Suggestion Selling

I’m a cellar dweller. There, I’ve said it.

They say that admitting the problem is the first step on the road to recovery, and in that spirit, I have decided to come out of the closet on my shameful record of obtaining refusals.

Now what is a refusal, you may ask? Good question.

Simply put, a refusal is a signed document stating that a potential patient (what exactly constitutes a patient is a matter of some debate) does not want an ambulance to transport him to the hospital for treatment of crotch rot demonic possession stubbed toe toothache for one month whatever ailment led to the desperate call to 911 for we stalwart EMS heroes to save the day.

The problem is, not everyone wants to go to the hospital in the bolance. Some indeed need to go, yet are reluctant for whatever reason, while others need an ambulance ride only slightly less desperately than they need forced sterilization and banishment to a deserted south Pacific island.

It’s the second category that I have a problem with.

I’m good at convincing those reluctant souls that need to go to a hospital. I’m a persuasive fellow. In the event that persuasion fails, I’m adept at documenting the considerable lengths I went to convince them that ambulance transport was in their best interest:

Ambulance Driver: Sir, in my professional medical opinion, you need to be evaluated by an emergency physician and perhaps a neurosurgeon for your injuries.

Head Injured Patient: Fuck you, Amma-lance Boy. I ain’t goin’ in no meatwagon. ‘Sides, it’s just a scratch. My cousin had the same thing happen to him, and he’s fine now. Ain’t that right, Cuz? Drool for the man!

AD: Sir, if that clear fluid were only draining from your nose, I’d say it was simply snot. But it’s draining from your ears, too. That’s not normal.

HIP: Jus’ a scratch, muh fucka. Y’all just want my money, thass all!

AD: Sir, The Borg requires no money up front for services rendered, and accepts all reasonable payment arrangements. You may even be able to break your $500 bill into 120 easy monthly payments, leaving you plenty of disposable income for spinner rims and a new diamond encrusted grill. We can also transport you to the charity hospital across town, but it is my duty to inform you that they have no neurosurgery capability and that their medical resources are slightly less extensive than Walgreen’s, Aisles 9-12. They do give out free condoms, though. Walgreen’s charges money for their condoms. It’s pretty much a tie.

HIP: Fuck you, man! I pays my bills!

AD: No doubt you do, Sir. You have ‘credit score of 800’ written all over you. Still, there is a growing puddle of brain matter on both your shoulders. I implore you, allow me to treat your injuries and transport you to an appropriate medical facility. Refusing medical care poses certain long-term health risks that – “

HIP: What kinda health risks?

AD: Seizures, permanent cognitive impairment, paralysis, blindness, deafness, possibly even death.

HIP: Fuck dat. Long as my dick works, I’m aight, boyeeeeeee!

AD: Erectile dysfunction has been identified as potential long term sequelae in 74.3% of head injury cases.

HIP: Huh?

AD: Your dick’s gonna fall off, dude.

HIP: Oh.

AD: Your stretcher awaits, Sir.

Nope, I’ll employ whatever means necessary, stopping just short of lying and outright coercion, to convince someone when I think they need to go to the hospital.

Now, I work a for-profit EMS company. Quite simply, we make our money by taking people to the hospital. I knew and accepted that when I signed on. Since we’re an employee-owned company, in a very real sense, I’m taking money out of my own pockets when I allow someone to refuse transport.

It’s a fine line I walk, legally and ethically. Statistically, upwards of 50% of civil litigation against EMS providers involved a refusal of care by the patient. It’s a minefield of potential liability. I’m cognizant of the dangers. Refusals usually require more documentation than if you had simply transported, so laziness isn’t a factor, either.

The problem is, when you start thinking that you have the knowledge and training to decide – for the greater good – whether an individual needs an ambulance or not, you take a long step out on a very thin branch. Taxpayer-funded systems see the ramifications of a bad decision more often than for-profit EMS, simply because when you take away the financial motive for the transport, that leaves you a good deal of leeway in deciding whether the patient actually needs that ambulance or not. Even if your system does not allow paramedic-initiated refusals, when no one is pressuring you to transport each and every patient, you’re less likely to expend great effort to enable a malingerer convince a patient with a minor complaint to take a ride to the hospital in the ambulance.

Such attitudes often become part of the departmental culture, resulting in the common stereotypes of EMS delivery systems:

For profit EMS = greedy bloodsuckers who transport anything to make a buck. Picture Snidely Whiplash twirling his mustache as he counts his piles of money.

Taxpayer funded EMS = stalwart heroes who stand resolutely like Horatio at the gate, keeping the malingerers and system abusers out of the ERs in our fair city.

Of course, like most stereotypes, neither is particularly accurate, but they first become stereotypes by having a grain of truth at their core. Many of my supervisors at The Borg look at transports as, if not the only relevant performance measure, certainly one of the most important.

And there I sit, month after month, down there at the bottom of the transport spreadsheet among the slackers and burnouts.

People like my partner, who envisions herself as heroic Horatio, but in reality is so burned out that if she were toast, I could scrape her over the garbage can until all the black crumbs are gone, and I’d be left with a wafer thin enough to read a newspaper through. She’s too young and inexperienced to realize it yet, but she’s not gonna be happy in any EMS system.

I think many of the higher-ups had heard the buzz about me, and perhaps hoped in vain that I’d be able to teach her some people skills. Heck, so did I.

We have abandoned that faint hope.

Her problem isn’t lack of people skills, at least not compared to the Higher Beings on that transport rankings heirarchy. They both pretty much act the same, albeit directed in different ways:

Burnout Partner: “What is this bullshit? I can’t believe you called us out here for your fucking gunshot wound! For p
ity’s sake, man the fuck up and get over it! What was it, a nine millimeter? You pussy. You gonna let a little nine millimeter hole in your thorax stand in the way of rubbing out the fucker who shot you? Suck it up, dude. Your homies are watchin’.”

Transport King: “What is this bullshit? Somebody called 911 for a stubbed toe. I got out of bed for a stubbed toe. I’m fucking taking a stubbed toe to the hospital. What’s that? You didn’t call 911? What the hell do I care? Somebody called 911, and I’m not leaving until somebody gets on my stretcher. If I have to, I’ll park my ambulance in your driveway and sing Henry the Eighth, I Am over the loudspeaker until someone gets in my rig. Don’t test me, I’ve done it before. You know, last week we had a lady with a stubbed toe who refused to go to the hospital. Turned out the toe was broken, gangrene set in, and it mutated into some weird airborne strain. Killed her whole fuckin’ family. Swear to God, dude.”

Call me a namby pamby waffler, a fence-sitter if you will, but I kinda like to split the difference between those two extremes. This means that I will not likely get my company sued in the near future, because I don’t get inappropriate refusals, and my documentation is thorough…

…but I probably ain’t gonna wind up in that upper tier of performance appraisals, and thus my raises will be less, and I will be stuck in a dead-end field job in Crack Central for the foreseeable future.

That I can deal with. What is mildly irksome is that I will be regarded by some of those less-enlightened supervisors as an inferior medic to Transport King. The reality is that I daily flush more EMS knowledge into the sewer system after my morning constitutional than Transport King currently possesses.

My problem is that I’m a salesman who doesn’t believe in his product. In high school, my distributive education teacher, Mr. Kilpatrick, used to say, “you sell the sizzle, not the steak.” He’d go on to wax eloquent about the steroid-laden, semi-charred hunk of animal flesh and sinew we were supposed to be hawking:

“Mmmm, smell that? That’s the smell of certified Angus beef grilling over a hot hickory fire, my friend. A nice thick porterhouse -why have just the filet or the New York strip when you can have both, am I right? – rubbed with sea salt and a secret blend of seasonings, seared to utter perfection, thirty seconds on each side. Just enough to seal in that rich flavor, lock in those juices…and when you cut into that steak, my friend – your fork is all you’ll need – those juices run across your plate, right into that heaping mound of garlic mashed potatoes and crisp, steamed fresh vegetables, grown right here in our own garden. In fact, the only thing not grown right here is the fine German beer that we serve with it – dark, thick and yeasty. I tell ya, friend, it’s the perfect complement to a fine American steak. You owe it to yourself to have a meal like this, my friend. You’ve worked hard all week. You’ve earned it.”

And if you’re a carnivore like myself, you can picture it. Hell, you can probably even do a better job of describing it, because you believe the pitch.

When I try to convince a patient to go to the hospital when they really don’t need an ambulance, I come off like a gay vegan waiter trying to sell that same steak to the Marlboro Man.

What’s that, Sir? Don’t find that appetizing? Me neither, Sir. Perhaps some tofu, then?