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andré picard

Imagine if, instead of transporting patients to hospital, where they will sit for hours in the emergency department waiting for minor – and often routine – treatments, paramedics treated them in their homes.

It seems like an eminently sensible approach, but the idea is only now starting to take hold.

Ontario recently announced a $6-million investment in community paramedicine that will allow the expansion of programs that target seniors who call 9-1-1 frequently. Instead of waiting for the all-too-predictable calls to come, paramedics will proactively visit their homes to check vital signs, to make sure they are taking medications as prescribed, and to refer them to appropriate home-care services.

"It's all about providing the right care at the right time and in the right place," provincial Health Minister Deb Matthews said.

It's also about spending health dollars more wisely, and allowing health professionals to use their full range of skills.

Pilot programs like the one in Ontario have, to date, provided eye-catching results, namely a 50-per-cent reduction in calls to 9-1-1 and a 65-per-cent drop in ER visits by so-called frequent fliers.

The patients who will benefit from the expansion of paramedicine are, by and large, frail seniors with multiple chronic conditions, one of the fastest-growing demographics in health care. This clientele is not abusing "free" medicare services, as many people assume. Rather, they are victims of the system's inefficiencies: Patients with a host of health problems, big and small, but no ready access to primary care (physician or nurse practitioner) or to transportation, not to mention significant mobility problems and cognitive challenges. By default, they end up going to hospital by ambulance, time and time again. Paramedics know a lot of these patients by name.

If we want to keep seniors in the community and out of hospitals and long-term care facilities – and that should be our goal for financial and humanitarian reasons – then we need to provide better community-based health care.

Canada's 37,000 paramedics can play an important role in that long-overdue change. Yet their public image needs a makeover.

We tend to think of paramedics as ambulance drivers, essentially cabbies whose clients lie on stretchers. But the profession has changed quite dramatically in recent years. Paramedics now administer a lot of "pre-hospital medical care" to patients with injuries, and a host of medical and psychiatric illnesses. There are primary-care, advanced-care and critical-care paramedics and, in a number of provinces, paramedicine is now a self-regulating profession.

Paramedics often make a life-or-death difference for people who suffer heart attacks or strokes, doing cardiopulmonary resuscitation and defibrillation, and administering clot-busting drugs. They save many patients from overdoses with injections of naloxone and do emergency wound care to prevent accident victims from bleeding to death or going into shock. But they also have the training and skills to do a lot of routine medicine that doesn't require hospital admission. In rural communities in particular, where there are notable shortages of MDs and NPs, paramedics are increasingly delivering primary care, and should do a lot more.

Paramedicine got its start in Canada back in 2001, on Long and Brier Islands, remote communities in southwestern Nova Scotia. There, paramedics spent a lot of time sitting around (a common problem in rural areas, but not urban ones) and when they did have to transport patients, it involved a long drive and ferry ride to Digby. So, instead of merely transporting the same patients over and over, they started helping them out at home. Working with physicians and nurses on the mainland, they started doing wound care, patching up and suturing minor injuries, administering immunizations and antibiotics, and checking patients' adherence to prescriptions. Within a year, ambulance trips dropped by 25 per cent and ER visits by residents of the islands fell 40 per cent. The average cost of health care for residents of the small communities fell from an average of $2,380 to $1,375.

In Calgary, there is a program in which paramedics visit nursing homes and long-term care homes and do all sorts of routine care on-site, including EEGs, collecting specimens, catheterization, rehydration, wound care and the like. In the first year, they avoided 700 ambulance trips to the ER.

In Saskatoon, paramedics and nurse practitioners operate a Health Bus, which travels to poor parts of town and nearby First Nations communities, again with the goal of staving off 9-1-1 calls and transport to hospital.

In Winnipeg, they placed a paramedic full-time in a downtown detox centre. The move reduced ambulance trips from the facility by 50 per cent and saved $250,000 a year.

The concept of paramedicine has proven itself time and time again. The challenge now is one that is eternal in Canadian health care – to take successful pilot projects and scale them up so that they because the norm, rather than the exception.

Follow me on Twitter: @picardonhealth

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