“Your ankle has hurt for months, what brought you in today?”
“It’s quiet on Sundays.”
The instant dismay of seeing a well person in emergency is somewhat offset by her disarming honesty. She is poor, ill-supported and not sure what symptoms to report where. In the corridors of disadvantage where I work, this is typical.
“What made you call an ambulance?”
“So they’d see me quickly.”
Now, I am irked.
Next door is a young man with brittle asthma whose condition lands him in hospital every year. His mother says the ambulance used to arrive quickly but now when they call, her heart is in her mouth. It’s hard to believe her son who follows every advice could yet be the casualty of an ambulance delay.
A lot of my time is spent inside the hospital where help is one call away. But outside this privileged environment, when a medical disaster unfolds, the surest sign of reassurance for me is the sight of an ambulance. Paramedics act quickly and methodically. They treat the injury while thinking ahead about what could go wrong. I have watched them with my own family and marvelled at their skills.
Anyone experiencing an emergency deserves the same meticulous care but only if we treat the ambulance service with equal care.
In Australia, an ambulance attends an incident more than 5 million times a year. Incidents are prioritised as emergency (lights and sirens), urgent, non-emergency and emergency room attendance.
In 2021-22, 42% of calls were considered an emergency, a further 32% as urgent, but a quarter of calls were for non-emergency reasons.
Constipation (515 calls in one year according to New South Wales Ambulance), toothache (186) and blocked ears (78) are some reasons people summon an ambulance. Also nightmares, nappy rash and tonsillitis.
Unsurprisingly, paramedics who are treating trivialities are then unavailable to the toddler who drowns, the father having a heart attack and the worker slashed by a chainsaw.
There are situations where an ambulance should always be called: severe pain, breathlessness or bleeding, sudden numbness or paralysis, trauma, altered consciousness and large burns. But on any given day, a snapshot of the emergency department shows that many patients are (thankfully) not a true emergency.
It’s not uncommon for doctors to wait for an “emergency” patient who has stepped out to smoke or buy better food. One woman asked us to return so she didn’t lose her place in the queue for concert tickets (we obliged). There are many elderly patients, infirm, lonely and clearly in need of help though not from an acute hospital.
The volume of inappropriate emergency presentations via ambulance invites puzzlement that people could be so frivolous with a precious asset. But when I listen to their stories, they don’t sound manipulative. A useful explanation may be that professionals and patients have different definitions of a health emergency.
Professionals consider a health emergency as a sudden or unexpected event requiring urgent assessment and treatment. This definition is based on clinical judgment and physiological cues. But the patient’s perception is based on emotional cues and layperson views. Patients cannot be expected to accurately evaluate the urgency of a health event.
A perfect illustration of this occurred when my friend’s son returned from a flu shot. Noting his lethargy, she called an ambulance to say her son was unresponsive. Unresponsive has a very specific meaning in medicine and it does not include grunting teenagers. Two ambulances with lights and sirens roared to the rescue, only to find a surprised child and a sheepish mother.
I remember that day only because my mother had waited until morning to tell me about the severe pain that had stolen her peace all night. She hadn’t wanted to bother the ambulance, although I think like many of my patients not fluent in English, she was unsure how to explain her symptoms. Versions of both incidents happen every day, each harmful to the public purse.
Paramedics say when people call an ambulance, a risk-averse system searches for the worst-case scenario at the expense of the most likely one. Dispatchers must adhere to a script that prevents making a judgment call, which is not how real-life medicine operates.
In a time of scarcity, all resources must be used wisely. One positive step may be pairing experienced doctors with dispatchers and allowing room for clinical judgment.
Research shows that people who arrive at an emergency department by ambulance have a higher self-reported perception of the seriousness or urgency of their problem than patients who self-present. They also believe they will receive better and safer care. Using the ambulance service wisely means improving health literacy. In 2006, just 41% of Australians aged 15-74 were assessed to have adequate skills to understand and use health information. In the 60-74 age group, the most likely to develop problems, the figure was an abject 22%.
Every time we make way for a lights and sirens ambulance, I tell my children about the situations that might warrant it, thus providing a sliver of education. I also counsel my patients that “I’ll just call an ambulance” is not a panacea.
Besides seeing a GP where feasible, free round-the-clock options for medical advice include calling a registered nurse and accessing a virtual emergency department.
Care-coordination and democratising access to different types of care are both important aspects of good healthcare.
Finally, it is surprising how many people face bill shock for ambulance transport and even more surprising how cheaply one can circumvent it. One ambulance trip can cost more than $1,200. In Victoria, the cost of ambulance membership is $53 for the whole year. If your private insurance doesn’t fully cover it, you should consider protecting yourself with ambulance cover.
In our lengthening lives, many of us will need an ambulance. For the remedies and reassurance that paramedics provide, it behoves us to save their skills for the people who need them the most.
• Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is called A Better Death
