The job description of the universal emergency service worker is simple. Hire an individual to report to work and check their emergency vehicle, then receive a briefing of Canada’s Most Wanted, patrol the streets to prevent crime, while on the streets perform two or three fire inspections per shift, and when required, respond to the 9-1-1 call. And for added value, while eating lunch, perhaps engage in a restaurant inspection for public health.

Yes, the bureaucrat dream is to achieve efficiencies by multi-tasking the emergency worker. Why not, all you need is an emergency vehicle with lights and sirens, a radio, some Band-Aids, and perhaps a Taser gun. The Taser gun could double as a non-lethal weapon and a cardiac defibrillator. Just point and shoot, depending on the circumstances.

But the name Universal Emergency Service Worker has no appeal for recruitment purposes. Thus, perhaps the term FIREMSCOP will work?

Ok, end the sarcasm. As municipal jurisdictions battle a restrictive funding envelope, and the cost of emergency services continues to rise, there can be some savings in amalgamations. However, prior to entering the fray, administers need to weigh the advantages and disadvantages of such amalgamations.

Cost Curve

In economic terms, as an organization increases its output, the total cost is reduced. This negative portion of the curve is often referred to as economies of scale. In emergency services, there is often the discussion that by amalgamating services there is greater opportunity for bulk purchasing (vehicles, fuel, uniforms, supplies, etc.) and thereby reducing costs by bargaining a lower cost per unit.

However, as the organization purchases greater units, there are greater costs due to storage, inventory control measures, distribution, etc. These costs cause the curve to increase. The positive portion of the curve is referred to as diseconomies of scale.

Another advantage cited to amalgamations is the restructuring of management. For example, if an organization were to amalgamate fire and EMS services, then there is an elimination of the Fire Chief and the EMS Chief to a consolidated Emergency Services Chief (or General Manager). The consolidation of positions reduces costs and thus causes the cost curve to decline.

However, when you consolidate, there is often a need for specialists (such as a Deputy Chief for Fire and a Deputy Chief for EMS) and greater support staff. In addition, consolidation management tend to have greater salaries and benefits. These costs work against savings and force the cost curve to increase.

Overall, the goal of amalgamation is to achieve economies of scale and thereby generating savings. However, as the organization increases, there are other variable factors that will counter savings and may actually create more costs. Prior to considering amalgamation of emergency services, a comprehensive long-term economic assessment is required.

Labour Relations

One of the greatest challenges in considering the amalgamation of emergency services is the various labour issues that will arise.

One issue is simply stress. Change causes stress. If the transitional managers fail to plan, develop and implement an effective transitional plan, then there may be a negative impact on the front-line workers. The unmanaged factors causing stress will not promote an atmosphere of compliance.

Then there is the clash of cultures. A front-line police constable’s performance is based on interpreting the environment and enforcing the law, whereas the front-line firefighter is focused on receiving orders from command to reduce loss of life and property, and the front-line paramedic is engaged in assessing the patient and providing treatment and transport. Each of these primary functions generates a unique culture and camaraderie specific to the job. Blending primary job functions can generate cultural conflict and rivalry.

However, the greatest challenge in the amalgamation is the consolidated bargaining agent for the front-line worker. In a unionized environment, an amalgamation will cause the respective bargaining agents to compete with one another for representation. Once the successful union emerges, the unionized workforce has greater bargaining power.

A powerful union has advantages, even for management. The administrators of both the management team and the union representation can focus on priorities and work towards improving the workforce and labour environment. However, with greater bargaining power, the trend typically leads to greater clout at the negotiation table.

Alternative Models

Another goal of amalgamation is to reduce the duplication of services by combining the operations of the consolidated organizations. Although this goal can be achieved, there are alternative models that can produce the same outcome of reducing duplication.

One such model is the Inter-Departmental Model. Working towards the corporate mission, each department coordinates their functions to compliment each other. For example, the department of human resources offers services to all departments rather than each department having their own human resources personnel. Another example is the department of information technology (IT) where computer services are offered across the corporation in lieu of each department supporting their own IT staff.

An Inter-Departmental Model approach is successful when there is a clear corporate mission. The mission specific goals and objectives are developed by the heads of each department and are measured via performance standards.

Specific to emergency services, another viable model is the Inter-Agency Agreement Model. With this model, each emergency service (police, EMS and fire) have written agreements with each other in order to coordinate their efforts on scene and avoid duplications.

A prime example of an inter-agency model is a local CBRNE (chemical, biological, radiological, nuclear and explosive) team. Rather than one service developing a CBRNE team with their own specialists, an inter-agency approach to CBRNE is forming a team with personnel from each of the three emergency services. Each service provides the team with specialists from their sector and the team functions successfully by training and working together.

An Inter-Agency Model is successful when there are pre-established written agreements defining standards and procedures in order to promote interoperability.

A third alternative model is the Regionalization Model that amalgamates neighbouring jurisdictions specific to the sector. With this model, a municipality can partner with neighbouring jurisdictions to form a regional EMS system, a regional police services system or a regional fire system.

There are two options to the Regionalization Model. The first option is for one jurisdiction to function as a “host” municipality and neighbouring municipalities purchase services from the host. The second option involves the neighbouring municipalities forming a public utility system. With the public utility, each municipality has representatives on a Board of Directors that sets policy direction, in addition to budget approvals. The Regionalization Model has the same advantages and disadvantages as amalgamation in terms of the economics and labour relations. The appealing factor to the regionalization model is the avoidance in the clash of cultures.

Taming the Beast

Having a cardiac defibrillator in a police vehicle makes sense. The police constable is mobile and may be at the right place and at the right time to assist the patient in cardiac arrest. The police vehicle is equipped with lights and sirens and communication equipment for a rapid response. Does this justify cross-training the police constable to also function as a paramedic? Yet, the cost of emergency services continues to rise at a rapid pace, forcing municipal jurisdictions to re-assess service delivery. Amalgamation of emergency services is an option that needs to be included in the assessment. However, rather than the short term gain, one needs to assess the long-term economic impacts, the clash of cultures and the challenging labour relations that develop. The FIREMSCOP beast may be difficult to tame. Alternative models to amalgamation include a mission based Inter-Departmental Model, an Inter-Agency Agreement Model and/or a Regionalization Model.

Overall, any organization needs to continuously reassess their structure to identify inefficiencies. When engaged in the reassessment, one needs to look beyond the commonalities of the lights and sirens, and focus on service delivery. Then, and only then, can you tame the FIREMSCOP beast.

About The Author.

Carmen D’Angelo has a Masters Degree in Public Administration from the University of Western Ontario and a Bachelor of Science Degree in both Biology and Psychology from McMaster University. With 10 years of frontline experience as a Primary Care Paramedic and then an Advanced Care Paramedic, Carmen has been involved in municipal emergency management for the past seven years. The views contained in this article are his own. He can be reached at carmen.dangelo@sympatico.ca

December 06, 2007

By: Brent Browett

So how is the organizational structure relevant to your life and career as paramedic or a manager? While I acknowledge that the structure of your organization is not the beginning and end of your existence, and it will impact most of us in seemingly innocuous ways, I am going to submit that your organizational structure has immediate relevance to getting the work done in an effective manner and being recognized by your community, which allows the paramedic services to be the most it can be.

What I propose to you is that a “flat organization” subscribed to by many organizational design buffs is not likely to work well for EMS and that one size does not fit all. Rather, I am going to suggest that a reverse hierarchal design promoted for internal application will be of benefit to the paramedics' work life, and a traditional hierarchal design applied externally will benefit the managers who are trying to keep the service at the forefront to acquire and maintain the resources necessary for the paramedic service to excel.

Flat organizations

Let’s start with the argument by some that flat organizations are more nimble because their staff are jacks of all trades, and that those organizations will also be more inclusive and consultative as everyone is at a similar level. This theory is a derivative of the private sector and having work groups where a number of staff put together, say, a product. Likewise, at an EMS call, there will be two medics who together work to get the job done. We are a jack-of-all-trades in the usual course of street service. However, as soon as you move a multi-patient incident, someone has to be in charge, you shift to command and control. I do not know of any incident command program that puts 10 staff at the scene and they are all considered of equal authority. Surely you are not stopping to take a vote on triage, resources needed, etc. You probably should have a five-second consult with each other but someone, not everyone, has to take the lead and make decisions. Do you take turns at each function? Maybe, but there is also a case to be made to limit the numbers so that there is enough exposure for at least one or two people in your team get good at it. The threshold for how many you spread out the experience to will differ for each organization and at various levels within the organization, but what you want to achieve is at least one person on duty with specific expertise and continuous practice and exposure. Once there is one candidate with that level of expertise you'll be better off with a second person for sustainability, but if you continue to spread out the role, at some point quality will suffer. Don’t be sucked into that popular one-size-fits-all mentality that says flatter is better. Not always.

As for flatter creating a more consultative environment, it doesn’t fly with me. The idea, as I understand it, is that if you do the work that others do, you will be more appreciative of others' views and seek out their opinions as peers. While I think there is potential, in theory, for that to occur, I think it would be just as easy to argue that it eliminates the need and motivation for communication. After all, if I think that my peer has no more skills or knowledge than I have and I am overworked and on a deadline, why would I stop and take the time for more consultation? There will be minimal, if any, added value and only a loss of precious moments, which I need to complete the task. Where there is greater reliance upon each other for specific skills and/or authorities, the communication is forced. I maintain that effective communication and meaningful consultation are not found on an organizational chart, but rather that it is organic and inherent in the culture of the organization. Writing names besides each other or above and below each other on a piece of paper does not create dialogue. Opportunities for open discussion are the hallmark of inclusiveness.

Reverse hierarchal design

So I am a proponent of a hierarchal design for EMS, but specifically a reverse hierarchal design for internal purposes. So the traditional design is top down with the ‘boss’ at the top and the medics at the bottom. However, the issue here is that there is an appearance that the medic is there to ensure the director's existence. The reality is that EMS does not exist to get the manager profits but to serve the public. The role of the manager in this environment is to serve the staff and unify their efforts. An orchestra offers a good comparison, since the conductor supports the work of the musicians, and it is not the musicians that support the work of the conductor. This is not to minimize the importance of the conductor. Without question, the more musicians playing, with different instruments, and more complex pieces of music, the more critical the skills of that conductor become. In the end, though, nothing illustrates the point better than this: if the conductor leaves to go the washroom, the orchestra will continue to play. They may not do well and if that happened all the time it is likely the performance really suffers but they will get by for a while. If, however, all the musicians get up and leave, then you are left with just a crazy person standing in front of an audience waving a plastic stick in the air. Despite all the pomp of the conductor's role, without musicians, there is no orchestra. In my humble view, when the doors are closed the conductor (the leader) is supporting the orchestra and has to be at the bottom of the pyramid.

The conductor, front and centre

For the external world, I am going to suggest that a team wants its leader to be at the top of pyramid, and the depth of that structure generally equates to more organizational success. Back to the orchestra—the smaller orchestra, consisting of one violin, one flute, and one bass, while charming and intimate, is limited in its depth and diversity. If you have any mishaps like a broken instrument the vulnerability of a small organization becomes abundantly and immediately evident. Adding to your challenge, if the conductor of a small group goes out to raise support to continue to exist and/or expand, you will be fighting just to be heard and recognized. In contrast, consider how impressive it is to see the conductor who is standing out front of a deep pyramid with a wide array of resources that widens as it recedes and it is obvious she commands the respect of many layers. Each layer immediately responds to the flick of her wand and join the larger whole to build the performance. That exudes confidence and history suggests it yields support. You do not want the pyramid to be so narrow that those at the back cannot be seen or heard, but you also do not want it so flat that musicians are so far to the left and right of the stage that they are hidden behind curtains, invisible to the audience and they can’t see the conductor. For your orchestra to be successful and to continue to draw an audience, your conductor needs to be up on a pedestal, held in the highest regard and needs to appear in complete control and the musicians need to be working as one.

So I have sought to make the case that flat organizations may have merit in particular industries; however I am not convinced it is the design to emulate in EMS. I embrace the concepts of inclusion and collaboration, and I can’t think of a case where it should not be the goal. I do not think, however, that flattening an organization in itself achieves that and if one introduces that as the sole intervention, more harm than good may result. I also believe that the hierarchal design is in most cases the right fit for paramedic services, particularly on the emergency ground, but also in the structure that supports the work of the paramedics. The buck has to stop somewhere, and the reality is that even if you disagree with a hierarchal design, various pieces of legislation and likely your governance bodies hold the managers ultimately accountable for all that happens in the workplace, not the team. There is nothing more revealing to what structure is really in place than when there is a critical injury in the workplace. You can bet that the flat organization suddenly takes a different form—more like a straight ladder up.

The reverse pyramid with the leader at the bottom supporting staff, in my view, is more often than not the more appropriate approach to a sustainable unified unit. With the doors closed the conductor helps to ensure all the musicians have their instruments. When the doors open to the audience the structure has reversed with the conductor at centre stage representing all that the musicians collectively value. That message resonates with every bar played by the team and it is reinforced with solos. There is a performance that will draw applause.

About the Author.
Brent Browett has been working in EMS since 1979, starting as primary care paramedic and working ambulance dispatch part time. In 1984, he became an Advanced Care Paramedic and for 16 years he worked full time on the street and maintained the Program Director position for the local Base Hospital. During that period he also managed an in-hospital cardiac arrest team for seven years. From 2000 to 2005, Brent was the EMS Operations Manager in Hamilton and is now the Director. Brent’s management education includes an Ontario Supervisory Studies Certificate, a Bachelor Degree in Prehospital Care and a Masters Degree in Justice Public Safety Leadership and Training.

The views expressed in this article are those of the author and are not intended to be representative of any views of any agency or organization with which the author may be affiliated.

November 19, 2007

I was a mere child when I started this job in 1983, three months before my twenty-first birthday. Now, close to a quarter century later, I look back on my career and think: how the heck did I get here? I never imagined I would be in this profession for quite so long. It seemed that when I was a young ambulance attendant there were no old ones around. Guys with four or five years on the job were revered as being worldly and all-knowing. Guys with eight years or more were, well, antique. And I sure didn’t know of any ambulance attendants in 1983 that had been around as frontline medics for more than 20 years!

My college preceptors had been on the job less than a dozen years, but to me that seemed an eternity. To any 20-year-old, someone over 30 is really old. My daughter, who is 15, and my son, who is 18, think I’m a dinosaur. Today, as much as yesterday, the truth holds that you can’t trust anyone over 30.

So here I am, as old as Noah, writing a column about what it’s like to be in this career called paramedicine for almost 25 years. And like any old-timer, I’m going to tell you that it doesn’t feel any different than it did so many years ago. And that’s the truth. Because—and you old codgers out there will agree with me—nothing has really changed. Our job, with all the toys we have at our disposal, is essentially the same: drive to the scene, bed, oxygen, blanket, drive to the hospital. Sure, now we can do a few more things, like IVs, symptom relief, cardiac monitoring, ALS stuff, et cetera, but in the end our job is still about caring for people. How do we ensure a long and fulfilling career in paramedicine when, essentially, the job from start to end stays the same? How do you add variety to a job that basically is never-changing? Well, I guess there are a couple of approaches.

You can go to work day in and day out and stay totally uninvolved in labour relations, company policies, planning or anything else. One of the beautiful things about our job is that we can leave it all behind us when we walk out the station door. Once you turn the keys over to your relief, or lock them away after the shift, your job is done. It’s not like being a teacher, where there’s papers to mark or lesson plans to be created. No, for us the day is over when it’s over. Aside from the occasional studying we have to do to keep current or to move to the next level of care, we’re no different than the mailman or the line worker. When it’s over it’s over.

In a way, I envy anybody who can do that, but I’m afraid I am not one of them. I have always been one to get involved with my profession. I’m passionate to a fault. I listen to stories from my peers or hear things come through the pipe and feel I have to do something. It’s the reason I started the Toronto EMS list server almost 10 years ago, and I suppose it’s why I write this column. My career, I’m sure like yours, is and has been evolutionary. I started out wide-eyed and green behind the ears. There was that initial stage of being so clueless, even after graduating with honours from college. Then, as I gained experience, I thought I was the cat’s pajamas. And I went through a phase where I was a little unsure of myself, as the more I saw the less confident I was that I had all the necessary skills to handle every situation. I went through a long period of anger and frustration, too. Anger at the city that employs me for disrespecting us so much. Anger at the fire department for putting a proposal in to city council to take over EMS, saying they could do it better, faster, cheaper. Anger at hospitals for not recognizing our value to the community and holding us hostage endlessly in off-load delay. Anger at the union for missing opportunities to get us whatever we needed, whatever that was at the time.

There is always reason to be disenchanted with work. But that kind of constant focus took a toll on me. I burned out and for a while I became angry and bitter. When you are angry and bitter at work it’s hard not to carry all that baggage home with you. Instead of leaving the problems of work behind, you bring them home and share them with friends and family who become unwilling participants in your misery. Your attitude towards your work pollutes your home life, and hostility between you and your spouse grows and festers, resulting in problems on the home front that manifests as marital discord. I don’t know of any comprehensive studies that have examined the marital dissolution rate amongst paramedics in Canada and the United States, but I would venture to guess that it must be very high, if only because anecdotally I have seen a lot of it close to me. I would suggest to those studying critical incident stress amongst emergency responders that this topic should be the next one to be examined closely, as I believe it plays a vital role in our mental health.

I have painted an ugly picture of one toxic scenario that snowballs out of control, but that is not the only way things can go. Longevity in this profession depends on our ability to recognize problems in ourselves and to take corrective action along the way. It is not unlike sailing along a treacherous coastline. A novice sailor will crash his vessel against the rocks and perish with his crew. An experienced helmsman with skillfully guide his craft through the dangerous waters, maybe suffering some bumps and bruises along the way, but with his vast knowledge of the dangers that lie ahead and his understanding of how other sailors successfully negotiated these same waters, our second seaman makes it through to safe harbour with his vessel and crew intact.

I consider myself lucky that I am more the latter than the former. Most of what I now know I learned the hard way. My ship has been damaged, but I’ve made repairs while at sea, and now she’s holding up fine. So, what have I learned?

Well, indulge me for a bit here, if you please. In my case, each time I felt myself edging closer and closer to those hazards along the way that threatened my trusty ship, I changed course. Sometimes not always as soon as I should have, but nevertheless I sought and charted a new direction. They say that change is as good as a rest, so I became an acting supervisor for three years and got to see the job from a whole new perspective. But I also wanted to be an ALS medic, so I gave up my acting supervisor position when I was able to pursue training as an advanced care paramedic. And when off-load delays were driving me close to quitting this job, I got into the emergency response unit program, where I seldom transport patients, and then only the most ill, so off-load delays are not usually an issue.

For a while I was involved in community work. I volunteered at a chronic care centre in an educational program to help teach teenagers to “take less chances” and to make smart and safe lifestyle decisions. I sat on a community police liaison committee in my neighbourhood. I worked on various committees: one ad hoc committee dealing with EMS issues; a couple of committees at Toronto EMS dealing with various work issues over the years; I participated on a committee working to preserve Algonquin Park; and I held a committee position with the ministry of health for a couple of years.

I volunteered in search and rescue work for about seven years, and learned a lot along the way. I took up various hobbies: dog training, photography and others. I kept up old ones, like canoeing, hiking and camping. I spent time away from work as much as possible with my family. And recently I was fortunate enough to join a police tactical team as a medic, which is different enough from my day-to-day work that it feels like a whole new job. For me, the key to my survival all these years has been variety on and off the job.

Our profession is full of perils. Whether we get dashed against the shore and drown, or whether we can persevere and reach safe harbour is up to us. Steer wisely and heed not the siren’s song.

About The Author
Steve Urszenyi is an Advanced Care Paramedic with Toronto EMS, where he has worked since 1983. He is also a tactical paramedic with the Ontario Provincial Police. He lives in Toronto with his wife and two teenaged children. Steve welcomes your comments and suggestions and can be reached at medic.steve@rogers.com.

November 14, 2007

It’s a beautiful day. It’s warm, the leaves are colourful, and life seems pretty relaxed. It is a bit foggy, the air feels damp and salty, and you can hear the waves and the foghorn in the distance. The alarm doesn’t go off, your pager doesn't buzz, ring or vibrate, your radio doesn’t even squawk, but you get in your unit, knowing it’s already stocked as per ALS standards, and drive down a bumpy country road. There is no one standing in the driveway frantically flagging you down, there isn’t a trail of broken tail lights to direct your path. But the teapot is on and an elderly lady hollers “Come in dear” when you knock on the door. You aren’t there to slap oxygen on her, take her blood pressure or start an I.V. after you pick her up from the bathroom floor where she has fallen and broken her hip, and transport her to hospital. She is in no distress. She hasn’t called 911. In fact, you are there to assess her home so you can prevent her from having a fall and breaking her hip. You are there to tell her that her scatter rugs although artfully displayed on the old hardwood floors are a bit of a hazard, that her back porch rail could use some strengthening and that her burnt out lightbulbs on the way down to the cold storage room in the cellar should be replaced. And by the way, you do know how she can get that done.

Doesn’t sound like a typical Canadian Emergency News scenario? Welcome to the 21st century in prehospital care delivery. And where has this advanced delivery originated? Two very remote islands off Digby neck in Nova Scotia. Long and Brier Islands collectively have a population of about 1,200 year round with some escalation during the summer months. Many of the residents are over 65 and have the typical health concerns of an aging population; CHF, falls and home injuries, diabetes and chronic illness conditions.

The islands are remote, a 50-minute trip requiring two ferries to reach the general hospital in Digby, another hour to reach the regional hospital in Kentville. Not only does that mean difficulties in accessing hospital care, for the residents of the islands, it also means they are unable to attract and maintain a family physician practice on the island. If not for some collaboration between community primary health care delivery and the local ambulance service, residents would be dependent on the mainland for not only hospital care but for family physician care as well.

Nova Scotia has a provincially funded ambulance service and therefore is integrated at least to some degree with other aspects of health care delivery. To help meet the health needs of Long and Brier Island residents a 24-hour, seven-day-a-week emergency paramedic service was established in Freeport on Long Island. An abandoned clinic, once the island's physician office, was renovated to accommodate this service. With a call volume averaging approximately one call every three days, and residents still needing to leave the island to address the concerns one normally takes to a family physician, the service needed to readdress the way they did business.

In 2003, a nurse practitioner, under the guidance of an off-site physician, was added to the clinic and the paramedic service began evolving into what it is today. There are now 16 paramedics who work shifts on the islands. They rotate between working two, 24-hour shifts in Digby where they are able to enjoy the typical trauma and medical calls enjoyed in a larger service area and hone their ALS skills, to working two, 24-hour shifts in Freeport where they work delivering and refining their “community paramedic tag “ skills.

A day in Freeport is certainly not typical of most paramedic services in Canada. It begins by checking the ambulance unit and stock with a partner, but they also check the medication fridge for appropriate temperature control, check the triage room for stocking and the appointment book to see who they need to visit that day. From the hours of 8 until 10 a.m., Monday through Friday, the two paramedics are in the clinic drawing blood from residents who have been referred by their family physicians or the nurse practitioner for blood work. They also go out to homes throughout the community and draw blood from people unable to make it to the clinic. By 10:30 a.m. a courier arrives to ship the blood off to Digby for lab analysis. Paramedics on the island do approximately 95 per cent of the blood work drawing; the other five per cent is performed by the nurse practitioner. The rest of the day may be spent providing wound care in residents' homes, doing fall assessments, helmet and bicycle safety in the school, home blood pressure, glucose or prescription compliance checks, or visiting their adopt-a-patient (a patient, typically with CHF complaints, they visit on a regular basis to ensure they are functioning at their “normal” levels).

The scope of practice for a community paramedic includes I.V. antibiotic administration, wound care, phlebotomy, glucose checks, prescription compliance, fall assessments, CHF follow-ups, flu vaccinations, B12 injections and tetanus immunizations. Paramedics also do first responder training for the three island fire and first responder departments and work closely with the local coast guard, which has a prominent role in this fishing community. At the same time, these paramedics are always on call to respond to the more traditional EMS events, such as motor vehicle accidents, injuries and medical emergencies. New protocols have been developed to guide paramedics through this community care delivery and they remain licensed under Dr. Ed Cain, the same medical director as the rest of Nova Scotia’s paramedics, with the addition of having their community paramedic “tag.” But above these skills, community paramedics are always looking for new ways to integrate with primary health and preventative health care delivery. Needs assessments done on a regular basis determine what skills and programs paramedics should bring to the islands.

Steve Menzies, the Paramedic Supervisor, Operations, for the Digby and Islands Service explains one of the key methods of success is to get involved in local community health initiatives so others can see the role of paramedics in non-emergency ways. Through sitting on boards and committees, paramedics have often come up with innovative ways to extend their services into the community and provide essential services in preventive programs.

Menzies is excited about the progress paramedics have made in the community and the possibilities for the future. He’s not the only one. Emergency Health Services Nova Scotia hosted the First Annual International Round Table on Community Paramedics and Rural Health Care Delivery in Halifax in July of 2005. The conference drew a lot of attention nationally and internationally and a second conference is being planned in Scotland. In the meantime, supervisors and management groups from around the world that have some form of community paramedic delivery programs have formed a core group and continue to keep in touch and strategize on how best to implement, maintain and improve this new approach to the scope of practice for paramedics.

If there is any draw back to the program, it may be the fact that it isn’t a money making proposition. As Dr. Cain explains, only patients that are transferred are charged any fee by the ambulance service. In a provincially run service this is acceptable and just part of doing business. In the future, perhaps funding can be achieved through the bigger pockets of overall provincial and community health budgets. Certainly there is a cost savings, not only to the residents who no longer have to arrange transportation to and from the mainland to receive care, but from the mainland hospitals. In 2003, from February to July, the emergency department of Digby hospital saw a 47 per cent decrease in the number of visits from residents of the islands. This certainly provides a cost savings for hospital budgets and an increase in the accessibility of health care delivery for residents of the islands.

The future of health care is changing. As budgets get tighter and the population ages there is a demand to provide better care in more cost efficient ways. While health change and reforms have brought centralized health care, primary care clinics and a wealth of resources, specialists and diagnostic testing within easy access to most of the population, it is perhaps easy to forget or ignore the fact that all Canadians do not enjoy ease of access to health care. The Long and Brier Island model of community paramedic delivery is most definitely a model that increases that accessibility and the efficiency of health care delivery. Out of the fog of Long and Brier Islands a new wave of paramedic care emerges.

About The Author.
Heather MacKenzie-Carey has experience in the Health Care Industry as an emergency practitioner, educator and consultant.

She has a Health Education Degree from Dalhousie University, a diploma in Paramedicine from the Northern Alberta Institute of Technology, and a Certificate of Social Work from the University of Waterloo. She completed a Masters of Science in Risk, Crisis and Disaster Management from the University of Leicester and focused her thesis on bio-terrorism in Canada.

Heather has written two textbooks; Bio-terrorism and Biological Emergencies: A Handbook for Emergency Medical Responders, and Criminal and Terrorist Emergencies: A Handbook for Emergency Medical Responders. Both are published by Pearson Canada/Prentice Hall and can be found on their website at www.pearsoned.ca.

Having recently moved back to the Maritimes, Heather is the co-owner/operator of an A&W restaurant in Bridgewater, Nova Scotia, but continues to write and provide safety consultation and training services for public, private and volunteer sectors as well. For more information she can be contacted at .

May 29, 2006