Vicesimus Knox wrote in 1788, “You can’t get blood out of a stone.” He wasn’t the author of the original proverb when he expressed it in one of his musings titled “Winter Evenings,” but he did raise an interesting point. Today, my take would be: Just how much can you reasonably ask of a paramedic?
This week our assistant deputy minister for emergency health services for Ontario opined that ambulance services across our province should “consider” “batching” patients at the emergency rooms to free up paramedic crews. Sorry to disappoint you, minister. Paramedics are already up to speed with this phenomenon. I hope readers share this blog with friends who are not responders to illustrate how desperate the politicians are becoming.
Firstly: for the uninitiated, the term offload refers to the act of holding up patients that have arrived at the emergency room by ambulance when there are no free beds or chairs in the department. The area is usually in a back hall out of sight from others sitting patiently in the waiting room out front.
Each paramedic crew is ideally suited to treat and transport one patient from the scene to the hospital. Most emergency ambulance services did away with multiple patient ambulances nearly two decades ago. One crew can not reasonably be expected to care for two critically ill or injured victims simultaneously. One patient would not receive adequate care in the worst of situations. Today it is one ambulance, one patient, and one destination. Otherwise, you should issue paramedics yellow buses.
The slick term batching used by the Toronto-based politician can be interpreted as economizing healthcare. The paramedics are already with a patient. Why not double patients up and send a now surplus crew back out on the road. It kind of makes sense. Occasionally.
Secondly: don’t worry. Nurses and clerks are delegated to assess or “triage” all patients to ensure the most acute are seen first. A repeated process to prevent patients in distress from missing out on vital care in the emergency department. Paramedics are trained to a greater depth in the same procedure for disaster scenes. Much as that notion might dispel your fears and doubts over emergency care, it should not. This ongoing condition is NOT the fault of any staff delivering care. The problem is systemic.
Nurses care for multiple patients within the emergency room. Some have been assessed by physicians, while other victims wait for tests and procedures to follow doctors’ orders. The process is well organized by nurses with resources at their fingertips. Patients are under constant observation. On the other hand, Paramedics stay in a hallway with their patients who may not meet the threshold as an acute condition but are still very ill.
When a patient arrives in the hospital, they become the responsibility of that institution. Registering patients, assessing them for severity and attaching an armband assigns the ultimate responsibility to the hospital. Paramedics are caught in the lurch, with the patient still on their stretcher regardless of the location. Patients are left in U.K. ambulances outside the emergency rooms in some cases, avoiding taking ownership.
When a patient’s condition deteriorates in the offload area, the institution buffers itself with “you could always get a nurse to reassess if you think the patient is getting worse.” It’s a subjective statement often used after the fact since no definitive tests have been applied to the patients’. Those who worsen in the holding area have caused paramedics to catch the heat. In fact, delaying comprehensive care that is just around the corner is a flaw within healthcare. Responders tasked initially with assessing, treating and transporting patients to the hospital have indirectly become hospital staff by default.
Paramedics and their respective services have paid the price for years, giving up breaks, going without food, being reassigned when they clear the hospital and going into overtime at the end of their shifts. Beyond tiring physically and mentally for the responders, those spinoffs share a more ominous side effect with the community they serve.
The backup in the hospitals is the result of several problems. There is a lack of beds on hospital wards, a lack of long-term beds in the community, and the list goes on. The buck stops with your ambulance service. Paramedics are the stop-gap solution for the hospital system. Acting like an overflow pond to prevent flooding, paramedics come and go as the patient tide peaks and ebbs.
Communities and their ambulance services have been very creative in managing the issue and supporting the valuable human resource under their direction. Years have come and gone “batching” or doubling up patients with a single crew. EMS Chiefs started by providing food for paramedics caught in the offload areas for hours. Rooms not designed to act as rest and eating areas offered little to no relief for exhausted medics looking for some respite from the gruelling demands.
What started as a pre-hospital healthcare career has morphed into a comprehensive and demanding existence. Hospital staff can separate themselves from the rigours of frontline care for periods to recharge with food and quiet in a darkened lounge. Paramedics sit on stacking chairs eating pizza or lunch next to ambulance equipment hung from walls and a desk where their colleagues sit completing computer-generated reports and talking on telephones or radios. There is no recharging here except for the computers plugged into nearby outlets.
Paramedic supervisors work tirelessly swapping units out for breaks just to get reassigned to high-priority calls again. Authority was granted to take crews out of service to get them the much-needed and entitled relief. Ambulances received major upgrades with eco-friendly systems to conserve engine idling time reduce fuel consumption and carbon footprints while sitting outside emergency rooms.
Communicators at dispatch centres experience overwhelming frustration searching for units to respond to increasing call loads. When communities and their Chiefs add resources to peak demand periods using evidence-based data to justify increased budgets, call loads continue to rise, leaving paramedics marooned in the halls of our hospitals.
“Code zero or code red” conditions when no ambulances are available to respond to life-threatening emergencies happen in some communities daily and even hourly. Hospital staff are as worn down as responders. Most attempts at supporting the system have seen limited success. The problem is still systemic. Ontarians are overdue for an overhaul of their healthcare delivery system before the hospital staff and responders lose all hope.
This is no time to kiss up, but it needs to be said that EMS Chiefs and community representatives are really not to blame. They are saddled with a systemic problem and do what all public servants do best. Solving problems and making the best of the worst should be in all our resumes. Partisanship aside: put my vehicle license renewal fee towards healthcare or potholes. God knows both are causing me pain.
Working as one of those paramedic supervisors, I can safely say that everyone is giving 100% and then some with first-hand knowledge. I love retirement, don’t miss the stress, but I regret leaving the one hundred percenters still on the front lines on the street and in the hospital.
I salute you all!
Chris
It's always a conundrum for politicians isn't it? Put more money into patient care, or more money into management. For the Longest time hospitals have been expanding management infrastructure while reducing the numbers of personnel that are directly responsible for patient care.
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