With lights flashing and sirens blaring, they run to the address of the call and assess the patient. he needs to go to the hospital. Fast forward, the drive to Queensway Carleton Hospital in Ottawa’s west end is quick. But as the paramedics arrive at the hospital, the rush of activity stops. There are already six ambulances parked outside and the ER is full. The two nurses should wait with their patient, monitoring him, until his care is transferred to the hospital. “Essentially, we’re stuck here,” Waterhouse said. The experience is known as “delayed unloading”. That means their ambulance will remain parked at the hospital for now, instead of back on the road, where it can respond to other incoming 911 calls. Paramedics and ambulances line the emergency ramp at Michael Garron Hospital in Toronto on April 12, 2021. (Frank Gunn/The Canadian Press) “While I’m here with this patient, I could be here for hours. I can’t respond to a call. All these paramedics have been taken off duty while we wait to get out of the hospital,” Waterhouse said. “So you have fewer ambulances going around the city to respond to emergencies.” This waiting time adds up. Last year, Ottawa’s paramedic service transported 72,000 patients to hospitals and spent 49,000 hours waiting in a discharge delay. In the first five months of 2022, paramedics in Ottawa spent 25,000 hours waiting in hospitals, with 28,000 patients attended. At that rate, the agency estimates more than 60,000 hours could be lost to clearing backlogs by the end of the year. It’s a condition that obviously affects patients and their families, Waterhouse said. “They are rightly disappointed,” he said. “Because they have a pretty reasonable expectation that they would call 911, get an ambulance right away and get to the hospital and be seen right away.” WATCHES | Paramedics under pressure as city runs out of ambulances:
Paramedics are under pressure and a city is running out of ambulances
The extreme strain on hospitals across Canada is having a ripple effect on ambulances and paramedics. The National has gained exclusive access inside Ottawa’s paramedic service as it deals with an unprecedented number of “level zero” incidents – when there are no ambulances to respond to 911 calls. According to the Ottawa Paramedic Service, long hospital waits are the result of many reasons, including increased 911 call volume, lack of access to family doctors and understaffing across the health care system. “The onus is on the hospital system to manage the entire health care system — and it’s just not capable of doing that,” said Ben Ripley, superintendent of the Ottawa Paramedic Service. “Because of that, we’re seeing backlogs in the emergency room … and that’s why we’re seeing our trucks sitting there for hours.”
Level zero
Unloading delays are not unique to Ottawa. are a problem in many hospitals across the country as the health care system collapses the burden of staff shortages which have been described as endemic. They also lead to another problem felt in Ottawa and beyond: “Level Zero,” when all of a service’s ambulances are already responding to calls or waiting at the hospital. It means there are no ambulances to dispatch to incoming 911 calls. Ottawa has recorded 1,041 zero-level cases this year from January to July – something paramedics say can happen multiple times in a day. It’s a problem that grows over the years, to the point where it’s becoming commonplace, Picknell said. “It’s very rare to have decent levels at work,” he said. “When I walk in and there are ambulances available, that amazes me.” When ambulance availability is low, it also affects response time, notes Ottawa paramedic Josh Picknell. (Yanjun Li/CBC) When ambulance availability is low, it also affects response time, Picknell said, noting that when that happens, it can be the closest off-call unit in the entire Ottawa area — and still be 30 or 40 minutes away. “This is where there’s a lot of frustration among doctors, among the patients we deal with, it’s not appropriate for people in life-threatening and serious situations to have to wait that long for an ambulance. It’s just not appropriate.” The nerve center of the Ottawa Paramedic Service is the Ottawa Ambulance Communications Centre, which receives the emergency calls that come in for paramedics every day. CBC’s The National had exclusive access to the Center on a Friday afternoon in August as business ground to a halt. A screen appears at the Ottawa Paramedic Service’s 911 communications center as it registers a “level zero,” where no ambulances are available to respond to incoming calls, as indicated by red markers. (Stephanie Kampf/CBC) “This happens almost on a daily basis,” explained chief Pierre Poirier. “And especially in the last few months, it’s been terrible.” To continue responding during a level zero, either ambulances will be dispatched from a neighboring community or the call will be queued until one becomes available. And just like unloading delays, level zero — sometimes called code zero, critical code, black code or code red in other areas — is not unique to Ottawa, Poirier said. “Our experience is replicated across the country. It’s not just in the city of Ottawa and it’s not just in the province of Ontario. It’s across the country — coast to coast.” People shouldn’t be afraid to call 911, despite the current pressures on the health care system, says Ottawa Paramedic Service Chief Pierre Poirier, shown here at the 911 call center. But he says more help is needed for a system in crisis. (Yanjun Li/CBC) While there are no nationally collected statistics on the phenomenon, Hamilton Paramedic Service Chief Mike Sanderson says that in Ontario, both smaller services in rural areas and larger urban services are experiencing an “increasing frequency of level zero incidents.” Sanderson also co-chairs a task force on hospital discharge delays with the Ontario Association of Paramedic Chiefs (OAPC). In Hamilton, he said, they’ve had 209 code zero incidents so far this year — a marked increase compared to the past two years. “We’re just over seven months into the calendar year and we’ve had more than double the number of code zero events than we did all of last year — and seven times more than we encountered in the first year of the pandemic,” he said. Sanderson. “There is a direct correlation with the frequency of code zero events and the time required for paramedics to wait for hospitals to accept the transfer of care for inbound ambulance patients.” According to the Paramedic Chiefs of Canada (PCC), based on anecdotal discussions with their members, zero levels exist to varying degrees in all provinces and Unloading delays are a problem in most provinces.
Community care as a solution
In Ottawa, the paramedic service is taking steps to mitigate the problem, including an initiative where patients are distributed to local hospitals based on capacity, as opposed to automatically going to the nearest centre. The agency has also introduced community paramedic programs, which use specially trained paramedics who provide patient assessment, diagnostics and treatment in the community to help prevent emergency calls. Similar programs are also offered through long-term care organizations to help improve seniors’ quality of life by allowing them to remain in their homes as long as possible and reducing ER visits, as well as for patients in the community with complex care needs. “We’re trying to help the health care system fill the gaps … and not take people to the hospital, but still provide that excellent care at home,” Poirier said. Ottawa paramedics are pictured parked outside Montfort Hospital in June 2022. (Jean Delisle/CBC) Another initiative implemented at three area hospitals — Queensway Carleton, Ottawa Hospital General Campus and Montfort — is to place a paramedic in the emergency department who can attend to up to four patients until care can be transferred to the hospital, freeing up crews that would otherwise experience a delay in unloading. (At Montfort Hospital specifically, this paramedic is part of the facility’s emergency department team.) And despite the current pressures on the system, Poirer says people shouldn’t be afraid to call if they need medical help. “Please call 911, but use the system appropriately,” he said. Even during a level zero, he said, the agency typically has paramedic single responders who are able to provide care. it’s a bridge they’ve put in place over the last few years “to make sure we can still provide that primary health care service and that primary medical service to patients in need.” If no other resources are available, the Ottawa Fire Department will also respond to high priority calls. But the system is “in crisis,” Poirier said, and it needs help. “We need people to advocate on behalf of the paramedic service,” he said. Colin Waterhouse has been a paramedic for 11 years, calling it the “best job in the world”. But amid intense pressure on hospitals and the wider healthcare system, his service is also feeling the strain. (Yanjun Li/CBC) As for Waterhouse and Picknell, the unloading delay at the hospital was about 1.5 hours this time. “But we can, sometimes, be with these patients for many, many hours … watching them as they wait … and that’s normal for quite some time,” Picknell said. And while Waterhouse believes he has the “best job in the world”, he says he’s not sure if…
