As far as medical emergencies go, those of us who are relatively healthy perish the thought of two fire trucks and an ambulance racing across our quiet neighborhood with two-tone sirens, red fresnels spinning in front of our house -- unless, that is, we're in real dire straits: I told him to cut that T-bone smaller but he would he listen, no, and now he's as purple as Grimace; I would say the blood is a-geysering, ma'am, painting the walls Jackson Pollock style; yes, sir, from where I'm standing the head and/or torso seem to be on fire at this point. You get the picture. We'd only call 911 if the benefits of emergency care outweighed the risks of social embarrassment. No one wants to be the neighborhood hypochondriac.
Because for most of us, calling 911 is like punching the big red button on the nuclear football: a potent barrage of medical warheads are now headed inexorably our way. This is probably why only 30-50% of people truly having a heart attack or stroke call an ambulance. They'd rather be driven or, heaven forbid, drive themselves to an emergency room to get checked out than "go nuclear". That's unfortunate, because these are illnesses for which every minute counts and EMS is the most efficient means of getting people to lifesaving treatment. Somewhat discouraging is also the fact that it doesn't matter whether public health groups barrage communities with television spots or put up billboards exhorting people to call 911 if they're having chest pain or stroke symptoms; still only around 50% will call emergency services for transport. This makes some sense because many heart attacks and strokes can be mild in presentation and folks quite naturally wait to see if symptoms pass before dialing for help. Indeed, the propensity to call 911 seems to be associated with the severity of stroke symptoms in some studies. Plus, we live in a world of outrageous medical cost in the United States. Who wouldn't think twice about a little chest pain before calling 911, especially if you're uninsured? (An ambulance ride can cost anywhere from $224 to $2,204.) However, the basic hesitancy to activate EMS seems to be a worry about bothering a bunch of people unnecessarily and this concern seems like a fixed attribute of human nature that is immune to public health campaigns, regardless of country or healthcare system. The bottom line is that too often people don't use 911 for potentially serious stuff. If there were a less "nuclear" way in which providers could respond to these emergencies, perhaps people would be less shy about calling. Many of us in EMS are thinking of ways to do just this and some communities have even developed a nurse hotline, working in parallel and in conjunction with 911 to field questions like "I'm a little worried about how hard it is to breathe through my nose with all this congestion. Do I need to see a doctor right away for this?"
Given the hesitancy of most people to dial 911 for true emergencies, it is somewhat understandable that my friends, even my emergency physician colleagues, can be amazed to learn that, by contrast, there are people in every urban community who dial 911 once a month, a few who call once per week, and even several who call once or more per day for extended periods of time. (I know this because we EMS medical directors compare notes at medical conferences and the academics among us report findings of such EMS "superuse" in print.) In the Wichita, Kansas area, for example, 50 individuals accounted for 1,335 calls to 911 over a one year period, according to the Wichita Eagle. 911 is not a long number to punch into your tricorder, but these people have it on speed dial! These heavy users have been variously referred to as superusers, frequent flyers, or customer loyalty club members and, as you might imagine, they can cost the municipality or private ambulance services a lot of money in unreimbursed care, not to mention wear and tear on city streets and the environmental costs of a large carbon footprint when big firetrucks are being continuously dispatched to check them out.
What compels this segment of society to use 911 so frequently? We're not totally sure because the study of this potential problem is only recently starting to receive the attention it deserves. What is apparent, however, is that many lack other means of transportation to go to the hospital, often due to poverty and homelessness; age and Medicare insurance are both associated with increased use; and alcoholism, chronic seizures, and chronic respiratory illness and poor access to primary care may also play a part. It should be emphasized that while frequent users are statistical outliers, it is not entirely clear how often these transports are truly medically unnecessary, because this determination requires a definition of medical necessity that is symptom-based and not reliant solely on the ultimate diagnosis. Patients cannot diagnose themselves, so they must clearly have symptomatology that any prudent layperson would consider a non-emergency before they can be classified as using 911 in a manner not in good faith -- something very hard to define. Making this distinction more difficult, heavy EMS users sometimes have significant medical comorbidities and are frequently advised by discharging physicians to return immediately to the ER to seek care should they experience any of a host of symptoms that might represent an acute exacerbation of their underlying illness. Free access to a medical professional over the phone who can provide alternative pathways of care in the prehospital setting might help these patients get the right care at the right place or even reassure callers that their symptoms can wait.
As you can see, the psychology of 911 is a tricky business. We want you to call if you are possibly having an emergency. We just don't do a good job of helping you figure out whether your symptoms could be an emergency requiring ambulance transport or even evaluation in an emergency department. Nor do we currently help you figure out how to navigate a very confusing system of outpatient care that may or may not see you depending on insurance status, nor do we provide alternate means of transport to medical evaluation for less acute patients. The future of 911 dispatch and emergency care needs to recognize these opportunities and challenges.
