Canada's healthcare system is struggling to provide primary care and acute care for ever-increasing numbers of patients, who are turning to emergency medical services (EMS) agencies to obtain timely care when in need. Paramedics are experiencing the downstream effects of these challenges, leading to a diversion of ambulances away from the communities they serve, increased call volumes and staff burnout. Well-intended policies, such as a borderless EMS system, should not be used as a stopgap measure to service non-emergency calls, and there should be a defined and enforceable process for returning ambulances to their home communities. Community paramedic and alternative treatment destinations represent an evolving area of paramedic practice that could offer solutions to some of the challenges faced by the healthcare system and relieve some of the occupational issues faced by paramedics. However, to fully realize the benefits offered by some of these changes in paramedic practice, they must adopt evidence-based best practices and be accompanied by relevant changes in paramedic education and supportive government policy.

The Impact of Canada's Healthcare Crisis on Access to Emergency Medical Services Care

Canada's healthcare system is in crisis, with ever-increasing numbers of patients turning to emergency medical services (EMS) and emergency departments to obtain needed care. None of the issues identified in the accompanying paper by Newton et al. (2024) have to do with the clinical practice of paramedics, but the problems affecting paramedics arise because of issues in the healthcare system. A borderless EMS system ensures that a patient suffering an emergency has a likelihood of getting an ambulance predicated solely on the whereabouts of all available paramedic resources, not just those associated with a specific municipality. The borderless system in Alberta is but one example of how EMS policies were created to address healthcare resources made increasingly scarce by the widespread and systemic deficiencies in our healthcare system. Ontario has a similar borderless system that is ensured through legislation and where the minister of health is responsible for maintaining a balanced and integrated system of paramedic services, coordinated through Ontario's centralized ambulance communication centres. However, the borderless system policy should not result in the poaching of ambulances to service non-emergency transfers in the larger cities. This use of the borderless system policy is not acceptable and may even be unethical when it deprives rural and First Nations communities of paramedic resources, exacerbating the existing disparities that these communities face in access to healthcare. An equitable borderless system policy should have metrics in place to monitor its performance in responding to emergency calls, where timely response has proven beneficial in improving health outcomes for a number of clinical conditions, including trauma, stroke, heart attacks, mental health and addictions and out-of-hospital cardiac arrest. There should also be a defined and enforceable process for returning ambulances to their home communities in a timely manner as soon as there are no remaining emergency calls that require a response.

Community Paramedicine's Evolving Role

One central concept the authors were able to highlight in their article (Newton et al. 2024) is the diversity of front-line EMS providers that now exist in many paramedic services, including community paramedics who are empowered to look beyond acute healthcare crises and manage people in their homes. These paramedics may serve increasing roles in healthcare education and promotion, diverting care away from overcrowded, understaffed hospitals, provide access to alternative destinations and enable virtual access to physicians for service and care. Community paramedic programs are an area of evolving but as yet incompletely developed practice that have the potential to contribute solutions to some of the problems in the broader healthcare system.

Although this was not addressed by Newton et al. (2024), the extent to which the public will tolerate adverse clinical outcomes that take place in the community setting is yet to be defined. For example, a patient with a benign-sounding complaint, such as fatigue, who later is found to have had sepsis or a myocardial infarction, may result in some taking a dim view of non-transport or alternative destinations. Perhaps, a safe middle ground might be to offer a clinical online consult with a dedicated EMS physician for certain clinical presentations before deciding on treatment courses at home or at alternative, non-hospital sites. We agree that innovative programs in community paramedicine not only have promise for their patients but may also have benefits by decreasing occupational stress injury for the responders, increase their sense of purpose and increase morale, thereby making a difference in long-term retention of the paramedic workforce. For these changes to successfully take hold, paramedic education at the college or university level needs to include training in all these aspects of paramedic practice. In addition, governments could play a role by supporting the development of community paramedic programs and alternative destination and care practices that incorporate performance metrics and adopt evidence-based best practices.

Conclusion

Partnering with paramedics to develop a healthcare safety net to manage structural challenges in the Canadian healthcare system is a Sisyphean task, one that cannot be borne by EMS agencies and their governing policies alone. Paramedics are suffering the effects of Canada's healthcare crisis, just like the other sectors of our healthcare system. Failing to consider and study the potential roles of paramedics in the broader healthcare system, beyond just their responses to emergency calls, risks undermining the very things they have been doing well and are striving for. In the end, the solution to some of the challenges in EMS brought about by the crisis in Canadian healthcare may be addressed by including paramedics in the broader healthcare discussion, examining proposed solutions they bring to the table, ensuring that there is a supportive government and educational system in place and applying similar metrics for measuring outcomes they might be able to offer.

Correspondence may be directed to Michael Feldman by e-mail at michael.feldman@sunnybrook.ca.

Commentaire : La crise des soins de santé au Canada et le rôle émergent du personnel paramédical

Résumé

Le système de santé du Canada a du mal à fournir des soins primaires et des soins de courte durée à un nombre toujours croissant de patients qui se tournent vers les services médicaux d'urgence (SMU) pour obtenir des soins en temps opportun lorsqu'ils en ont besoin. Les ambulanciers paramédicaux subissent les effets de ces défis, ce qui entraîne un détournement des ambulances loin des collectivités qu'ils desservent, une augmentation du volume d'appels et l'épuisement du personnel. Les politiques bien intentionnées, comme le système de SMU sans frontière, ne devraient pas être utilisées comme solution de rechange pour répondre aux appels non urgents, et il devrait y avoir un processus défini et exécutoire pour le retour des ambulanciers dans leurs collectivités d'origine. Les services paramédicaux communautaires et le choix d'autres établissements pour le traitement sont des domaines en évolution dans la pratique des ambulanciers paramédicaux. Ces domaines pourraient apporter des solutions à certains défis auxquels le système de santé est confronté et pourraient soulager certains problèmes professionnels auxquels sont confrontés les ambulanciers paramédicaux. Toutefois, pour tirer pleinement parti des avantages offerts par ces changements dans la pratique paramédicale, ils doivent adopter des pratiques exemplaires fondées sur les données probantes et s'accompagner de changements pertinents dans la formation du personnel paramédical et dans les politiques gouvernementales de soutien.

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