Topic: "Call for help botched by emergency services"

[mariomike]

Toronto
Aug 13 2011
"Rose called 911 hoping paramedics would help the 69-year-old, but Toronto Emergency Medical Service first botched the call, then lied to Rose saying they had checked his friend out and the man was fine. The ambulance didn’t reach Logan’s condominium for more than two hours.":
http://www.thestar.com/news/article/1039251--call-for-help-botched-by-emergency-services?bn=1#article

"The Roses, Logan’s long time friends, who have taken over as his caregivers, launched a $10 million lawsuit against Toronto’s emergency medical services on behalf of Logan and his three adult children."

[Container]

While unfortunate, Mr. Logan was the author of his own demise. He called off the paramedics- as is the right of any person. It was a third hand complaint- perhaps a bus could have been rolled but there are Im sure any number of calls in the queue for EMS in Toronto- I wouldnt imagine they have the luxury of double checking every call by the disptach.

As for the followup call to dispatch, I beleive the information that the dispatcher would have had available would have stated that the patient cancelled the call. The assumption that it had been done in person was a mistake by the dispatcher. But these are admin errors.

A man who doesnt "believe" in doctors, tells dispatch he's fine- perhaps EMS should have followed through and had him sign the forms in person. However, that is not a 10 million dollar error. And EMS services are unlikely to improved by losing 10 million.

Third hand calls are always treated with suspicion- people only have to look at the abuses heaped upon 911 on daily basis to see why. The new trend of calling in armed standoffs to see SWAT is a good example.

[mariomike]

It was a third hand complaint- perhaps a bus could have been rolled but there are Im sure any number of calls in the queue for EMS in Toronto- I wouldnt imagine they have the luxury of double checking every call by the disptach.

Toronto EMS Communications Centre receives 425,700 calls per year. ( To show the increase in call volume, in 1967 they handled 45,000 calls for the entire year. The geographic area - 243 sq. miles - remained unchanged. )
I was not qualified as an Emergency Medical Dispather EMD, but I spent time in there over the years. I wish the reporter could do that - sit beside an EMD and plug in. I was am in awe of some of them.
 

[Sheerin]

10 million dollars is incredibly excessive, especially when take into account the fact that even if the medics had arrived he wouldn't have met the provincial standard for stroke bypass as there isn't a clearly defined onset of symptoms. 

[mariomike]

For reference, this is the Acute Stroke Protocol for T-EMS: ( I believe it is province-wide? )

Paramedic Prompt Card for Acute Stroke Protocol
Indications for Patient Transport to a Designated Stroke Centre:
Transport to a Stroke Centre must be considered for patients who:
Present with a new onset of at least one of the following symptoms suggestive of the
onset of an acute stroke.
• Unilateral arm/leg weakness of drift
• Slurred or inappropriate words or mute
• Facial droop
AND
Can be transported to arrive within two (2) hours of a clearly determined time of
symptom onset or the time the patient was “last seen in a usual state of health”.
Contraindications of Patient Transport Under Stroke Protocol:
Any of the following conditions exclude a patient from being transported under Stroke
Protocol.
• CTAS Level 1 and/or uncorrected airway, breathing or significant circulatory
problem
• Symptoms of the stroke have resolved
• Blood Sugar ≤ 4 mmol/l
• Seizure at onset of symptoms or observed by paramedic
• Glasgow Coma Scale < 10
• Terminally ill of palliative care patient
CACC will authorize the transport once notified of the patient’s need for transport under
the Stroke Protocol.

[Sheerin]

the protocol was updated a few months ago. 
The major changes are the window is now 3.5 hours, and the BGL requirement has dropped to 3 mmol/L or less. 

[mariomike]

Thanks, Sheerin.

Update.
Looks like the Star is still holding their feet to the fire.
"We need answers on emergency services":
http://www.thestar.com/opinion/editorials/article/1039805--we-need-answers-on-emergency-services

"Unfortunately, this is not the first time concerns over how EMS handled a medical emergency were followed by silence. Jim Hearst died in the hallway of his Toronto apartment building in 2009 while paramedics who were sent to help him sat in their ambulance a block away for half an hour. It took a provincial investigation to get any answers in that case. In other cases, information has come to light only through lawsuits by families."

[Sheerin]

What's up with the Star's hate-on for EMS? 

[mariomike]

What's up with the Star's hate-on for EMS?

I wonder if T-EMS will give them next year's "print media award"? 
2011:
"Kathryn Stocks, editor at the Toronto Star, won the print media award":
http://digitaljournal.com/print/article/306964

What sells the morning papers and the 6 o'clock news - the PR the public remembers -  has always been, and always will be, the photos and film: "If it bleeds, it leads!"

I believe their complaint investigations are thorough.
"Complaint Investigation Policies and Procedures":
http://www.torontoems.ca/main-site/pdf/PSU-Manual-v.5-March-15-2011-1.pdf

Regarding the coroner's inquest into the 2009 call mentioned in the article:
http://news.ontario.ca/mcscs/en/2010/04/inquest-into-the-death-of-james-hearst-postponed.html

[BadEnoughDude]

For reference, this is the Acute Stroke Protocol for T-EMS: ( I believe it is province-wide? )


• CTAS Level 1 and/or uncorrected airway, breathing or significant circulatory
problem

Why would a case being Level 1 exclude them from the protocol? I'm just a bit puzzled since Level 1 cases are resuscitation cases and if a patient had a major stroke it's definitely possible that they could code in the bus and become a Level 1.

[mariomike]

Why would a case being Level 1 exclude them from the protocol?

Because there are only three Stroke Centres in Metro. There are lots of hospitals. If you have a CTAS 1, you can't by-pass them to go to a Stroke Centre. 

[ColdNorth]

Why would a case being Level 1 exclude them from the protocol? I'm just a bit puzzled since Level 1 cases are resuscitation cases and if a patient had a major stroke it's definitely possible that they could code in the bus and become a Level 1.

To add to mariomike's comment to clarify further...
Patients need to be stable enough to make it to the stroke center.  If they are CTAS 1 they are not stable, therefore must go to the closest hospital. 

If a paramedic decides they are stable enough to make it to the closest center, they would come in on a CTAS 2 most likely so that their patient falls under the protocol. 

[mariomike]

To add to mariomike's comment to clarify further...
Patients need to be stable enough to make it to the stroke center.  If they are CTAS 1 they are not stable, therefore must go to the closest hospital. 

If a paramedic decides they are stable enough to make it to the closest center, they would come in on a CTAS 2 most likely so that their patient falls under the protocol.

CTAS improved things. It standardized communication between paramedics, emergency medical dispatchers and the hospitals. CTAS 1 are transported to the nearest hospital regardless of how busy the emergency department is, and less seriously ill patients are to be transported to the hospital providing the most appropriate treatment.

It wasn't always like that. There was an inquest, followed by a lawsuit:
"A tragedy in Toronto early this year ( 2000 ) became the flash point for a health care system in crisis.":
http://www.cjem-online.ca/v2/n3/p212
"Later that day, I issued a directive to the land paramedics of the City of Toronto Emergency Medical Service (EMS) indicating that, under specified circumstances (see Table 1), they should transport patients to the nearest facility regardless of hospital bypass status."

Same call:
"The legal duty of physicians and hospitals to provide emergency care: ACCESSIBILITY OF HOSPITAL EMERGENCY SERVICES HAS BEEN an issue of increasing concern and was recently brought into public focus in Ontario by the tragic death of Joshua Fxxxxx, whose ambulance was redirected from the nearest hospital.":
http://www.cmaj.ca/content/166/4/465.full
"The new system, implemented province wide in October 2001, has standardized communication between paramedics, dispatch staff and hospital emergency personnel by having them use the Canadian Triage and Acuity Scale (CTAS) to evaluate and describe the needs of patients."

[Sheerin]

While CCB no longer exists we still face similar problems.  We have issues with hospitals going on consideration at various points throughout the day.  Consideration basically means that they don't have enough beds available to deal with the influx of patients and that they are requesting that we take CTAS 3, 4 and 5 patients to another facility.  Only thing is it's very common for all three adult emergs in the city to be on consideration at the same time.  So we end up going regardless.

For crews it means extensive offload if the patient isn't capable of being offloaded to the waiting room. 

Under consideration we can still bring CTAS 1 and 2 patients (though 2's we can play with a little more depending on things and of course if they meet any bypass considerations). 

[mariomike]

While CCB no longer exists we still face similar problems.  We have issues with hospitals going on consideration at various points throughout the day.  Consideration basically means that they don't have enough beds available to deal with the influx of patients and that they are requesting that we take CTAS 3, 4 and 5 patients to another facility.  Only thing is it's very common for all three adult emergs in the city to be on consideration at the same time.  So we end up going regardless.

For crews it means extensive offload if the patient isn't capable of being offloaded to the waiting room. 

Under consideration we can still bring CTAS 1 and 2 patients (though 2's we can play with a little more depending on things and of course if they meet any bypass considerations).

They made a documentary about the "hall of shame":
http://www.youtube.com/watch?v=EDHwAwhf-xs&feature=player_embedded

It was made in Los Angeles, but could have been Toronto, as far as I am concerned.

[ColdNorth]

Offload delay decay can be curbed by the use of an offload nurse which I have seen here in Simcoe County (said Offload-nurse is employed by the paramedic service not the hospital at which they are located). Crews transfer care to OLN after triage and are free to respond to the next call while the previous patient waits for a bed.

Has Toronto EMS ever entertained this idea?

[mariomike]

Offload delay decay can be curbed by the use of an offload nurse which I have seen here in Simcoe County (said Offload-nurse is employed by the paramedic service not the hospital at which they are located). Crews transfer care to OLN after triage and are free to respond to the next call while the previous patient waits for a bed.

Has Toronto EMS ever entertained this idea?

Yes. They have off-load nurses in all adult emergency departments ( except one, apparently ). MOHLTC pays T-EMS, and T-EMS pays the hospital. They also created a 24/7 management position in the Communications Centre known as the Duty Officer. The Duty Officer’s responsibility is to "provide minute-by-minute system oversight with particular attention to offload delay."

More on OLD ( 2008 ):
http://chealth.canoe.ca/channel_health_news_details.asp?channel_id=41&relation_id=1826&news_channel_id=41&news_id=24297
Toronto Sun: "Hospital backlogs that leave patients in waiting rooms or on stretchers in a so-called "hall of shame" are to blame for three people dying within 24 hours at Etobicoke General Hospital, a city paramedic union leader alleges."

[BadEnoughDude]

Offload delay Crews transfer care to OLN after triage and are free to respond to the next call while the previous patient waits for a bed.

Where I am, we have Code 7 rooms for overflow where the patient is waiting for a bed. Is this a common practice in the GTA?

[mariomike]

Where I am, we have Code 7 rooms for overflow where the patient is waiting for a bed. Is this a common practice in the GTA?

Each province legislates the administration and delivery of emergency medical services within its own borders. I do not not know which province you are in, but in Ontario Code 7 means "no patient carried" NPC. Hospital codes are usually colours.
There are holding rooms in the GTA. But, they must overflow often because it is common practice to see, and put, patients in the "hall of shame".

Hospital overflow in Vancouver: triage in a Tim Horton's:
http://www.youtube.com/watch?v=ivk3MWtS29w

[BadEnoughDude]

Each province legislates the administration and delivery of emergency medical services within its own borders. I do not not know which province you are in, but in Ontario Code 7 means "no patient carried" NPC. Hospital codes are usually colours.
There are holding rooms in the GTA. But, they must overflow often because it is common practice to see, and put, patients in the "hall of shame".

Hospital overflow in Vancouver: triage in a Tim Horton's:
http://www.youtube.com/watch?v=ivk3MWtS29w

I worked Emerge as a Unit Aide for a number of years, and we always called our holding room the Code 7 Room. Anways, the Paramedics would have their overflow patient in the "Code 7 Rooms" and wait around not allowed to take calls until their patient got a bed (this pissed them off royally), which caused an uproar amongst both Emerge medical staff and the Paramedics. I remember that we'd do anything possible to get that dang room cleared so the Paramedics could get back out there. I think it's since been corrected in the entire region given the absolute chaos that it caused, not to mention loss of essential emergency services, but I'm not entirely sure. The Hall of Shame did still occur despite there being an overflow room, regardless.

 As a side note, it depends which Emerge in this area you go to: One uses the so-called Code 7 Room the other exclusively uses the Hall of Shame for overflow. They're soon to start renovations on the Emerge that I worked at to expand it tremendously, meaning more beds, more space and more services provided, so hopefully less overflow, given the HUGE catchment area of the hospital (Thank God!).

Also as a side note, I guess using the term "overflow" in the "Code 7" room's name in any capacity would make some LHIN bonehead throw a hissy during their assessment of that particular Emerge, given LHIN's obsession with reducing overflow and wait times even when their IHSP suggestions are contrary to providing proper care (the example of a Level 3 chest pain patient to be discharged in a time before a second set of heart enzymes can be completed comes to mind). Our LHIN is particularly bad, in terms of its administration and IHSP recommendations.
 

By the way, speaking of the Colour Emergency Codes, do you know of any hospitals that have implemented the new(ish) Code Purple and  Code Grey and their policies? We've yet to implement them in our LHIN; still the same old ones.

[mariomike]

Anways, the Paramedics would have their overflow patient in the "Code 7 Rooms" and wait around not allowed to take calls until their patient got a bed (this pissed them off royally), which caused an uproar amongst both Emerge medical staff and the Paramedics.

Based on experience and observation in a "Hi-performance" system, I believe it was T-EMS management who were the most royally pissed off because their crews had to "wait around not allowed to take calls". OLD costs significant loss in paramedic productivity, and millions of dollars in end-of-shift overtime. They also have to pay the crews a penalty for missed / delayed meal breaks.

T-EMS Offload Nurse Program:
http://www.toronto.ca/civic-engagement/council-briefing/pdf/1-3-38.pdf
"The ED Director for a Toronto hospital recently said “The hospitals have tried a lot of things to reduce ambulance wait times. The only thing that has had any effect is the Offload Nurse Program.” "

[Sheerin]

Hamilton we have offload nurses 12 hours a day at the 3 adult hospitals.  It's costing around $750,000 a year.  It hasn't made a significant dent in our offload delay issues, which we are told are statistically the worst in the province.  On a nearly daily basis we drop down to zero trucks available for calls due in large to offload delay.  It's actually pretty bad.  Forced overtime, missed meal breaks, cab fare for switching crews at the hospital at end of shift, are all costs that are rising fast. 
The offload issues were exacerbated by the LHIN's incredibly insightful decision under their "Access to Best Care" plan to turn McMaster hospital in a paediatric only facility.  This has resulted in the west end being without an ER, and increased the workload on the other emergs.  We all knew it would fail, everyone from city council, to the medics, to the emerg physicians all knew it would be a total CF, and we were right.

The main reason why the offload nurse doesn't make a huge dent is that they can only cover 4 patients and we typically bring in far more than 4 patients per hour so there can be a huge backlog.  True some of the patients we bring in can be offload straight to the waiting room, an option i full endorse, but even with that it doesn't always work. 

[mariomike]

Just to add to Sheerin's post.

Mar 17 2011
"Hamilton is on track to record its worst ambulance shortage ever,...":
http://www.thespec.com/news/local/article/502786--city-on-track-for-worst-ambulance-shortage-ever
"In the first two months of the year, the city’s paramedic service reported 39 “Code Zero” incidents..."

"That’s more than double 2010’s figures for the same two months and triple the year before."

"...the city is on pace for 241 Code Zero incidents this year."

Exactly as you said, Sheerin: "On a nearly daily basis we drop down to zero trucks available for calls..."

[BadEnoughDude]

Once again LHINs screw up healthcare around the province. They are the best example of a bureaucratic pipe dream that I could ever think of. Seriously, who runs those things, certainly not anyone with an ounce of experience in or knowledge about the realities of healthcare. I'm convinced that they're run by pigeons and chickens that randomly peck at buttons that determine whatever a policy will consist of.

[recceguy]

Once again LHINs screw up healthcare around the province. They are the best example of a bureaucratic pipe dream that I could ever think of. Seriously, who runs those things, certainly not anyone with an ounce of experience in or knowledge about the realities of healthcare. I'm convinced that they're run by pigeons and chickens that randomly peck at buttons that determine whatever a policy will consist of.

I would bet that they are simply close friends and supporters of our super nanny McGuinty, being rewarded for their years of servitude to said emperor and party.

[BadEnoughDude]

I would bet that they are simply close friends and supporters of our super nanny McGuinty, being rewarded for their years of servitude to said emperor and party.

I think you nailed it right there. I swear it's so typical of the Ontario government to give positions not based on skill or merit but to those who blindly follow McGuinty and see him as some sort of visionary. I wouldn't be surprised if these types had paintings of him on the walls of their homes.

Not to hijack the thread, but the bottom line is that the Liberals have completely FUBAR'ed all systems within the province. Hopefully a PC government can sort out the complete cluster$%^ the province has become. Just my  .

[mariomike]

Not to hijack the thread, but the bottom line is that the Liberals have completely FUBAR'ed all systems within the province. Hopefully a PC government can sort out the complete cluster$%^ the province has become. Just my  .

This goes beyond provincial party politics.

"Off-load delay is a problem that's happening in cities across Canada and the United States.":
http://www.cbc.ca/whitecoat/episode/2008/05/14/off-load-delays-highlight-paramedic-powerlessness/
"This week on White Coat Black Art, we show you the impact of off-load delay on emergency responsiveness in Halifax."

"Three years ago, Emergency Health Services Nova Scotia had a contractural guarantee to off-load their patients within 20 minutes of arrival in emerg. Now, it's not uncommon for medics there to complete an entire 12 hour shift alongside a patient in a hallway in the emergency department."

"I just listened to this and if I closed my eyes it could be Calgary."

Same problem in British Columbia, California and elsewhere.

2011 Memphis (Tenn.)
"Stories continue to pour in from across the country about emergency department (ED) wait times, which continue to be a problem for EMS."":
http://www.jems.com/article/administration-and-leadership/value-your-agency-s-best-asset-0
"The waiting game at the ED is only going to get worse as time goes on."