Myron Cybriwski died alone, in his bed in LaSalle, on May 14th 2022 while waiting for paramedics who arrived almost 11 hours after his first call to 9-1-1. He was 65 years old and had just retired.
Condolences to his family from Urgences-santé, the organization with the monopoly for providing ambulance services in Montreal and Laval, didn’t arrive until yesterday, March 22nd 2023.
A lot of changes have happened in the way emergency prehospital care is delivered since Myron Cybriwski died. Coroner Dr. Louis Normandin made recommendations last November and Urgences-santé implemented several processes designed to prevent the same type of tragedy from re-occurring.
Sadly, no one thought it was important to share that news with Cybriwski’s grieving daughter who single-handedly has been battling multiple layers of bureaucracy with varying degrees of success to ensure no other family has to experience the trauma of what happened to her father last May.
“On a spiritual level, I’m hoping all the love expressed for my dad is like a balloon sent up to the heavens so that he knows how much he was loved and what a difference he made in peoples’ lives,” said Stephanie Cybriwski as we talked about her late father.
According to the Coroner’s Report (30 November 2022), Myron Cybriwski called 9-1-1 at 05H32 on the morning of May 14th to say he had headaches and had fallen repeatedly the previous week. Ten minutes later, he re-contacted 9-1-1 to say that he had gotten back into bed. The initial call was then cancelled.
At 07H32, he called 9-1-1 for the third time. This time he said he was unable to get out of bed. At 07H56, the emergency medical dispatcher at Urgences-santé's Medical Communication Centre (MCC) transferred the call to Info-Santé for a clinical evaluation by a nurse to judge whether or not paramedics should be assigned to the call. The nurse contacted Cybriwski and confirmed the need for paramedics.
At 07H58 am there was an incoming call on Cybriwski’s phone of 10 minutes from a ‘No Caller ID’ : Urgences-santé provided the following information to Stephanie about that call: “The incoming call you’ve identified is most probably the nurse of Info-Santé Laval calling back. Please note that Info-Santé Laval is mandated to do the secondary evaluation in cases such as your father’s. We do not have any recording of this call. To obtain it, you must address a request to CISSS Laval.”
After the Info-Santé nurse’s evaluation, Cybriwski was triaged as a Priority 4 – there was a risk of clinical deterioration in the following hours. The time was 08H17.
At that moment there were eight Priority 4 calls holding for assignment with one of them already holding for 7 hours and 18 minutes. There was a shortage of personnel in the MCC with only 11 of 17 staff on-duty. The situation was equally challenging on the streets. Urgences-santé had 29 ambulances on the streets instead of the full complement of 53 for that day and hour.
The first ambulance was assigned to the call at 09H32 but was reassigned to a higher priority call at 09H46. The second ambulance was assigned to the call at 10H12 but was cancelled a minute later for another higher priority call.
In theory and according to protocol for all Priority 4 and 7 calls, a re-evaluation via telephone should have been made two hours after the initial call. It wasn’t.
The third ambulance was assigned to the call at 15H33 and was cancelled again to respond to a higher priority call. The fourth ambulance was assigned to the call at 15H37 and was rerouted to another call.
At 16h15, the MCC tried, without success, to reach Cybriwski by telephone. A voicemail was left, and the person said she was calling in regard to his call for an ambulance at 08H (likely referring to the third call he made at 07H32 am) and said unfortunately they were still responding to an enormous amount of calls and that they could respond to the request. She said she was calling to re-evaluate his condition and asked that he call 9-1-1 back as soon as possible. She ended by saying they had not forgotten about him or his request to send an ambulance but that they still had large delays.
The fifth ambulance was assigned to the call at 16H28 and paramedics arrived on-scene at 16H47. They found Myron Cybriwski dead in his bed. According to the Coroner’s report, the presence of lividity and rigour suggested he had died several hours earlier, in his bed, waiting for emergency prehospital assistance that didn’t arrive in time to save his life.
In his report, the Coroner, Dr. Louis Normandin, asked why the verification call, which was part of protocol, wasn’t made at 10H30. He noted that it could have permitted a new evaluation of the call and perhaps accelerated the process. Normandin asked why so many ambulances were rerouted to other calls.
Normandin wrote that “in effect, a more rapid intervention might have saved Myron Cybriwski.”
Normandin recommended that Urgences-santé analyze the situation related to the death of Myron Cybriwski and put appropriate measures in place to avoid a similar event from re-occurring.
I contacted Urgences-santé to ask what had changed since Myron Cybriwski’s death.
Chantal Comeau, Urgences-santé’s Chef de service, Communications, began by saying that the corporation wished to offer its condolences to the family of Mr. Cybriwski.
Comeau acknowledged that on May 14, 2022, Urgences-santé dealt with an exceptionally high level of calls with a limited number of staff.
She said the organization “intends to use the coroner’s report as part of its continuous improvement process. For example, the reassessing low-priority calls awaiting assignment was the subject of particular attention.”
“We should also mention other initiatives aimed at continuous improvement including the accelerated deployment of secondary triage with nurses at the medical communication centre (MCC) and co-evaluation with paramedics; the implementation of a directive for the release of stable and ambulatory patients in the ER; and the modification of the training plan for emergency medical dispatchers in order to be able to integrate them more quickly into taking calls at the MCC,” Comeau said.
Following discussions with the Ministry of Health and Social Services, Urgences-santé received authorization to begin the 'co-evaluation program' which could also be described as an enhanced triage and alternate-pathway-to-care model.
The project provides an additional tool for Urgences-santé to ensure the safety of their patients, to better deal with staffing challenges, and to find appropriate care destinations for low-acuity patients rather than systematically transport all patients to the high-acuity setting of the Emergency Department.
To do this, alternative care trajectories are being established with the various integrated university health and social services centers (CIUSSS) and integrated health and social services centers (CISSS) in the territory served by Urgences-santé.
“All in all, these continuous improvement initiatives aim to maximize the use of prehospital resources and actively contribute to the decongestion of emergency rooms. The goal is to optimize the care trajectory of patients so they can receive the care required by the right person at the right time.
“The deployment of co-evaluation is designed to assign paramedics more rapidly to certain types of low priority calls to ascertain the patient’s condition, in particular when the patient is alone and where response times may be longer,” Comeau said.
Comeau concluded by saying “In addition, despite the labour shortage affecting all sectors of the economy, Urgences-santé is actively pursuing its efforts to recruit paramedics and emergency medical dispatchers.”
I asked Stephanie why it was so important for her to tell the story of her father’s death publicly.
“My father was a kind man, someone who would always do his best to help others, and so rarely did he ask for help in return. The day he died, he tried reaching out for help by making 3 phone calls to 9-1-1, and unfortunately, help arrived 11 hours too late. He passed away at home alone waiting for help to arrive.
“I felt it was important to share what happened the day he died in order to bring about change to our current healthcare system and the real issues that Urgences-santé is facing. Had help arrived sooner, if certain protocols were followed, or other solutions had been implemented, there would have been a chance that my father would have survived. This fact was confirmed by the Coroner’s report.
“No family should ever have to grieve knowing that their loved one died alone waiting for help that never came. There was no wellness check conducted. There was no call placed to me as his emergency contact to reach out to him. He was not well enough to call anyone else for help or to get to the hospital himself. He was told help was on the way, and it came too late.
“I firmly believe it is my duty as a citizen to share his story to ensure change is brought about and to do everything I can to make sure this does not happen again.”
“Going public, I was hoping that Urgences-santé along with the Minister of Health and Social Services, Christian Dubé, would realize that errors like the ones that happened on May 14, 2022, are fatal. Not having the right training, the right amount of staff, or the right protocols in place can lead to someone’s death. All healthcare workers need more support from the government, and essential services are being overlooked by our current politicians.
“I believe Urgences-santé needs to take public accountability for the errors that played into my father’s death, implement necessary changes, and vocalize to the public what are the changes being put in place. It is important to me to hear what these changes are, as it is the least they can do for a grieving daughter.
“It is equally important to all the citizens of Québec to know what is being done to address the long wait times when calling for an ambulance. I had several people reach out to me after this story came out, and they expressed their fears of what if it happened to them or their loved ones. Unfortunately, my father’s story is one of several that happened in 2022. This was not a one-time event.”
I asked Stephanie if she had ever heard back from Info-Santé about the missing segment that was recorded that morning – the call from the Info-Santé nurse to her father to confirm whether or not he needed emergency prehospital care.
“After numerous attempts since my father’s passing in May 2022, I have yet to obtain the last recording from Info-Santé the day he died. I had received the recordings of phone calls that he made to 911 that day back in July 2022, however, the last one, which is a call back to him that lasts about 10 minutes, has not been provided to me.
“It is important for me to hear this phone conversation, as it is the last person he would ever speak to, and this was the call that decided his fate. The person who evaluated him assessed his physical and mental state, and based on that, determined he was a level 4 priority.
“According to protocol, there should have been a follow up phone call made to my father two hours after this assessment to re-evaluate his priority level if an ambulance had failed to arrive. However, this follow up call was never done.
“Info-Santé’s current archive system that deals with these types of request needs to be fixed. It is astonishing the amount of phone calls, emails, forms and documents I had to send, to only get a one-page rejection letter saying they cannot locate this missing recording.
“Even to obtain the recordings I do have was a battle. It is with the help of the media that I have been able to get so far with the answers that I have. It is a lot of stress on someone who is already grieving. It is incredible that 10 months after his death, I am still having to fight for answers.”
Finally, I asked Stephanie about her own well-being since sharing her late father’s story.
“Since my father’s passing, I have been struggling with anxiety and depression, and had to go on medical leave for several months. It has been extremely difficult to continuously fight to get answers while grieving. There is not a day that passes by that I don’t think of him.
“After his story came out in the media, I received an outpouring of messages from his former co-workers, friends, and even strangers. I don’t think my father realized how many lives he touched over the years, and how loved he was. I can only hope that wherever his spirit is, that he felt all of the love being sent out. I am very appreciative of all the support I received.
“I do hope we will see changes to our healthcare system, but it is really terrible that change only comes in the wake of tragedy. It is sad that we only get a reaction once something tragic happens. I truly hope in the wake of my father’s death that something positive can happen.”