As recently as 10 years ago, paramedics were generally regarded as just ambulance drivers. Today, paramedicine is a rapidly evolving field and it appears Atlantic Canadian paramedics are leading the way.
They are triaging and caring for patients in hospital emergency departments, delivering primary health care in rural communities and engaging in clinical research on ways to deliver the most effective front-line health care possible.
Dr. Andrew Travers, provincial medical director for Emergency Health Services in Nova Scotia, says paramedics are triaging and caring for patients with minor injuries at the new Charles V. Keating Emergency & Trauma Centre at the QEII Health Sciences Centre. They're doing similar work in other hospitals around the province including Valley Regional, Bridgewater, Northside General and Cape Breton hospitals.
On Long and Brier Islands, in the remote rural southwestern part of Nova Scotia, community paramedicine has been in place for several years. Dr. Travers says paramedics have partnered with a family doctor based on the mainland and a nurse practitioner to create a mobile health care unit capable of offering geriatric assessments, administering antibiotics and immunizations, performing wound care, as well as teaching CPR and proper use of child seats.
"Ultimately, they are not transporting these patients and they've reduced the number of visits to physicians by half and the number of emergency department visits by 40 per cent," says Dr. Travers. "It's huge. What's been done in Long and Brier we now say should be done in other places, not as a pilot, but as a standard of care. That's what's coming."
"One of the best examples was a pilot project in 2008 that put the same clot-busting drugs given to hospitalized heart attack patients in the hands of paramedics in a rural setting," says Dr. Travers. "There's only a few places in Canada and only a few globally that do that."
The clot-busting drug tenectoplase, or TNK, should be delivered within three hours of a heart attack in order to be effective. Paramedics in Cape Breton were enabled to deliver the drug to heart attack patients with great success. The procedure is being rolled out across different parts of the province, specifically in Halifax, Bridgewater, and the Annapolis Valley, over the next six to 12 months.
For the last two years, every ambulance in Nova Scotia has used new 12-lead defibrillators to mitigate heart attacks.
"That lead saves about 30 minutes from treatment time," says Dr. Travers. "When seconds make a difference and you want to open up the blood vessels in the heart as soon as possible, 30 minutes is massive. When the paramedics diagnose a patient with a heart attack, they send the 12-lead in. As they're pulling into the hospital, the emergency physician is running out to meet the ambulance and patient. The door-to-needle time is one minute. That's a great example of the care patients get when they call 911."
Craig Pierre, general manager of Island EMS in Prince Edward Island, says new 12-lead defibrillators were installed in every ambulance in September 2009.
"The Philips MRx monitors all have 12 leads and they can pace and defibrillate heart attack patients," says Pierre. "The 12-lead ECG gives a picture of your heart from many different angles and now we have the ability to do that in the field."
Island EMS paramedics are also involved in a direct transport pilot project for stroke patients. If the patients are assessed less than six hours after their stroke, they are taken straight to the stroke centres, Prince County Hospital and Queen Elizabeth Hospital, rather than the closest rural hospital.
Pierre says speed in stroke care is important because the longer the blockage is there, the longer the tissue on the other side isn't getting healthy, oxygenated blood.
"The sooner you can restore circulation," says Pierre, "the less chance there is of a long-term deficit or a larger deficit." The direct transport project is part of a provincial initiative with the Heart and Stroke Foundation, Island EMS, Murphy's Pharmacies, Queen Elizabeth and Prince County hospitals and the neurologists in PEI.
In New Brunswick, paramedics are also improving care to heart disease patients with their Quality CPR project. Susan Dugas, of Ambulance New Brunswick, says, "Early CPR is a very important factor in in-creasing a heart attack patient's chance for survival. In the past, paramedics had to rely on their education and instinct to gauge the quality of chest compressions and overall CPR delivery. Now, technology is available to provide paramedics real-time feedback on the quality of their chest compressions using the Philips MRx defibrillators equipped with Q-CPR technology available in all ambulances in New Brunswick."
While providing resuscitative efforts to a patient, the paramedics will receive audible and visual prompts to help them determine correct depth of compression, the proper rate and when to provide interventions such as electrical shocks and ventilation according to the latest guidelines.
"The fact that Ambulance New Brunswick is serving a fairly large geographic area with a significant population in both rural and urban settings makes New Brunswick a prime site for research possibilities related to the quality of CPR," says Dugas. "It has captured the interest of researchers from Oslo, Norway, since there are few sites in the world with such technology used within the given demography. Developments are proceeding for research opportunities."
While the Medavie EMS Group of Companies manages the staff and services of Emergency Health Services in Nova Scotia, Island EMS and Ambulance New Brunswick, the paramedicine delivery system in Newfoundland and Labrador is fractured into private ambulance operators, hospital-based services, and community services.
Bob Paton, president and chairman of the provincial ambulance operators' executive board, says private operators do about 80 per cent of the ambulance work in the province and the other 20 per cent is done by a mixture of 11 hospital-based services and 29 community services, which are usually one-machine operations.
"A few years ago," says Paton, "the government started to devolve the ambulance services from the department of health and community services over to regional health authorities. Now we're in the process of negotiating a new contract."
Paton hopes to see a provincial board take responsibility for ambulance service province-wide.
He says, "We see a conflict of interest where the regional health services that operate their own ambulance services will be tasked with the responsibility of policing and fining other ambulance services. In our mind, it's not really a fair system."
The provincial medical oversight (PMO) program, designed to establish the same ambulance care in all Canadian provinces, was to be in place by December 31, 2009. It has provided the opportunity for two province-wide capital projects in Newfoundland and Labrador this year. One involves the transition to electronic patient care reporting (e-PCR). Laptops will be supplied to ambulances across the province and will be an important tool in service quality assurance and research. The second project will upgrade and implement new 12-lead cardiac monitors in nearly 150 ambulances in the province.
"We're kind of in a rush now to make up the difference so that the ambulances in Newfoundland have the same level of care as they do in Ontario, Nova Scotia, and everywhere else," says Paton.
Dr. Travers says just 10 years ago, Nova Scotia was in the same situation Newfoundland finds itself in now. "In the mid-90s, there were about 55 ambulance companies in Nova Scotia," says Dr. Travers. "They were funeral homes and ambulance operators and service was incredibly variable across the province. Nova Scotia made some changes, amalgamated some things together and incorporated it into the department of health. It can go from something that seems really chaotic to something state-of-the-art. I think Newfoundland is going through some of those experiences."
Paramedicine's clinical and academic evolution has contributed to many solutions in the region's health care gaps. "Paramedics do more than drive ambulances," says Dr. Travers. "They treat all these different diseases the same way we do in the emergency department. They're getting trained, publishing and producing research relevant to out-of-hospital care and putting all that important knowledge into practice."