My phone is ringing, there is no need to even look at the call display as I know exactly who is calling me and the reason why. “Hi, it’s dispatch. I’m calling to let you know that coverage is not very good right now…”
This is a call that I am used to receiving; this is a call that Ontario Paramedic Superintendents and Shift Commanders are used to receiving. I quickly run through a status report with the communications supervisor and together we devise a plan to move some coverage around. It’s busy, there are a variety of calls ongoing, and one factor that compounds the issue is our geography.
Paramedics working in rural or remote settings face the same calls that those in a suburban or urban setting face: strokes, heart attacks or traumas. The varying factor, however, is the distance to definitive care. Increased distance and area of response pose clinical, operational and logistical challenges for paramedics working in rural settings. Large geographic service areas force services to become innovative and strategic in their response to calls for service while simultaneously maintaining a safety net for their communities.
In an attempt to streamline, the healthcare system continues to centralize key services, which are often located in urban centres. The downfall to this, however, is that for much of Ontario those specialized services are at arms length. This means paramedics must leave their own communities and puts them on the road to access specialized care, which is often hours away, whilst dealing with very sick and clinically complicated patients for an extended period of time. This leaves that community devoid of a much-needed resource.
In recent years many services have implemented bypass guidelines, which have resulted in a dramatic decrease in the time from injury/insult to definitive care. In bypassing local hospitals that lack the ability to provide definitive care and heading directly to a cath lab or trauma centre, the patient receives lifesaving treatment sooner. (1,2,3,4,5) Most hospitals rely on Paramedic Services to transport patients between health care facilities. While stable patients are transferred for routine appointments or procedures, critically ill patients are transferred at a priority. Increasing demands for service has forced many Paramedic Services to restrict the number of low priority transfers and have worked at a regional level with healthcare facilities to implement more effective and efficient means of transporting patients. Community sponsored low priority transportation or transfer services are often used to transfer stable patients.
My issue tonight, however, is that I have two trucks headed to the city on transfers, one additional “city” transfer waiting to go and additional emergency calls that are ongoing in the community. It is not lost on me that only two paramedic units are available in a county of over 7,000 square km.
For rural services it’s not always the population and associated call volume that is the challenge, it’s the sheer distance that the paramedics must travel to reach those in need, while still ensuring that appropriate coverage is also available. I have worked in a number of areas of Ontario; remote, rural and urban. For rural and remote services staffing needs are often dictated by geography and call duration, rather than strictly call volume.
Municipality of Greenstone
City of Ottawa
Source : 2016 Census Statistics Canada 6
In densely populated regions of Ontario with higher call volumes, paramedic resources get pulled out of neighbouring rural communities. This makes it very challenging if not impossible for rural communities to provide appropriate coverage levels in their community, where the local resource originates and is in part, paid for.(6,7,8) Often, when those rural-based ambulances are in urban areas where definitive care exists, they are then called upon to help shoulder the burden of the urban service and are assigned emergency calls in that jurisdiction. We have at times “lost” a crew for an entire shift as a result of them clearing the tertiary care centre after completing a transfer or bypass, only to be assigned repeated emergency calls in other catchment areas.
I hear dispatch calling out a unit number on the radio. There is a call in an isolated area of our county – someone has had a fall and broken an ankle on a remote hiking trail and darkness is only a few hours away. Accessing this patient will be difficult. Transporting them safely to a point accessible by an ambulance presents more challenges.
Rural Ontario is a playground for outdoor enthusiasts, sportspeople and those urbanites seeking to escape the concrete jungle. The choice of activity or lack of experience can sometimes lead to misfortune, or perhaps it’s just a very ill-timed medical event. Nevertheless, rural and remote paramedics are called to access, assess, treat and transport these patients in diverse settings and environments. The complexity of these rescues can prove to be logistically challenging. Often times a “shelter in place” approach must be taken to stabilize the patient prior to transport. Preparations are conducted to ensure safe extrication in a manner that does not cause further injuries to the patient or endanger the crew.
Services in many parts of Ontario have reached out and formed working groups with other agencies such as police or local volunteer fire departments, forestry authorities, or park wardens and staff. Locally we have worked numerous times with these agencies to assist in locating lost persons in Algonquin Park or along the Ottawa River, using a service drone to assist in search or reconnaissance, or mobilizing our Sierra Team which specializes in remote access treatment and transportation with side-by-side utility vehicles. These locally provided innovations and services are the result of necessity being the mother of invention. Forward-thinking leadership and rural councils have responded to ensure that the residents and visitors to their communities have the access to advanced prehospital healthcare when they need it.
I activate our Sierra team and soon they are en route to back up the responding ambulance. The team comprises specially trained and equipped paramedics. They have tools such as a side-by-side UTV with specialized extrication equipment, camping and extended stay gear, GPS and communication equipment. This call that will no doubt take several hours to complete. Due to the nature of the call, I know we will be short another paramedic unit for an extended period of time. Another check-in with dispatch and more shuffling ensues.
Low frequency, long duration. The challenge continues. Not only do rural communities lack the diversity and specialized care that urban centres have, they also typically have a shortage of primary care physicians, home care, appropriate care facilities and associated support systems.(8,9) Paramedic services have seen this first-hand. The lack of long-term care beds means our aging population needs additional support to continue to live in their homes, support that often is spread far too thin in rural and remote jurisdictions. Many rural and remote services in Ontario are adapting and are shifting their focus from reaction to prevention by implementing Community Paramedic (CP) programs. In many cases these programs fill gaps that exist within the community’s healthcare system or supplement existing ones. By focusing on the most vulnerable populations, CP programs are able to mitigate issues before they progress to the need for a visit to the emergency department or hospitalization. In focusing on prevention, the goal is to keep people safe and healthy in their own homes longer, thereby ultimately decreasing the burden on long term care.(10,11,12) From our experience it seems that local governments, patients and community members understand and support this proactive, community paramedic model.
But more work needs to be done at a provincial level to convince the powers that be that the community-based approach is not only patient-centric, it’s also a sound economical choice.
I’m certain that although this story is based on our experience in Ontario, the same holds true across Canada as it relates to rural and remote paramedic services. In the face of an aging population, financial austerity and increasing demands for service, perseverance and innovation have led to unique, diverse and solution-based programs that will continue to be needed and expanded upon to serve our communities in the years to come.
1. The Impact of a Statewide Pre-Hospital STEMI Strategy to Bypass Hospitals Without Percutaneous Coronary Intervention Capability on Treatment Times. Fosbol El1, Granger Cb, Jollis Jg, Monk L, Lin L, Lytle Bl, Xian Y, Garvey Jl, Mears G, Corbett Cc, Peterson Ed, Glickman Sw.
2. Paramedic Contact to Balloon in Less Than 90 Minutes: A Successful Strategy for ST-Segment Elevation Myocardial Infarction Bypass to Primary Percutaneous Coronary Intervention in a Canadian Emergency Medical System. Cheskes S1, Turner L, Foggett R, Huiskamp M, Popov D, Thomson S, Sage G, Watson R, Verbeek R.
3. Evaluation of a Primary Care Paramedic Stemi Bypass Guideline. Kwong Jl1, Ross G2, Turner L2, Olynyk C3, Cheskes S4, Thurston A3, Verbeek Pr2.
4. Resources for Optimal Care of the Injured Patient 2014. Committee on Trauma, United States College of Physicians. Rotondo M, Cribari C, Smith S.
5. The Mortality Benefit of Direct Trauma Center Transport in a Regional Trauma System: A Population-Based Analysis. Barbara Haas, MD, Therese A. Stukel, PhD, David Gomez, MD, Brandon Zagorski, MSc,
Charles De Mestral, MD, Sunjay V. Sharma, MD, Gordon D. Rubenfeld, MD, MSc,
and Avery B. Nathens, MD, PhD, FACS, Toronto, Canada
6. Statistics Canada – 2016 Census https://www12.statcan.gc.ca/census-recensement/2016/dp-pd/prof/index.cfm?Lang=E
8. Northern Ontario Health Care Priorities: Access to Culturally Appropriate Care For Physical And Mental Health. Briefing Note 2 | June 2015. Areej Al-Hamad and Laurel O’Gorman
9. Issues Affecting Access to Health Services in Northern, Rural and Remote Regions of Canada. Annette Browne
10. Community Paramedicine Is Growing in Impact and Potential. Michael J. Nolan, Katherine E. Nolan And Samir K. Sinha CMAJ MAY 28, 2018
11. The Economic Value of Community Paramedicine Programs Prepared By: Kathryn A. Wood, BA (Hons), BSc. (Hons) Dr Christopher Ashton, B.Eng., MD, MBA (Finance), MACP Denise Duffie-Ashton, BBA, MBA on behalf of the Paramedic Services of Hastings-Quinte and County of Renfrew
12. Evaluation of a Community Paramedicine Health Promotion And Lifestyle Risk Assessment Program For Older Adults Who Live In Social Housing: A Cluster Randomized Trial. Gina Agarwal, Ricardo Angeles, Melissa Pirrie, Brent McLeod, Francine Marzanek, Jenna Parascandalo and Lehana Thabane CMAJ May 28, 2018