The history of transporting the seriously ill is one with gruesome origins, as Christina Frangou explained in her compelling Maclean’s piece on emergency medical services (EMS) here in Canada:
“In 1832, a cholera outbreak in the town of York – now Toronto – led to the creation of the first known ambulance service in what would become Canada. The town approved a wooden “cholera cart” to tow sick patients away from crowded areas, sometimes straight to funeral homes. These carters, as they were called, did not provide medical care. They simply carried the dead and dying away from the living.”
Modern paramedics are not, of course, just ambulance drivers. .
Paramedics are recognized as skilled healthcare professionals, and their work is often a matter of life and death.
Yet, as Christina reminds us:
“Emergency medical services are in serious trouble.
“One COVID surge after another piled even more stress onto a system that was riddled with cracks long before the pandemic began. The number of 911 calls has been rising for at least a decade. At the same time, rampant overcrowding in Emergency Departments means paramedics get backed up in hospitals, where doctors and nurses are already swamped. During these periods, known as offload delays(1), they care for patients in hallways and ambulance bays, unable to move on to the next person in need.”
Ottawa paramedic Colin Waterhouse explained to CBC News how local offload delays can affect his own workday:
“While I’m here with this patient, I might be here for hours. I can’t respond to a 911 call. All of these paramedics are taken out of commission while we’re waiting to get out of the hospital. So you have a smaller number of circulating ambulances in the city to respond to emergencies.”
Imagine how terrified patients and their families must feel when a 911 call cannot guarantee that an ambulance will be dispatched to help them. Imagine the frustration and helplessness of paramedics who are unable to hand over the sick people they’ve just transported to Emergency – all the while knowing that they and their colleagues are no longer available to respond to urgent 911 calls – sometimes for hours. And what does this new reality mean to the important advice to “call 911 if you believe you might be having a heart attack?” Will we decide to drive ourselves to the hospital (NOTE: a very bad idea) if we no longer trust that an ambulance is actually on its way?
The stressful nature of paramedic work itself can also have an overwhelming impact on the psychological and physical health of paramedics. Researchers who study paramedic stress tell us that mental health issues can result from both exposure to traumatic events and the way their managers and colleagues respond to worker distress.
Enter “ambulance diversion”, a concept which (in typically understated science-speak) researchers in California defined as “a practice in which hospital Emergency Departments (EDs) are temporarily closed to ambulance traffic, which might be problematic for patients experiencing time-sensitive conditions, such as acute myocardial infarction”.
MIGHT be problematic? I’d say that’s a safe bet if the patient in the back of the bus is having a heart attack, only to find that the hospital Emergency Department their ambulance is speeding to is closed. This is particularly important for heart patients because they need to be taken to a hospital capable of offering specialized cardiac care.
A California study(2) followed up on over 13,000 heart attack patients to help answer this question: how long is too long when ambulances are delayed due to ambulance diversion? What they found by comparing daily ambulance diversion logs with patient outcomes was that anything longer than 12 hours of diversion was associated with increased 30-day, 90-day, 9-month, and 1-year mortality.
The concept of ambulance diversion was created to offer temporary relief to Emergency Departments that were already full. Diverting ambulance-transported patients to a neighbouring hospital was initially meant to be used rarely and for short periods, just to allow an ED to quickly recover from its temporary overcrowded condition. The reality, of course, is that ambulance diversion of one hospital increases the neighbouring hospitals’ congestion.(3)
Here’s how that might look in this example offered in “Looking for a Solution. . .to the Solution” by Drs. Theodore Delbridge and Donald Yealy in the journal Emergency Medicine:
“The Emergency Department at Hospital A is too busy. It requests ambulance diversion. The Emergency Department at Hospital B receives its usual patients – plus the diverted traffic from A. Soon, B too is overwhelmed and requests diversion. Perhaps by that time A is caught up and no longer diverting ambulances. If so, it will soon be burdened with those ambulances diverted from B, and the cycle begins anew.”
Walk-in patients and patients with major trauma, by the way, are not associated with ambulance diversion.(3) Walk-in patients are generally admitted regardless of the hospital’s ambulance diversion policy. If the hospital is in AD status, only ambulance-transported patients – not walk-ins – are diverted to the nearest open hospital.
In July 2022, the Paramedic Chiefs of Canada (PCC) issued their official statement on dangerous hospital offload delays in Canadian Emergency Departments:
“Acceptable offload interval performance varies across paramedic services; however, 30 minutes is a generally accepted measure and anything greater than this is considered an offload delay. Regularly occurring offload delays of individual patients are reported by PCC members in excess of 12 hours with periods of 4–6 hours of a patient remaining on a paramedic stretcher being common.
“Patient safety in hospital is also threatened as paramedics are pressured to work outside of their paramedic certification with uncertainty to clear legal authority of patient responsibility. Paramedic resources are being used to augment hospital systems, including forced overtime for paramedics to continue caring for patients past the end of their shift.”
And 911 calls may still not be responded to in the way we have always expected. In the past 12 months, as Christina Frangou pointed out, cities all over Canada have increasingly reported code reds (also known in other regions as Level Zero, Code Zero, Code Critical, Code Black) – meaning there are no ambulances or paramedics available to respond to 911 calls – no matter how critical the emergency.
And it’s not just the patients waiting for help who are affected by this stressful reality.
David Deins is the President of the Paramedic Association of Canada, and the provincial vice-president of the Ambulance Paramedics of B.C. In his Maclean’s interview, he took a wider overview of some of the stressors for EMS staff:
“What makes the current moment unique is a combination of the last three years: not just the tainted opioid crisis, not just COVID, but climate disasters, too. We had the record-setting “heat dome” at the end of June. More than 800 people here in British Columbia died during that heat dome, putting a huge strain on the paramedic service. BC’s Health Minister Adrian Dix confirmed there were 2,000 ambulance dispatches on June 28 alone during that weather crisis, the highest-ever one-day total. Last November, we had flooding and rainstorms. Any external factor that increases call volume puts additional demands on a service that’s operating at close to 100 per cent most of the time. It’s exhausting to continually operate at those levels.”
Ryan Woiden, president of Winnipeg’s MGEU Local 911 paramedic union, observed in a Globe and Mail interview that the intensity of paramedics’ shifts is driving away newer hires, who are desperately needed:
“I think something that’s important here is not just a high volume of calls, but the types of calls, and the inability for a paramedic or a dispatcher to decompress from those.”
Phillips, W. J., Cocks, B. F., & Manthey, C. (2022). “Ambulance ramping predicts poor mental health of paramedics.” Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication.
Shen YC, Hsia RY. “Association between ambulance diversion and survival among patients with acute myocardial infarction”. JAMA. 2011 Jun 15;305(23):2440-7.
Schull M, et al. “Emergency department contributors to ambulance diversion: A quantitative analysis.” Annals of Emergency Medical Services, April 01, 2003, Volume 41, Issue 4, P467-476.
Q: Have you or somebody in your family been affected by ambulance delays?
NOTE FROM CAROLYN: I wrote more in my book about why cardiologists like to say “Time is Muscle”to remind us to seek immediate care for cardiac symptoms. “A Woman’s Guide to Living with Heart Disease“ is available in bookstores (please support your local independent bookseller!) or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from my publisher Johns Hopkins University Press (use their code HTWN to save 30% off the list price).