999: ambulance emergency
Too many emergency vehicles arrive too late, and when they do, people can die. Can anything be done to improve this underfunded service?
Colm Murphy, an advanced paramedic with Dublin Fire Brigade, provides the kind of response that anyone making a 999 call for an ambulance would hope for.
In the middle of Dublin recently a cyclist crashed into an opening car door. It cut a sizeable hole in his chest, and as his chest filled with air his lungs started to collapse. Murphy was on the scene within four minutes of the emergency call being received.
“When we arrived he was in huge difficulty. He was on his knees, making very short sentences, pleading for help. He couldn’t breathe.” Murphy and several fellow paramedics got him into the back of the ambulance. “As he was taking his last gasps we drove a needle into his chest wall, to allow the air that was trapped in his chest out and, therefore, to allow the lungs to reinflate.”
Had Murphy arrived five minutes later the cyclist’s heart would probably have arrested. The cyclist received the kind of prehospital emergency care we expect in a society with some of the best medical care in the world. Not all are so lucky.
We do not expect a person who is choking, or in cardiac arrest, or who has been assaulted, to be left waiting for an ambulance for 30 minutes, 45 minutes or even an hour or more. It happens. And when people die after such delays, we do not expect the Minister for Health to say in Leinster House that the emergency was responded to correctly and appropriately.
Families across the Republic have told The Irish Times about the trauma of watching their loved ones at their most vulnerable, needing emergency medical help, and their own helplessness as they wait for an ambulance that arrives too late.
Maura Porter, a Donegal woman, was hit by a car on her way home from Mass in December. She lay on the road for almost 50 minutes before an ambulance arrived.
Elizabeth Riordain choked on food in Tralee last November. She was left waiting for half an hour after her husband, Michael, called 999.
Wayne McQuillan (see panel, right) was stabbed and left bleeding for so long that a garda brought him to hospital in Drogheda in his squad car.
All these patients died. Their families are not only shattered by the traumatic deaths but feel bewildered, angry and let down by a front-line emergency service they believed they could depend on.
When the circumstances of these deaths were raised in the Dáil, by Charlie McConalogue of Fianna Fáil , the Independent TD Michael Healy-Rae, and Gerry Adams of Sinn Féin, Minister for Health James Reilly gave answers provided by the HSE National Ambulance Service, or NAS. The answer he gave McConalogue, a TD for Donegal North East, about Porter’s death was typical of those given to the other TDs.
“The call,” he said, “was triaged as clinical status 1 delta (life-threatening). The nearest available resources – a rapid-response vehicle with an ‘advanced paramedic’ and an emergency ambulance, both in Letterkenny – were dispatched . . . The response vehicle and ambulance arrived in 40 and 43 minutes, respectively. A second ambulance from Letterkenny arrived in 50 minutes . . . The NAS has reviewed this call and is satisfied that the call was triaged correctly and that the nearest available resources were dispatched.”
A 999 call is classified as “echo” if it involves life-threatening cardiac or respiratory distress and as “delta” if it is another type of life-threatening condition. In 2010, to help improve the ambulance service, the Health Information and Quality Authority (Hiqa) set target response times for emergency care, following a process in which the National Ambulance Service was closely consulted.
Hiqa said that both echo and delta calls must have a first responder on the scene within seven minutes and 59 seconds. A first responder can be a paramedic, an advanced paramedic or a trained cardiac first responder. A fully equipped ambulance should then arrive within 18 minutes and 59 seconds.
Hiqa set targets for the proportion of calls that should get such timely responses. The seven minute and 59 second response time should be met for 75 per cent of echo and delta calls, for example. The target time for the fully equipped ambulance to arrive was set at 85 per cent of cases by December 2012, rising to 90 per cent by December 2013.
These targets have never been met. In fact the HSE lowered the ambulance-time targets to 80 per cent in 2012 and 70 per cent in 2013. Compliance rates have improved on paper as a result, although reports emerge constantly of failings in ambulance response times or mishaps with the ambulances themselves.
More than 100 parliamentary questions about ambulances have been tabled in the Dáil since January. The more than 30 TDs who have asked them, including McConalogue, Healy-Rae and Adams, are almost all from outside Dublin. Most of their questions are about the impact of delayed response times or about National Ambulance Service resources. The NAS operates mainly outside the capital but does have ambulances in Dublin; Dublin Fire Brigade provides emergency ambulances within the city.