Wednesday, July 12, 2006
Synopsis of Emergency Medical Services in Peoria
Peoria’s Medical Mafia documents thoughts regarding Emergency Medical Services (EMS) in Peoria, Illinois. There are approximately 65 posts on this web log, many of them regarding EMS.
Peoria has a population of 113,000. The Peoria Fire Department (PFD) is non transport and provides service at Basic-D level with basic medication. Several years ago the PFD purchased a very nice ambulance using the Foreign Fire Fund. The PFD applied to the Peoria Project Medical Director for permission to outfit this vehicle, their only ambulance, with various basic and advanced life support materials and equipment. This request was denied by the Project Medical Director. The PFD then sold this ambulance because it was not being used.
Peoria has an advanced life support company, Advanced Medical Transport (AMT), which transports patients and gives the only paramedic care in Peoria. It is considered a not-for- profit entity but grosses over 7 million dollars per year. AMT is supported by all three of Peoria’s hospitals. OSF-SFMC, the largest medical center in downstate Illinois, is considered the “resource hospital” for the Peoria Area EMS. All three medical centers have administrators that sit on the AMT Board of Directors. AMT suffered significant legal troubles several years ago when the federal government investigated it for Medicare fraud based on coding and charging. AMT was fined over 2 million dollars by the federal government.
The OSF-SFMC Emergency Department Director is also the Corporate Medical Director for AMT. He was the Project Medical Director for many years in the Peoria area and was salaried by both AMT and OSF-SFMC for his services. Numerous people in the area believe this arrangement constitutes conflict of interest. The PFD also believe that many obstacles have been created over the years to keep them at a basic non transport level so AMT can continue as the only paramedic and transport agency in Peoria.
I believe that Peorians have suffered and died in the pre hospital setting and continue to do so because of the paramedic/transport monopoly. Incredibly, the PFD has paramedics that cannot use their life saving abilities at the scene when they work as firefighters; however, when they “moonlight” for AMT, they are able to use their advanced life support skills.
Similar business arrangements as described above probably occur in other locations around the nation. But just because banks are robbed in many cities, does not mean it is right to rob banks in Peoria.
I hope this web site is informative. Some day Peoria will change for the better regarding EMS and pre hospital care. The system took a while to become this ill and it will take a while to recover.
John A. Carroll, MD
July 12, 2006
September 30, 2006
Arthur Kellermann, M.D., M.P.H. published an article in the September 28, 2006 New England Journal of Medicine. He is chairman of the Emergency Department at Emory University School of Medicine.
Dr. Kellermann begins his article describing waiting in the ambulance bay at Grady Memorial Hospital in Atlanta on July 27, 1996, awaiting 35 severely injured bombing victims in Atlanta. It sounds like things went as well as possible and the ER was working normally five hours later. Would that happen in Peoria? I don’t think so.
The Institute of Medicine recently released three reports regarding Emergency Medical Care in the United States. It can be seen at www.iom.edu. Dr. Kellermann sat on a committee which did the report.
Collectively, the committees describe an over burdened emergency system that is rapidly approaching its limits. Dr. Kellermann states, “With more patients needing care and fewer resources to care for them, emergency department crowding was inevitable.”
Dr. Kellermann writes about “boarding patients in exam rooms or hallways who need inpatient care”. He notes the very negative and dark side of ambulance diversion and that cities may experience the “health care equivalent of a “rolling blackout”. Everyone’s care is affected…”
Congress enacted the Emergency Medical Treatment and Labor Act (EMTALA) in 1986 which allowed everyone in the United States to acquire legal rights to emergency care. However, Dr. Kellermann argues that because this mandate (EMTALA) was unfunded, it created a perverse incentive for hospitals such as OSF-SFMC to tolerate Emergency Department overcrowding and divert ambulances while continuing to accept elective admissions.
My letter to OSF CEO Keith Steffen in September, 2001 was asking for his leadership and help for problems in Peoria that were very similar to problems addressed by the IOM in 2006. I was fired several months after writing Mr. Steffen in 2001.
I communicated with Dr. Kellermann and spoke to the Project Medical Director of another city with 5 million people regarding the unfortunate EMS situation in Peoria. The Project Medical Director asked me what would happen in Peoria if there was a mass casualty with the Peoria Fire Department at a Basic level and nontransport. Good question, but I doubt this will be answered in Peoria, until after the problem occurs. Peoria will be in for a cruel awakening.
Dr. Kellermann stated in the article that the “IOM committee calls on hospitals to end the boarding of admitted patients in emergency rooms and the diversion of ambulances, except in extreme cases, such as community wide disasters”. OSF, are you listening?
He concludes that the IOM envisions a “coordinated, regionalized, and accountable emergency care system that is capable of delivering lifesaving treatment to all in need”.
Currently, this is not the system in Peoria for reasons outlined in this web log.
October 20, 2006:
The September, 2006 issue of Emergency Medicine News published a letter I wrote regarding emergency department overcrowding in Peoria and the consequences of what happens when doctors bring up sensitive topics. ("Paying the Price for Speaking Up").
Emergency Medicine News:
September 2006 - Volume 28 - Issue 9 - p 10-11
Paying the Price for Speaking Up
Carroll, John A. MD
I agree with Dr. Edwin Leap's opinion in his March column, What Are We Afraid Of? (2006;28:15.) Physicians need to go public with patient care concerns. I believe physicians don't speak up because they fear losing their jobs and being marginalized in their community. That was my experience.
I live in a mid-sized, Midwestern city, and in September 2001, I was placed on six months' probation from my job as an emergency physician at a large medical center. I was confined to working in the urgent care center. My probation occurred the day after I wrote a letter to the hospital administrator (with copies to all the attending physicians in the ED including the director) about my concerns regarding long waits in the ED. When I wrote the letter, the ED was crowded, patients were lying on gurneys in ED hallways, and patients were signing out because I could not admit them to a bed in a timely fashion.
After I started my probationary period, the ED director told me that I could return to the main ED if I were evaluated by the hospital's wellness committee for burnout (a point not mentioned in the probationary letter). The hospital administrator referred to me as a cancer in the department who needed to be cut out before it metastasizes.
The ED had a dismal patient satisfaction rating of 33 percent and a low employee satisfaction level at that point. As the weeks went by, I continued to work in urgent care, but I refused to be evaluated by the wellness committee. The administrator who had referred to me as a cancer was discussing my case inside and outside the hospital. I was made the problem rather than placing the blame on the systematic deficiencies that plagued the ED.
While working an urgent care shift in December 2001, I was called to the administrator's office, and with another administrator, the ED director, and hospital legal counsel present, I was fired. After 20 good years as a resident and staff physician there, I packed up my gear and left.
The reason I wrote to the hospital administrator that September was that ED crowding and hospital bed capacity are systemic hospital issues. I also did not think the ED director would do much. Besides being the ED director, he had been the project medical director for the previous eight years, and he was still on the payroll of the city's only private ambulance company, the exclusive provider of the city's paramedic and transport prehospital care. The hospital is the base station for the area, and is the main supporter of the lucrative private ambulance service. Our fire department is held to a nontransport basic level, and according to the firefighters, obstacles were thrown up over the years by my boss when they attempted to advance their level of care for the citizens of the city. This arrangement was known all over the state in EMS circles and considered a serious conflict of interest by many.
Before and after I was fired, I attempted to go through channels within the medical center to explain my concerns for the prehospital patient and about the long waits in the ED. Administrators, corporate, and the ethics committee would not address my complaints. Letters to the JCAHO and the state department of public health were not helpful.
I have picketed the hospital, written letters to the local newspaper, and presented frequently to the citizens' forum at city council meetings. I also have written a web log, www.peoriasmedicalmafia.com about the past five years. Recently, a local newspaper editorial stated that our ED was seeing almost twice the number of patients that the original ED was designed to accommodate safely, and it noted that diversion of patients due to insufficient hospital bed capacity was a significant issue.
The most difficult part of this experience isn't being unemployed. It is abandonment by people who I thought would stand up for quality care issues facing our community. Many of my physician mentors who taught me patient care when I did my residency there no longer will see me or speak to me. The religious community that founded the medical center is silent, and the business community in our close-knit city supports the medical center and the private ambulance company. The EMS issues here that could be improved for public health reasons are relegated to secondary importance, with money taking precedence.
I would do this again but only reluctantly. Going public is necessary for physicians if we want positive change. It is not a heroic thing to do. It should be expected. But be ready to pay the price.
John A. Carroll, MD
© 2006 Lippincott Williams Wilkins