The Houston Fire Department
“We make a lot of runs where it’s not an emergency situation,”… “And while we’re on that run, we hear another run in our territory — it could be a shooting, or a cardiac arrest — and now an ambulance is coming from farther away, and it’s extending the time for the true emergency to be taken care of.”
On a recent morning, Houston FF Tyler Hooper drove through the rain to answer a call at an apartment complex near Hobby airport. Susan Carrington, 56, sat on her couch in a red track suit, coughing and gasping.
“Have you seen your doctor?” Hooper asked. Carrington shook her head.
“No? OK,” Hooper said.
Carrington doesn’t have a regular doctor. She called 911 because she got scared. It hurt to breathe, and the cough had been bad for four days, she said. In January, she had visited a hospital emergency room for similar symptoms and been given an antibiotic for pneumonia.
Houston firefighters also handle emergency medical calls, so all are cross-trained as EMTs. Many are also advanced paramedics. Hooper and three others reviewed the data from Carrington’s initial exam.
“Based on your vital signs, everything looks stable to us,” Hooper said. “Your lungs are clear. Your blood pressure’s great. Your pulse is good. Everything looks good.”
Previously, Hooper might have taken Carrington to the ER, just to be safe.
But now he has an alternative: a computer tablet loaded with a video chat application.
Hooper launched the app, and Dr. Kenneth Margolis appeared on the screen. Margolis was seated almost 20 miles away, in the city’s emergency management and 911 dispatch center.
“Can I just talk to Miss Carrington for a second?” Margolis asked.
Hooper swiveled the laptop screen toward the couch, bringing doctor and patient face to face, at least virtually.
Susan Carrington, 56, has a video chat with a doctor from her apartment. The doctor reviewed her symptoms and arranged a clinic appointment for the next morning instead of an immediate ambulance ride to the emergency room.
“Ms. Carrington, I’m a doctor with the fire department,” Margolis began. “So you’re having a cough, and feeling weak and having some trouble breathing, is that right?”
“Yes, sir,” Carrington said.
“And it hurts when you breathe and cough?”
“Yes.”
The questions continued, with Margolis able to watch Carrington’s face and reactions.
Margolis agreed an ER visit wasn’t necessary. Instead, he scheduled an appointment for her at a nearby clinic for the next morning. He also arranged a free, round-trip cab ride. He told her the taxi would be there at 8:30 a.m.
“They’ll take you to the clinic and your appointment is at 9:30. Does that sound reasonable?” he asked.
“Yes, sir,” she replied.
“OK, I hope you feel better,” he said.
The intervention is known as Project Ethan, an acronym for Emergency TeleHealth and Navigation. It rolled out across all city firehouses in mid-December.
“I think a lot of people are very surprised that they can talk to a doctor directly, and have been very happy with that,” says Dr. Michael Gonzalez, an emergency medicine professor at Baylor College of Medicine. He’s the project’s director.
Gonzalez says the idea is to direct patients like Carrington to primary care clinics, instead of just automatically bringing them to the emergency room. Ambulances can be tied up for precious minutes — even an hour — as EMTs or medics do paperwork or wait for a nurse to admit a patient to the ER. By sending some patients to clinics, ambulances can remain in the neighborhoods, and overloaded emergency rooms can focus on urgent cases.
Gonzalez says the program doesn’t just turn patients away from the emergency room. It offers an alternative — a doctor’s appointment that day or the next, and transportation there and back.
City health workers also follow up with the patients to identify other issues that may be leading them to use 911 inappropriately.
Houston has some grants for the program, including money from a federal Medicaid waiver. But the project costs more than $1 million a year to keep running.
Gonzalez predicts it will eventually reap far more in savings for the region’s overburdened emergency system.
A 2011 study of emergency rooms in the Houston area showed 40 percent of visits were for problems related to primary care. Treating those patients in the ER costs, on average, $600 to $1,200 per visit, compared with $165 to $262 if the patients were treated in an outpatient clinic. If all those ER visits could be referred to a clinic, the savings would be more than $2 million.
