Hanging up on 911

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This article was published 01/10/2015 (3373 days ago), so information in it may no longer be current.

The sounds of Elvis Presley warbling a ballad greet paramedic Karen Martin as she enters a cluttered and modestly furnished apartment in the West Broadway area. Dozens of magazine photos of ‘the King’ and Marilyn Monroe plaster the walls, where Martin’s patient, Amber, lives with her dad, Michael.

Martin takes Amber’s blood pressure using a portable kit she’s hauled in from her truck. She asks her how she’s doing.

Amber once frequented hospital emergency rooms in the city eight or nine times per week.

It’s now been months since she has taken an ambulance to the hospital.

Martin is there as part of an innovative pilot project operated by the Winnipeg Fire Paramedic Service that’s already saved the health-care system millions of dollars, while improving the lives of hundreds.

The Emergency Paramedics in the Community (EPIC) program, as the initiative is known, involves specially trained paramedics who work with habitual 911 callers to find out why they’ve begun to use the emergency line as a crutch.

The City of Winnipeg’s 911 service responds to close to 200 medical calls a day in which there is patient contact. Some of the top 40 users, which EPIC focuses on, can call the line almost daily. Generally, paramedics respond to members of this high-use group three to four times a day.

Until EPIC came along two years ago, there was little done in Winnipeg to address the problems of some of the most frequent ambulance riders — people who often fall through the cracks in the system.

The solution can be as simple as helping a patient reconnect with their family doctor, changing the timing of a home-care visit or having a side rail installed in an elderly person’s bed to prevent them from falling.

There are no flashing lights or blaring sirens when Martin arrives at the door of these frequent callers. She drives a small SUV that’s heavy with gear but light on flash. Her uniform is understated — not as official-looking as those normally worn by paramedics — so as to put clients more at ease.

Martin works almost full time with EPIC, while several other specially trained paramedics rotate into the job on six-week cycles.

“It’s a very different role. And it was a huge learning curve at first,” she says. “I really like doing this.”

Amber used to be a regular visitor to Winnipeg’s emergency rooms because she thought she was having seizures. They turned out to be false. What she experienced were the side-effects of an illicit drug habit.

“I do crack, so drugs are what’s causing the (symptoms),” she says matter-of-factly. “Since I stopped, I haven’t had a seizure.”

Martin provides positive reinforcement during her visit with Amber. “She’s been doing really good, right?” she says, addressing Amber as well as a Free Press reporter and photographer as she speaks.

Martin and other paramedics who rotate into EPIC have helped Amber make doctor’s appointments and ensure she keeps them — even accompanying her at times. They’ve also tried to ensure Amber takes her medication by arranging daily pharmacy deliveries.

The paramedics have worked together with a social worker at Health Sciences Centre to help the woman.

“I have asthma. I have chest pains. So, it’s sometimes hard to know where to go, whether to go to the hospital or to phone (911),” Amber says. “Karen has been a big help in my life. She’s been very supportive.”

Amber says she has not done crack for two weeks, and her overall health has improved since EPIC first made contact with her earlier this year.

At first, she was in daily contact with EPIC paramedics but now sees them about once a week. In between visits, Amber will often check in with EPIC staff over the phone.

EPIC was officially launched as a pilot project in 2013, but its origins go back nearly 13 years. The death of Leon Herman Bighetty in 2002 continues to reverberate within Manitoba’s health system today.

Bighetty was taken to the Main Street Project on Martha Street late one November afternoon by two city police officers who believed he was intoxicated. The next morning, when staff went to wake him up, he was unresponsive.

Bighetty was rushed to Health Sciences Centre, where it was found he was suffering from two subdural hematomas — bleeding in the brain due to a head injury. He remained in a coma for six days and died. He was 32 years old.

An autopsy showed Bighetty had suffered from head injuries in the past. The older injuries made him more susceptible to future ones.

An inquest into his death recommended staff at the detox centre receive emergency medical responder training. The 2005 inquest report also recommended a nurse practitioner be stationed at the facility to assess clients.

Four years later, paramedic Ryan Sneath volunteered to participate in a pilot project that would see emergency responders stationed at the Main Street Project. Local authorities felt a paramedic’s skill set was a better fit at the facility than that of a nurse practitioner. A year later, Martin joined him.

The paramedics’ presence at the Main Street Project is credited with saving lives and greatly reducing the need for expensive ambulance transports. Where the Main Street Project once generated about 600 ambulance transports a year, the presence of paramedics reduced that by 60 per cent.

The WFPS now staffs the facility around the clock, seven days a week.

The program, funded by the Winnipeg Regional Health Authority, costs $800,000 a year.

Paramedics at the Main Street Project did more than reduce the need for ambulance trips. They were also able to connect clients with the health care they needed. By triaging them and getting them to clinics, they provided a less expensive and more appropriate alternative than a trip to a hospital ER.

The WFPS then decided to take the practices it honed at the Main Street Project and apply them more widely, giving birth to EPIC in 2013.

The program, funded by the Winnipeg Regional Health Authority, costs $750,000 annually.

But it has saved an estimated $3 million over the past two years in ambulance costs alone — not to mention emergency room expenses.

One of the pilot project’s goals was to work with the top 40 most frequent callers of 911 — individuals who had called 911 more than 10 times in the past six months. The top one per cent of 911 callers account for about 12 per cent of paramedic responses. So working with frequent callers can pay big dividends.

Sneath, now director of the WFPS’s community paramedic program, as well as the service’s liaison with the regional health authority, says when a patient comes into the program — EPIC is not voluntary for frequent users — paramedics visit them and conduct an assessment.

“We assess not only the individual, but their social situation and their home, their living conditions,” he says.

The specially trained paramedics who work in the program all have experience at the Main Street Project. They are supported by two physicians, including Dr. Robert Grierson, medical director of the WFPS.

Some of the frequent 911 callers have complex medical and social problems that take time to control. With others, a solution is fairly simple.

“One lady would call the emergency line quite frequently at 10 or 11 at night,” Grierson recalls. When EPIC paramedics did a little digging, they found her last home-care visit of the day occurred at 7:30 or 8 p.m. That didn’t meet her schedule. She would get up later to go to the bathroom and had difficulty getting back to bed. EPIC talked to home care and asked them to come out later in the evening to better accommodate her schedule. The 911 calls stopped.

Before EPIC, her home-care case co-ordinator may not have known about the emergency calls for months, Grierson said. “Now we have a mechanism to provide that feedback.”

A computer software tool put in place when the pilot project began flags high users.

Some frequent callers have chronic obstructive pulmonary disease. Their respiratory problems cause them high anxiety, and they call 911.

Sneath says one such patient was being transported to hospital four to five times a week. All she needed was some mentoring and coaching to help her get control of her disease. The program made sure she attended appointments with the doctor to evaluate her condition. Previously, she’d make an appointment and then not show up.

“Her anxiety was such that a) she couldn’t make it to an appointment, and b) she would leave before she was seen,” Sneath says. “So, a lot of it is taking people by the hand and saying, ‘You have to have some trust here.’ ”

Slowly, over time, the woman got the help she needed. EPIC arranged for her to receive home oxygen service. She hasn’t called 911 in six months.

Another patient with chronic respiratory issues resumed calling 911 frequently after not using the emergency line for some time. After looking into his situation, EPIC staffers learned he had not filed his tax return and hadn’t been receiving all his income supplements, so he could not afford his medications. They helped him with his tax return and the 911 calls stopped.

Doing a patient’s taxes is not what your average paramedic signs up for when he takes the wheel of an ambulance, but Sneath and Grierson say these actions cross the line into social work in certain situations.

“If we don’t do something, we’re going to be transporting him every single day to the hospital, and something bad will happen to him if we don’t address this,” Sneath says.

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As well as working with frequent callers, EPIC has worked to reduce the pressure on emergency services at the Salvation Army Booth Centre on Henry Avenue. It also follows up with patients who have left a hospital emergency department before receiving critical test results — EPIC paramedics will track these patients down and help transport them back to hospital if needed. And, with the help of firefighters and other paramedics across the city, it is identifying those who are at risk of developing serious health problems and whose economic and social situation may lead them to frequently call 911.

If a fire or paramedic crew responds to a call and identifies a problem — be it mobility issues, hoarding, a lack of social supports, or an unaddressed need for home care — they will fill out a quick report to EPIC for followup.

The referrals come in at the rate of two to three a day. Grierson and Sneath can view them on their smartphones. EPIC staff will then investigate and attempt to address a problem before it gets out of hand.

On a recent call to the North End home of a woman named Tammy, Martin notices the lower part of the woman’s left leg is swollen and purple. She asks her how long it’s been that way. Three days, Tammy replies.

Martin takes a photo of the woman’s leg and emails it to Grierson. They chat on the phone. They decide she needs to go to hospital. They worry she may have a blood clot that could spread to a lung.

Tammy lives in a rental house with her nine-year-old daughter. Recently relocated from a town in rural Manitoba, she’s diabetic, suffers from a genetic nerve disorder and has few supports in Winnipeg. In her mid-30s, she has applied for home care but has yet to receive it.

She was referred to EPIC by firefighters when she rolled her motorized wheelchair to their station and asked for help to get inside her house. She did not have a proper ramp. EPIC has had a temporary one installed and is working on something more permanent.

Martin encourages Tammy to go to the hospital, but she is hesitant — she says she’s had such swelling before. She is worried about her daughter, who is at school. She is also worried about being transported in a regular ambulance and having to fend at the hospital without her wheelchair.

Martin assures her she will go to Tammy’s daughter’s school herself, if need be, and stay with her at her home. Eventually, Tammy arranges for her child to go to a neighbour’s home after school.

Martin allays Tammy’s concerns about losing her wheelchair by obtaining permission to have a major incident response vehicle, a large carrier the size of a transit bus, transport her. Then, she accompanies Tammy to the hospital.

EPIC has been operating on a temporary basis for 2½ years. Despite its success, it has yet to secure permanent, dedicated funding such as that which has been granted to paramedic services at the Main Street Project.

Currently, there is one EPIC paramedic on shift seven days a week from 7 a.m. to 7 p.m. The program’s leaders, Sneath and Grierson, would like to see that expanded. They believe there would be even greater savings to the system — and better care for more patients — if there were three EPIC paramedics on shift during the day and two others working evenings with some overlap with the other three.

“There’s not a lot of things in health care where you provide better care and it’s less expensive,” Grierson says.

Health Minister Sharon Blady says she’s impressed with the project, but she has yet to commit to a timetable for expanding EPIC or making it permanent.

She says she is looking into adapting the model to various parts of the city and other areas of the province.

“It’s going to be about working with all of the partners to find out how it is that we can custom do EPIC to different places that are interested in the model.”

Sneath is hopeful permanent funding will come. He notes EPIC’s efforts in identifying and intervening with at-risk patients have already won the program an award from the Paramedic Chiefs of Canada.

“(EPIC) is responding in a proactive way. It’s preventative health. It just makes more sense for patients,” Sneath says.

larry.kusch@freepress.mb.ca