Back in the middle of June, we had a lengthy discussion at Council about a couple of related topics: Naloxone and ambulances. It was an enlightening, frightening, and frustrating discussion; one that has humbled me as a person trying to understand issues enough to make intelligent and defensible decisions on issues that are literally life and death.
The two issues should really be dealt with separately, but are intertwined, so I will try to give some background and create the context for the discussions yet to come.
The province is in the middle of a public health emergency; so sayeth the Provincial Health Officer. Overdoses and overdose deaths have skyrocketed in the last few months, a direct result of a flooding of the illegal drug trade with powerful synthetic opioids, notably fentanyl. Provincially, overdose deaths are more than 2 per day, and some have projected up to 1,000 deaths in calendar year 2016. It is shocking, and something the community needs to react to.
Note: I am going to take a bit of a pass on what might be a lengthy lecture here on how we may have avoided much of the current Moral Panic approach caused by these shocking numbers if we had years ago started seriously investing in harm reduction, drug policy reform, and re-writing laws to make drug addiction a problem managed through a public health lens rather than a criminal justice one…
The Minister of Health has responded in part by issuing an unprecedented Ministerial Order giving firefighting first responders the legal authority to carry and administer Naloxone through intramuscular injection when they encounter a person suffering from an opioid overdose. I say unprecedented because it happened without full consultation of Health Authorities, with very little research backing the idea that this will be an effective public health measure, and without consulting with local governments for whom these firefighters work.
When this topic came to Council on June 13, we were provided with a comprehensive report by the Ambulance Paramedics of BC that outlines a number of concerns with this approach to managing what they agree is a significant public health issue. The report is 120 pages, and dense in spots, but here are my takeaway points from it (recognizing I am NOT a medical researcher, a paramedic, or a doctor, but am able to follow citations and assess the value of peer-reviewed research).
Naloxone is far from a “Miracle Drug”. This isn’t Uma taking a cardiac needle through the sternum in Pulp Fiction then getting a lift home. There are significant risks to both the patient and the first responder related to its administration.
Naloxone is effective at temporarily blocking the respiratory depression effects of opioid narcotics like Fentanyl, however does not reverse the effects of other street drugs like meth, ecstasy, cocaine or alcohol. It does not work on many now-commonly-abused prescription drugs. If the victim was mixing a narcotic like heroin with a stimulant like cocaine, the results of Naloxone can be dangerous and unpredictable. This brings into the picture risks to the first responder. Risks related to managing needles around high-risk persons with an unpredictable reaction to the intervention.
Naloxone has its role in harm reduction, but there is simple no data to support the suggestion that providing first responders trained in airway management with intramuscular Naloxone results in improved outcomes for overdose victim.
When a person is suffering from respiratory depression, and the person responding to that medical emergency is properly trained, “[it is] evident from the literature on the administration of Nalaxone [that] ensuring airway patency and adequate ventilation is far more important… than the pharmacological response”.
This is quite different than the “Take Home Naloxone” intervention, where people with opioid addictions are given a naloxone kit in the hopes that family, friends, or other bystanders in their presence can use as a first intervention in the event of overdose. There is a demonstrated benefit to this, because the intervention is performed by lay people (those not trained to use the more effective airway management approach) and there is likely some resistance to calling for professional help in a street drug situation due to fear of police involvement and arrest.
So Naloxone is an intervention that has proved to be sometimes effective for untrained bystander, when the alternative is doing nothing. However the evidence reviewed in this report seem pretty unequivocal to a lay person like me: the best result when a professional first responder meets a person with respiratory depression presumed to be caused by an opioid overdose is airway management, respiration, and getting the victim to a hospital as soon as possible so a doctor can properly assess and treat.
This brings us to the second part of the story, which causes me to ask, rhetorically, why the hell is the collapse of our local ambulance service not front page news? Does no-one actually care about this?
The tables in the report we received from staff are stunning:
To translate, our firefighters have responded to essentially the same number of calls annually from 2012 to 2015, and are generally the first responders on site. However in those 4 short years, Ambulance response in more than 15 minutes went from less than 1% of calls to almost 16% of calls. In more than half of those calls (8.6% total) the firefighters and victim were waiting more than 30 minutes for an ambulance to arrive at the scene.
How is this acceptable in 2016 in a modern country, in a Province “leading the Country in Economic Growth”? We are a City with a major trauma hospital, less than 15 square kilometres, I can ride my bicycle from RCH to any other point in the City in under 30 minutes- but a significant number of times (280 in 2015 – almost once per day!) a person in need could not get an ambulance in that time. That is shameful.
The firefighters cannot leave and attend to other calls, the apparatus and crews are tied to the site until Ambulance arrives. They cannot do much more than basic first aid and ABC care, cannot provide pain relief, cannot transport the patient or start an IV. They try to make the patient comfortable as possible and they wait.
Firefighters live to serve, helping people in need is in their blood. So it is natural that they want to be trained and permitted to *do something useful* during these unacceptable waits. There is a desire by some to train to an Emergency Medical Responder (EMR) level, allowing them to do many of the pain management and initial care procedures that ambulance paramedics are meant to be doing. There is an argument that the City should pop for the extra training cost to get this care to our residents. However, there is another argument.
From the staff report:
Please note that should NWFRS increase our level of medical training for Firefighters it is possible that BCEHS may alter the Resource Allocation Plan for NWFRS to align with our new scope of practice. This could possibly lead to additional medical calls which could engage apparatus at the scene for longer periods of time. This puts the City at risk of reduced firefighting capability should a structure fire occur in the same time frame.
There is every reason to believe that the response from the BC Ambulance Service to the uptraining of our local First Responders will be to reduced ambulance resources locally, in order to redirect the precious resources to lesser-served areas. This means the trend towards longer waits will increase, and more of our crews will spend more time waiting for ambulances to arrive and transport patients to Emergency, with more of our apparatus tied up at Ambulance calls, instead of doing their job. More overtime, eventually increasing the need for local government to pour more resources into the system that is being effectively abandoned by the Health Authority whose responsibility this is.
I’m not afraid of the training costs, I want our first responders to be as trained as possible, I want them to do what they got into this business for – to save lives and reduce suffering. But I cannot accept that if we train them, it is likely that we will see a further reduction in Ambulance service for local residents because the BCAS will no longer prioritize our community.
Taking a “high moral ground” on this kind of downloading is a terrible position for a local government to be in. In a City like New Westminster, we gave up waiting for homelessness to be addressed effectively by Senior Governments and instead took measures – spent your property tax money – to provide supports that we would otherwise go without. Why not do the same here?
If anyone could tell me it would make the situation better (as our proactive approach to homelessness has), I might follow that train of thought. However, I see no evidence that improvement in ambulance response will result from EMR training for our first responders. To fix that situation we need a Provincial government interested in investing in ambulance services consummate with reliable service.
Unfortunately, as long as the local media and the citizens of New Westminster are silent about this erosion of an essential service, don’t expect the Province to step up any time soon.