EMS in Ontario

STEVE ROWLAND

Mar 15, 2012

1. Where we've been
Prior to 1968, one of the few requirements needed to run an ambulance service in Ontario was to have a vehicle long enough to lay someone down. Generally speaking, the only people able to meet that specific requirement were the local undertakers - they were usually well staffed, their telephones were answered day or night, and they met the vehicle requirement. Occasionally, other dedicated citizens took up the challenge and provided local ambulance service - they were sometimes mechanics who loved the idea of driving fast on city streets. Cab or towing companies were also known to start their own service by buying an ambulance. With no regulations, there were frequently no qualifications and no equipment in these vehicles, aside from the stretcher.

In 1968, the Province of Ontario regulated ambulance services and tasked Dr. Norman McNally (a retired army doctor and Director of the Emergency Health Services Division of the Ontario Hospital Services Commission) with establishing "a balanced and integrated system of ambulance services".

Doctor McNally instituted standardized training, vehicles and equipment and radio communications. Part of the standardized training was held at Canadian Forces Base Borden for all provincial ambulance attendants. This training, called the Fundamentals of Casualty Care, consisted of 160 hours of anatomy and physiology, advanced first aid, splinting for fractures, and light rescue techniques. Benefits of the programs established by McNally and EHS included standardized vehicles and training, and a province-wide radio network in which an ambulance starting in Cornwall, Ontario could theoretically drive to Kenora, Ontario without ever being out of radio range of a dispatch centre or having to switch channels.

2. Where we are
In Canada the scope of practice of paramedics is described in a document by the National Occupational Competency Profile (NOCP) for Paramedics. It was developed by the Paramedic Association of Canada with financial support from the Government of Canada. The NOCP outlines four levels of providers: Emergency Medical Responder (EMR), Primary Care Paramedic (PCP), Advanced Care Paramedic (ACP), and Critical Care Paramedic (CCP).

With the establishment of the community college programs in the early 1970s, trained ambulance attendants were now providing a higher level of care across the province. Several ambulance services across Ontario had noted that an experimental program dealing with pre-hospital care cardiac patients had been successfully conducted in Belfast, Northern Ireland. Some services here began to believe that if pre-hospital cardiac patients could be dealt with in Belfast, then paramedics could do it in Ontario too.

With that in mind, Oshawa physician Dr John Forsythe approached the manager of a local ambulance service and proposed training the ambulance attendants to deal with out-of-hospital cardiac patients. This training began at the Oshawa General Hospital in January 1979.

The ambulance attendants took the training on their own time and at their own expense but received no additional increases in salary from their employer, the Ontario Ministry of Health. They started treating patients in their homes and on the street in December 1979.

The Advanced Care Paramedic (ACP) must have a minimum of 2 years of experience as a PCP before being able to qualify for training at the ACP level. The ACP program is an additional 1 year in length and is considered a post-diploma program (1200 hrs). The intensive ACP course requires weeks of in-class didactic training, weeks of in-hospital clinical training where the student works directly with physicians, and months of preceptorship practicum where the aspiring ACP must demonstrate competence to multiple paramedic service preceptors. In addition, ACP students must successfully complete many mandatory and elective continuing medical education courses on an annual basis to maintain their certification. ACPs can be recognized by the two stripes above the word "Paramedic" on their shoulder epaulettes.

The ACP typically carries approximately 20 different medications, although the number and type of medications may vary substantially across Canada. ACPs perform advanced airway management including intubation, surgical airways (although not all services can do this procedure), intravenous therapy, place external jugular I.V. lines, perform needle thoracotomy, perform and interpret 12-15 lead electro-cardiograms, perform synchronized and chemical cardioversion, transcutaneous external cardiac pacing, perform obstetrical assessments and out-of-hospital deliveries, provide pain relief for various conditions through medications, and reverse hypoglycemic diabetic states. A number of services in Canada have experimented with pre-hospital thrombolytic drugs (to dissolve blood clots) and rapid sequence induction intubations. Pre-hospital medical research has permitted a great number of variations in the scope of practice for ACPs. Current programs include providing ACPs with discretionary direct 24-hour access to percutaneous intervention labs, bypassing the local emergency department, and represents an essential change in the way that patients with S-T segment elevation myocardial infarctions (aka STEMIs) or heart attacks are treated.

3. Where are we going?
The health care system is in crisis. Emergency departments are overloaded, the hospitals have no empty beds and ambulances are being tied up - sometimes for hours - with patients on their stretchers waiting to be transferred to hospital beds.

One potential option being investigated, and which is currently operating in parts of Canada and around the world, is that of Community Paramedics. Specially-trained paramedics have been operating in conjunction with a nurse practitioner and an off-site physician at the two isolated island communities of Long and Brier in Nova Scotia. There has been a 23% decrease in Emergency Room visits by residents of the islands since inception of the new program.

Paramedics were used on the night shift at the Chedoke hospital in Hamilton for several years in place of on-site physicians. They used their paramedic directives to deal with any medical problem that arose - and if further treatment was necessary, the patient was transported by an EMS vehicle to a tertiary care facility.

Utilizing all of the resources available is one positive way to deal with the increasing number of hospital visits and the sky-rocketing costs of health care. If paramedics, nurse practitioners and non-emergency clinics that are open 24/7 were to be efficiently utilized, it might be possible to rein in some of the costs of health care without cutting essential services, staff or quality care.

EMERGENCY MEDICAL RESPONDER
In some rural areas of Canada, EMRs are volunteers who are trained to the Advanced First Aid level, have CPR training. They may also have access to S-AEDs (Semi-automated External Defibrillators).

EDUCATION AND TRAINING OF PARAMEDICS
In order to apply to one of the 22 Community College Programs approved by the Province of Ontario to become a Primary Care Paramedic in Ontario, a candidate must meet the following qualifications:

Ontario Secondary School Diploma or equivalent, or mature student status
Grade 12 English, or equivalent
Grade 11 or 12 Biology, or equivalent
Grade 11 or 12 Chemistry, or equivalent
Grade 12 Mathematics, or equivalent
Completion of admission testing for senior-level biology, chemistry, writing skills, and arithmetic
Submission of documented proof of current CPR-C for HCP and Standard First Aid certifications
Submission of documented proof of completion of current full Class G or G2 driver's licence.

Additional requirements include:

Complete immunization record including immunization against Hepatitis B, polio-myelitis, tetanus, diphtheria, MMR, chickenpox, influenza and test negative on the Two-Step Tuberculin Skin Test
Valid CPR-C for Health Care Professionals and Standard First Aid certificate
Students in programs or occupations involving direct contact with vulnerable persons are required to undergo a Police Record Check.

PRIMARY CARE PARAMEDIC

A Primary Care Paramedic (PCP) is a community college graduate from a program dedicated to the Paramedic profession. A diploma in "Paramedic Studies" is two years in duration, and emphasizes anatomy, physiology, pharmacology, and mechanisms involved in acute injury and illness. These programs involve classroom learning and clinical hours working directly in the field. Once a college program is successfully completed, a paramedic must pass a provincial examination. Known as the Paramedic exam or the Advanced Emergency Medical Care Assistant (A-EMCA) exam, this certification is needed to practice as a primary care paramedic in Ontario. In addition, PCPs must complete many continuing medical education courses on an annual basis to maintain their qualifications. The PCP is also certified by a physician to perform a number of controlled medical acts for individuals experiencing acute injury or illness. PCPs are distinguished by the one stripe above the word "Paramedic" on their shoulder epaulettes.

The PCPs function is to provide:

emergency patient care
cardiopulmonary resuscitation (CPR)
patient immobilization
oxygen therapy
basic trauma life support; and
blood glucose testing

The PCPs skill set and medications may also include:

acetylsalicylic acid
semi-automatic defibrillation
epinephrine
glucagon
glucose gel
nitroglycerine spray
salbutamol
peripheral IV starts
12-Lead ECG application; and
pulse oxymetry monitoring