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It began innocently enough, with an event Joshua Fleuelling's parents had witnessed more times than they could remember: Their son was having an asthma attack.

Joshua was lying on the living-room sofa, beneath the framed photo of Eddie Shack, one of his father's heroes. He stood up and asked his mother to get him his "puffer," an aerosol bottle of Ventolin, the medication that normally relieved his asthma and let him breathe again.

This time it didn't work. Joshua's mother dialled 911.

"My son can't breathe," she said. "Come quickly."

It was 1:48 a.m. Friday. The ambulance arrived eight minutes later. By then, Joshua's condition had deteriorated: His heart had stopped. The paramedics strapped him to a stretcher and loaded him into the ambulance.

Joshua was 18 years old. He lived with his parents in their modest home on Phalen Crescent in Scarborough. His mother is a driver for a courier company; his father works in an office. Joshua was a landscaper, had a girlfriend and dreamed of the day when he would be able to afford a car. He had suffered from asthma since he was 5.

None of the countless attacks he had suffered before was like this one. His parents pinned their hopes on the ambulance crew and the emergency-room doctors.

If things had gone as they should have, Joshua would have been in the emergency ward of nearby Scarborough Grace Hospital in 10 minutes or less. Instead, he went nearly twice as far, to Markham-Stouffville Hospital.

The trip took 18 minutes. It was the last ride of his life.

For a young man in respiratory crisis, the extra eight to 10 minutes it took to get to Markham-Stouffville Hospital may have been the difference between life and death. By the time he arrived at the hospital, Joshua was unconscious. He was put on life support, but never recovered. He was pronounced dead at 1 a.m. Saturday.

Then the questions started. How could it happen? Why was a young man who lived minutes from a hospital sent so far for treatment? Why couldn't the ambulance attendants help him breathe?

It appears that Joshua's death was the result of a series of circumstances. Just five minutes before he was loaded into the ambulance, nearby Scarborough Grace Hospital had placed itself on what's known as critical-care bypass, indicating that it couldn't accept any more patients arriving by ambulance.

Across the city, at the ambulance dispatch centre on Dufferin Street, a computer noted the bypass alert and automatically rerouted the call to the next nearest hospital -- in this case, Markham-Stouffville.

Until he arrived at the hospital, Joshua's life depended on the ambulance crew that picked him up. Again, luck was not with him.

Of the 700 paramedics who work for the Toronto Ambulance service, 150 are qualified to perform advanced airway-management procedures that could have helped him stay alive. The paramedics assigned to his ambulance were not.

The coroner's office will be investigating this week, and may decide to order an inquest to determine what, if anything, could have been done to prevent the death. For now, there are no clear answers.

Ron Kelusky, general manager of Toronto Ambulance, says the blame should not be laid on the ambulance crew.

"This was a tragic situation," he said. "It was gravely unfortunate. We give it our best shot, but there are circumstances where we cannot save the patient.

"They were presented with a situation, and they had to make a decision. They can't be faulted for that."

Mr. Kelusky said that although it would be ideal to have at least one top-qualified paramedic who could do airway procedures with every ambulance, the real world presents limitations."

Mr. Kelusky said the ambulance crew did what they were supposed to by taking Joshua to Markham when they saw that Scarborough Grace was on critical-care bypass, but he agreed that Joshua had fallen through the cracks of a flawed system.

Asked whether the extra eight to 10 minutes cost Joshua his life, Mr. Kelusky replied, "That's what we're looking at."

Louise LeBlanc, a patient-care director at Scarborough Grace Hospital, said the hospital's decision to put itself on critical-care bypass was a proper choice, given the situation at the time.

"The emergency department was overwhelmed. There were no stretchers. There were no staff. Everybody was working beyond their max."

At Markham-Stouffville, where Joshua died, spokeswoman Pam Brodie said emergency physicians had done everything in their power: "He arrived at our hospital. We did everything we could. After that, it was in the hands of God."

At Joshua's home on Phalen Crescent, shocked relatives crowded into the kitchen.

"It's a heartbreaker," said Richard Chapman, the young man's uncle. He blamed the restructuring that has racked the health-care system in recent years for Joshua's death.

"Something has to change," he said.


Fewer than 20 per cent of the 700 paramedics in the Toronto Ambulance service are qualified in airway-management procedures that might have saved the life of 18-year-old Joshua Fleuelling, who died this weekend after an asthma attack.

The paramedics in the ambulance that transported the young man were Level 2 emergency medical technicians (EMTs). Only Level 3 EMTs and critical care paramedics are allowed to perform airway treatments such as tracheotomies or chest-tube insertion.

Here are the four levels of EMTs who work in the Toronto Ambulance service, with their pay, qualifications and limitations:

EMT 1 ($50,000 base salary): Must graduate from a one-year (1,500 hours) community college program in ambulance and emergency care. May be trained to use a semi-automatic defibrillator and dispense five drugs, including ASA, glucose, nitroglycerin, epinephrine and salbutamol inhalers. EMT 1s are not allowed to perform airway treatments such as tracheotomies or breathing-tube insertion.

EMT 2 ($52,500 base salary): EMT 1 training plus an additional six weeks of clinical training and supervised field experience. EMT 2s are qualified to use manual defibrillators, to interpret electrocardiographs and to start intravenous lines. They are not allowed to administer intravenous drugs or perform airway treatments.

EMT 3 ($55,000 base salary): EMT 2 training plus 10 weeks extra classroom training and extra supervised field work. EMT 3s are qualified to dispense 16 drugs and perform advanced airway management, including chest-tube insertion and tracheotomy.

Critical Care Paramedic ($60,000 base salary): EMT 3 training plus six to eight weeks additional clinical training. CCPs are qualified to perform advanced lifesaving procedures including tracheotomies, blood transfusions and inserting arterial IV lines. CCPs are considered the equivalent of an intensive-care-unit nurse.

Of the 700 paramedics in the Toronto Ambulance service, 450 are EMT 1 qualified; 100 are EMT 2 qualified; 120 are EMT 3 qualified, and 30 are CCP qualified.