Abbotsford critical care specialist Dr. Michael Christian says British Columbia’s ambulance system needs major overhaul, one that will ultimately result in doctors and nurses working alongside paramedics to get to the sickest, most severely injured patients in the shortest amount of time possible to stabilize them before transport to a higher level of care.
Christian, the former medical lead of BC Emergency Health Services, has seen too many patients with time-sensitive conditions arriving at his hospital either dead or unable to fully recover from their injuries or medical conditions because they got there too late.
He's convinced rapid responses from the interprofessional teams he’s proposing will shrink health inequities that come as a result of the province’s vast geography and sparse density and will ultimately improve patient outcomes and save healthcare dollars, and he wants to lead that charge.
“We’re just arriving way too late right now,” Christian said. “If we want to make an impact on this, the system needs to do a lot better than it is.”
Christian, an international expert on pre-hospital care who served as medical lead of BCEHS from December 2021-January 2024, is a clinical professor in the critical care division of the UBC faculty of medicine and in May he testified at a coroner’s inquest into the death of 18-year-old Victoria university student Sydney McIntyre-Starko, who died of a fentanyl overdose in January 2024.
He is among a growing list of BC doctors who say BCEHS management is unwilling to change its operational procedures to methods he says have been proven more effective in other jurisdictions. He quit his job with BCEHS just before McIntyre died, frustrated that his suggestions to improve the province’s emergency health system were ignored.
Christian says hundreds of patients in BC every year suffer from inefficiencies in the ambulance system and the lack of paramedic coverage puts rural patients at even greater risk of harm than those in urban areas.
“If BCEHS can’t deliver high-quality care even in the capital, how likely is it to deliver for those in the North?” Christian said.
“That’s the biggest problem with BCEHS; they’re not measuring anything in the organization that you should be measuring to help ensure you drive good care. All this leads to health inequities which people face in rural areas and it also drives the need for hospital staff to go on (ground) transports.”
Putting doctors and nurses on air ambulances requires an additional up-front investment, but Christian says other jurisdictions have found utilizing hospital staff not only saves lives but decreases the severity of injuries which ultimately reduces overall healthcare costs.
“We have literally thousands of doctors and nurses who already have critical care skills who could spend part of their time in a hospital setting and part in prehospital to fill the gaps in the system, yet we’re completely not looking at those,” said Christian.
It’s estimated that more than half of BC’s economic wealth is generated north of Cache Creek, mostly through resource-based industries, which have some of the most hazardous jobs. If there is an accident, many of those workers are hundreds of kilometres away from a hospital equipped to handle severe trauma. That puts the onus on the ambulance service to respond quickly to those rural and remote areas for patient transfers or accident scene calls.
But according to Christian, a military-trained medic who worked as a doctor in England for London Air Ambulance, BC’s ambulance service lacks that quick-response capability to cover the province and ranks far below international standards. He says there are numerous deaths every year that can be attributed to delays getting urgent care-needs patients to the right level of medical care.
BC is an outlier with its paramedic-only staffing of medevac planes and helicopters. Alberta, Saskatchewan, Manitoba and Ontario utilize a combination of paramedics and doctors and nurses. Nova Scotia allows paramedics and nurses but not doctors.
Multidisciplinary medical teams are the standard in the United States, United Kingdom, Austria, Belgium, Croatia, Czech Republic, Denmark, Finland, Greece, Hungary, Iceland, Sweden, Japan and South Africa
“We need to recognize it’s not working, so let’s do something different,” said Dr. Neil McLean, an Abbotsford intensivist and ICU/emergency room doctor who served as BCEHS executive medical director of interfacility transport and critical care from January 2023-May 2024.
“Air medical is expensive, no question, but it’s money invested that can result in huge cost savings down the road. We know the sooner you can get care to a patient it exponentially decreases how much care they need down the road. It reduces hospital time. It gets them back to work quicker.”
The Ambulance Paramedics of BC CUPE Local 873 says paramedic staff shortages have reached critical levels, especially in the Interior and Northern BC regions, with some ambulance shifts only 50 per cent covered.
Christian and McLean say the solution is having doctors, nurses, nurse practitioners and paramedics working together on health teams to go on air ambulance flights to retrieve patients who require urgent care.
“There’s lots of interested physicians out there, from a manpower point of view, in the pre-hospital care world that we’re not using, said McLean, “But there’s also a bit of a culture in BCEHS, that they know exactly what they’re doing, that they don’t need any help, and that’s clearly not the case.
“When it comes down to transport, our critical care paramedics sort of have a large ego and they know it all and anyone who thinks they know it all in medicine is very dangerous, because no one knows it all.”
McLean tried to bring a team approach to the BCEHS executive, encouraging doctors and other healthcare professionals to share their observations and suggestions to improve the system but their ideas were shot down by management, and that was the reason he and others in high-ranking positions in the organization, including Christian, resigned.
In 2022, the province conducted an external review of its inter-facility transport and critical care system which raised issues even more concerning than the problems with dispatch, but McLean said the findings were suppressed and the report was buried.
“One of the final things that tipped it for me was one of the major things it said was they need better physician oversight and involvement,” said McLean. “Basically it didn’t say what they wanted so they just stopped it dead. It was never released publicly.
“They haven’t looked outside themselves, in many ways, they’re very insular,” he said. “They hire from within and they don’t look at diversity and bringing in people from other areas that could give a different outlook on things - they just think that they’re the best.
“The consequences are the quality of care is not being monitored and the other issue is there’s a focus on what’s best for the (service) provider and not what’s best for the patient. Decisions that are being made are what’s best for the paramedic that day. There’s lots of great models but there’s no interest at all in anything that doesn’t involve paramedics.”
In March, the BC government launched an internal review of the Provincial Health Authority to ensure the money it takes to run the health system is being spent on critical patient services and not on unnecessary administration. The six regional health authorities and BC Emergency Health Services, which oversees the BC Ambulance Service, are part of the study.
Christian said it is unlikely to have much of an immediate impact on the prehospital situation given the scope of the review which is tackling so many broad issues, including cancer care and all provincial programs.
He and McLean are among a growing list of BC doctors calling for an open and independent public inquiry into BCEHS to uncover the failings of the system and fix them.
BC has 72,082 registered nurses and between 5,000 and 7,000 have emergency medicine/critical care training. The province also has 15,338 doctors, of which between 1,500 and 2,000 have the skills for retrieval of a critically-ill patient, including emergency medicine, ICU and anaesthesia, some of whom would make themselves available when needed for ambulance work.
While some hospital staff who work for the First Nations Health Authority board military flights to get to remote patients, the CUPE Local 873 collective agreement prevents doctors or nurses who are not part of the union from flying on BCEHS aircraft. The BCEHS Act prevents any other emergency health service provider such as municipal firefighters, St. John Ambulance or the Red Cross from establishing a coordinated system to transport patients, which is the exclusive domain of CUPE 873 paramedics.
“It’s an aggressive strong union that the government is very afraid of,” said McLean.
Patients pay the price
Hospital mortality rates from trauma are 10 times higher for rural/northern BC patients than they are for urban patients. Christian said the rural-urban discrepancy would be similar for pediatric patients or victims of medical conditions such as heart attacks and strokes but statistics on those types of deaths are not available from BCEHS.
The lack of available flights in BC often forces healthcare staff to accompany patients in ground ambulances. In 2021, 2,711 (47 per cent) of Condition Red critical condition patient transports were escorted by health authority staff. The other 3,033 (53 per cent) were transported by BCEHS paramedics on flights.
“Doctors and nurses are already doing half the transports and they’re doing it in an inefficient way in a ground ambulance going hundreds of kilometres and getting involved in accidents with moose because they do not have an aircraft available to them,” Christian said.
“That’s because BCEHS won’t allow hospital staff to go in their aircraft and we don’t have these alternate means. So if they have an aircraft that’s not staffed, even though they have pilots paid and ready to operate that airplane, if there are no critical care paramedics to go, the airplane just sits for the shift.”
Those long ambulance rides take doctors and nurses out of their home communities, often for hours at a time, often with nobody to cover their shifts later that day or the next day and that can force temporary closure of hospital emergency wards, putting additional stress and staff and patients. In the interior region of Northern Health, 30 per cent of emergency department closures were due to staff having to leave to move a patient to a higher level of care.
The Rural Coordination Centre of BC found transport delays in smaller centres not only adversely affect patients but also healthcare staff who suffer psychological and moral distress for not being able to provide critical patients the prompt care they need. That leads to burnout and difficulty recruiting and retaining healthcare staff in rural communities.
As head of the BCEHS Patient Transfer Network, McLean dealt daily with doctors, especially those in smaller cities and towns, who continually reminded him that the ambulance system lacks the resources and staff to keep up with the demand of moving patients to higher levels of care.
“If you speak to most rural physicians, they’re very unhappy with the care they receive from BCEHS,” said McLean. “There’s a huge issue around retention and recruitment, especially in rural places. I can’t imagine being a poor rural doc that’s there and gets hung out to dry repetitively. You’re going to be like, ‘forget it, I’ll go somewhere else.’
“The reality is, doctors don’t have much of voice in this province. It’s not that we’re not speaking out, it’s that we’re not heard, they’re not listening to us. Doctors get villainized as being money-grubbing and it’s for our personal gain and that’s not the case.”
Staff shortages
Last year was the start of a 10-year, $673 million contract the province has budgeted for its air ambulance service. Parksville-based Ascent Helicopters Ltd., is the primary operator of a fleet of seven Leonardo AW169 helicopters (two for Vancouver, one in Parksville, one in Kamloops, one in Prince George, one in Prince Rupert, one backup) that serve BCEHS. Fixed-wing air ambulance service is provided by Carson Air of Kamloops, which last year brought into service 12 Beechcraft King Air 360CHW turboprop planes (three in Vancouver, three in Kelowna, two in Prince George, one in Fort St. John, three backups).
The air ambulance deployment model used by BCEHS keeps its resources closest to the receiving centres, which means that due to shift limitations and the number of hours crews are allowed to work each day, in most cases they have to be able to return to their base with the patient within the length of their shift or they will not launch. Shift limitations mean it’s virtually impossible to retrieve patents from the East Kootenay and far North regions of the province any time other than the start of a day shift to deliver them to the highest levels of care. Night flights are discouraged as a safety risk.
To make up for the lack of coverage for eastern BC, BCEHS has contracted the services of the non-profit STARS (Shock Trauma Air Rescue Service) from its helicopter bases in Calgary, Edmonton and Grande Prairie, which is sometimes is utilized to pick up a BC patient. But the system is far from perfect.
In January, an infant in Cranbrook died awaiting transfer on a BCEHS air ambulance flight that never arrived. Sparwood Mayor David Wilks wrote a scathing letter to Health Minister Josie Osborne, who has since launched a review of the incident.
The failings of the BCEHS medevac system are being blamed in the death of an 11-year-old Brayden Robbins who died Nov. 19, 2024 at Comox Valley Hospital. Transport staff were unavailable to fly the boy to hospital in Vancouver and he succumbed to a brain bleed, prompting his outraged mother, a 30-year nurse, to demand the province immediately invest in pediatric transport staffing and standardized use of the Provincial Transport Network (PTN) for complex pediatric cases, among several other recommendations.
Paramedic PTSD
PTSD is now the leading cause of lost worktime for paramedics. For every $100 spent in 2024 on BCEHS paramedics salaries the premium rate for WorkSafe BC was $22.55, compared to law enforcement officers ($4.53), firefighters ($3.53) and acute care doctors and nurses ($2.92).
“That’s mostly due to PTSD and (the paramedic premium) is increasing 20 per cent every year for the past few years for BCEHS,” said Christian. “This talks to all the disfunction in the organization in terms of the factors that lead to mental health issues with your staff. We’re asking too much of this profession and we’re not giving them the type of support of interprofessional teams that other clinicians in other aspects of healthcare have, and this leads to all the issues with absenteeism. This is all money that’s not going to direct patient care.”
In 2024, BCEHS had close to 4,665 emergency medical assistants, of which 3,900 were primary care paramedics (PCP). The ambulance service also had 350 advanced care paramedics (ACP) and 90 critical care paramedics (CCP) actively practicing on the frontline force.
BCEHS also hires emergency medical responders (EMR) with 80 hours of training and driver-only attendants who require only a valid Class 4 driver’s licence and a CPR course.
It takes 2½ years to train a critical care paramedic at a cost of between $250,00 and $300,000 each, plus the additional cost of $20,000 per year to keep up their medical skills training. With only 90 CCPs in all of BC, there are not enough of them to fill the vacancies and they only work in larger cities. Putting hospital staff on those flights is a way to immediately alleviate the current paramedic staff shortages.
“Literally tomorrow, I could hire 90 doctors to work with them side-by-side and we’d double our resources,” said McLean. “You don’t have to pay the doctors to train, they come trained. It just makes no sense they’re fighting it. BC has a huge opportunity if we do it right.”
Until the qualifications changed this year, PCP training involved a one-month online course, four months of classroom instruction and 13 practicum shifts totaling 156 hours. In January the PCP requirements were bumped to eight months of classroom instruction and a four-month practicum.
Compared to other provinces and countries, BC lags behind most jurisdictions in the level of training required to be a paramedic, including advanced care and critical care.
“A bulk of the hires to BCEHS over the past year have been drivers only, and the bulk of the paramedics — 60-70 per cent — are primary-care paramedics,” said Christian.
“And we wonder why we have such a PTSD problem with our crews, particularly when you pair these people with drivers only,” he said. “The more rural you are, the more likely you’ll have someone with lower skills and experience, the more likely you are to get an EMR or a PCP as a opposed to an ACP to treat you. In most areas of BC, the further away you are from a bigger city, the less likely you are to get any level of advanced care.”
There are BC doctors willing to help paramedics handle the complex cases through telehealth connections and are doing so through EPOS (Emergency Physician Online Support), but McLean said that service is underutilized. Four EPOS doctors were recently hired from a list of 80 applicants.
“There’s a huge desire and interest in doing prehospital medicine as physicians and if you look at STARS, there are hundreds of physicians trying to get on with the STARS teams,” said McLean. “You actually have the ability to go worldwide and pick the crème de la crème and it’s BC. It’s a gorgeous place to live. Who in their right mind would not want to come here?
“It has nothing to do with lack of interest. It’s all about the organization (BCEHS) unwillingly to relinquish what they think is their control and their system. The reality is, if you look worldwide and even to the United States they’re all moving towards mixed teams.
“We’d like to take people who have trained for 17 years - they’re our highest-level provider in our hospitals - and we’d like to put them out into the community and they’re like, ‘No, it can’t happen. You can’t do that.’”
Demand vs. capacity
Most smaller hospitals and clinics in BC are not equipped to deal with a critically injured patient, which puts additional stress on medical staff to provide immediate care and that takes away from the treatment available to other hospital patients.
Health services in Australia and Scotland that deliver medical teams of doctors, nurses and paramedics on flights to remote locations to support rural doctors have found that in nearly one-third of cases, patients treated by advanced medical teams do not have to be moved to another hospital to have their conditions stabilized. Doctors and nurse practitioners have the authority to discharge patients on the spot without having to go to a hospital, which saves money.
“You can make patient well enough that they don’t have to leave,” said Christian, “or a lot of time you can make the decision and have the discussion with the family that actually this patient is not going to necessarily survive. They’re not going to get better if you move them to a higher level of care.
“So why are we ripping them away from all of their supports and all their families and taking them somewhere else when we could make that decision to keep them here, surrounded by their loved ones in their final moments.”
He said the BCEHS system of moving patients in interfacility transfers is barely able to keep up to the demand for acute-care transfers, let alone provide timely returns for patients to their home communities hospitals once acute care is no longer required. Too many empty-leg flights are happening and planes return to their bases empty instead of coordinating flights with patients in hospitals waiting to go home. Delays in repatriating patients puts additional costs and stress on families and leads to bed-blocking in tertiary hospitals, surgical delays and backlogs in the hospital system.
“Even if you don’t live in a rural remote area, this could affect you if you’re surgery gets cancelled in the big city because that ICU bed or ward bed isn’t available,” said Christian.
“Anybody who uses our healthcare system needs to care about these issues. Having a good and effective retrieval/repatriation system and care for these people in smaller communities helps everybody in the long run.”
First Nations patients
BC lags behind much of the world in the time it takes to move a patient from one hospital or medical clinic to a higher level of care at a receiving hospital and not surprisingly the longest waits are for First Nations and rural patients.
Two hours is the benchmark set by the Royal Flying Doctors Service to get to a red (critical condition) patient in Queensland, Australia, an area nearly twice as large as British Columbia. By comparison, for residents of a BC First Nations reserve the response time in 2024 was three hours 58 minutes in the median percentile and 16 hours 54 minutes for most (90th percentile) patients.
In rural BC, the median response time was three hours three minutes and for the 90th percentile it was 11 hours 37 minutes. In urban areas it was one hour 51 minutes (median) and seven hours four minutes (90th percentile).
The lack of staff and ambulance resources continues to drive up response times and Christian says little has changed despite a nearly $1 billion investment by the province in the ambulance service over the past three years.
Ian Tait, a CUPE Local 873 spokesperson, told the Citizen in January that most ambulance stations in the province have only 50 per cent coverage and almost none have 100 per cent coverage, and it’s been that way for 40 years.
Improving the odds
Having paramedics working alongside doctors and nurses on interdisciplinary teams raises medical competency. When they’re not tasked with a patient retrieval call paramedics they are assigned to work in hospital emergency/operating rooms.
Christian cites an American study by a group of doctors that focused on trauma deaths in the U.S. which showed 29 per cent of prehospital patients had potentially a survivable injuries that could have been prevented had there been a quick intervention by a hospital-level EMS team. Wales introduced a new model of care with doctors and nurses involved with paramedics and found in the first five years the 30-day mortality rate dropped 37 per cent compared to the rate for ambulance service staffed only by paramedics.
Christian sees healthcare staff involvement in retrievals as a recruitment tool to get more doctors and nurses willing to relocate to BC. A survey of emergency physicians in the province found that over half of the 192 who responded have staffed the transfer of a critically ill or injured patient. Eighty per cent indicated a strong interest in wanting to get involved in prehospital and retrieval medicine and of the new graduates all said they wanted to pursue that kind of work.
Cost savings?
In 2015, the National Health Service in Wales introduced multidisciplinary teams to its revamped emergency medicine retrieval system and was able to recruit 12 consulting physicians and 55 other doctors who signed up for fellowships to work in in hard-to-fill rural hospital posts. In five years that saved the health system an estimated £2.75 million in locum/agency coverage costs and improved the regularity of shift coverage with a number of high-quality physicians being retained.
Providing quick interventions means patients usually recover quicker, freeing up hospital beds and reducing insurance claims and lost work time. The value of saving one life is immeasurable.
“The actual cost of this alternative system will be lower than the current model of care because we’re using doctors and nurses that already have critical care skills and training and practice it every day, so that will significantly increase the value of the system,” said Christian.
BCEHS spends $250,000-300,000 for the initial training of one critical care paramedic and it costs $20,000 each year for each CCP to maintain their skills working in hospital operating rooms. He said a 40-hour course in prehospital care is all it would take to prepare a physician and nurse already trained in critical care.
“When we have so many nurses in positions already trained to do critical care why are we investing all this to have so few paramedics that can do it when you could be investing in physicians and nurses that already have those skills,” Christian said.
“I’m not saying we should get rid of critical care paramedics. We need to get more paramedics working in primary care and emergency departments, but the only way we could ever do that is to get some of the in-hospital physicians to work outside.”
New business model
To circumvent the ambulance union’s collective agreement which that prevents hospital staff from flying on BCEHS air ambulances, Christian and a group of doctors and nurses have formed a not-for-profit society, Med Response BC (MRBC), which proposes to purchase its own aircraft to work with health authorities on medical missions.
MRBC wants to establish an inventory of privately-owned aircraft and watercraft with pre-qualified operators who can use an app to confirm availability to serve strategic locations in rural locations all over the province. That equipment would be tasked if needed by an MRBC medical crew.
“As opposed to waiting the 12 hours or whatever for a retrieval team to be available with a dedicated aircraft, I think that is ultimately how we change the game for patients surviving in a vast area like BC with adverse weather and long distances,” said Christian.
The ability to fundraise and accept private/corporate donations to provide an enhanced ambulance service has been the lifeblood of charitable organizations like London Air Ambulance, Essex & Herz Air Ambulance, German Red Cross and Alberta-based STARS, which raises $28.9 million annually through its lottery, calendar sales and special events in addition to $44.6 million in government funding.
Med Response BC is proposing a hybrid funding model that’s a combination of charity (individuals and organizations), industry, grants, government sources and in-kind donations.
Retrieval/repatriation teams will be the main thrust of MRBC, while its educational component would assist other organizations in clinical governance, education, supply chain access, online medical support for SAR teams and community groups wanting to establish their own societies involved in prehospital care.
All clinicians who work for Med Response BC will spend the majority of their work hours in the health authority to build their competencies and will only work part-time for the group.
“The ideal will be that on the retrieval team for MRBC there will be a couple of people in every centre on a longer-term contract who will be the senior leaders in those areas, still working part-time with MRBC, and everybody else, doctors, nurses, paramedics will rotate through on six- or 12-month experiences where they work with the system to develop skills in retrieval medicine,” Christian said.
The MRBC business model calls for the five health authorities to elect five voting board members. The organization will also have several non-voting board members representing immediate care societies such as KERPA (Kootenay Emergency Rescue Physicians Association), North Shore Search and Rescue, healthcare workers and members of the public. More than 50 per cent of the voting board members have to be rural and Indigenous and the group already has that covered.
