Wednesday, April 23, 2008

EMS in No Win Situation

In a classic no win situation EMS in Edmonton have been forced to station personal at local emergency rooms to care for patients during times of high call volume. In case, you the reader, have not heard of this problem before, EMS will bring patients into the ER during times of high call volume only to find that the emergency will not accept them because it's not safe to do so. In other words, there is not enough beds, space or nurses to accept the patient so the EMS crew can be left waiting for minutes to hours with the patient on the gurney.

With EMS crews tied up in the ER the result is delays to 911 calls and longer response times. In the case of Edmonton they spent only 92 minutes per day with high response times a year ago which ballooned to 4.5 hours this year. Rather than try and change the ER departments, they put crews in the ER to allow the ambulances to get back on the road.

Between 1997-2001 I helped organize the medical teams for the Caribana Parade in Toronto (a retrospective review of the event can be found here). Because of the crowds, EMS response times would quickly become horrific because it took so long for ambulances to get too and from hospitals. To rectify the problem we put a medical tent on site (with excellent effect). It improved service for the patients, relieved the load on the EMS system (because each ambulance could respond to many more calls) and was a blast to work at.

In Edmonton, it's a similar problem except that the slow turn-around for ambulances is because of the delay at the ER. My opinion on this? Congratulations to the EMS chief that had the guts to put crews at the hospital. I suspect passing the patient from one EMS crew to another (especially in an ER) is not without it's legal liability but they're looking at the greater good and doing the best they can with the system. As for the emerg departments, I cannot find fault. To accept a patient that you know you can't monitor carries great risk. On the one hand, they've now transferred the burden of slow response times to the EMS service but on the other hand EMS usually has a greater pool to call on in dire situations (such as neighbouring ambulances and other first responders).

The government could act decisively in this situation with staffing for this specific situation or legislation to protect the ER personnel that accept the patient in a bad situation. Having the staffing, physical space and legal protection to create a non-ambulatory triage area would go a long way to allow ER departments to accept these patients during busy times. The long term answer, unfortunately, is greater long-term beds to get chronic care patients out of the emergency. And that will not be a quick fix. In the mean time, someone from the government needs to look to a better solution other than creating a virtual ambulance in the emergency department.


Joe Black said...

Hi Ian
Interesting post about EMS. There is a distinct difference though between Urban EMS and Rural EMS. In a rural remote area the crews are often volunteer, meaning that they have “daytime” jobs with the exception of having to be on-call for EMS duties. If I refer a patient to “The Big City Hospital” – I have already arranged with the specialist to accept care of the patient. Then my staff has to leave on a 4 hour return trip – not only leaving their jobs and families, but also leaving the whole area without service for the time they are gone. We have to depend on the receiving facility to take over care of the patient right away. But this does not happen, unfortunately. The EMS crew sits around in hallways, corridors and makeshift monitored rooms. Ambulance transfers in Saskatchewan are not covered by the province – the patient has to pay. Per hour. The longer the wait, the higher the bill. Also – many rural crews only have EMT’s – meaning that if the patient is unstable or receiving any drug that is not in the schedule of approved drugs – the physician has to accompany. So I fully agree with you – let EMS crews do what they are supposed to, and that does not mean sitting in hallways.

Ian Furst said...

point well taken joe -- even though I work in cow country I had the downtown core in mind when I wrote this post. the message is that ems doesn't always have the resources.