"Risky Business" The IFT Industry in Ontario

[rock_shoes]

Hello,

If BCAS was properly funded and had enough ALS the hospital wouldn't have to send its staff. That is what I wanted to say. Now, a lack of ambulances and properly trained crews for ALS transfers costs hospitals money, time and staff. Not to mention effects patient outcomes.

Yep. That’s the bottom line right there. It’s not as much the fact that it costs hospitals money (though that is important given our tax-payer funded system), as it is the fact that it hurts patients.

For example, a small town sent in a patient with a green BLS crew and a new grad RN with no critical care background. It was a inferior/right-sided MI. The guy was hypotensive, gray, nauseated, and barfing for the whole long ride in. On arrival his BP was 70. No interventions were made. Who fault is that.......not the wide-eyed paramedics or nurse. No, it was a funding issue for BCAS.

Been there done that. I originally started with BCAS as an EMR (roughly equivalent in education and scope to a US EMT-Basic). My first station was in Lillooet where the yearly call volume is around 750 calls a year. The nearest Hospital of any size relative to Lillooet is in Kamloops approximately 2 hours away running hot on highways that wouldn’t even be classed as highways in most first world countries. All I can say is it will never happen on my car again. Whether we have a nurse escort or not I look at labs, ECG’s etc. before anyone gets on board. No exceptions. On more than one occasion I’ve refused to take a patient, nurse escort or not. Occasionally hospital staff are frustrated when I say no. That’s too damn bad. The only way to prevent these disasters on wheels is to refuse.

Holly....do not get me started on this one. Once it took 36 hours to get a sepsis/ARDS patient transfer to us. An other time a fairy young patient with failed TNK needed a rescue angio in Vancouver. After 12 hours of hurry up and wait BC bedline broke the bank (gave a P#....bill to an other service) and Alberta came in a took the patient to Edmonton. Also, in my area STARS and other Alberta services have been doing more and more transfers for us.

I think we may have got our wires crossed on this particular point. I am in total agreement with you that air ambulance services in BC are nearly non-existent. We have some excellent providers but they number so few that they can’t possibly provide any real semblance of a service.

I do feel bad that BCAS has fallen behind from it glory days. When I think of good ambulance systems I think of Emergency Health Services Nova Scotia. Or new kids on the block with great potential like Ambulance New Brunswick and Island EMS (Prince Edward Island).

I’ve given up feeling bad about what’s been lost. Right now I want to look beyond what was and do everything possible to fix what is. I know we can agree the repair job will neither be short or easy.

If BCAS funding dose not come around and transfer (ground and air) do not improve I can see each health region developing its own CCT program (the Trail boon-doggle notwithstanding).

This is one of the places in which the health authorities are standing in their own way. This year the budget for patient transfers was shifted from BCAS to the health authorities. As a result it is the health authorities’ responsibility to fund whatever programs are necessary for those transfers to take place. If the health authorities refuse to shift some of that budget back to BCAS for training costs the training doesn’t happen. As a result some of the health authorities have tried to run their own CCT teams using CCRN’s and RT’s. On the rare occasions BCAS CCT teams have been available to our local hospital their performance has consistently been exceptional. By contrast the “Hospital CCT” team is a complete disaster from the word go. Why? Because transport medicine is not the same as ICU medicine. I repeat. The “Hospital CCT” teams I’ve seen and dealt with thus far are a complete and total failure. With that in mind, I think it’s far more sensible to properly fund the paramedic based program that actually works (currently on the rare occasion you can find a BCAS CCT paramedic).

Ed

Edited December 28, 2009 by rock_shoes

[DartmouthDave]

Hello,

I think I may have to stop posting here. LOL! Nothing makes me go from calm and mellow to ranting mad man is 10 seconds is the current state of ALS coverage and ground/air CCT in BC. Because, I have seen some crazy situations with sick people stuck waiting for advanced care.

If BC can host the Olympics it should be able (95% of the time...there are always unique situations) get a failed TNK patient to Vancouver. Or take less than 36 hours to move a ARDS/Sepsis patient. This is not the crew fault. You only can be in one place at a time.

The answer is simple.....more planes and staff. More ALS coverage. It makes common scene to build on and improve an organization (BCAS)that has the equipment, experience, ambulances, staff and aircraft rather then trying to reinvent the wheel. If BCAS won't I think others will step in and try. Heck, where I work STARS Alberta came by to show off their simulator and 'plug' their program. "In a tight spot??" "Call us!" "Bed are tight....ICU is full? Well....let us help"

Ed, I agree that thus far CCT (Hospital Based) in BC has been lack luster. Why? They cobble a team together without training or practice and say...have at it. Get the patient gone and free up a bed. No transport medicine is not the same as the ICU.

When I think about hospital based programs (RN) that work well Airlift Northwest, Stollery NICU team, Vanderbuilt and Duke come to mind. Or mixed teams (RN/ACP or CCP) such as Lifeflight Nova Scotia. If a hospital wanted to make a good program they should look to these as example to follow.

Or even BCAS leadership. Heck, BCAS position papers (written in the 70's....read some of it for a course I took...yawn) looked at Medic One in Seattle for idea on how to establish an ambulance service.

BCAS just needs to shake things up and get back in the game again.

Cheers

David

[rock_shoes]

Nothing makes me go from calm and mellow to ranting mad man is 10 seconds is the current state of ALS coverage and ground/air CCT in BC.

That makes two of us. The other issue that gets me hot under the collar is nurses trying to take on transport work for which a competent level of paramedic exists. A paramedic’s job is the provision of care on a scene and the provision of care in transport. A nurse’s job (as they are traditionally used in most of Canada) is the provision of care within a health care facility. If CCP’s did not exist I wouldn’t have a problem with nurses trying to make that move. The fact of the matter is that they do exist. If those nurses wanted to work CCTs they should have become paramedics.

The answer is simple.....more planes and staff. More ALS coverage. It makes common scene to build on and improve an organization (BCAS)that has the equipment, experience, ambulances, staff and aircraft rather then trying to reinvent the wheel. If BCAS won't I think others will step in and try. Heck, where I work STARS Alberta came by to show off their simulator and 'plug' their program. "In a tight spot??" "Call us!" "Bed are tight....ICU is full? Well....let us help"

Exactly. BCAS budgets have grown in the neighbourhood of 40% over the last few years. If you’ve followed any of the recent threads regarding the labour situation here in BC it’s pretty obvious that budget increase has not gone to paramedic wages. What has grown significantly is the number of management staff. Funny. Things seemed to operate just as well without all of those new management positions before. We need boots on the ground and birds in the air. Since smaller hospitals have lost much of their functioning capacity to cut-backs, demand for CCTs has skyrocketed without any corresponding increase in CCT capacity.

Ed, I agree that thus far CCT (Hospital Based) in BC has been lack luster. Why? They cobble a team together without training or practice and say...have at it. Get the patient gone and free up a bed. No transport medicine is not the same as the ICU.

Precisely. There’s no doubt that this is the reason hospital based CCTs in BC are a failure. I can’t help but feel as though we’re taking a Ford Pinto to the prom when all the Ferrari needs is an oil change. BCAS has the talent pool to make this happen. Educate that talent and put them to use.

Or even BCAS leadership. Heck, BCAS position papers (written in the 70's....read some of it for a course I took...yawn) looked at Medic One in Seattle for idea on how to establish an ambulance service.

BCAS just needs to shake things up and get back in the game again.

Ah yes, the glory days when BCAS was actually showing some real leadership. Unfortunately it feels like we’re still in the 70’s. One of the first things on my own personal list would be laying an axe to the Justice Institute. There’s no way it’s beneficial to any of us for one school to have such a monopoly on paramedic programs. BCIT was always the logical choice for paramedic programs anyway. The fact that other emergency services attend the JI is not an indication that paramedics should attend the JI.

Ed

[DartmouthDave]

Hello,

School is an other issue in BC. The JI needs to have more ACP programs. Some logical picks would be one in Prince George, the Okanagan area for example (..along with a few others...). This would cut down on the training costs for the 'funded' BCAS students as well as making it available for experienced PCP who can not afford to take time to travel and be off work. Also, have it set up for adult learners with families. I know quite a few good PCP that would be excellent ACP or CCP but can not take the 'time off' for the JI or afford to live in the few ALS posts.

BCIT has a good reputation for Critical Care Nursing and Neonatal Nursing as well (...not as good as Mount Royal...wonder where I went!). They could develop, staff and run an excellent PCP and ACP program. Something along the line of an ONT program. You become a paramedic and get a nice academic transcript full of management, leadership, pharm, and other good stuff. Like I said on my last post......look at a solid educational program that works and learn from it!!! This would be ONT.

Even enhancing the BLS/PCP (I hate this term......it downgrades what is really done) standard of care in BC. For example, EKG and 12-leads. Obtaining a 3-lead or better yet....a 12-lead on chest pain or high risk patients is useful. Supraglotic airway devices (King LT, ect...) as well would be useful. Just to name a few.

Also, more ALS like I said. Here is a simple example. A 50ish year-old women develops pneumonia/sepsis and is found unresponsive in her home. If I was at the U of A in Edmonton she would arrive (odds are) tubed, IVx2 and a bolus or two. Same patient where I work (no ALS sent or available) arrives with no IV or tube (EMR crew I think). Requires 2:1 care while being tube and stabilized. This 2:1 was 50% of the ER Nursing staff of the day.

This example highlights two issues. First, the most important, patient outcomes. Good ALS/BLS is an extension of primary care. You start it we finish it so to speak. Two, workload. Staffing is an issues. Good EMS helps reduce the insane pressure most ER are feeling these days.

However, I disagree with your point on staffing of CCT. Personally, I do not care if a paramedic model, nurse/paramedic or all nursing model is used. There are numerous examples of each that work very well. Just as long as IT works well and get the job done in a cost effective model. Because, like it or not budget is an issue.

David

[Jamie Hersey]

This is one of the places in which the health authorities are standing in their own way. This year the budget for patient transfers was shifted from BCAS to the health authorities. As a result it is the health authorities’ responsibility to fund whatever programs are necessary for those transfers to take place. If the health authorities refuse to shift some of that budget back to BCAS for training costs the training doesn’t happen. As a result some of the health authorities have tried to run their own CCT teams using CCRN’s and RT’s. On the rare occasions BCAS CCT teams have been available to our local hospital their performance has consistently been exceptional. By contrast the “Hospital CCT” team is a complete disaster from the word go. Why? Because transport medicine is not the same as ICU medicine. I repeat. The “Hospital CCT” teams I’ve seen and dealt with thus far are a complete and total failure. With that in mind, I think it’s far more sensible to properly fund the paramedic based program that actually works (currently on the rare occasion you can find a BCAS CCT paramedic).

Ed

Good discussion fellas.

I agree with the majority of what is being said.

As for the hospital CCT comment I agree when Trail is used as an example. I think that is the exception vs. the rule. Many systems use hospital based CCT, but with a few important differences. The issue with Trail is you have two management chains, two sets of SOPs, simmilar but overlapping and conflicting roles, in an area that has a low call volume. This creates, in my words, the 'perfect storm' for developing issues, and inter-personal conflict. In my mind, I worry that the Trail experiment might bias individuals into not giving this model of care a serious look. A team needs one employer, be that BCAS or one of the health autorities. The model is sound but the implementation failed.

I wonder what the outcome would be if the Trail ground CCT was operating in the lower mainland? A change of venue. Much of the discussion thus far has been the rural transfer with limited resources, but this is not exclusive to the rural setting. Valid 'CCT' work here in the lower mainland gets moved all the time with hospital staff providing care. I think this is wrong; as wrong as it is in the rural setting. There is enough work to keep a CCT working in Vancouver. Heck, if BCAS is not providing this service then someone else will. HA with cash + no current service provided = BCAS will loose out in the end, unless they address this issue. Simply put someone else will come along and do the work, be it hospital staff and a BLS crew moving a patient or a hospital based CCT. I put forward this: if hospitals are moving patients, with their own staff, by default isn't this some form of an ad hoc CCT? I was at work the other day and the small ED I was in moved 1 intubated post arrest, two STEMIs, and something else... I forget. All staffed with someone from the ER and a transfer unit. Managers see this.

I would like to end with saying I am not picking on BCAS, rather I am saying what I see as an issue. Nor, am I saying fire BCAS from the CCT role, rather if they don't change they will be out of a job.