Saving lives in a booming region: How Peel Paramedics are planning for the region’s explosive growth
Three to four times a day in the Region of Peel, a person collapses. A healthy 50-year-old man could be pouring a cup of coffee in the remodelled kitchen of a large family house when the mug slips from his hand. A 40-year-old mother of two might be walking up the stairs of her condo, when the laundry basket suddenly drops to the floor.
The location may be different, but the cause is the same – the heart stutter-steps in a chaotic arrhythmia.
When it stops beating, a clock starts ticking.
Every second that passes with the heart failing to push blood to the brain, lungs and other organs means it’s inching closer to never pumping again.
Studies have shown that for every 60 seconds without intervention after a cardiac arrest, the chances of survival are reduced by 7 to 10 percent.
It means Peel’s first responders are often in a race against time.
The starting line runs across one of Peel’s four paramedic reporting stations, or 21 satellite stations, located strategically throughout the region’s 1,247 square kilometres. They create a web of coverage allowing ambulances to reach emergencies in most parts of the region in enough time.
Most parts of the region.
At least once a year an unlucky soul has their heart stop while hiking the forested depths of the Forks of the Credit Provincial Park. It’s one of the worst spots in Peel to have your heart stop.
“Your chance of survival in those areas is almost zero and to hope for something,” says Paul Snobelen, Peel’s specialist in community resuscitation programs. Snobelen recalls one lucky survivor who went 30 minutes before an automatic external defibrillator (AED) arrived to jumpstart their heart. The person happened to be hiking with a paramedic who was able to perform CPR until help arrived; CPR can drastically improve a person’s chances of survival between cardiac arrest and the use of an AED.
As the Region of Peel continues to grow, remote locations will become less remote, but dense urban environments also pose their own challenges, especially when cities stop growing outward and start scaling upward.
“Vertical is now the new challenge,” Snobelen says. “We know that’s going to become a bigger challenge in this region.”
Approximately 85 percent of cardiac arrests occur inside the home. When more of those homes are constructed high off the ground in multi-storey condos, accessed only by climbing multiple floors or through an elevator, it makes timely, effective response by paramedics near impossible.
As the City of Mississauga continues to grow upward, how can Peel Paramedics respond in time to save someone who lives 30 storeys off the ground?
The dichotomy between the urban and the rural in Peel creates unique challenges for paramedics who need to be equipped and ready to respond to all types of needs in the region. This need will only grow over the next 15 years — call volumes are expected to double by 2036 — meaning if Peel paramedics are going to continue saving lives in Peel, they will need to find new methods to do their job.
“Either you can own the change, or the change can own you,” Snobelen says.
Responding to the health demand of a growing region over the last 15 years has seen Peel paramedics shouldering a larger and larger workload.
Between 2005 and 2019 the number of calls has surged by 103 percent to 137,741 in 2019. That’s 377 calls a day, or 15 every hour.
The increasing demand is not expected to slow anytime over the next decade.
In 2041, 2 million people will call the Region of Peel their home, about 400,000 more residents than today. That’s like the entire population of London moving into the region. It’s the continuation of a trend that has seen Peel grow by nearly 20 percent between 2006 and 2016.
With so many newcomers settling in Peel, call volumes are projected to increase to between 208,633 and 356,603 calls annually by 2036. It means, on the low end, Peel paramedics will need to handle 572 calls every day, or, at the high-end, they will be rushing out from stations nearly 1,000 times a day. It’s a staggering amount of life-saving work.
It’s a “dramatic pace” says Paramedic Chief Peter Dundas, one that will require a significant investment in infrastructure and staff to be able to handle. Current projections show a needed capital investment of $139.6 million between 2021 and 2030 in order to add new reporting and satellite stations and expand the ambulance fleet to be able to effectively respond.
“I’d love to have a crystal ball to tell you what it’s going to look like in 10 years. The numbers, the evidence is a point in time,” Chief Dundas says. “Right now, it is indicating that we need quite a bit, but if we can start mitigating some of the demand in different ways, and the resourcing, the tax that needs to be put into it, may reduce the amount of vehicles that we need and it may reduce the amount of footprint that we need.”
The dual challenges for Peel Paramedics are growth and time. As fast as the Region’s urban environment will grow, creating difficulties from an operational perspective, what is currently one of the youngest regions in the GTA will continue to age, giving rise to more complex healthcare needs.
Statistics Canada estimates that by 2036, roughly 1 in 4 Canadians will be over the age of 65, compared to 1 and 7 in 2011. This increase in seniors will be mimicked in Peel where in 2011 only 1 in 10 residents were over 65, but that will dramatically increase to 1 in 4 by 2041. A discussion paper from the Region published in 2016 states many municipalities are not prepared to handle this wave of residents aging into their senior years, including Peel.
Peel’s urban environment is already problematic for an aging population.
“Today’s suburbs are no place to grow old,” stated Glenn Miller, past director of the Canadian Urban Institute, in the Region’s document.
The car dependent nature of Peel makes it difficult for seniors who, for a variety of reasons, may no longer be able to drive, disconnecting them from their community and crucial services.
To better serve this population, paramedics organizations across Canada are pursuing what is known as “community paramedicine”, a model of care that looks to do more than just take people to hospital in emergencies. Instead, paramedics will become advisors, educators, and nodes of connection to Peel’s network of diverse healthcare resources.
The aim is to create connections between residents and the array of resources in the community. That way, when a healthcare issue arises that may not require them to go to hospital, but traditionally saw them call paramedics for answers, they would be able to lean on other services in the community for help.
Chief Dundas believes this approach will reduce the pressure on both Peel’s over-burdened hospital system and long-term care sector — which have buckled under the increased strain during the COVID-19 pandemic.
“People who would today have to be placed in a long-term care facility may be able to stay home if appropriate care was around them and their families,” he says.
Community paramedicine responses are as diverse as the healthcare needs they respond to, but all have the same purpose, to shift healthcare response upstream and prevent avoidable emergency calls and hospital visits and bring down the projected surge in workload. Projected cost increases could also be curbed.
In a “limited capacity”, Peel Paramedics have been implementing such programs over the last several years. In 2008, they started the Community Referrals by Emergency Medical Services (CREMS) program which provides 911 callers with additional resources, referring approximately 600 callers to home and community services in 2020. The goal is to redirect these residents to alternative forms of care that can meet their needs and have paramedics focus on responding to the most severe emergencies.
Since 2018, Peel Paramedics have also run weekly seniors’ wellness clinics out of Peel Living homes in Mississauga. These drop-in clinics targeted low-income seniors and were an asset to many in the community before COVID-19 forced the suspension of the program.
Since 2005, Peel’s elderly population has been rapidly increasing, a trend that is expected to continue over the next two decades.
“Right now, everything is a 911 response, but in the future, can we handle a lot of the calls that come in, which are mostly low acuity, in a different fashion, lessening the burden on paramedics?” Dundas ponders.
To make this approach successful, an operational shift in the way calls are dispatched in the Region of Peel is needed. Dispatch services for Peel Paramedics are operated by the Ministry of Health, which relies on a “very antiquated, out of date triage system,” Dundas says. This dated approach sees many calls being sent out as a lights-and-sirens priority response when it doesn’t need to be. Dundas estimates that only about 20 percent of the calls that are being sent out currently as top priority actually need to be classified this way.
“There are steps being made, but these are the things we’re looking forward to, to be able to manage the system in a much different design from where it’s at right now,” Dundas says.
These programs can help Peel paramedics focus their efforts on the most serious of medical emergencies, but the rapid urban growth in Peel will still be a hurdle that community paramedicine will not be able to fully clear.
In the near future, for residents of Peel who call 911 for help with a cardiac arrest, the arrival of assistance may not be marked by the wail of sirens, but the whir of a drone.
There are only so many ways to shave off time in an emergency response. More staff and ambulances can be added to spread out the workload. More reporting stations can be built to expand the paramedic service’s web of coverage and ensure that when 911 is dialled, the ambulance starts its race as close to the caller’s home as possible. Paramedics can also streamline current processes to trim the fat on tasks that are taking up too much time. Currently, Peel paramedics spend about 52 percent of their time transferring patients into hospital care, a process that can be delayed for a myriad of reasons, so finding streamlined approaches can improve response times overall.
Despite the growth pressure that has been pressing down on Peel Paramedics in recent decades, the service has been able to reduce the average time spent per call by approximately 6 minutes since 2005.
But distance and travel time are two nagging challenges, and bound to get only more difficult as the region grows and more people and cars arrive on local streets. Ambulances are in a life or death situation. The more obstacles in the way, the greater the chance of tragedy.
It leaves paramedics with two options. Either find a new, quicker method to arrive on scene, or find some way to have medical assistance begin before paramedics arrive.
The AED drone ticks both of those boxes.
For close to two years, Peel Paramedics, in partnership with Drone Delivery Canada, have been testing the feasibility of a drone that can respond to 911 calls of cardiac arrests with an AED. While the pandemic has delayed implementation — and the service is awaiting final approval from Transport Canada for flying the drone in the region — the possibility is getting closer to reality.
Snobelen explains test flights for delivering the AED — which would be completely automated — were ongoing throughout 2020, using volunteers with no CPR knowledge or training experience to see how effective the tool could be.
In theory, when a 911 call comes in for a cardiac arrest, if the location is far enough away, or difficult for ambulances to access — like the Forks of the Credit — a signal can be sent to the drone to take off. GPS coordinates are uploaded, the drone does a quick scan of the weather to ensure it is safe to fly, and if so, it takes off. Test flights from up to 50 kilometres away have proven the initiative works. An initial study in 2019 found that in four test flights, the drone was able to arrive at the determined location 2.1 minutes to 4.4 minutes faster than EMS. When it comes to responding to cardiac arrests, this additional time is an incredible advantage.
For two years, Peel Paramedics have been working to finalize the use of a drone to respond to cardiac arrests.
“These results suggest the potential for AED drone delivery to decrease time to first defibrillation in rural and remote communities,” the study concluded.
“When it arrives it doesn’t land, our drone will hover over, come to a specified height, and the AED will eventually drop out of the bottom,” Snobelen explains.
The AED is cushioned from the fall, tucked inside what Snobelen describes as a “custom-made Otter box”.
“When you open the package, there is already a cellphone that is connected to FaceTime and I’m able to guide the bystander through what they’re seeing, what they’re doing and have that visual connection and actually being able to coach them through what it is they need to do,” he explains.
The potential future locations for the drones have yet to be decided, but initial planning sees two drones serving the Caledon area, one in the area of Caledon Village and another somewhere between Caledon East and Bolton.
In a space race-style competition, paramedic services across the country, and the globe, are studying this technology, many looking to be the first one to respond to a 911 call with an autonomous drone.
“It would be great to be first, but we also want to make sure that if we’re going to do it, we’re going to do it right,” Snobelen says.
When the drone is put into use, Peel Paramedics will essentially have an assistant healthcare provider with propellers, and the autonomous flyers could go a long way toward reducing the investment needed to expand Peel Paramedic’s footprint over the next decade.
Current projections for the next 15 years suggest the paramedic service will need three more reporting stations — full service facilities where paramedics begin and start their shifts, ambulances are stored, cleaned and stocked, and team meetings are held — and five new satellite stations — “posts'' where paramedics stage themselves during shifts in order to provide quick responses across the region.
A new reporting station costs approximately $38 million. If a drone is able to shave some valuable minutes from response times, closing the gap for an ambulance to respond from further away, it can potentially reduce the need for additional physical stations. It may also potentially reduce the need for a drastically expanded ambulance fleet, which Peel paramedics predict needs to grow from its current 134 vehicles to 250 by 2036.
The addition of the drone, while serving a critical role in remote locations, will not do anything to address the intense vertical growth that will continue to erupt over the next two decades, particularly across Mississauga’s rapidly rising urban cityscape.
In Mississauga alone, the M City development, currently underway, will include eight condo towers, one of which will stand 77 storeys; the Oxford Properties development surrounding Square One will include a staggering 37 towers, the initial construction includes two towers of 36 and 48 storeys; there’s the Oro at Edge Towers, 50 storeys; Artform Condos, 17 storeys; Gordon Woods, 29 and 36 storey towers; and Westport Condos, 22 storeys, to name just a few of the planned developments.
Square One project.
In medical emergencies like a cardiac arrest, when every minute is critical, the time paramedics spend waiting for an elevator to arrive on the ground floor can mean the difference between life and death. The higher you live, the lower your chance of survival, especially if your floor is in the double digits.
On Mount Everest, everything above the 8,000 metre mark is known by climbers as the death zone due to the inability for the human body to survive with such low oxygen levels for prolonged periods.
For condo dwellers, a study completed by York Region Paramedic Ian Drennan in 2016 found the “death zone” is pretty much everything above the 16th floor.
In the event of a heart attack, “science shows you’re dead,” Snobelen says.
Drennan’s study of over 7,000 cardiac arrests in Toronto and Peel found that for those who collapsed above the 16th floor, the survival rate was less than 1 percent. There were no survivors above the 25th floor.
“How do we start addressing that?” Snobelen says. “You’re dealing with elevators and if one elevator is not working. What we’re trying to do is how do we get ahead of this so that we’re not trying to catch up later.”
In the same way that the drone can buy paramedics extra time by starting the work before they arrive, is there a similar resource that can be employed in urban environments?
Enter the community responder program.
In October 2019, Peel Paramedics soft-launched the program which aims to connect with willing residents in the community who have some level of medical training and can respond if an emergency occurs in their neighbourhood, or condo tower.
“There’s probably someone in that neighbourhood who is willing to help. Why are we not leveraging that opportunity to get someone who is willing to help us to go ahead and do something?” Snobelen says. “How do we as paramedics enable the community to respond when it's needed?”
While the pandemic has forced the program to hit the pause button, the region has seen sustained interest from individuals in the community willing to help their fellow residents in a time of need. During the initial soft-launch, 118 individuals stepped forward to be a part of the program, and about the same number of volunteers are waiting in line for it to start back up again.
Using an app, registered community responders are sent an alert when a cardiac arrest is called in their area, and can be dispatched details, if they are able to provide assistance. Each community responder is registered with the program to ensure the information is not being sent out to the broader community.
Peel Paramedics are able to dispatch calls to community responders through an app on their phones so they can respond to nearby emergencies before paramedics arrive.
“As a service, we vet the calls we’re going to send them to,” Snobelen says.
This response can be particularly impactful in areas like downtown Mississauga that see a lot of people living in close proximity. The chances of someone knowing CPR in a condo tower who is able to reach an emergency before paramedics is particularly high.
And it works. In two instances, between November 2019 and March 2020, before the program's suspension, inside Peel highrise buildings, the community responder was able to beat the paramedics to the emergency, one involving a resident on the 11th floor, the other above the 20th floor.
Now, the program is just awaiting the end of the pandemic to once again start serving the community.
A recent report from the Region of Peel made it exceedingly clear that the type of work being performed by Peel Paramedics and Snobelen to find new ways of addressing Peel’s growing health needs has been complicated by COVID-19.
The pandemic has exposed gaps in Ontario’s medical system, and shown that the demands for long-term-care space and hospital care are already outpacing existing resources.
Community paramedicine offers a chance to move that care upstream and “offer an expanded primary care role for paramedics to help address health system pressures and contribute to overall system efficiency,” the recent report states.
The report noted an increased investment from the Province of $9.75 million over the next four years will help expand its existing community paramedicine programs, to allow for more assessment and referrals, home visits and wellness clinics.
“Community paramedicine programs can also play a role in alleviating increasing emergency call volumes, as fewer individuals will seek emergency care if they are adequately supported in the community,” the report states.
As Snobelen said, “Either you can own the change, or the change can own you.”
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