Producer George Porter at Rotary Club talking about the 'Status Code Red' issues.



George Porter talks Code Red with Pincher Creek Rotary

George Porter speaks to Pincher Creek Rotary Club
Chris Davis

Veteran Alberta paramedic George Porter spoke to the Pincher Creek Rotary chapter last Thursday evening, March 19 about ‘Code Red’, a social media initiative that provides first responders (including paramedics, EMTs, and EMRs) with anonymous platforms to air their concerns about the state of ambulance services in Alberta.

At the time this was written the @StatusCodeRed Twitter account has 2389 followers. The Alberta EMS Code Red Facebook page has over 4500 "likes”. Via those social media accounts, paramedics can and do post when ambulance service is code red in a community, meaning all available ambulances are in service and therefore none are available if there’s another call for emergency response.

Porter said he was involved in one call that involved a patient who was reported as a "chest pain collapse" in Eden Valley. He said he was dispatched from Nanton to respond to that call, and when he told dispatch that he was over an hour away from the location "with lights and sirens" he was informed that he was the nearest responder. He stated other similar examples. He said Vulcan has had to respond incidents in Claresholm and Chain Lakes. "They have tried to send me from Nanton to the Crowsnest Pass."

"Nanton is flexed in to cover High River... 30 to 40 times a month, 550 times last year."

According to Porter a documentary called Code Red is in the works, and he told the Rotary audience "Somebody that may or may not be in this room may or may not be instigating a class action lawsuit on behalf of a number of people that have had bad outcomes from long response times". On March 24 Code Red stated on Twitter and Facebook that a major announcement is coming soon, without stating what it will be about. On March 18 the Alberta government issued a press release that states in part "The Rural Health Services Review Committee has delivered its final report and recommended actions – a number of which are underway, including: developing a provincial EMS service delivery model; and establishing eight to 10 Alberta Health Services (AHS) operational districts to give communities a stronger voice in local decision-making".

According to Porter, inter-facility transfers are a major problem for some communities. An inter-facility transfer is when an ambulance is used to transport a patient from one medical facility to another, usually from a suburban/rural community to one of the cities. He listed Claresholm, Okotoks, Black Diamond, Turner Valley, High River, Vulcan, Stavely, Parkland, Nanton, and Fort Macleod as examples of communities facing a resource crunch. "This is suburban rural health. We're in a code red because... there's times when these code reds are code red because every single ambulance is on an inter-facility transfer."

Most transfers are not for urgent or life threatening situations, according to Porter. "A lot of them are wait and return."

"I heard Pincher Creek the other day. They sent Pincher Creek to Claresholm for a transfer. Shortly after that, I heard Pincher Creek being sent to Lethbridge to pick up somebody and take them to Calgary. Excuse me, but what about Pincher?”

From the Alberta EMS Code Red Facebook page: "My father had a stroke almost two years ago. He went to the hospital and they diagnosed it right away. They called IFT and they said they had no ambulances and they’d send the nearest one. Calgary dispatched a BLS out of Pincher Creek, and half way to the Pass they realized they didn’t want them they needed a paramedic. So then they sent Fort Macleod which is an hour away from Blairmore to come get my dad. IFT was called at 4:30 and my dad didn’t make it into Lethbridge emerg /ct till 9:30 pm! Well, obviously it was waaaaaay too late for tnk which would of dissolved the clot in his one eye. He is lucky that it was only his one eye effected. My mother and I both went to the director of south zone ambulance and formed a formal complaint with AHS. They arranged a meeting up and basically said ’We will try to make the system better.”

Porter said that according to Alberta Health "Albertans are pleased to know that when they have a real emergency in their life, in this borderless system, you’re going to get the closest ambulance”. He said the critical question was "By the way, where is that nearest ambulance?”

Porter said that once a rural ambulance has completed a transfer in Calgary, while trying to return to their base they may be further tasked as the closest ambulance to situations within the city.

"That in a nutshell is what’s going on with Alberta Health Services. A lot of these inter-facility transfers, they do have a system in place that’s not followed. It’s called the System Status Management Guide (laughter from first responders in the audience). Part of that plan is to color code patients.” Color codes include blue, green, yellow, red, and black in an ascending order of urgency. Porter gave an example of a "blue” (least urgent) patient who was a wait-and-return patient who was getting insoles fitted for her shoes. He said that took five or six hours. He said other examples of blue patients would be those attending dental or ultrasound appointments. "You can’t blame the hospitals, because their focus is ‘I have this patient that needs to go there’ for whatever reason. The simplest thing is to call this number that they have, and somehow an ambulance shows up and takes them.”

Porter said that in the staff management plan blue patients should not use an ambulance, and approximately 60% of green patients also do not need to go by ambulance, which would leaving yellow, red, and black status patients as a priority. "We take them all, with fewer ambulances, fewer resources.”

"The hospitals learned pretty quick. ’I’ve got this green patient that needs to go for a test, his appointment time is in an hour, and we’re 50 minutes from Calgary’. So he becomes a yellow, based on appointment time… not on patient condition, but based on appointment time. Or they might be a code red. You go there for a red transfer, and the guy won’t even ride on the stretcher. He’s in street clothes and he could drive the ambulance.”

"That’s how the inter-facility transfer system works in rural systems. In Calgary they have 28 they call them IFT trucks. That’s all they do, is transfer from hospital to hospital. They won’t come out of the city, empty. They will bring somebody back once in a while but they won’t leave empty. Rural has none. So all of our transfers have to be done by ambulance.”

Porter said he had a chance to see dispatch in action, and the transfer problem was illustrated clearly at that level. "They see the whole picture. They have these big screens, and a call comes in and bing, a little flag goes up. They can see where all the ambulances are, and he (the dispatcher) said ‘Look at this. We only have one unit left out here and we’re going to get another transfer’. Bing, sure enough, there it is, out of Black Diamond Hospital, a yellow transfer that was actually a green routine transfer, ‘I have to send the closest unit’. They had seven IFT trucks sitting idle. He said ‘Look at that. I can’t pull one of those trucks to do that transfer, so to have one emergency ambulance down here I’d have to use that truck’.”

Porter said he met with "a couple of bosses, down in Black Diamond,” and during this meeting an opportune moment happened, allowing him to show them that every single ambulance in the area was tasked to a transfer, at least one of which was a code blue. "I said, ‘I got nobody for this area. So, you, being the bosses, I would like you to explain to me in detail how I’m supposed to respond to somebody having a chest pain in Stavely, a serious car accident over by Carmangay. You tell me what I’m supposed to do’. I’ve seen a lot of bovine expressions in the last five years.”

"So, we have a problem with inter-facility transfers, that you now understand. We have a problem with the emergency departments, bottlenecks that you hear about all the time, about wait times in the hospitals.”

"I sent emails to the health minister, the Premier, I sent them all over. Nobody even acknowledges they got them.” Porter said he invited them to go to any emergency waiting room at anytime and look at the people who are waiting. "This isn’t an emergency department, it’s a convenience department.” He said the busiest time for an emergency department is after supper, Monday through Friday.

Porter cited the example of a patient he said was waiting in a hallway for 36 hours, with an ambulance crew in attendance. He said their supervisor had to bring in relief crews to allow his staff to end their shifts. "36 hours that ambulance was tied up in the emergency department, waiting for that patient to get in a bed.”

"I told management five years ago, ‘You are not running the ambulance service in this province, the hospitals are. You need to grab the reins on this runaway, and start dictating how ambulances work. We are not nurses. We are not hospital employees. It’s a grey area.’”

"Our job is providing pre-hospital emergency care.”

"We need to be out on the road, and be available.”

"You guys are blessed in Pincher. Because Dave and Marg here (Fire Chief Dave Cox and his wife, Deputy Chief Margaret Cox), they have a contract with Alberta Health, they are not run by Alberta Health.”

Porter explained that Pincher Creek’s contract with Alberta Health Services supplies two ambulances to be dispatched 24-7. "He (Chief Cox) snuck in a third one that is parked in the fire hall, someplace.” This means that Alberta Health can task the first two ambulances, and is aware of the third but not in control of it. "How he’s managed to do that, and keep that, is a bit of a mystery to me, but good on them.”

According to Porter, the Code Red Twitter and Facebook accounts have gone viral among first responders because "They are between a rock and a hard place.”

"From day one I’ve been saying you cannot, cannot, cannot keep using your only ambulance in the community for inter facility transfers that don’t require an ambulance. You need alternate methods for doing that.”

He said Calgary’s 28 IFT trucks average 4 calls a day. "There’s different ways they could deploy those, and make them work.”

To make the situation even more difficult the new ambulances have been designed to carry only one patient. "In the old ones, you could at least put somebody on a spine board, or on an auxiliary stretcher, or on a bench seat. Some of them had two stretchers in them.”

"That’s ridiculous, having something you can only put one patient in, in a rural setting.”

"Central Dispatch, in my opinion, is not a bad thing. There is a lot of angst and animosity about that, though.”

Porter said it’s not all doom and gloom, citing improved technology at dispatch, in the ambulance, and in the pockets of their patients – they can now zero in on a caller’s cell phone to within 30 feet.

Alberta Health Services published a "Beyond the Headlines” statement on January 22, 2015 titled "EMS response times remain steady”. It states, in part: "Recent media reports have suggested patient care has been compromised as a result of longer response times and delays waiting to transfer patients in hospital. This is absolutely not true. While Alberta Health Services continues to work on finding ways to provide additional support to front line staff, patients continue to receive high quality care. Even with growth in population and a 34 per cent increase in call volumes since EMS became part of Alberta Health Services (AHS) in 2009, response times have remained steady across most of the province. We have been able to keep on top of call volumes thanks to the dedication of our staff, increased and improved resources, and by using those resources more effectively. When a 911 call is made, trained dispatchers quickly determine how sick or injured the patient is. In life-threatening cases, EMS responds as quickly as possible. In cities, that time averages around seven minutes. It is inevitable that ambulance response times to isolated locations will be longer than in cities, but that is when AHS uses other resources to ensure a rapid response including STARS helicopters, air ambulance planes and local medical first responders.”

A Rural Health Services Review was announced by Premier Prentice and Health Minister Mandel on September 23, 2014 and released earlier this month, which can be read in its entirety at this link. It states at one point that "Dissatisfaction, frustration, and anger with the current state of rural EMS was one of the most common concerns expressed by dozens of communities.” It also states "Residents of remote areas feel that it takes too long for EMS to reach their community. In other instances, ambulances transport people into the urban centres and are unavailable to respond to emergencies back in their "home community”. Many communities described cases where ambulances would wait for hours in urban hospital bays waiting for patients to be examined or admitted. There are also frequent reports of rural ambulance crews being diverted to calls or transfers within urban centres, further delaying a return to their home community.”

The Rural Health Services Review includes the following recommendations to the government of Alberta for changes to EMS:
Develop and implement operational practices that mandate ambulance crews to discharge transported patients within one hour of arrival at the ER. Prioritize this practice for crews whose home base is farther from the facility.
Issue a directive that rural ambulances are to return to their home community directly and not be divertedfor calls outside their region.
Ensure that rural communities are adequately staffed with emergency personnel with training commensurate with the degree of remoteness and the time required to reach the nearest emergency care facility.
Develop EMS access, response and performance standards. Measure, monitor and report EMS response times. Ensure that performance standards form the basis of future service planning decisions.
Implement a system of non-emergency transport vehicles and reserve the use of ambulance crews to situations clearly designated as emergencies.
Provide support for additional training of community volunteer first responders and work with the Alberta College of Paramedics to implement reduced fees for training and licensure of volunteers.
Expand the AHS Volunteer Emergency Medical Response programs implemented in southern Alberta.
Porter expressed scepticism about the review. "When they started this, the plan was to have a provincial EMS model. Now they’re saying ‘We don’t know what that’s going to look like yet, but what we think is over the next 4-5 months we’ll be able to come up with a EMS model.’ What happened to the last 5 years? Is there an election coming up?”

"That, ladies and gentlemen is in a quick nutshell where we stand with Alberta Health services, in spite of what they say on TV and in print. This is the gospel truth. I’ve offered to the health minister to come and meet with him, to tell him exactly what’s going on. I strongly recommend that he needs to clean house, that the people he had advising him are not giving him good advice. I said I’ll come in and spend a short period of time and tell you exactly what’s going on, and tell you what to do about it. It’s not going to cost you money, some things are going to save you money.”

"I’ve never heard anything back from him.”

He said there are plans to have significant media coverage about an upcoming class action lawsuit. "Somebody, that may, or may not be in this room, may, or may not be instigating a class action lawsuit on behalf of a number of people that have had bad outcomes from long response times. People have died. A lady in Edmonton, she, just a while back, called an ambulance in the city of Edmonton and watched her husband die for over half an hour before the ambulance got there.”

"We’ve had a number of cases where people have called the ambulance and had to call again, ’They’re on their way’.”

"We’ve had cases where the ambulance never did show up at all. But dispatchers are not allowed to say, ‘You know Dan, I realize your mom’s having trouble here, so you’re five minutes from the hospital, the ambulance is 40 minutes away, you might be better off to get her out there yourself.’ They’re not allowed to say that. They’re not allowed to tell you where that ambulance is coming from. They’re just allowed to tell you ‘Hang on, the ambulance is coming, don’t panic, don’t despair, they’re coming, they’re coming.’”

"That’s what happened with those folks in Eden Valley. One brother phoned the ambulance and they said ‘Yup, they’re on their way,‘. They phoned another brother who was coming back from Calgary around Black Diamond. His dad still had a pulse at that time, semi conscious. They called the ambulance again. ’They’re coming, the ambulance is coming.’ They called and said should we just take him in? ‘No, no.’ He was getting agitated and angry and ispatch said ‘Calm down, calm down, just relax, the ambulance is on its way.’ Three or four times they called before I got there from Nanton, an hour and 17 minutes later.”

"Normally, before AHS, we had better response time.”

"It’s a major stressor for the EMS guys, because now you have this long response time. You know it’s not going to be a good situation when you get there, and now you have to deal with the anger, and the frustration, and everything from the family, like we did out at Eden Valley. And you can’t blame them.”

Despite such experiences, Porter said he does not encourage people to try and drive themselves or someone else in medical distress.

Porter said he has vowed to keep applying pressure until the situation is resolved to his satisfaction. "I will see this through, until it’s done.”

"I don’t want to be doom and gloom and fear mongering here, that’s why I’ve been flogging these guys. It’s going to get better. I thought it would be long before now.”

"I have to believe that.”

Related links:

@StatusCodeRed (Twitter) , ‪#‎EMSredalert‬

Alberta EMS Code Red (Facebook)

Rural Health Services Review Final Report

EMS response times remain steady (AHS)