999: ambulance emergency

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.

A former director of the National Ambulance Service, Robert Morton, said in a teleconference with Hiqa in April 2012 that “the current configuration of the NAS impacts more on rural areas, as ambulances . . . have longer distances to travel, and this takes emergency ambulances out of the service for a period of time”.

Previously unpublished data released to The Irish Times indicates that the areas suffering most from delayed response times are the west and northwest. In the northwest in January 2012 just 28.6 per cent of echo calls had an ambulance on the scene within the target time. In July that year just 33 per cent had. In the west in January 2012, again only 28.6 per cent of echo calls had an ambulance on the scene within the target time. Nationally that year, when the target was 80 per cent, only 70 per cent of echo calls resulted in an ambulance on the scene within 18 minutes and 59 seconds. The figure was 67 per cent for delta calls.

Denis Naughten, the Independent TD for Roscommon, says swathes of the west have been left critically short of emergency-care cover since the closure of the emergency department at Roscommon County Hospital. “If I have a heart attack in Roscommon an ambulance has to bring me to Galway University Hospital. That is the equivalent of someone in Dublin having to be taken to A&E in Cavan. The bottom line is we need more ambulances and we need more paramedics – lots more.”

In 2013, when the target had been cut to 70 per cent, 72.1 per cent of echo calls nationally had an ambulance within the target time; 63 per cent of delta calls were answered within the target time.

Failings remain. Again in the west, in July 2013 just 38.1 per cent of echo calls had an ambulance within the target time. In the northwest, in March last year, only 45.5 per cent of echo calls met the target.

It has also emerged in documents released to The Irish Times that Robert Morton warned Hiqa on November 8th, 2011, in a teleconference held to finalise "the appropriate target for clinical status (echo and delta) calls", that the National Ambulance Service would need an extra €30 million in funds, and 400 additional staff, to meet the response-time targets.

In a follow-up teleconference, on February 23rd, 2012, Morton said that the ambulance service “has concerns in relation to meeting the current or future targets for clinical 1 echo and delta calls . . . in the absence of additional resources identified as required” and that “no extra resources” were forthcoming that year. But it is also clear from these documents that he agreed to the targets and signed the NAS up to them.

Morton, who has taken a career break from the NAS and is now chief executive of the South Australia ambulance service, had made significant changes in an attempt to improve response times. The biggest change, which is already well in train, will be the opening of a single ambulance-control service – divided between Tallaght, in southwest Dublin, and Ballyshannon, in Co Donegal – and the eventual closure of all regional control centres.

The National Ambulance Service says that when the new control centre is fully operational, next year, dispatchers will be able to see the location of each of its vehicles. This model, the service says, means the nearest available resource will always be dispatched to the most serious cases.

No matter how dynamic the model, the service will need enough resources to meet Hiqa’s targets. The National Ambulance Service provides one ambulance per 16,600 people, with a budget of about €30 per head of population. The Northern Ireland Ambulance Service provides one ambulance per 5,750 people, with a budget of about €41 per head of population.

Paul Bell of the trade union Siptu says that his paramedic members want to provide a service to the highest international standards but that this is impossible with current budgets. He welcomes a planned review of the National Ambulance Service's capacities, which will include its resources.

The HSE’s director general, Tony O’Brien, appears to agree with Bell. In a letter to Ambrose McLoughlin, secretary general of the Department of Health, last October O’Brien warned that a “sustainable and safe level of service” would require investment in a range of areas, including ambulances. O’Brien described the National Ambulance Service as one of several “very significant areas” and said €2.5 million was needed to pay and train new staff, in order to improve response times. The department turned down the request.

Among the effects of low funding is that thousands of paramedic shifts are vanishing. When an NAS paramedic calls in sick, the shift is dropped – which is to say not covered – meaning an ambulance will be off the road that day, as each vehicle must have two paramedics.

At least 35,164 paramedic hours were lost in 2012 and 2013 in dropped shifts. Dublin Fire Brigade, by contrast, never drops a shift, instead calling in a paramedic to do overtime. In the east, since January, shifts have been dropped in Tallaght, Gorey, Baltinglass, New Ross, Dundalk, Drogheda, Naas, James’s Street in Dublin, and Swords, according to a HSE paramedic who is recording dropped shifts.

Rostered hours have also been cut. In the northeast region, for example, between 2012 and 2013, the number of rostered paramedic hours at Dunshaughlin ambulance base, in Co Meath, was cut from 336 a week to 312. Ardee, in Co Louth, and Virginia, in Co Cavan, also had their weekly cover cut by 24 hours. Dundalk and Monaghan each lost 48 hours. Similar cuts have been imposed at bases in Cos Leitrim, Donegal, Roscommon, Galway, Westmeath and Dublin.

Although some new ambulance bases have opened, such as those in Mulrany, in Co Mayo, and Tuam, in Co Galway, late last year, their vehicles have been taken from Galway, Castlebar and Ballinasloe, reducing cover in those areas.

Tony Gregg of the National Ambulance Service Representative Association says the service is being asked to “run further and do more on less and less resources. What is becoming clear as the result of the latest incidents is that we do not have the personnel or vehicles on the ground to adequately meet the response-time targets being demanded by Hiqa.”

At the request of James Reilly, Hiqa has brought forward its review of the ambulance service, which has started to examine governance arrangements, timely assessment, diagnosis, initial management and transport of an acutely ill patient to an appropriate healthcare facility. Hiqa was unable to say when it would be complete.

In the absence of extra funding, are there other ways to increase capacity? It would perhaps make sense for the National Ambulance Service to develop the capacity of community first responders – volunteers who are trained to provide an emergency response in stroke and cardiac cases in particular. The development of a network of them has been repeatedly recommended in reports on the ambulance service since 1993.

John Fitzgerald founded Wicklow Cardiac First Responders, a network of more than 30 groups across the county. Each group has between five and 20 members, all volunteers, who have been trained in cardiac first response.

“We have 40 trainer-instructors, all accredited, all voluntary,” he says. When an echo call is made in Wicklow the National Ambulance Service can dispatch one of the volunteers ahead of an ambulance. “There is no doubt we have saved lives.” He says the national roll-out of a network of cardiac first responders would be “very doable”.

Martin Dunne, director of the NAS, agrees that first-responder groups are “one of the most important initiatives in relation to patient-care delivery in the country” and says the NAS is “hugely interested in them”. Would the NAS invest in rolling out more programmes? The service would, he says, “support them in any way we can” with training and accreditation.

John Kidd of the Irish Fire and Emergency Services Association suggests another approach: all fire and ambulance services in the Republic should be integrated as one emergency service. This would increase capacity immediately, he says, as all firefighters are trained to first-responder level, and they could stabilise echo and delta patients before an ambulance arrives.

Responding to deaths following delayed ambulances, Dunne told The Irish Times : "Any patient who feels they were let down by the National Ambulance Service is a bad day for us. There's nobody coming on duty in the NAS today going to do a bad job or going to delay on a patient. Unfortunately in some cases, when there are other calls ongoing, calls have to be responded to by level of priority. There are a finite number of resources, and they are deployed as best they possibly can, with the sickest patient in mind at all times. Are we always looking to improve? Yes, we are, and we are going to continue to improve. I need people to know the NAS has probably one of the best ambulance services in the world and is going to continue to improve."

A comprehensive roll-out of first-responder programmes and service-level agreements with fire services could help make the NAS one of the best in the world. Both would have cost implications. But the job of the National Ambulance Service is to provide emergency care – which by its nature must be provided fast. Failure costs lives, and to fail at all is to fail too often.

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