Winnipeg Free Press - PRINT EDITION
Perspective: Not a healthy system
Rural Manitoba ambulance service is a patchwork
WINNIPEG — IF you’re going to be hit by a car, don’t have it happen near Hamiota.
If you do, it might take more than an hour for a paramedic to arrive.
Watch out for the next tornado in Elie. That community's paramedic station was closed more than 33 times last year -- the most closures of any station in the province.
As for a stroke or a heart attack, avoid pretty much everywhere in rural Manitoba.
Outside the Perimeter Highway, there are virtually no paramedics trained to the highest level and able to administer clot-busting drugs or perform intubations.
Ten years after the regional health authorities took control of ambulance services, Manitoba's rural paramedic care is a patchwork. Only about 20 per cent of the station halls are staffed full-time, there are almost no advanced- care paramedics working outside Winnipeg and more than 30 stations were closed for days last year due to a paramedic shortage.
It can take more than half an hour for a medic to get to a patient in rural Manitoba, compared to five or six minutes in Winnipeg.
But some stations -- Dauphin, Souris, Teulon, Rivers -- have pretty good response times, given Manitoba's geography, and some regional health authorities like Interlake have a relatively good record of fully staffing ambulance halls.
Some stations serve thousands of patients a year, while others might go days without a call, but there has been no will to rethink station locations to make better use of medics.
Paramedics, the Opposition and even the Doer government's own reports say rural ambulance service run by 11 regional health authorities was supposed to be better than it is, now that 10 years have passed since the RHAs took control.
With call volumes up 36 per cent over the last five years, paramedics say it's time the Doer government end the balkanization of ambulance service and create a centrally run system.
Many other provinces, like Nova Scotia and British Columbia, have operated their emergency medical services that way for years, and Alberta and Saskatchewan are next.
At the very least, Manitoba's record as one of the stingiest funders of EMS services needs to change.
"It is a tragedy that rural people get short shrift compared to city people," said Ross Alcock, a recently retired City of Winnipeg paramedic and the former head of the Paramedic Association of Manitoba. "When you know what the problems are and you elect to keep the status quo, that borders on negligence."
But rural EMS service has made huge strides in the last decade -- new ambulances, vastly superior training requirements, more money for full-time staff, a new high-tech dispatch centre.
A decade ago, ambulances were sometimes little more than converted hearses. They were run by dozens of individual municipalities, driven largely by volunteers with only basic skills whose job was mostly to transport patients -- otherwise known as the "scoop and run."
Little information was kept on response times and there was no central dispatch system. If you wanted an ambulance, you might have to scrounge up the number of the nurses' desk at your nearest hospital.
Now, medics are a profession like nurses or doctors, their skills often match what you'd get in an emergency room and they've been better integrated into the health-care system.
The province has bought a fleet of new ambulances -- 11 over the last five years, with another 13 on order -- and standardized them so their equipment is all the same, created a super-high-tech provincewide 911 dispatch centre and implemented the "closest unit" policy, which one medic called "absolutely great."
The policy means the central dispatch centre in Brandon ignores regional health authority boundaries and sends the closest available ambulance to a call. So, medics from Souris on their way home from a drop-off at St. Boniface General Hospital could get diverted to a call in Carberry.
"We have come an enormous distance from the system we inherited," said Health Minister Theresa Oswald. "It was really the proverbial dog's breakfast."
But response times still vary wildly depending on where you live, and there's no getting around the fact that Winnipeg attracts most of the advanced-care paramedics, the ones with the most life-saving skills.
Brenda Gregory, Manitoba Health's acting director of provincial EMS, cautions that response times are only one element of a good EMS system. These days, the paramedic who arrives on the scene is far more able to treat and stabilize a patient.
"It's not just response times -- that feeds into the mentality that it's pedal to the metal, scoop and go," Gregory said. "There needs to be patient care."
The province has a guideline -- not a policy or a rule -- that says 90 per cent of rural people should get an ambulance within 30 minutes.
Data from 2008 show that response times are closer to 32 minutes provincewide. Brandon Regional Health Authority is the fastest, but it just covers the city. At 41 minutes, Parkland RHA in the province's midwest is the slowest.
Chute times -- the cool term for the speed with which a paramedic gets out of the station once he gets the call -- should be two or three minutes if the staff are in-house. If the paramedics are on call like they are for most shifts at most stations in the province, that adds anywhere from another two to six minutes in most cases.
On-call staff aren't paid to be in the station ready to leap into an ambulance and race out to a call. Instead, they carry pagers and head to the station when a call comes in. In places like Glenboro, Lynn Lake and Fisher, that can take more than 15 minutes.
"There are 11 different RHAs and 11 different employment models," said Paramedic Association of Manitoba chairman Eric Glass. "We need to look at a more sustainable rural system."
It might also be time to think about mothballing some stations.
Take the Assiniboine Regional Health Authority in the province's southwestern corner. It has 24 ambulance stations, but none is staffed 24 hours a day.
Eight of the stations get less than 150 calls a year. That's less than one call every two days. The Hartney station got only 50 calls last year, and the Elkhorn station got just 56.
A year ago, the provincial committee charged with doing the 10-year checkup on the province's regional health system suggested the province's ambulance stations are out of whack with populations and call volumes. Things were supposed to be more smartly co-ordinated under the RHA system.
But even hint at closing down an ambulance hall in a small town, even if it might mean faster response times with better-trained medics, and all hell breaks lose.
Take the North Eastman Health Authority, which earlier this year floated the idea of closing stations in Pinawa and Lac du Bonnet and building a more central station that might be staffed full time. Those two stations have slow response times -- 42 and 36 minutes, respectively.
Residents raised a stink, and the RHA quickly did some more studies that found better response times and ideal staffing levels could be achieved just as easily by keeping the two stations open.
CEO Jim Hayes said he's confident there will be funding down the line to hire enough on-site paramedics in both stations, especially given a new training program at Red River College.
Here's another conundrum -- the almost total lack of advanced-care paramedics in rural Manitoba. Winnipeg has 77. Rural Manitoba has eight, and many of those are in Selkirk or cottage country.
Rural medics and EMS directors argue that rural people need more advanced-care paramedics than urban dwellers, as rural patients are often travelling farther and longer in the back of ambulances. If you're having a stroke at the farm and you've just waited half an hour for your ambulance, you want a medic who can dispense clot-busting drugs on the spot, especially if you've got another 40-minute ride to the nearest emergency room.
The struggle to keep rural hospitals viable and hire more rural doctors won't likely get much easier, which makes investing in high-quality EMS care even more vital, say medics like Glass.
But others worry a big menu of medical skills just wouldn't get used often enough in rural areas. How do you maintain big-city skills when your hall gets 150 calls a year, and most of those are elderly people? You rarely see a child patient or a violent trauma from a gunshot or stab wound. Advanced skills, which could be used in downtown Winnipeg every day, atrophy.
Winnipeg, already attractive to rural paramedics because the pay and pension package is at least 50 per cent better, becomes an irresistible pull for someone who wants to make a career as a professional paramedic.
The solution to the patchwork of paramedic services, argue many, is to do away with the 11 versions of EMS run by the RHAs and create one uniform provincewide system with the same pay, staffing levels, response-time targets, skill requirements and administration.
Critics say the province has always been reluctant to pluck services away from the regional health authorities because the RHAs create an accountability buffer that insulates the government from criticism. Was your ambulance slow to arrive or is your local station hall closing? Call the RHA, not the health minister.
Though she wouldn't put a timeline on it or say what model the province might favour, Oswald says the province is starting to gather data and create broad policies to eventually move toward a provincewide system.
"That's our target off in the distance," she said.
Republished from the Winnipeg Free Press print edition May 17, 2009 B1
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