Medical services credit union

Toronto Emergency Medical Services was involved with this spring's outbreak of Severe Acute Respiratory Syndrome even before SARS had its name. Five months later, the organisation is still dealing with the uncertainties and stress it caused, even as the city's economy and tourism are recovering.

Stopping the spread of SARS both within our community and among our own paramedics, was a huge challenge for Toronto EMS It is a credit to the courage and professionalism of our paramedics, and the rest of our staff, that so few of our people got SARS and that we played such a large role in containing a very serious disease that continues to claim victims in our city.

It all started innocently enough. Toronto EMS paramedics attended the residence of a woman who passed away from an apparent cardiac arrest on March 5, 2003. She turned out to be the original carrier of SARS from Hong Kong to Toronto. A couple of days later, we transported her son to Scarborough Hospital, Grace Division with respiratory problems, where he died shortly thereafter. On March 13, paramedics moved two more respiratory patients from Scarborough Grace to isolation units at other hospitals

Based on descriptions of these patient transports, and on World Health Organisation and Toronto Public Health notifications of an outbreak of atypical pneumonia affecting residents of Hong Kong, China and Vietnam, Dr Martin Friedberg, Medical Advisor, and Peter Macintyre, Manager, Community Safeguard Services, sent out their first memo about 'atypical pneumonia' to all Toronto EMS Staff on March 14. The memo advised paramedics to use standard universal infection control precautions, including wearing N95 respirators, gloves and gowns, and de contaminating vehicles, stretchers and equipment. From that point on, daily updates were emailed to all Toronto EMS staff, posted at stations and recorded on a 1-800 number so staff could get information over the phone In what turned out to be a very prudent move, Toronto EMS Operations Sup port ordered 250,000 N95 respirators and a large supply of disposable gowns and gloves.

Two days later, the WHO identified the out break as 'Severe Acute Respiratory Syndrome'. Even though the disease had a name, there was a lot of fear and uncertainly in the health care system and in the general public. In the face of this unknown syndrome, our paramedics continued to come to work. As Acting Chief, I am proud of the way our staff met and continue to meet the many challenges of SARS.

The disease really hit home when a Toronto EMS paramedic was hospitalised with SARS-like symptoms on March 25, and when the next day, a second symptomatic paramedic was admitted to hospital. Altogether, four medics were hospitalised with SARS. It is a great relief to the whole EMS family that they all survived, although a couple are still recovering from the effects of this very serious illness five months later. Tragically, three health care professionals, two nurses and a doctor, have succumbed to SARS to date.

On March 26, 2003, the Premier of the Province of Ontario declared a Provincial Health Emergency and activated the Provincial Operations Centre (POC). I was one of the Toronto EMS representatives at the POC, bringing our organisation's issues and concerns to the table. We worked closely with Ministry of Health, Long Term Care and Toronto Public Health officials to produce directives related to infectious control procedures, protective equipment, and patient transports. Personally, I was greatly impressed by communicable disease specialists on the scientific committee and by the way the officials from all levels of Government worked together.

Upon the health emergency declaration, our Healthcare Divisional Operations Centre (H-DOC) was activated. The H-DOC acted as the command centre for all EMS operations in our city and in the Greater Toronto Area, collecting and distributing information to regional EMS services and private transfer companies, and providing logistical support to our own operations.

Toronto EMS staff had a lot of help at the H-DOC. Representatives from the Sunnybrook and Women's College Base Hospital programme, which oversees our paramedics, set up a Medical Support Unit to monitor the health of quarantined paramedics and answer their questions about SARS.

Toronto's emergency services operate in a tiered response system. First response-trained firefighters and police officers also respond to medical emergency calls, so their staff needed to be informed about SARS precautions and personal protection regimes. Toronto Fire Services (TFS) and Toronto Po lice Services (TPS) staff were stationed in the H-DOC from the very beginning which enabled the TFS and TPS to get the latest information out to the front line firefighters and police officers who were responding to medical emergency calls.

Things happen fast in an emergency, and SARS was no different. As communicable disease authorities learned more about SARS, personal protective equipment protocols changed. To help ensure that health and safety concerns of staff were addressed, representatives from the unions representing paramedics and dispatchers, the Canadian Union of Public Employees (CUPE), Locals 416 and 79, were stationed in the H-DOC and took part in our daily briefings. This allowed the unions to review, provide feedback and approve any new procedures, equipment and policies on the spot, working with management to ensure the health and safety of the paramedics. Working together to fight SARS has paid ongoing benefits as the lines of communication between union and management remain open.

Provincial authorities closed Scarborough Hospital, Grace Division on March 20 and advised anyone who had been there since the first SARS patients arrived to go into voluntary isolation for ten days from their last visit. Supervisory staff at the H-DOC had to contact all the paramedics who had been in Scarborough Hospital to ask them to go into voluntary isolation. This meant that we lost 140 paramedics for up to ten days. One of the lessons Toronto EMS learned was that we need to streamline our information systems to make it easier to pull together lists of medics who may have attended a given facility.

From that point forward, the Medical Sup port Unit called all the quarantined medics daily, to monitor them for possible symptoms and to arrange delivery of supplies to them. With the help of our retirees group, the Toronto EMS Pioneers, we delivered everything the quarantined medics needed, from masks to prescriptions to groceries. At the peak of this first outbreak, there were 160 paramedics on voluntary isolation, out of a total of 850 paramedics. To maintain our operational car counts, we cancelled training and redeployed staff.

The Commissioner of Public Health directed paramedics to wear an N-95 respirator for all patient contacts. However, N-95 respirators do not seal perfectly if you have a beard. So l issued a directive requiring all paramedics to remove all facial hair that might interfere with the seal of a mask. Some of these paramedics had not shaved their beards off for 20 years or more, but they understood that coping with this emergency warranted this unusual decision.

On March 29, Toronto EMS was given two important areas of responsibility by provincial authorities. First, all privately owned medical transportation providers in Ontario were put under the direction of Toronto EMS for the purposes of organising large scale patient movements related to SARS. Toronto EMS was also responsible for co-ordinating all inter facility patient movements in Ontario, to prevent the spread of SARS from one hospital to another.

The Patient Transfer Authorisation Centre (PTAC) was set up in our headquarters and processed over 1,000 patient transfer authorisation requests daily. Paramedics screen transfer requests and if any anomalous information, for example, respiratory problems or high fever is involved, a doctor calls the sending institution to review the patient's history and charts. After the PTAC was up and running, inadvertent transfer of SARS patients stopped.

Second, Toronto EMS was designated as the central purchasing agent and distribution point for medical supplies related to the SARS outbreak, including masks, gloves, gowns, eye protection and disposable linen. Centralised purchasing and distribution by Toronto EMS prevented regional EMS operations and private transfer services from competing for the same products from the same suppliers. This prevented hoarding, kept costs down and ensured that all the services had adequate supplies of these crucial protective items.