The Curious Case of the Andrea Gail

Andrea Gail was a 72-foot (22 m) commercial fishing vessel owned by Robert Brown. Her home port was Marblehead, Mass. She also sailed from Gloucester Mass., where she would offload her catch and reload food and stores for her next run.

Andrea Gail began her final voyage departing from Gloucester Harbor, Massachusetts, on September 20, 1991, bound for the Grand Banks of Newfoundland off the coast of eastern Canada. After poor fishing, Captain Frank W. "Billy" Tyne Jr. headed east to the Flemish Cap where he believed they would have better luck. Despite weather reports warning of dangerous conditions, Tyne set course for home on October 26–27. The ship's ice machine was malfunctioning and would not have been able to maintain the catch for much longer.

The last reported transmission from Andrea Gail was at about 6:00 pm on October 28, 1991. Tyne radioed Linda Greenlaw, captain of the Hannah Boden, owned by the same company, and gave his coordinates as about 162 mi (261 km) east of Sable Island. He also gave a weather report indicating 30 ft (9.1 m) seas and wind gusts up to 80 knots (150 km/h; 92 mph). Tyne's final recorded words were, "She's comin' on, boys, and she's comin' on strong." Junger reported that the storm created waves in excess 100 ft (30 m) in height, but ocean buoy monitors recorded a peak wave height of 39 ft (12 m). However, data from a series of weather buoys in the general vicinity of the vessel's last known location recorded peak wave action exceeding 60 ft (18 m) in height from October 28 through 30, 1991. A buoy off the coast of Nova Scotia reported a wave height of 100.7 ft (30.7 m), the highest ever recorded in the province's offshore waters. The entire ship was lost at sea. It was later turned into both a book and movie entitled "The Perfect Storm", documenting a pseudo "swiss cheese" model of error that lined up amongst a combination of weather patterns, risk, and ship malfunctions.

Fast forward to Paramedicine in Ontario, 2022 (Easy segway, right?):

Paramedics from Gananoque, Ont., had to drive an ambulance almost two hours to respond to a 911 call in Ottawa's urban core last week during one of several recent instances when dispatchers had no local paramedics available to send. You can read the CBC article on this story here below:

Paramedics respond to call almost 2 hours away due to "Level Zero" in Ottawa

And in the first few weeks in January 2022 we are starting to realize a perfect storm event is brewing in EMS in our great province. From a chronic underfunding, a "You call we come" approach, to hospitals keeping Paramedic hostages for hours on end, to a lack of primary care, and now a pandemic where a decent amount of Paramedics are sick or isolating away from COVID-19, we have reached maximum capacity. To the point where some Paramedic Services are actually telling people not to call 9-1-1 unless their life is in danger (which I agree should be what 9-1-1 is reserved for but more on that later).

How did we get here? Let's jump way back here about 20ish years when the province of Ontario decided to download Paramedic Services (Back then, ambulance services) to upper-tier municipalities. Prior to the download the provincial Ministry of Health ran the entire ambulance service either directly, or in smaller communities subcontracted such to private entities in a sort of public-private partnership with the Ministry still having ultimate control. Come the turn of the century the province decided they were done with this style of approach and gave the option of upper-tier municipalities to either run the service directly, or also have the option of a similar private-public partnership. The large majority of UTMs run the service directly with a tiny fraction opting for the services of Medavie Health. What failed to come however is the sufficient capital to go with it - then and to date, the Ministry of Health only pays for 50% of a UTM's budget for Paramedic Services. They also don't increase funding until the municipality puts their foot forward first. What I mean by that is if the Region of Smith chooses to put an additional ambulance on the road, they will fund that increase themselves for the entire first year of operation with the Ministry share not kicking in until year 2 and beyond. They also have the authority to not actually chip in any increase, though this rarely occurs. This funding delay and cost share model is akin to a game of money chicken, where the Ministry will never offer up their chequebook, and the municipality is never really sure if the province will pony up their portion and when they do it comes a year late. This has resulted in now two decades of chronic underfunding of Paramedic Services across the province. If you take a look at your local tax levy and ask where your money goes, you may or may not be surprised to find out that police and fire departments get a significant amount more of your tax dollars than your Paramedics do. Take for example the most recent budget allotment for Ottawa Paramedic Services who kicked off the article above with the two hour call delay:

Ottawa Police Service: $346 million dollars

Ottawa Fire Service: $177 million dollars

Ottawa Paramedic Service: $120 million dollars

And this is even a bit of an apples and oranges comparison as the Paramedic Service has an even greater reach into the suburban and rural areas of Ottawa that the other two don't. So in reality their share of the pie is even less (if you added the cost of policing and fire service for the outlying areas that the Paramedic Service does cover). It's simple math: Paramedic Services have been underfunded for over two decades and as the population continues to age, and as we push the envelope of chronic health conditions, one can surmise we are not headed in a good direction without a significant influx of resources to change the course. When the fire service wants money, it happens. When the police service wants money, it happens. When the Paramedic Services want money, it's met with "What can we do different?". And don't get me wrong almost every service in Ontario has grown leaps and bounds and have added ambulances and staffing in an effort to try and keep pace. But they certainly don't match anywhere near the increases seen across the other partners in the emergency service sector.

This also seems like a good time to discuss you "You call we come" approach I alluded to above. For those unaware while the Ministry of Health downloaded services they still keep a large area of control through education, training, licensing, and various aspects of overseeing Paramedic Services operations. They also control the ambulance dispatch centres entirely (with a few exceptions in some areas). They have unflexible systems in place that make Paramedic Services at their mercy. Quite literally if somebody calls 9-1-1 and asks for an ambulance and tells the dispatcher they want an ambulance to come and grab their remote control for them from the coffee table - we have to send them out an ambulance. What then results is a truck with two paramedics going out, maybe moving the remote, maybe not, offering to medical assess the patient, offering transport to the emergency department, and then 15 - 20 minutes of paperwork. All the while that ambulance is not available for what it was intended for: calls involving potential threats to life. We have zero wiggle room to tell the above caller that we aren't coming. We have to send out a truck. Which brings me to my next point about "abuse" of the 9-1-1 system and how Paramedic Services are at their mercy for the example above I just mentioned. Twenty years ago then ambulance services call volume was primarily calls involved serious medical issues. The primary call volume back then consisted of motor vehicles accidents & trauma, seizures, and cardiac and respiratory issues. Fast forward to today and 9-1-1 has quite literally become the safety net for whatever anybody sees as a medical problem no matter how minor. Coupled with the fact that many people believe that taking an ambulance into the emergency department is a line/queue jumper (tip: it is not) and we have insane rises in call volume. Add in mental health calls which have increased 25-40% percent over the last decade and the cup has already started to runneth over. And herein lies the problem: Our system has not adapted to the culture change. And quite honestly I blame ourselves. Ambulance patients used to actually get a bed and be seen by healthcare personnel quicker. We changed this and told nobody and so the thought process remains the same - no matter how many people we continue to bring to the hospital on a stretcher and end up taking them straight out to the waiting room. The public doesn't know any better and that's on us. Before I go any further I am not being an apologetic for people who quite frankly have minor issues and other means to get to the hospital or walk-in clinic and choose to use us anyways (ie true "abuse" of the system) but we certainly play a part in not informing the public of what their Paramedic Service is actually for and what we do (this is changing). But the solution isn't merely public education campaigns. You've probably seen them popping up on social media over the years. The Ontario Paramedic Association has a fantastic poster on this topic actually and highlights what to call 9-1-1 for. My own shop has a great "Right Call Right Care" campaign, along with a similar one a few cities down the road from me in London. And as I spoke about earlier fast forward to today's crisis points in EMS we have some services literally shouting "Don't call 9-1-1 unless you're dying". I think public education is important and they should have been happening for decades. I think we should keep doing them long after COVID is behind us. But it's not the answer to any of our problems. We should never be discouraging use of 9-1-1 for two reasons. 1) There will always be outliers. What I mean is there will always be the old frail people who have minor issues that need us to need to attend an ED for frailty reasons. If grandma is bed bound and can't walk - it really doesn't matter how minor her medical issue is - it's a situation that warrants an ambulance. We don't want these people to fall through the cracks and ignore a minor problem that could potentially become a major one because we told them to leave us alone. 2) Quite frankly people won't listen anyways. As I said before public education is important but if it requires any budgetary assignment beyond some artwork, we're using the money wrong. We cannot change human behaviour. We can give a blank cheque to public education and there is no dollar amount available that is going to get us back to a time where we were before. If you look at any education on human factors specifically the hierarchy of intervention effectiveness, education & training (ie, human behaviour) is the least effective intervention possible. The most effective is forcing functions (ie, system change). So let's absolutely keep doing public education but more important let's change our system. Let the public call 9-1-1 for whatever the hell they damn well please. But let's have a responsive and adaptable system who's "menu" of offerings to that 9-1-1 expand beyond "We will send out an ambulance with two paramedics" and "We will take you to an emergency department". Again that's on us. We need to stop trying to change human behaviour and create a system that can take that 9-1-1 call and do a dozen different things with it.

Next up is offload delays. A bane of every Paramedic Service in Ontario. I won't speak about them at length here because I've already written an article on this topic. You can find it here:

The Curious Case of the Unpaid Babysitter

But we need to get a handle on them and start taking some aggressive steps to say the least.

Why are people calling 9-1-1 for things that they never did 20 years ago? We can blame lack of access to primary care as a major reason. While Ontario has done an amazing job at producing doctors over the last decade (physicans have outpaced population growth by 3x) it's where they are located that becomes a problem. First, a look at the numbers. Ontario has 220 doctors for every 100,000 people — that’s up from f203 in 2012. But what does this number mean? Let’s unpack the first part — the doctor side. A simple head count of doctors ignores where doctors are located. In Ontario and across the country, doctors are poorly represented in rural and remote areas, and this disparity between the health services available to urban and rural patients is larger in Canada than in other countries. In fact, only 8 per cent of doctors provide health services to the 19 per cent of the population that’s located in rural areas. Are there enough doctors in rural areas? The answer there may well be no. And what about access? Simply having a GP doesn't necessarily mean you'll be able to see them in a day or two. Many citizens who have GP's continue to report 3, 5, and 7+ days lead time to get in to see them. What happens in the meantime? They access the ED and/or Paramedic Service because they either don't want to wait that long or their medical condition has degraded before they could make it to their appointment. Marry this up with the fact that "open late" for an urgent-care of walk-in clinic usually means 6 or 7pm and we can see how everything spirals together. Many large cities have co-located nearly round the clock urgent care centres with hospitals and this is a great idea that needs to be expanded on around the province where the population volume makes sense.

And finally enter COVID-19. The straw breaking the camels back for many Paramedic Services in Ontario. Where at the beginning many services saw a small drop in call volume that has quickly turned around and become exponential call volume increases. From chronic health conditions being ignored and becoming worse because people are afraid to access healthcare, to PPE and cleaning procedures making every single EMS call take 25% longer from start to finish. Add in the rapid spread of the Omicron variant and Paramedics both acquiring COVID-19 and/or having to isolate from high risk contacts, services are having trouble keeping their heads above water.

So where do we go from here? Thankfully it's not all doom and gloom. The ball is already rolling on a number of solutions. Provincial funding for Community Paramedicine programs that sees patients preemptively and has already proven it's worth in reducing call volume for high frequency patients continues to flow freely. This needs to continue and be expanded to it's maximum capacity as we have long proven it's track record. There is legislative framework in place and services already trialing "treat and release" programs which allow people to remain at home after Paramedic care. This is not Valhalla however - while indeed reducing volume in the emergency department it doesn't change the fact that it's still a call for the Paramedic Service and the associated time, cleanup, and paperwork that comes with such. But it will certainly help to some degree.

But the hard part still lies ahead with no solutions just yet. The reality is Paramedic Services in Ontario need funding to keep up with population growth, aging, and ergo call volume increases. To date the funding provided has not matched such and the disparity continues to grow. Hospitals need both beds and staffing and stop the backlog of hallway medicine and the trickle down effect of offload delays because there is no room at the inn. We need to aggressively change our delivery model and eliminate our "You call we come" approach. We need a system in place that offers a variety of solutions to every 9-1-1 call, and a system that is fluid and scalable. One similar to where Niagara EMS is headed with nurses and ACP's making clinical decisions and sending out a single person EMS car - or nobody at all and simply referring the caller to the right resource (Note: this is obviously one of the dispatch centres not directly managed by the province). We also need a safe and healthy workforce. Services need support systems in place where by Paramedics both want to, and can actually make it to retirement and not ride out long term benefit plans or simply leave the career altogether.

As Morpheus once said, "There is a difference between knowing the path and walking the path." I'm still quite bullish on Paramedicine in Ontario. But both our time, and our people are starting to run out.