"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

 

[BadEnoughDudeRescueRonny]

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. 

 

[cn]

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.

 

[cn]

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."

 

[BadEnoughDudeRescueRonny]

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

 

[BadEnoughDudeRescueRonny]

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.