Reflections on a broken EMS system

What have I learned since starting The Last Ambulance in February 2022 ? I’ve learned the entire prehospital emergency care system – right across Québec – is profoundly dysfunctional.

I’ve learned that despite multiple warnings, little or no efforts were made to improve the way paramedics, emergency medical dispatchers and support staff are treated.

Their salaries, their ability to achieve work-life balance, their opportunities to grow within the profession, their pensions, their mental health support, their day-to-day working conditions are not a priority for their employers or the government.

Neither, apparently are their patients or the communities they serve. The government announced 'improvements' to ambulance coverage in the lead-up to the last election campaign. In reality, many communities saw their local access to paramedics eliminated during evenings and overnight hours.

This has led to extensive ambulance deserts where, quite literally, the last ambulance may be responding long distances to a critical emergency.

It takes more years for a paramedic to reach the top pay grade than the majority of newly hired paramedics remain in the profession. Starting pay for a paramedic in Québec is more than $11/hr less than their counterparts in Eastern Ontario. Same qualifications. Same career. Bottom-line : Quebec places less value on paramedics.

The advanced care degree program at the Université de Montreal remains on hold -- indefinitely. Because, unlike the entire rest of the world, Québec is still grappling with the notion of allowing paramedics to be a force multiplier with clinical-decision making autonomy. Reinventing the EMS wheel has become a specialty here.

The entire system is operated under a cloak of secrecy. The only way to seek the facts is to file multiple access to information requests. Even some of the CISSS (regional health authorities) refuse to divulge operational data on the grounds it might affect the competitive advantage of the private ambulance companies.

I’m trying to think of a single other public service where the senior leadership would be allowed to remain silent in the face of a series of preventable tragedies. The question of accountability is raised time and time again, and quite frankly, I have no idea who is responsible for the operational integrity of Québec’s out-of-hospital emergency care system.

It’s not only a predicted and critical shortage of human capital that is preventing the system from operating at its full potential. It is a lack of coordination between elements of the healthcare system.

It is a failure to recognize that if a hospital requests all three ambulances from a rural region to embark on long-distance interhospital transfers there will be no paramedics left to respond to local emergencies.

It is a failure to recognize sunk-cost bias and continue to invest tens of millions of dollars in a system which is broken – quite literally throwing good money after bad. And the problem is that throwing more money at the system is not going to avert any preventable tragedies. It may delay their occurrence however if we don’t address the root problems, we are doomed to repeat the same errors.

It may be hard to believe but we have paramedics in multiple regions who have been trained to administer Fentanyl for pain management (under certain conditions) on-scene and en route to the ER.

We have ambulances with drug boxes installed in them. The codes work to open the boxes. But there’s nothing inside of them. The drugs themselves haven’t been added to the on-board stock.

And the paramedics’ training is already approaching its expiration date. So we’ll need to train them again to give drugs that they don’t carry aboard their ambulances.

There is an overt unwillingness to think and act globally preferring instead to operate each CISSS or CIUSSS like its own fiefdom. As far as I can tell there is no strategic vision stitching all of the regions and all of the frontline personnel together.

The government spent $1.25M on the CNTSPU which submitted an indepth report with a series of recommendations detailing a complete transformation and reimagination of Québec out-of-hospital emergency care system.

The only evidence of that report were the first 35 pages that Christian Dubé lifted to announce his “major investments in the system’ in June.

I believe that his team of advisors, when they're not nodding in unison, have led him to make announcements about how much better the system will be when, in reality, services and access are being reduced – often drastically – and there’s no hint of anything better on the horizon.

So what have I learned?

The system is profoundly, perhaps irreparably broken and only a true long-term strategic re-orientation with goals everyone is willing to share and pursue will bring the results necessary to ensure we have the world-class out-of-hospital emergency care system we deserve.

Thanks for your consideration.

Be well. Practice big medicine.

Hal