New Brunswick Boasts Provincial Ambulance System

On December 16th New Brunswick EMS, a subsidiary of Medavie Blue Cross, assumed responsibility for management of operations for a new provincial ambulance service. It will manage the service on behalf of Ambulance New Brunswick, the public company responsible for providing land and air ambulance service throughout the province. This new system operates close to 130 land ambulances and employs over 730 paramedics.

In April 2006, the NB provincial government announced a plan to evolve the nearly 40 separate EMS service operators in the province into a single province-wide operation, similar to a change already in place in both Nova Scotia and Prince Edward Island. The key focus for this was to ensure safe and consistent ambulance service to all residents by:

• establishing performance response standards;
• utilizing a dynamic ambulance deployment system;
• ensuring consistent clinical standards province-wide;
• implementing recruitment and enhanced training strategies;
• development of a centralized medical communications management centre;
• coordinating all non-emergency transfer services; and
• expanding and standardizing fleet vehicles and equipment.

Ambulance New Brunswick has signed a ten year deal with Medavie to run the new provincial ambulance system. Under its contract, Medavie will have to meet service delivery targets, including response times of nine minutes in urban areas and 22 minutes in rural areas, 90 per cent of the time.

The benefits of managing an ambulance system province-wide are outlined in PAM's White Paper, Emergency Medical Services - Manitoba's Quiet Crisis. Many of the goals outlined by the New Brunswick Health Minister to ensure more consistent pre-hospital care in that province are already in place here in Manitoba, albeit to limited and restrictive extent. Our provincial fleet vehicle program has provided a level of standardization and improved ambulance equipment. We have a medical communications centre capable of dynamic system deployment and coordinating inter-facility transfers...but efforts to phase the MTCC into full operation have been met with operational and administrative challenges as a direct result of regional differences in those areas. The Manitoba Emergency Services Medical Advisory Committee (MESMAC) has legislative responsibility to develop and oversee clinical standards across the province, but Medical Directors in each region often dictate differing skill-sets and treatment policies with resulting inconsistencies. New (2006) legislation has increased the minimum training requirements for personnel licensing, but some regions still have great difficulties recruiting and retaining staff. Although a significant amount of government funding has been introduced over the past five years to improve EMS training in the province (Primary Health Transition Funding and the Red River PCP Program), each region still differs dramatically in their training levels and strategies. Add to this the regional disparities in staffing models and deployment practices, and there's little wonder as to why we have yet to develop any standardized response times.

There have been significant advances in our EMS system over the past decade as evidenced by much of what I outlined above. We have a provincial dispatch centre, a fleet vehicle program, enhanced communications, improved legislation and less reliance on "volunteers" to staff our system. But many opportunities to further improve the emergency and pre-hospital care we provide to Manitobans are hindered by the fact that we have eleven Regional Health Authorities and close to thirty licensed land ambulance operators. Each RHA has its own EMS management structure and is very distinct in their approach to the delivery of emergency medical services. It is in part this governing model that contributes to inconsistent Emergency Medical Services across our province.

Many Canadian provinces have opted for some form of a provincial ambulance and paramedic service. British Columbia has a single service owned, operated and managed by the provincial government. Nova Scotia, PEI and now New Brunswick have all now opted for province-wide service models owned more or less by the government but managed by a contractor. Alberta is considering a system that would see funding for ambulance service administered by a centralized board with regional representation that would oversee operations to improve care and consistency across the province.

Here in Manitoba we have an RHA "umbrella organization" (Regional Health Authorities of Manitoba - RHAM) that might be well positioned to ensure continued regional involvement in a more consistent province-wide delivery system. The task of moving to a province-wide delivery model would most certainly be met with both labor and logistical challenges. But there are far more benefits associated with moving in this direction than there are reasons not to, for our profession, our careers and most importantly our patients.

PAM Annual General Meeting

As advertised on the Paramedic Association of Manitoba web site, PAM will hold it's Annual General Meeting on Saturday, January 12th, 2008. The meeting will be held at the Fairmont Hotel located at 2 Lombard Place in Winnipeg commencing at 13:00.

In addition to regular AGM agenda items (association reports and finances) there are three business matters to be conducted:

• the election of 2 Directors and a Chairman;
• voting on proposed Bylaw amendments;
• voting on proposed membership fee structure revisions.

Three Executive terms (two Directors and Chairman) expire this year and are scheduled to be filled by election at the AGM. The election notice and nomination form can be found on our web site using the link below. All Full/Active members-in-good-standing of the Paramedic Association of Manitoba are eligible to nominate and/or accept a nomination for these positions. Written nominations must be received at the PAM office no later than December 22nd. Nominations after this date can only be made at the AGM.

The Bylaw amendments proposed for discussion at the meeting are related to the make-up of the Board of Directors for the Association. The original Bylaws call for the Board to be comprised of two EMRs and two EMTs (Paramedic) or higher. Not only has wording associated with these license levels been changed in amended legislation (2006), but it has proven to be very difficult to elect the appropriate numbers from each category over the years. The proposed wording and rationale for this changes can be found using the web link below.

Membership fees for registration with the Paramedic Association of Manitoba have not changed since their introduction in 2001. Since that time the Paramedic Association of Canada has slightly increased member fees and the Benevolent Society has instituted a very modest member surcharge to ensure it's future viability. These costs and anticipated financial requirements associated with an application for self-regulation make it necessary to review our fee structure and propose a slight membership fee increase that would take effect on July 1, 2008 entering into the 2008/09 fiscal year.

The Paramedic Association of Manitoba is the professional association for EMS providers in our province. As members of the Association your input is valuable to the well-being of our patients and the profession. I encourage all members to attend the January 12th Annual General Meeting.

More information regarding the PAM AGM and business to be conducted at the meeting can be found using this link. I hope to see you at the Fairmont.

Proposed Federal Legislation to Protect Paramedics

On December 12, 2007 Liberal Member of Parliament Mario Silva introduced a Private Members Bill in the House of Commons to amend the Criminal Code of Canada. Bill C-495, An Act to amend the Criminal Code (emergency medical services workers) would make it an indictable offence to assault "an emergency medical services worker engaged in the execution of his or her duty".

Bill C-495 was introduced by Mr. Silva following an outcry from paramedics across the country. Earlier this year Silva proposed another Criminal Code amendment making it an offence to assault firefighters in the line of duty. The fact that the proposed bill did not also recognize the dangers faced by EMS personnel resulted in correspondence and calls not only to Mr. Silva's office and staff but to many other MPs as well. In a letter addressed to Canada's Paramedics, Silva (Opposition Critic for Labour Issues) indicated that he planned to draft legislation that would include paramedics in the same context as police and firefighters within the Criminal Code.

When this issue first came to light, staff from Silva's Ottawa office called to discuss the concerns raised by paramedics and apologize for the oversight of paramedics in the original draft. The error, they admitted, was due to a lack of understanding that paramedics were not necessarily included in the firefighter ranks. They immediately asked that we help them rectify this situation by providing a definition of paramedic that would be suitable for use in subsequent legislation. As Chairman of the Paramedic Association of Canada Board of Directors, I undertook to coordinate that effort.

Through consultation with various stakeholders, including the PAC Board and Chapter members as well as the EMS Chiefs of Canada, we arrived at the definition of emergency medical services worker that has been used in Bill C-495. The challenge was to make it narrow enough that it clearly represented practitioners associated with PAC and yet broad enough that it didn't exclude practitioners by restricting it to titles not recognized by some jurisdictions and was inclusive of practitioners working in many of the non-traditional EMS roles we are starting to see across the country. That process proved to be somewhat more difficult than originally anticipated, but was vital to moving forward with planning the proposed legislation.

Both PAM and PAC will continue to follow Bill C-495 in the coming weeks and months. You can read the proposed legislation and follow it's status on the Parliament of Canada web site.

When is Service Not Really Service?

Earlier this year I commented on an article that ran in a western Manitoba community newspaper suggesting legislative changes would make it difficult to recruit "volunteer ambulance attendants" (Ambulance Driver's Good Enough for Municipal Politicians). That same argument has surfaced once again...this time in the Interlake. A story that ran in the Interlake Spectator on December 7th was mirrored by CBC News yesterday...with municipal officials stating that elimination of the Ambulance Operator (AO) license could result in Riverton Ambulance Service having to close it's doors.

The emphasis that is placed on maintaining volunteer ambulance services in Manitoba is imprudent and ill-conceived. While I acknowledge that changes in our legislation have introduced challenges for ambulance operators and personnel alike, it is most certainly in the public's best interest for all stakeholders to work toward achieving those milestones rather than arguing against the obvious benefits. As suggested in this latest furor, rural ambulance transport times are often quite long. Add to that the fact that a single rural ambulance responding to a motor vehicle collision or other accident may very well need to treat multiple patients and one would assume the need for increased licensing requirements as set out by this legislation is both clear and sensible.

Until the Emergency Medical Response and Stretcher Transportation Act and accompanying Regulations became law in April of 2006, Manitoba had the lowest education requirements for ambulance personnel amongst all provinces in the country. When first implemented over two decades ago, an Ambulance Operator (ambulance driver) license required only a sixteen hour basic first aid course. While that may have seemed acceptable for ambulance attendants at the time, I find it absolutely inconceivable that anyone might condone this in today’s society. Even Manitoba's new requirement for ambulance personnel to be trained to a minimum Emergency Medical Responder level (Technician) would be considered low in many other Canadian jurisdictions.

Access to our emergency medical services system should not be measured simply by how quickly an ambulance arrives at a residence, but rather how quickly the patient receives appropriate and definitive treatment for his or her health emergency. Those who place emphasis on immediate response times and volunteer service should be encouraged to utilize whatever resources might be available to them and seek to enhance the EMS system in a first responder capacity…an area where volunteer commitment can and should be encouraged.

Public policy regarding upgrading or changing an EMS system is far too frequently clouded by the emotions of providers, patients, and elected officials. Talk of losing an ambulance because of this legislation triggers unwarranted fear amongst residents and I would argue deprives them of the very health care they really deserve.

We expect police car “drivers” to be police officers. We expect anyone driving a fire truck to be a firefighter. When we need emergency medical care, why don’t we expect an ambulance to be staffed by people able to provide that care? Anything less, I suggest, is a disservice.

RHA External Review Submission

In April of this year Health Minister Theresa Oswald appointed a three person panel to assess Manitoba's regional health authority system. The mandate given to the review committee was to examine and recommend strategies for improvement of the regional delivery model. A final report is expected to be delivered to the Ministers of Health and Healthy Living by years end.

The Regional Health Authorities Act legislation came into force in 1997. It sets out the conditions under which the RHAs are incorporated, and defines their duties and responsibilities for ensuring effective health planning and delivery. The decision to regionalize the operation and administration of health in Manitoba was a major change in the way that health care is planned and delivered.

While regional governance authorities were tasked with decision making related to most health planning and delivery, some core health services remained the primary responsibility of central agencies or Manitoba Health. The belief was, and I expect still is, that certain specialized health services could be more safely or efficiently administered centrally, and as such needed to remain outside of the regional governance model. Angiography, radiotherapy, some mental health services and Lifeflight air ambulance are all examples of health services that remained directly funded and administered provincially. Certain health facilities such as Addictions Foundation Manitoba and the Riverview Health Centre also operate outside of the regional health authority governance model.

Emergency health, including ground ambulance service, is identified as a core health service for which RHAs have been legislated direct responsibility. The decision to include EMS in the list of RHA services was probably given very little thought. I don't mean that to sound negative or critical...but the reality is that EMS was already void of central administration in that each municipal government had responsibility to ensure ambulance service availability. In the process of trying to de-centralize most other health services I doubt anyone gave much thought to centralizing EMS administration and delivery...that just wouldn't fit the mold under consideration at that time.

Today Manitoba has eleven regional health authorities and each is very distinct in their approach to the delivery of emergency medical services. As result, staffing models, alternatives to improve system efficiencies and even the level of care provided by paramedics across the province is very inconsistent. In an effort to assist the RHA External Review Committee with their examination of RHA operations and subsequent recommendations to Government, the Paramedic Association of Manitoba prepared a written submission for consideration. This report outlines current system challenges and recommends the committee consider the benefits of operating Emergency Medical Services within the context of a provincial model that includes regional input. It's an administrative model that has already proven very effective with many specialized health services, and one that EMS across this province would benefit from.

The PAM submission to the RHA review committee is available on our web site and can be found using this link - PAM Sumission to RHA External Review Committee.