Last year, the Houston Fire Department logged more than 318,000 incidents, but only thirteen percent of them were actual fires. The rest were medical calls, and many were for minor things like cuts, coughs and colds. Those small problems can add up to a big burden for the entire 911 system, so firefighters and doctors are using video chat to work out a possible solution.
On a recent drizzly Monday, Houston firefighter Tyler Hooper tried the intervention for a 911 call that came from an apartment complex near Hobby airport. Susan Carrington, 56, was slumped on her couch in a red track suit, coughing and gasping. Her adult son sat nearby.
"Have you seen your doctor?" Hooper asked. Carrington could only shake her head.
"No? Okay," Hooper said.
Carrington later said she didn'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 St. Joseph's ER 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 higher-level paramedics. Hooper and three others reviewed the data from the 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."
Hooper told Carrington she may indeed need a doctor's appointment, but she didn't need to rush to an emergency room right away, where she could wait hours to be seen.
Panasonic G1 Touchpad is the device used in Project Ethan. Photo credit: HFD
"What I'm going to try to do, if you're alright with it: the city has a new program called the Ethan program and they're going to get you set up with either a ride to the hospital of your choice, or to a clinic to be seen."
Carrington agreed to try it. Hooper used his computer tablet to open a video-chat program and Dr. Kenneth Margolis appeared on the screen. He was seated in the city's emergency management and 911 dispatch center, almost 20 miles away.
"Can I just talk to Miss Carrington for a second?" Margolis asked.
Hooper swiveled the laptop screen towards the couch. Doctor and patient were face to face.
"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?"
The questions continued, with Margolis able to watch Carrington's face and reactions.
"You had chills or just sweats?"
Eventually, Dr. Margolis agreed an ER visit wasn't necessary. Instead, he scheduled an appointment for her at a nearby safety-net clinic, for the next morning. He also arranged a free, round-trip cab ride.
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," said Dr. Michael Gonzalez, an emergency medicine professor at Baylor College of Medicine. He's the program's director.
Houston firefighters learn how to use a live video chat program, so they can consult with an emergency medicine doctor while out on 911 calls. Image credit: HFD
Gonzalez said the idea is to direct patients like Carrington to primary care clinics, instead of just automatically bringing them to the emergency room, where ambulances can be tied up for precious minutes — even an hour — as EMTs do paperwork or wait for a nurse to admit the patient.
By diverting some patients to clinics, ambulances can stay out in the neighborhoods, and overloaded emergency rooms like Ben Taub can focus on urgent cases.
Hooper drives the busiest ambulance in the city, out of station 46 in the Southside neighborhood. The low-income neighborhood is east of 288, near the South Loop. Hooper says many residents don't have insurance, but even ones who do have coverage don't always have a regular "medical home" or a car to get to appointments.
"They didn't know they could walk into certain clinics without appointments or without insurance," Hooper said. Calling 911 is "just what they've always done or what they've been taught."
The calls for trivial injuries or minor illnesses can be a strain on the system, Hooper explained.
"We make a lot of runs to 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, something where an EMS unit is truly warranted. And now an ambulance is coming from further away and it's extending the time for the true emergency to be taken care of."
Experts say the problem is a growing one, all across the country. More people are calling 911, and for more reasons than ever before.
It seems almost any firefighter you ask has memories of a minor call. Firefighters from Station 46 had many examples:
- A prescription refill
- A spider bite that's two or three weeks old.
- A nosebleed that's been going on and off sporadically for two weeks.
- A headache, or a laceration.
- Anything from simple colds, toothaches, stubbed toes to paper cuts.
Across the country, emergency medical services can't keep up with the demand, said Dr. Richard Bradley, Chief of the Division of Emergency Medical Services and Disaster Medicine at UT Health in Houston.
"In my experience the people who do this most often are people who do not have a pre-existing relationship with a primary care provider," Bradley said. Many times people have no car to get to appointments or the pharmacy, and use the 911 ambulance as transportation.
"I think that the Ethan approach is really a novel idea and really quite a good," said Bradley, who is aware of the project but not involved.
Other cities have experimented with programs to relieve the burden on emergency responders. Some programs analyze 911 data to identify "super utilizers," and send teams into their homes to arrange needed services such as transportation and follow-up care after hospitalization. Those home-visit programs are often called "community paramedicine," especially if they use paramedics to problem-solve the medical issues.
Other cities have tried to divert 911 callers by using nurse hotlines. Houston has also tried that approach, but firefighters complained it took too long, and patients never spoke directly with the nurse.
Ethan's innovation is the visual interaction between the doctor and patient, and the use of a emergency medicine doctor, not a nurse.
"One of the advantages of having an emergency physician on the other end of the line is you've got someone who is best suited to be able to look for subtle indicators of what may be an emergency," Bradley explained. "One of the last things we want this Ethan system to do is to have a significant miss."
Gonzalez said the program is also unique because it 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 Ethan patients to identify other issues that may be leading them to use 911 inappropriately.
Firefighters can refer patients to an Ethan physician on weekdays between 10 a.m. and 6 p.m. Many said the program looks promising but they'd love to add early morning and evening hours, and have weekend access. Dr. Gonzalez has said that will happen when the program is able to recruit more physicians for the four- or eight-hour shifts.
Firefighter Alberto Vela works in Houston's East End. He said Ethan could provide a permanent solution for "frequent fliers" who call 911 often.
Vela recalled one neighborhood resident who typically called 911 up to 40 times a month, often just to get a prescription refilled. He tried the video chat with her:
"I was so surprised by how long it took, it took maybe 6-7 minutes, tops," Vela said. "It was awesome, and then we left the scene and were making more calls after that."
Vela believes the program helped the woman find a regular clinic and transportation, because he hasn't visited her home for months.
"I would ask others shifts, ‘Hey, did you meet this lady?' The other shifts said they hadn't heard from her either.
"And that's very rare. So it's working," Vela said.
Back in Carrington's apartment, Dr. Margolis wrapped up the video call. The taxi would come for Carrington in the morning at 8:30 a.m.
"They'll pick you up and take you to the clinic and your appointment is at 9:30 with the doctor. Does that sound reasonable?"
"Yes, sir," said Carrington.
"Okay, I hope you feel better," Margolis said.
"Thank you," she responded.
The city has some grants for the program, including money from a federal Medicaid waiver, but for now it costs more than a million dollars a year.
But Gonzalez predicted the program will eventually reap far more in savings for the region's overburdened emergency system.
HFD ETHAN PROJECT