Paramedics Colin Waterhouse and Josh Picknell are in their ambulance in Ottawa on a Friday afternoon when the call comes in: a Code 4, which means they need to get there fast.
With lights flashing and sirens blaring, they race to the call’s address and assess the patient; he needs to go to the hospital. Moving quickly, the drive to the Queensway Carleton Hospital, in Ottawa’s west end, is fast. But as the paramedics arrive at the hospital, the rush of activity stops.
There are six ambulances already parked outside and the emergency room is packed.
The two paramedics will have to wait with their patient, monitoring him, until his care can be transferred to the hospital. “Essentially, we’re stuck here,” said Waterhouse.
The experience is known as an “offload delay.” It means their ambulance will stay parked at the hospital for now, rather than head back out on the road, where it can respond to other incoming 911 calls.
“While I’m here with this patient, I might be here for hours. I can’t respond to a call. All of these paramedics are taken out of commission while we’re waiting to get out of the hospital,” said Waterhouse. “So you have a smaller amount of circulating ambulances in the city to respond to emergencies.”
That waiting time adds up. Last year, the Ottawa Paramedic Service took 72,000 patients to hospitals and spent 49,000 hours waiting in offload delay. During the first five months of 2022, paramedics in Ottawa have spent 25,000 hours waiting at hospitals, with the 28,000 patients they have taken there.
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At this rate, the service estimates they could lose more than 60,000 hours to offload delays by the end of the year.
It’s a situation that obviously affects patients and their families, too, said Waterhouse.
“They’re rightfully frustrated,” he said. “Because they have a pretty reasonable expectation that they would call 911, they would promptly get an ambulance to them, and they would get to the hospital and get seen right away.”
Paramedics under pressure and a city running out of ambulances
The extraordinary pressure on hospitals across Canada is having a ripple effect on ambulances and paramedics. The National got exclusive access inside the Ottawa Paramedic Service as it faces an unprecedented number of “level zero” incidents — when there are no ambulances left to respond to 911 calls.
According to the Ottawa Paramedic Service, the long waits at hospitals are a result of several reasons, including increased call volumes to 911, a lack of access to family physicians, and staffing shortages across the health-care system.
“All the weight is falling onto the hospital system to manage the entire health-care system — and it’s just not capable of doing it,” said Ben Ripley, a superintendent with the Ottawa Paramedic Service.
“Because of that, we’re seeing backlogs in the emergency room … and because of that we’re seeing our trucks sit there for hours on end.”
Offload delays aren’t unique to Ottawa; they’re a problem at many hospitals across the country, as the health-care system buckles under the weight of staff shortages that have been described as endemic.
They also lead to another problem being 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 send to incoming 911 calls.
Ottawa has recorded 1,041 Level Zero instances this year, from January to July — something that paramedics say can happen multiple times in a single day.
It’s a problem that has been growing over the years, to the point of becoming commonplace, said Picknell.
“It’s very rare to have decent levels at work,” he said. “When I come in and there’s actually ambulances available, that’s surprising to me.”
When availability of ambulances is low, it also affects response time, said Picknell, noting when that happens, he might be the closest unit free for a call in the entire region of Ottawa — and still be 30 or 40 minutes away.
“That’s part of where there’s a lot of frustrations amongst medics, amongst patients that we deal with, it’s not appropriate for people in life-threatening and serious circumstances to have to wait that long for an ambulance. It’s just not appropriate.”
The nerve centre of the Ottawa Paramedic Service is the Ottawa Central Ambulance Communications Centre, which receives the emergency calls that are coming in for paramedics on any given day. The CBC’s The National had exclusive access to the Centre one Friday evening in August, as the operation hit Level Zero.
“This happens almost on a daily basis,” explained Chief Pierre Poirier. “And particularly over the last few months, it’s been terrible.”
To continue to respond during a Level Zero, ambulances will either be dispatched from a neighbouring community, or the call will be queued until someone becomes available.
And just like offload delays, Level Zero — sometimes called Code Zero, Code Critical, Code Black or Code Red in other regions — is not unique to Ottawa, said Poirier.
“Our experience is being 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 — from coast to coast.”
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 events.”
Sanderson is also co-chair of a working group on hospital offload delays with the Ontario Association of Paramedic Chiefs (OAPC).
In Hamilton, he said, they have had 209 Code Zero events so far this year — a marked increase compared to the past couple of years.
“We are just over seven months into the calendar year and we have had more than double the number of Code Zero events than we did in all of last year — and seven times more than we encountered in the first year of the pandemic,” said Sanderson.
“There is a direct correlation to the frequency of Code Zero events and the amount of time paramedics are required to wait for hospitals to accept transfer of care for incoming ambulance patients.”
According to the Paramedic Chiefs of Canada (PCC), based on anecdotal discussions with their members, Level Zeros exist in varying degrees in all provinces, and offload delays are an issue 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 service has also introduced community paramedicine 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 via long-term care organizations, to help improve quality of life for older adults, allowing them to stay in their homes as long as possible and reducing visits to the ER, and also for patients in the community with complex care needs.
“We’re trying to help the health-care system to fill gaps … and not take people to the hospital, but still provide that excellent care in the home,” said Poirier.
Another initiative implemented at three hospitals in the region — Queensway Carleton, Ottawa Hospital’s General campus and Montfort — is to station a paramedic in the emergency department who can monitor up to four patients until the transfer of care to the hospital takes place, freeing up crews who would otherwise face an offload delay. (At the Montfort Hospital specifically, that 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 service typically has single-responder paramedics who are able to provide care; it’s a bridge they implemented in recent years “to ensure that we can still provide that initial health-care service and that initial medical service to patients in need.”
If no other resources are available, Ottawa Fire Services will also respond to high-priority calls.
But the system is “in crisis,” said Poirier, and help is needed. “We need people to advocate on behalf of the paramedic service,” he said.
As for Waterhouse and Picknell, their offload delay at the hospital was about 1.5 hours this time.
“But we can be, sometimes, with those patients for many, many hours … watching them as they wait…and that’s been normal for quite some time,” said Picknell.
And while Waterhouse thinks he has the “greatest job in the world,” he says he’s not sure if he can keep doing it, if the current status quo continues indefinitely.
“If you were to tell me today that the way things are right now is the way it would be for the rest of my career, I would resign tomorrow.”