Lights and Sirens

Nearly every minute in Alberta, paramedics are called to a potential emergency that may require the use of medical and pharmaceutical interventions, as well as a variety of psychosocial skills, to save lives and prevent further illness. Hence, paramedics and the work they do on the streets (in ever-changing and unpredictable environments) and off the streets (in hospitals and other facilities) are central to the provision of health care in Alberta. For many Albertans, paramedics are the first point of contact in the health and social care system in the province. Suffice it to say, paramedics are a key component of this system.

Prehospital emergency medical services and the workers central to the system — the paramedics — are in a state of crisis in Alberta. This is evidenced by increased rates of paramedic burnout/moral injury, staff retention issues, increased response times, increased number of code reds/red alerts” (which refers to instances where no ambulances are available for emergency calls for a specific community), and paramedics being “parked”/stuck in emergency departments. While SARS-COV-2 (hereafter COVID-19) and the opioid and overdose crisis (hereafter overdose crisis) have exacerbated the challenges experienced by paramedics in Alberta, the root of the current crisis dates back at least to the amalgamation of emergency medical services in the province in 2009. 

Paramedics in Alberta deserve to be heard and listened to. They deserve to have policies and practices reflect their actual work practices. They deserve to work in an environment that promotes their wellness while allowing them to deploy their complex medical and non-medical skills to support patients in the community and, when necessary, transport their patients to a care facility in a timely manner.

This report explores the current state of affairs of prehospital emergency medical services in Alberta from the standpoint of those who live it, experience it, and breathe it on a daily basis. More specifically, it outlines findings from a study that explored how COVID-19, the overdose crisis, and other factors have impacted EMS in the province of Alberta.

In doing so, I aim to give voice to those who work on the front lines of emergency medical services, a voice that has been absent from how policy in Alberta is informed and developed. Hence this report, and the research that it is based on, aims to correct a major blind spot in how policy is developed in Alberta, contributing to how EMS in the province is reformed or transformed to better support the work of paramedics and those they care for both on and off the streets.

This study deployed an institutional ethnographic research methodology that focused on the lived experiences of paramedics and how their lived experiences and their work are socially organized. Semi-structured interviews were conducted with 29 individuals, including 27 Alberta paramedics, including Advanced Care Paramedics (ACP) and Primary Care Paramedics (PCP) that together represent over 400 years of EMS experience.

Interviews were in-depth, lasting over one hour each on average, and focused on gaining a complex understanding of the work of paramedics, particularly in relation to how recent (e.g., COVID-19 and the overdose crisis) and historical (e.g., reform and restructuring practices) events have shaped and reshaped the work and experiences of being a paramedic in Alberta. The interviews also aimed to provide empirical evidence grounded in the everyday lives of paramedics that could support transforming EMS in the province.

Complementing this study, data from an institutional ethnographic study conducted nearly a decade ago was used to provide additional empirical depth and ethnographic nuance to the current EMS crisis. In addition to this primary ethnographic research, secondary research was conducted to explore how EMS in Alberta could be reimagined to better meet the current and future health and social care needs of Albertans. 

The findings are separated into three sections. The first section explores the health care crisis from the standpoint of paramedics, highlighting the everyday lives of paramedics as they gave meaning to and experienced the current state of affairs of EMS in the province. In this section, paramedics discussed a multiplicity of intersecting elements that constitute the current crisis. For example, they spoke of a lowering of standards and a toxic work environment that made providing good care nearly impossible. They locate this lowering of standards within policies and practices primarily rooted in reform and restructuring practices that began in 2009 and have only gotten worse over time. 

Paramedics also discussed an erosion of key work processes that are central to being a competent paramedic. This erosion of the ability to be competent was facilitated by a system that one-dimensionally focused on efficiency and the simplistic yet harmful ethos of doing more with less. This one-dimensional focus on efficiency increasingly resulted in limited resources being available to paramedics to respond to the demands of their work environment. The lack of resources and efficiency ethos had a cascading effecting on paramedics, as they were forced to “make out” in a system that was designed to “break” them. 

Section 1 of the findings also draws attention to how COVID-19 and the ongoing overdose crisis were the metaphorical straw that broke the camel’s back. For instance, paramedics drew attention to how COVID-19 made a problematic work environment even worse due to the unpredictable nature of the virus, fear of the unknown, ever-changing information, lack of appropriate personal protective equipment (PPE), and other factors. COVID-19, combined with the drug overdose crisis, increased system pressures in an already depleted system that had no capacity to respond to unplanned emergencies. 

Section 1 ends with a focus on how these factors all resulted in a decrease in morale and paramedic well-being. Simply put, the EMS system caused considerable structural violence to paramedics, resulting in a dire state of affairs characterized by diminished joys of the job, classic descriptions of burnout and moral injury, and an overall sense of inability to cope with an EMS system that is neither patient nor provider-centred. 

Section 2 of the findings dives deeper into the socially organized roots of the current crisis. More specifically, I focus on the historical context of the current crisis, with a focus on reform and restructuring practices that began in the 1990s and culminated in the 2009 reform – the “AHS Armageddon,” as one paramedic described it. 

The 2009 reform resulted in Alberta Health Services and the Government of Alberta assuming responsibility for most EMS in the province. Organized by neo-liberal styles of management and governance and facilitated by technologies of knowledge and governance, what resulted was a “command and control” style of organizing and governing EMS with hidden and not so hidden deleterious effects for paramedics and the EMS system as a whole. 

Based on this research, it appears such consequences have only worsened over time as paramedics increasingly appear to be treated as “cogs” or “pawns” in a never-ending game of trying to garner efficiency out of an already very “lean” system. The analysis in Section 2 extends our understanding of Section 1 findings by exploring how the current crisis has been in the making for some time. 

Section 3 offers an in-depth action plan where I offer 15 recommendations for change based on the lived experiences of paramedics and available evidence based on secondary research. Recommendations draw attention to the need to address both EMS-specific changes and changes more geared toward “upstream medicine” and the social determinants of health, which generally occur outside of traditional EMS.