Kevin A. Roberts
At the beginning of the COVID-19 pandemic, when none of us knew what was happening, Chris Prener…also did not know what was happening. But unlike most of us, Prener, an urban and medical sociologist and assistant professor at Saint Louis University, had the benefit of expertise in public health, statistics, and mapping. So he decided to become a one-man band for all things COVID-19 data–related in Missouri and began posting numbers and context to his Twitter feed, as well as his weekly email newsletter, River City Data. It took off. Running the numbers was partly for his own benefit: Prener has a young daughter and wanted to make informed decisions about school and her health. “At the time, Johns Hopkins was the only large, cobbled-together COVID data set for the United States,” he says. “So I used their data and made some graphs and put them on Twitter. And people were interested in them, so I was like, Well, I’ll do it tomorrow night, and we’ll see how they change.” That was two years ago. Now Prener uses data from over 15 sources to present a more complete picture of COVID-19 in our area. As he winds down the COVID-19 data project, Prener, a former paramedic, is working on another issue in a forthcoming book: EMS resources.
Why do you think your COVID data project has been successful? I think there’s been a real desire among people to understand what’s happening around them. At the same time, what we saw over the course of that first spring was that all of a sudden different counties have dashboards, and SLU has a dashboard, and I’m guessing St. Louis Magazine doesn’t have a dashboard?
Correct. But major employers, right? Everyone’s got a dashboard. So if you live in St. Charles County, but you work in the city, now you’re checking the St. Charles dashboard and the city dashboard. We’re getting dashboarded to death here, and none of them provide regional context. One of the positive things that I think this has done is to provide a single place where you can see information and get a regional perspective on what’s going on. Then there’s this thought of, Now I have a bunch of information, but I don’t actually know what these numbers mean. How do I know if this is a good number or a bad number? Some of the positive response has been about guiding people through this process of understanding what’s happening.
During the pandemic, it was estimated that 25 percent of EMS calls in the city were COVID-related but were not true emergencies. You’re a former EMS worker, and you’re looking at the issue of what constitutes a “real emergency” in EMS in your book. What have you found? I think we all have this image of, This is what I would call 911 for. Someone gets hit by a car in front of you or you’re having crushing chest pain. But I think the thing people don’t realize is that maybe 10 percent of the call volume in a busy urban system is going to be the things you imagine calling 911 for. Then there’s a chunk of calls that you think, I guess I could see calling 911 for that. Someone’s fallen and they can’t get up, and they don’t have another option, so they push their medical alert button. Then there’s a whole chunk of calls where you’re like, Seriously, someone called 911 for that? My favorite example is that paramedics told me they were called because someone flossed and they had some gingivitis, so there was some blood when they spat. Paramedics look at that and go, “Well, that’s bullshit.” It’s this enormous chunk of the job of the EMS system—addressing these non-acute, very sub-acute, clinical problems.
Researchers have spent time looking into this. Providers put all this emotional energy into hating on patients—they see this as abusing the EMS system. Emergency departments have this nickname, GOMER, for patients, which stands for Get Out of My ER. We have this whole rich language around talking about it. Paramedics and doctors in EDs will sit patients down and admonish them and say, “You shouldn’t have come here.” The point I make in the book is that we’ve got to get away from that. It doesn’t do anyone any good. The patients are still calling 911, and you’re still not helping them. We need to change how we think about the 911 system, and instead of trying to self-select the patients that we get, acknowledge that people are going to call us for all kinds of reasons and try to meet them where they’re at instead. And COVID certainly fits into that.
What would your reimagined 911 system look like? Let’s say I’m still working in EMS. If you insist on going to the emergency room, I have to take you there. No matter how ridiculous I think your situation is, we’re going to the ED if that’s what you insist on. Alternatively, if you are like, “Well, I’d really like to go to urgent care, but I can’t get there on my own,” I can’t take you there. I have no choices to offer you other than the ED, and I can’t refuse you going to the ED and routing you somewhere that’s more appropriate. So it’s about offering different choices to EMS crews. Maybe the urgent care really is appropriate. Maybe what we need to do is get on the phone and talk to your primary care provider and help you get an appointment for tomorrow and arrange a ride for you. That’s just not work EMS providers do right now.
Is there anyone doing anything close to what you’re envisioning? In some places, there is this thing called community practice paramedicine. One of the things the Affordable Care Act did was basically penalize hospitals that have a lot of patients who are quickly readmitted. The way we started to think about addressing that was community practice paramedicine. We know that a chunk of 911 call volume is a relatively small number of people who call 911 a lot. We call them frequent fliers—you could get miles from my ambulance. Why wait for them to call? Let’s go to them proactively, check in on them, make sure they’re filling their prescriptions, make sure they’re checking their blood sugar, and make sure their basic social needs are being met, and maybe that prevents the 911 call from happening. So it’s creating a community practice system that doesn’t just pop up in a couple of cities in the United States as pilot projects, but is part of the fabric of how we think about pre-
hospital medicine—that’s really the solution that I’m thinking of. There would be no more, That person shouldn’t have called 911, because all of a sudden, now we can deal with a lot of different patients with a range of issues.
This would also critically fix the career ladder problem for EMS providers. Some folks go and work for helicopter-based EMS systems—that’s considered the elite level of EMS. But for most people, they max out at being a paramedic, so we have career retention problems. It’s a short-term gig for a lot of people, myself included, and having community practice levels would create more opportunities for advancement and more opportunities for specializing. It would help deal with these workforce issues.
FYI: Look for Prener’s Medicine at the Margins in September. Preorder the book now through Fordham University Press or Amazon. Visit his COVID-19 tracking project.
