Houston`s New Prescription for Busy EDs, Ambulances: Technology

June 21--It is nearly 6 o'clock when Ambulance No. 46 begins its return to the station. The skies over south Houston, undecided for most of the day, choose now to let loose sheets of rain.

Alden Speer is behind the wheel, Arturo De La Garza is in the back. The hours are starting to wear on them. They could use a bite to eat.

The firefighters, both 25, both emergency medical technicians, have been driving miles of circles through the tough streets of Sunnyside and South Union, from house to hospital, again and again, almost like a cab, picking up fares.

Then, as the ambulance slows to turn into the station, there's another call. A 75-year-old with abdominal pains. Dinner must wait. Lights flashing and siren wailing, Speer threads the aging box of a truck through rush-hour traffic.

"How can we help?" Speer asks the group of about a half-dozen as he snaps on purple surgical gloves. Cars clog the driveway; a child peeks out a screen door. He learned in EMT school to keep his voice calm yet forceful. But now he sounds puzzled. No one seems in distress.

A grizzled, barefoot man in sagging jeans and a green T-shirt stumbles forward. He winces as he walks, his legs jittery. He tells them his name is Douglas Benjamin, and it hurts when he pees. He has to go all the time. He had some medicine but stopped taking it. His friend called 911, so he can go to the emergency room to see a doctor. And he wants to go by ambulance.

"If I go by ambulance, they take me right to a bed," Douglas says.

"No sir, that's not how it works," Speer replies steadily.

But in truth little works in a system that has been broken for years. Over the past generation, patients began to see emergency rooms as doctor's offices, taking ambulances to get there.

It's the most expensive ride to the most expensive kind of medical care in the world.

An ambulance trip costs at least $1,000. Just walking through the ER doors adds another grand and a half.

More troubling is a recent study by the University of Texas' School of Public Health that showed 40 percent of patients streaming into Harris County's overburdened ERs don't need to be there; either their condition is not urgent or they are using the ER for something that can be or should have already been handled by a primary-care doctor or clinic.

The reasons behind this shift are not fully understood, buried somewhere in a tangle of public misperceptions, lack of access to primary care and habit.

Speer rolls his eyes at the 40 percent figure. "It's higher," he says. Last year, Ambulance No. 46 was the busiest in the city with 5,154 trips to the hospital.

What if, he suggests to Benjamin, they call a cab on the city's dime to take him to Ben Taub, Houston's largest public hospital? Or maybe -- he glances at the cars out front -- somebody could drive him?

An ambulance does not bump you to the head of the line. ER staff triage the incoming based on urgency, not how they arrive, and schedule accordingly. At Harris Health System, which Ben Taub is part of, ER wait times are five times longer than the national average.

"I want to go by ambulance," Benjamin says, his voice rising. "I'm a senior citizen, and I've got a right to go by ambulance."

De La Garza and Speer shoot each other a look, neutral but knowing, as they help him into the ambulance: another one.

In 1986, Congress enacted the Emergency Medical Treatment and Labor Act, which compels hospitals with emergency services to provide screening and stabilizing treatment for patients regardless of ability to pay.

What's happened since bears little resemblance to the law's intent. Hospitals believed the law meant everyone had to be treated for everything. No one wanted to risk overlooking someone sicker than they appeared. And patients began redefining the notion of emergency.

"An evolution has occurred in the last 20 years or so," says Charles Begley, professor of management, policy and community health for the University of Texas' School of Public Health. What once had been predominantly trauma care in ERs has turned into treatment of chronic conditions and basic health care for the poor and nearly poor, he says.

At the same time, 911 became no longer a call of last resort.

Last year in Houston, 318,630 calls to 911 got routed to the fire department, with medical calls outstripping fires by nearly seven times. About 80 percent resulted in trips to the hospital. It is not known how many were true emergencies, but one indicator is how often lights and sirens were used en route to the hospital. The best guess is more than half are not urgent, fire officials say.

The result has created a crisis, especially for public hospitals. At Harris Health System, there were 144,891 ER cases between March 2014 and February. Of those, 61.5 percent of patients were indigent or uninsured.

"It's unsustainable," says Dr. David Persse.

He has seen all sides. In the 1980s, he worked as an EMT and paramedic in Buffalo, N.Y. He then went to Georgetown University to study emergency medicine. He came to Houston in 1996 and is now physician director of Emergency Medical Services for the Houston Fire Department and head of Houston's Public Health Authority.

Six months ago, he helped launch a first-of-its kind project that had been percolating for years. It is called ETHAN, for Emergency Tele-Health and Navigation, a common-sense concept that mashes EMT tradition with emergency-room triage and wraps it in modern technology.

When a fire truck or ambulance arrives on a 911 call, a quick assessment is done. If the patient appears critical, he or she is transported. But if the complaint does not seem to rise to an emergency, a doctor trained in emergency medicine is called to talk to the patient by video chat on a specialized tablet.

The doctor searches troubled voices, inconsistent stories and the grainy images for clues. If the condition could be handled by a primary care physician or at a clinic, the doctor makes the appointment on the spot and arranges city-paid transportation by cab -- a sliver of the cost of an ambulance. If the patient still wants to go to the ER, the ETHAN doctor has the power to insist they go by cab or find another ride.

Not only does this cut costs, it gets ambulance crews back into service faster.

Since the December launch, there have been about 1,000 ETHAN calls. By some estimates, it has already saved the city $1 million.

Once patients are in the ETHAN system, they are contacted by a public health nurse or counselor for a follow-up home visit to make sure they have a doctor and keep their appointments. Living conditions are assessed to see if other types of assistance are needed. The goal is to keep people from returning to the ER.

ETHAN's funding comes through a provision of the Affordable Care Act that supports programs using technology to find more efficient and less costly health care.

"We're at an interesting crossroad in the U.S.," says ETHAN's program director Dr. Michael Gonzalez. "We are at the intersection of 'Can we safely triage that need?' and the emerging technologies of 'Right now, from anywhere.'?"

In a darkened first-floor room of the Houston Emergency Center, banks of computers cast an eerie glow. The hum of lowered voices is constant as paramedics take calls, sent from the main 911 switchboard a floor above, and sort which ambulance goes to which hospital with the speed and precision of a blackjack dealer.

Up front a lone figure in blue scrubs and headset sits with his own computers and phones. He is dealing from a different deck.

"ETHAN doctor." A video call comes to Dr. Kenneth Margolis, an emergency medicine physician at CHI St. Luke's Health, who is working a 10-hour shift parsing ETHAN requests from the field.

His fingers fly across the keyboard as he takes information from the ambulance crew: Hypertension. Diabetes. Swollen toes. In pain for one week.

"Is she out of her medicine?" No, the crew tells him.

"It was prescribed on April 23? Why is it still full?" That was a month earlier. She was in the ER two days before. "Her infection is not going to heal if she doesn't take her medicine."

The screen flickers and a middle-age woman's face appears. Margolis speaks gently but firmly.

"I'd be glad to set you up with an appointment, but you don't need to go to the ER," he says.

More fast typing. A 1 p.m. appointment is made at the Good Neighbor Healthcare Clinic. A cab is called to take her there.

"I hope you get to feeling better soon. Good luck to you."

It took 15 minutes. Another call is on hold.

A chatty 25-year-old man says he vomited, feels weak and wants to go to the hospital. He just started a new diet and hasn't eaten in two days.

Margolis struggles for patience. "The hospital is just going to tell you to eat something," he says.

The man changes his story. He wants to eat but "can't keep anything down."

Margolis tells the young man he can go to the hospital -- by cab.

Then there's a woman who is out of her medication. A refill is at the pharmacy, but she doesn't have a ride. Margolis reminds her the wait at Ben Taub could be hours. Isn't there someone who can drive her to the pharmacy? A family member volunteers.

Margolis rubs the bridge of his nose and exhales hard. He takes a long swig from the jumbo caffeine-free diet soda nearby.

"ETHAN doctor."

This time a young woman's face is streaked in tears. Her headaches are getting worse. She has a 101.2 fever.

"Why are you crying? Are you scared? Don't be scared. We're going to make sure you feel better," Margolis says. No impatience this time. He books a cab to take her to the ER.

Emergency medicine is about making snap decisions. It's about sorting the urgency. He knows mistakes will be made. He'd rather err on the side of caution. But the volume of non-emergencies irritates him. He worries about becoming cynical.

"I'm 10 years out of residency and you walk into a patient's room and you wonder, 'Is there really anything wrong with them?' That scares me."

ETHAN is imperfect. It needs more doctors. It is unavailable after 10 p.m. There is a learning curve for everyone, including the public.

A few days before, Ambulance No. 46 was called to a convenience store for a homeless man named Johnny Bruins. His clothes were torn, he was disoriented. A string of drool hung from his lips. "Fix my mouth," he pleaded. He was still wearing the plastic bracelet from the hospital he walked out of earlier in the day.

The crew set up the ETHAN call, and it was decided he will go back to the hospital but by cab. The cab driver took one look at Bruins and balked. "I'm not going to take him," he said and sped away.

Bruins went by ambulance.

Back at Houston Emergency Center, the calls are backing up. A woman had called 911 from inside a medical clinic. It is 12:20 p.m., and she has a 1 p.m. appointment. She wants to be taken to Ben Taub because she doesn't want to wait. Margolis talks her out of it.

"I really think this program is going to work," he says, taking a breath between calls. "This program has to work."

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