Out of Time: One Month Inside Quebec's Paramedic Shortage

Part 1: The crisis is costing lives and the paramedics who haven't quit are hanging on by a thread.

EDITOR’S NOTE: This is part of The Last Ambulance, a collaboration between The Rover and former paramedic turned journalist Hal Newman. In this article, the first of a two-part series, Hal gives you raw data from the frontlines of the crisis and a pair of stories that highlight just how bad things have gotten.

By Hal Newman

The prehospital care system in Quebec has been broken for a long time however the month of March has been particularly brutal – and tragic. 

It shouldn’t come as a surprise to anyone who pays attention to reports that ambulance services are overloaded, paramedics are exhausted, and ERs are so overcrowded that paramedics and their patients are sometimes forced to wait hours before the patient can be transferred to a bed.

But it seems likely that all of the dysfunction may have contributed to the death of a 38-year-old man being investigated by the coroner. 

Long before I ever became a paramedic, I was raised with the understanding that if faced with a life-threatening emergency, I should call for help and help would come. That was true for a long time. 

Certainly, there were ebbs and flows in the prehospital care system as it experimented with different models. However, the bottom-line was that if we called for emergency medical assistance, there would be help on the way.

That’s still true for the most part. Except now there’s an air of uncertainty because the underlying framework of the prehospital care system is breaking down. And the guts of that system — the paramedics — are demoralized and exhausted.  

In this investigative journalism report, The Rover’s The Last Ambulance project tracked the crisis in Quebec’s prehospital care system on a daily basis throughout the month of March. 

The timeline will take you through 31 days as communities across Quebec had to come to grips with the reality that local paramedics were out-of-service because there are no longer enough of them to fill all the blank spaces on the schedules. 

These are the stories we chose to highlight the profound challenges facing the government as it undertakes a $370M commitment to improve prehospital care over the next five years.

But merely improving the existing prehospital care system in Québec may prove to be an expensive exercise in futility. The entire system needs to be transformed including a cultural shift to a point where caring for patients and saving lives are not mutually exclusive.

TIMELINE

March 1: At 08H25 Urgences-santé is dealing with a serious paramedic shortage. -57 paramedics for the dayshift. Only 49 on-duty ambulances. No available ambulances for Montreal & Laval at the moment.

The ambulance based in Waterloo which also covers Shefford, was out of service for 12 hours on Sunday night due to a paramedic shortage.

As of 16H00 there have been no ambulances available in Quebec City's metro region. The ambulance service is at max capacity. As soon as an ambulance reports for duty it's being dispatched to one of the calls on hold.

March 2: At 11h00, Urgences-santé is operating at max capacity. No ambulances available in Montreal or Laval. More than two dozen lower priority calls on hold. Moderate volume of calls from 911. Emergency Plan Level 1.

At 12H45 the situation at Urgences-santé continues to be complicated. More than three dozen lower priority calls on hold. No ambulances available at the moment. Moderate volume of calls via 911. Emergency Plan Level 1.

Paramedics in Quebec City are responding to calls which have been on hold for more than 3 hours. Delays at Emergency Rooms are a big problem - with 20 per cent of Quebec city's on-duty ambulances currently waiting to transfer their patients to beds at Centre Hospitalier Enfant Jesus.

March 3: At 08H00 The paramedic shortage continues at Urgences-santé. -52 paramedics for today's dayshift. That's -26 ambulances available to respond to calls in Montreal and Laval. Already almost a dozen lower priority calls on hold.

March 4: The shortage of paramedics continues to impact Urgences-santé operations in Montreal and Laval. -43 paramedics for the day shift, -21 ambulances. -11 paramedics for the evening shift and -10 for the night. Another rugged day in the metropolis.

March 5: At 10H45 there are no ambulances available in Montreal or Laval. Urgences-santé is at Emergency Plan Level 1. More than a dozen calls on hold. 

March 6: At 10H20 with wicked weather impacting southern Quebec, Urgences-santé is running at max capacity. As paramedics clear one call in Montreal or Laval, they are immediately dispatched to another. There are more than two dozen lower priority calls on hold.

***

I've had a lot of questions about what I mean when I refer to lower priority calls being placed on hold when there are ambulance shortages.

So I prepared these guides based on the MSSS operational protocols for prehospital priorities. Now we have a shared frame of reference — these are the assignment guidelines from the MSSS. We know every day across Québec, due to ongoing paramedic/ambulance shortages these guidelines are not being properly applied.

March 7: 08H45 Urgences-santé is struggling. No ambulances available in Montreal or Laval. -40 paramedics for the dayshift, -20 ambulances. Several Priority 3 calls have been waiting more than an hour for available ambulances.

At 08H55 there was only one ambulance available for Gatineau Metro in the Outaouais. There were several ambulances waiting to transfer their patients to beds in hospital ERs.

Incredible scene playing out at Centre Hospitalier Pierre-Le Gardeur (Terrebonne) this morning as the crews of 11 ambulances wait to transfer their patients to beds in the ER. All those patients & paramedics waiting more than an hour. Meanwhile calls keep coming in to the system.

March 7 cont’d:At 15H30 Urgences-santé has almost four dozen lower priority calls on hold. They are running at max capacity. As soon as paramedics clear one call, they are assigned to another.

No ambulances available available in Saguenay currently. Crews will have response delays of up to 20-25min depending on where the calls/crews are located. 

March 8: At 10H05 there are 9 crews of paramedics waiting to transfer their patients to beds in the ER at CH St Eustache. At 12H There are 6 crews of paramedics waiting to transfer their patients to beds in the ER at CH Honoré-Mercier in Saint-Hyacinthe. 

At 12H25 Urgences-santé paramedics are working at maximum capacity. As soon as a crew finishes a call they are assigned to another. Almost three dozen lower priority calls on hold. Emergency Plan Level 1. 

March 9: No ambulances available in Montreal or Laval at the moment. Emergency Plan Level 2. More than four dozen calls on hold. Hospital ERs are overloaded and so are the paramedics of Urgences-santé. At 13H40 there are more than 15 Priority 3 calls on hold. These calls - which should have a 20-25 minute response time - are almost on a 2-hour response delay at this point. 

March 10: Mont-Laurier in the Hautes Laurentides is a long haul from other hospitals and patient transfers mean 2.5 hr-long calls for paramedics. Depending on the day, Mont-Laurier can be left without ambulance coverage until one of its crews returns. Today is one of those days. Until 09H00, the closest ambulance for emergency response will be 45 minutes away. 

Montreal and Laval's ambulance service continues its struggle to meet optimal levels in assigning paramedics to calls. At 09H30 there are half a dozen Priority 4 calls which have been holding for more than 4 hours. These are calls that should be assigned in 30 minutes or less 80% of the time - or in 60 minutes of less 90% of the time. Clearly, hold times of more than 4 hours are not good for the patients who are waiting for paramedics. 

Earlier this evening in Montreal and Laval, there were 5 Priority 4 calls which had been waiting more than 9 hours - almost 10 hours for paramedics. Those calls should have been assigned to paramedics in less than 60 minutes. There's no good excuse for making people wait more than 9 hours for an ambulance.

March 11: At 08H10 there are no ambulances available in Montreal or Laval. Very high volume of calls from 911. Almost a dozen Priority 3 calls with a hold time of more than 45 minutes. Guidelines for Priority 3: Potential risk of clinical deterioration. Immediate assignment. 

At 08H45 there are nearly three dozen lower priority emergency calls on hold in Montreal and Laval. No ambulances available. Emergency Plan Level 2.

No ambulances are available in Québec City. Back up crews responding from Jacques Cartier. Two emergency calls on hold including one Priority 1.

March 12 : Last evening, paramedics in Montreal were dispatched for a Priority 0 call - high risk of cardio-respiratory arrest. This is the highest priority emergency. The closest available ambulance was almost 10 km (13 precious minutes) away. Hoping first responders were as effective as possible. For every minute that passes without CPR or a lifesaving shock from a defibrillator, the chances of survival for a victim of cardiac arrest drop by approximately 10%. Do the math.

STORY ONE: Out Of Time

March 12 turned out to be a tragic day for one patient and his family.

The  paramedic shortage and the profound dysfunction plaguing the prehospital care system may have contributed to the tragic outcome of an ambulance call for a 38-year-old man in Lac Superieur in the Laurentians.

The Bureau du coroner confirms “an investigation is underway to shed light on the cause and circumstances of this death.”

On March 12 the paramedic shortage meant there were only two ambulances on-duty in Saint-Faustin instead of the three which were scheduled. There was a solo paramedic on the third ambulance to provide a measure of emergency assistance until a full team of paramedics could arrive.

With one ambulance already assigned to a call, the second team of paramedics were assigned to a Priority 1 call at the Station Ski Tremblant — a 20-minute drive from the ambulance station.

With both fully-staffed ambulances assigned to calls, the solo paramedic on the third ambulance was on standby in the station when another call to 911 was placed for medical assistance in the Lac Superieur area.

The call was triaged as a Priority 3 emergency (potential risk of clinical deterioration “immediate assignment”). Lac Superieur is only 8 minutes from the ambulance station in Saint-Faustin however, the closest available fully-staffed ambulance was leaving from Sainte-Agathe — 25 minutes away.

En route to the scene, the call was upgraded to a Priority 1 emergency. Priority 1 calls are defined as “Immediate risk of mortality. Urgent immediate assignment.”

For reasons which remain unclear but may be related to a lack of communications interoperability between the different ambulance zones, the solo paramedic in-station in Saint-Faustin wasn’t notified of the call in Lac Superieur.

When the paramedics from Sainte-Agathe arrived on-scene, the 38-year-old patient was in cardio-respiratory arrest and despite their best efforts, he did not survive.

The Rover contacted the Sûreté du Québec who referred us to the Bureau de Coroner.*

***

March 13: Late last night in St-Hyacinthe, the SQ had to transport a seriously ill patient to the ER because no ambulance was available to respond to the call.

In Windsor QC today there will only be one ambulance available during the dayshift. The second shift - an horaire de faction (on-call shift) - has not been filled.

The following cities are affected by the shortage of paramedics today: Rawdon, Drummondville, Coaticook, Windsor, and Acton-Vale. Each is missing an ambulance crew on today's dayshift or evening shift.

There will only be one ambulance tonight for Les Maskoutains (including St-Hyacinthe) and its 87,000 residents. For the next several hours there will be only one ambulance in Sorel-Tracy because the other crew is out on a transfer to Montreal. 

In Weedon (Estrie), the shortage of paramedics combined with their gruelling shift schedule is causing major problems for ambulance personnel. The ambulance company is now trying to prevent service disruptions by offering 12-hour on-call shifts instead of the usual (and archaic) 24-hours on-call, seven days in a row.

Last night, in Sainte-Sophie, the evening paramedics had to wait 2.5 hours before having access to an ambulance to start their shift. And once they actually had access to the ambulance, there was another 30-40 minutes for inventory and a vehicle check before they could get into service.

Incredibly, the one ambulance that was available for Les Maskoutains - including St-Hyacinthe - has been sent out on an inter-hospital transfer.

March 14 : The shortage of paramedics is also affecting communities in Abitibi-Témiscamingue. Even with paramedics working over 40 hours of overtime to avoid service interruptions, they're still struggling to cover all shifts. Tomorrow (Tuesday) brings even more complexity to the situation with only one of the two ambulances scheduled to serve Abitibi Ouest available tomorrow - the emergency department at Hopital de La Sarre will not be able to accept critically ill stroke or trauma patients. If a seriously ill patient needs to be transferred to another hospital, the back-up ambulance will come from Rouyn-Noranda - more than 75 km away. Hopital de La Sarre has already been facing a service breakdown for several months in the intensive care and pediatrics departments due to a lack of nursing staff. And last week, the ambulance serving Malartic (near Val d'Or) was unavailable for 56 consecutive hours due to a shortage of paramedics.

March 15: The closest available ambulance for a Priority 0 — a life-threatening emergency — in the Plateau is leaving from LaSalle. 27 minute response time.

Paramedics in the Laurentides and Lanaudière regions have been advised the process of choosing their summer vacation, which began last week, has been suspended while the employer analyzes the results of the decision of the Administrative Labor Tribunal (TAT) in connection with the Paramedics' strike scheduled for March 16.

The TAT's decision requires qualified managers to replace paramedics on the road in order to avoid service disruptions during the strike. At this point, the only region where we can confirm paramedics being affected by this suspension of booking their summer vacations is in the Laurentides and Lanaudière regions. It's certain this will only further complicate the challenges facing the prehospital care system.

Both of the on-duty ambulance crews for Granby are on transfers at the moment. Back-up crews will be responding from neighbouring towns for the next hour or so.

March 16: Geography and paramedic shortages make for an interesting & complicated mix: With only one of three ambulances on-duty today in Val-des-Sources, it's possible one of the ambulances based in Windsor would respond to assist. Except only one of two ambulances is on-duty today in Windsor. Managing the ambulance network is an exercise in risk management. The ongoing paramedic shortage increases the risks while reducing the available resources to mitigate said risk.

March 17: In Bedford (Estrie), only one of two ambulances will be on-duty today until 16H after which there will be no ambulances on-duty in Bedford until 08H tomorrow morning. The closest back-up crew of paramedics will be at least 15 minutes out.

STORY TWO: “Robbed on Both Sides” 

Students working for the STM this summer can earn more than a paramedic.

Starting salary for a paramedic: $23.63/hr. 

Québec has a paramedic shortage and enormous problems with recruitment and retention - and yet, in their infinite wisdom, the government has created a pay scale with 12 grades (echelons) to climb before earning the top salary. 

You're asking me "How does that work, Hal?" 

Paramedics starting out can look forward to working at least 12 years before they achieve the top salary available. If paramedics are working part-time it can take two years or more to move up another echelon. 

One paramedic said, “We’re getting robbed from both sides. When we don’t work enough hours, we don’t move up an echelon and we do more – by working at another company to gain more hours – those hours don’t count towards moving up an echelon.” 

And we wonder why we're hemorrhaging younger paramedics. 

Who would want to stay in a job where they're shouldering the same responsibilities but getting paid thousands of dollars less than their colleagues — even after managing to survive in a dysfunctional system for several years? 

Helpful hint: Make it a five-year minimum-to-maximum pay scale and I'm certain we'll have more success in retaining the next generation of paramedics.

As one paramedic told me, "No mystery here, just common sense. If a kid starts to think about leaving after three or four years, they're going to think twice about it, knowing that in two years, they'll be making $75,000 or $80,000 easy. "

Instead of starting over, going back to night school for another five or six years, and starting again at the lowest part of the ladder. No big science here!" Alas, common sense and the Quebec prehospital care system seem to have a tenuous relationship these days.

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SOME HOUSEKEEPING…

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After taking a few weeks to get my mind right post-Ukraine, I’ll be back with a piece on Montreal’s rental crisis next week. In the interim, it was great to publish Hal, Diane and Nora. Three of the best people I know.

Your friend,

Chris