The September 4 Northern Health announcement, that our ER would be shut down after hours, was followed by an apology for the way the announcement had been rolled out. Then came a second announcement, stating that the shut-down would be temporary, but there have been more recent indications that Northern Health is not planning to return to after-hours ER care as we know it. The result seems to be that residents feel confused and scared.
I therefore want to provide you with my thoughts on why a permanent shut-down is so dangerous, and why it is so important that we, Mayor and Council and our MLA continue to make our feelings and opinions clear. We have learned through experience that when services are cut it is very hard to ever get them back. I want to present four fairly common conditions to you as examples of what comes through BC ERs: stroke, heart attack, pneumothorax (punctured lung) and labour/delivery, and which of these need a 24/7 ER service here.
At a recent Open House in Tumbler Ridge, Northern Health seemed to suggest ‘stroke’ as justification for sending patients straight to Dawson Creek rather than via the Tumbler Ridge ER. This is because an important potential treatment for an acute stroke is the clot-buster drug (thrombolysis), and patients need to have a CT scan in Dawson Creek to know whether they are suitable for the clot-buster or not. If given to the wrong person, it can harm (even kill) rather than help. I actually helped draw up the ‘stroke protocol’ for Tumbler Ridge, which involves bypassing the Tumbler Ridge ER to save precious time. In other words, there is nothing new here and it has already been happening for years. (Nowadays, however, we need to remember that Dawson Creek might be on diversion). So, in this case I agree with Northern Health: our ambulance should not waste valuable time coming to our ER with a stroke victim.
However, the problem is that representatives of Northern Health, in promoting the virtues of a second ambulance to help in stroke management, are selecting data that ignores many other conditions. For example, the situation is very different for heart attacks. Again, the clot-buster drug can be life-saving, and again, the sooner it can be given, the better the potential outcome. A ‘door-to-drug’ time of 20 minutes is the goal: if it determined that you are having a heart attack and will benefit from the clot-buster drug, the goal is that you begin receiving it within 20 minutes of your arrival in our ER. All that is needed to make the decision is a competent reading of an electrocardiogram (which gets done here) and the completion of some checklists and questions, followed by your consent. This was started in Tumbler Ridge in the early 1990s and has helped to save countless lives since. If there is a delay in receiving the drug, critical time is lost. The local rule is that a physician stays with the patient throughout the process, as sometimes side effects occur, and one wants to be in a place where these can be dealt with efficiently. Heart attacks are therefore totally different from strokes in terms of where and when the best initial management occurs: the sooner treatment is begun, the better, and the best place is local.
Then there is the question of a punctured lung (pneumothorax). This can occur, say, if you fall on a weekend and break your ribs. We in Tumbler Ridge are unusual in one way: to get from our ER to Dawson Creek, Chetwynd, or any other larger centre, you either have to ascend 2000 feet to the summits of our mountain roads, or you need to be flown out. In both cases, if you have not had a chest tube inserted in the Tumbler Ridge ER, your pneumothorax (air around the lung) will get bigger and may put increased pressure on your lung and heart and other organs. You might be young and fit, and might make it over the mountain passes, or you may be weaker and more frail, in which case the reduced atmospheric pressure associated with elevation gain may be a killer. Every community is different, decisions on the Tumbler Ridge ER have to take our unique geography into account, and Northern Heath leaders need to acknowledge this. This is another example of why we need 24/7 ER care in Tumbler Ridge: as in the case of heart attacks, it will save lives.
As for labour and delivery, thankfully most pregnancies go full term and most deliveries either go well within our region (usually in Dawson Creek), or pregnant moms have been selected in advance to deliver in a larger centre. But no system is perfect, and things can go wrong. And for those who do go into labour unexpectedly here, it is often a sign that something has gone wrong – premature labour, a bleed, a breech delivery, etc. Not having the benefit of local assessment and management by a competent physician or midwife or nurse practitioner is, quite simply, a bad idea. These practitioners have the ability to bring in air transport to help in such cases, rather than subject patients to a long ambulance ride.
These four examples do not even touch on other possibilities: complex wounds that do not need the attention of a surgeon but that definitely do need to be seen and fixed as soon as possible, paediatric emergencies, end-of-life care… the list goes on, and in each case an ER in Tumbler Ridge that is open for business after-hours is what’s needed, and what is often life-saving. Plus, there is the unfairness of burdening our wonderful paramedics with unnecessarily long transfers of people who should have been assessed and treated close to home.
Are there other examples where by-passing our ER might be indicated? Yes, there are a few. In a severe case of major trauma, what the patient might need is emergency access to a surgeon in a larger centre, and the availability of air ambulances and similar services means that this can happen in minutes rather than hours. However, such cases are the exception, and our paramedics are already able to make such calls.
Over the past decades our health care has been impacted many times, in what I call ‘death by 1000 cuts’. You, the citizens of Tumbler Ridge, have made it clear that you are tired of this, you don’t want to take it any more, and that after-hours ER care is not negotiable. In turn, I have pointed out that some of us will die as a result of the Northern Health decision.
What is the way forward? We need clarity from leaders in Northern Health, who, in addition to being entrusted with our health care, are required to collaborate with communities to find solutions. In my view, Northern Health needs to state unequivocally that once physician and nursing staffing levels are adequate, the ER will re-open after hours, and that we will have 24/7 ER care available when we need it. And then Northern Health needs to stick to that position and not vacillate. Plus, we URGENTLY need to be discussing Virtual ER support (VERRa) as an interim measure to get us out of this crisis as quickly as possible. VERRa has an excellent track record of helping communities get through similar situations, and every night and weekend that our ER is closed puts our lives at risk unnecessarily.
In the meantime, I will continue to try to support our Mayor and Council in telling Northern Health the truth, based on our local knowledge and experience. And if Northern Health does release such an announcement, you will find me first in line, offering to collaborate in what is a very difficult time. Those of us who are trying to make a difference to health care in the North are so thin on the ground that we all need to be pulling together.
The Northern Health rationale for closing our ER after hours involves denial of the concept of the ‘Golden Hour’. Why do I believe passionately in this concept? Because I worked in our ER for almost thirty years, and I know how many lives our team saved on weekends and at night. I hope that all this explains why restoring ER after-hours care is so important. And I hope it explains why I suggest that you are extremely wary of any claim that having two ambulances but no ER is actually good for us.
