPAA concerns, to review this blog’s content. Unless there are good reasons to stop, I am going to carry on with my 911 Updates.