Toronto EMS

Toronto Emergency Medical Services
Established	1975
Headquarters	Toronto, ON
Jurisdiction	City
Employees	1,171
BLS or ALS	Both
Ambulances	150
Chief	Paul Raftis
Website	www.torontoems.ca

Toronto Emergency Medical Services (EMS) is the statutory Emergency medical services provider for the city of Toronto, Ontario, Canada. The service is operated directly as a branch of the municipal government as an independent, third-service option provider, which means that the service is funded by the municipal tax base, and operates in much the same manner as any other municipal department, such as the police or fire department, or in some cases like a public utility, but retains its complete independence from all other departments. While under municipal government control, it is required to comply with legislation and licensing standards provided by the Ontario provincial government.^[1] It is not the only service provider in its area; private-for-profit medical transport services also provide routine, non-emergency transports and coverage for special events, but the statutory EMS system is the only provider permitted to service emergency calls.

History

Toronto EMS paramedics prepare to transport victim

The City of Toronto has operated an ambulance service directly on an uninterrupted basis since 1883, when the City of Toronto Health Department acquired two ambulances to transport those with infectious diseases to the local sanitarium. Full-time emergency ambulance service began in 1888, with the provision of emergency ambulance service by the Toronto Police Force, which eventually operated four horse-drawn vehicles.^[2] Prior to these two municipal initiatives, ambulance service was provided for the young city by a variety of means, including both hospital-based and private companies. This 'broad spectrum' approach to service delivery would continue for more than ninety years.

Toronto may very well be able to claim to have the first formally trained 'ambulance attendants' in North America, with the Toronto Police Force ambulance service staff receiving five days of formal training in their jobs from the St. John Ambulance Brigade in 1889.^[3] Training included both first aid skills and anatomy and physiology, including all eight pairs (at that time) of cranial nerves! Such training for ambulance attendants was unheard of at that time, outside of military circles. The police constables assigned to the ambulance also did regular policing, when not required for ambulance calls. As the city grew and technology progressed, so did the ambulance service. The first motorized ambulance was actually purchased by a local funeral home in 1911, and the Toronto Police Ambulance Service began the conversion from horse-drawn to motorized vehicles in 1913, with the process largely completed by 1918. Over the years, the two City of Toronto departments would have their services supplemented by more than 130 individual ambulance operators, most of them private companies, and in suburban areas by several of the tiny, local fire departments. The two municipal services would finally be merged in 1933, when the Toronto Police Department turned the operation of their ambulances over to the Department of Public Health, and ended their involvement in the City's ambulance service.

This service would grow again in 1953, as the result of the creation of the municipality of Metropolitan Toronto, dramatically expanding the required service area. Service would continue in this fashion until 1967, when the amalgamated City's suburban fire departments surrendered their ambulances, resulting in the evolution of the Department of Public Health Ambulance Service into the City-operated Department of Emergency Services (DES).^[4] Some private companies, and one operated by the provincial government, would continue to operate in 'Metro' Toronto until 1975, although with centralized dispatch services provided by DES.

The Metropolitan Toronto Department of Ambulance Services was created in 1975, and absorbed the five remaining private ambulance companies and single provincial service, providing a single, unified ambulance service in Metro Toronto. Known colloquially as Metro Toronto Ambulance (never its official name) or simply 'Metro Ambulance' (although never its official name) the service provided ambulance services from 1975 to 1998.

Metropolitan Toronto was restructured during 1998,^[5] transforming it from a regional government overseeing six member municipalities into a single, unified city, and many municipal and regional services were restructured as a result. Metro Ambulance became Toronto Ambulance, and later adopted its current name, in order to reflect its evolving role from primarily a provider of medical transportation to an actual provider of medical care.

The service introduced its first paramedics in 1984 (although experiments in pre-hospital advanced life support actually began in 1969).^[6] Toronto EMS introduced many other innovations, including the concept of dedicated ground-based critical care transport ambulances, as well as many specialty support units described in this article, many of which were originally conceived and pioneered by the service.

As of April 2005, the departments and commissioners were replaced by divisions under the City Manager (and Deputy Managers). Toronto EMS now operates under the city's Emergency Medical Services Division. It is the largest municipal EMS operation in Canada.

Staff

Toronto EMS has 1,171 members including paramedics and other support staff.^[7] These are categorized as follows:

• Paramedics

• Level I - (Primary Care Paramedic)- 463 positions. Must complete minimum of 1,400 hours of training in a community college prior to employment. Successful completion of provincial certification exams is also required.
• Level II - (Enhanced Primary Care Paramedic)- 217 positions. Requires an additional 572 hours of training in order to use expanded skill set and scope of practice. Only uses advanced skills when teamed with a Level III paramedic.
• Level III - (Advanced Care Paramedic)- 184 positions. In addition to Level II training requires a further 360 hours of training and 480 hours of preceptorship. Always the senior paramedic on a normal emergency unit.
• CCTU - (Critical Care Transport Paramedic)- 17 positions. In addition to Level III training, requires an additional 1,142 hours of training and 240 hours of preceptorship. Typically work only on Critical Care Transport ambulances.

• Emergency Medical Dispatchers - 112 positions. (Service trains its own EMDs to international standard)
• Management/Supervisory staff - 100 positions.
• Clerical support staff - 15 positions.
• Facilities maintenance - 19 positions.
• Vehicle maintenance/mechanical - 18 positions.
• Materials management/Logistics - 10 positions.

Uniforms

EMS paramedics uniform consists of:

• dark short or long sleeve job shirt with EMS patch on side, reflective strips on arms and left chest area
• white polo shirt with EMS patch (summer)
• dark cargo pants with reflective strips
• bicycle helmet and shorts for bike crews
• Hard hat with visor for some crews
• work boots
• tactical shirt, Ballistic helmet (SPECTRA helmet) and Ballistic vest for tactical units
• formal jacket, shirt, slacks and ties for senior staff
• dark or chartreuse jacket with word PARAMEDIC on the back (winter)

Staff also have Shoulder mark on formal shirt and jackets:

• 1 stripe - Paramedic
• 2 stripe - senior
• 3 stripe - senior ranks (supervisor)
• 4 stripe - Deputy Chief
• 5 stripe - Chief

Training

In addition to the education and skills training obtained prior to employment, the EMS Education Unit performs all pre-employment skills assessments, and also new employee orientation courses. Toronto EMS also provides all inservice education for a staff of more than 1,100 people. Inservice education may include the introduction of new equipment, procedures or techniques, may include items which have been mandated by the provincial government, or may include issues which have been identified in past practise. Toronto EMS provides all education and training for all advanced care paramedics (those above Level I), through its Christopher J. Rubes Centre for EMS Studies. Level I training must be obtained prior to employment. The service also operates a network of pre-selected Field Training Officers. The Christopher J. Rubes Centre for EMS Studies, which is operated directly by the service, has received accreditation as a training academy for both primary and advanced care paramedics, through the Canadian Medical Association.^[8] Although in the past, the service has trained all of its own advanced care paramedics, training Level I to Level II has been suspended indefinitely and Level III training has slowed significantly in the past three years. Factors including new dispatch and management approaches, as well as funding has resulted in this discontinuation of further Advanced Care training. Toronto EMS has chosen not to pursue primary care paramedic training over the short term.

Fleet

Of the 242 vehicles in the Toronto EMS fleet, 150 are CMVSS / Ontario Standard Type III ambulances. Of these, approximately 100 are in service at any time on a typical, mid-week, day shift. The rest of the fleet are support vehicles (mainly buses and trucks) supervisory vehicles, and single paramedic response vehicles. Toronto EMS operates its own repair facilities, located at the service's Headquarters complex. All maintenance and repair work (with the exception of body work), and all equipment, radio, and medical electronics maintenance and repairs are performed on site by service staff.^[7]

Fleet numbering

• X - Special Operations
• XXX - ambulances: regular, Critical Care, tactical medics, CBRNmedics
• ERUXX - Emergency Response Unit
• ESUXX - - Emergency Support Unit
• XX-XXX - non-ambulatory vehicles: Paramedic Supervisor, Logistics Support, community medicine

• EMS in Toronto
• 

  Emergency Response Unit (ERU)/Supervisory vehicle

• 

  Toronto Type III Ambulance

• 

  Ontario Air Ambulance operated by Ornge

Communications

Toronto EMS operates its own Communications and System Control Centre (called a Central Ambulance Communications Center or CACC "Kaack"), including emergency medical dispatch, patient distribution and system oversight. Toronto EMS participates in the community-wide 9-1-1 system, and triages emergency calls using the Advanced Medical Priority Dispatch System. The system uses Computer-Aided Dispatch, including Tritech VisiCAD, augmented by PDS and Siren software and technology.^[9] The service utilizes a satellite-based Automatic Vehicle Locating system in order to ensure that the closest appropriate response resource is consistently sent to each emergency call; all emergency response resources are included. The service utilizes a 800mhz Smartzone trunking radio system for dispatch purposes. The Control Centre has direct landline contact with the 9-1-1 Center, all other emergency services, all acute care hospitals, and all EMS Stations. The service utilizes “Language Line” service to provide instant simultaneous translation of emergency calls in more than 140 languages. Toronto EMS operates the largest EMS Communications Centre in Canada, which was recently accredited as an International Centre of Excellence by the International Academy of Emergency Dispatch.^[10]

Operations

Service is provided to a residential population of approximately 3.2 million people, which rises to approximately 5 million on most business days.

Toronto EMS operates a total of 41 dedicated EMS stations, geographically distributed across the 246 square miles (640 km²) of the City of Toronto. Emergency service headquarters (which is shared with Toronto Fire Services, but both services operate independently) is located at 4330 Dufferin Street in Toronto. This facility includes administrative offices, some education facilities, the EMS Communications Centre, Fleet Maintenance, Planning and Operational Support, and Materials Management/Logistics. The service is supplemented by well-developed EMS systems in neighbouring communities on three sides, with Lake Ontario providing the southern boundary of the service area. Air ambulance operations are provided within the City of Toronto by Ornge, a privately owned air ambulance contractor, under contract to the Government of Ontario.

Based upon information provided by Toronto EMS, the service processed in excess of 535,000 calls through its Control Centre in 2007 (the most recent year for which complete data is available), resulting in 223,769 emergency calls being dispatched.^[7] Using the AMPDS system, which triages calls by severity for dispatch purposes, the actual dispatch volume by category for that same year was:

Echo: 4,311

Delta: 76,595

Charlie: 31,126

Bravo: 64,572

Alpha: 36,674

Non-Emerg: 25,775

Special operations

A close up of a CBRN medics ambulance

In addition to regular operations, Toronto EMS staffs a Special Operations Unit, tasked with the provision of EMS services in unusual circumstances. The elements of this unit include:

• Tactical Paramedics - Cross-trained paramedics providing medical support to the Toronto Police Emergency Task Force.
• Marine Paramedics - Cross-trained paramedics staffing the patrol vessels of the Toronto Police Marine Unit, in order to provide support for Toronto Police personnel, EMS services on the waters of Lake Ontario, and EMS service to the Toronto Islands.
• HUSAR - Specially-trained Toronto EMS paramedics operate together with elements of the Toronto Fire Services and Toronto Police Service to provide a joint-service Heavy Urban Search and Rescue team.^[11]
• CBRNE Paramedics (Chemical, Biological, Radioactive, Nuclear & Explosive) - Specially-trained Toronto EMS paramedics operate together with elements of the Toronto Police Service and Toronto Fire Services to provide a joint-service Terrorism / Hazardous Materials Response team.
• Public Safety Unit - Cross-trained paramedics providing medical support to the Toronto Police Riot Squad.
• Emergency Response Unit - Single paramedics in rapid response vehicles, tasked solely with response to high priority emergency calls.
• Bicycle Unit - Paramedics equipped with mountain bikes, capable of providing either BLS or ALS services in off road areas, or at special events.

Challenges

Toronto EMS operates in a system of universal health care, with no one being refused care because they cannot afford it. As a direct result, hospital in-patient beds and Emergency Departments tend to be severely overcrowded, resulting in difficulties for paramedics transferring the care of their patients to hospital staff in a timely manner. Two to four hour delays in the transfer of care are commonplace, and six to eight hour delays are not unheard of. When this occurs, the service's ability to provide service to emergency calls in a timely manner will often degrade, because of decreased unit availability. Multiple stakeholders and various levels of government are currently seeking solutions to this problem, but have, so far, experienced only limited success.^[12]

The funding for Toronto EMS occurs as a result of a mixed formula, with fifty percent of funding coming from the municipal tax base and fifty percent from the provincial government.^[13] The funding of Toronto EMS is based upon its residential population, not its business day population. As a result, there are always more people requiring EMS services than the system has been funded for.

Language barriers and cultural misperceptions in Toronto's multicultural landscape are commonplace for Toronto's paramedics. The service subscribes to Language Line, a simultaneous telephone-based translation service which operates in more than 140 languages.^[14] This service is used by Emergency Medical Dispatchers processing 9-1-1 calls, or by paramedics treating patients in the field, on a daily basis. The service also operates its own ethnocultural access program.

The 'Baby Boom' generation is aging. As it does so, all of those 'boomers' become net consumers of health care, driving up demand for services. Simultaneously, all of those 'boomers' employed by the service in the early 1970s are reaching the end of their careers and retiring. Since subsequent generations are typically much smaller, the service is experiencing difficulty in recruiting suitably trained replacement staff, just as demand for services is increasing.^[15]

Research

Over the years, the presence of such a large system and call volume, along with a commitment to consistently capture high quality data, has permitted Toronto EMS to become a 'test-bed' for research projects involving both EMS and emergency medicine. This has resulted in a service which is extremely research-oriented and interested in outcome-based medicine. While this has provided any number of research opportunities for physicians and emergency medicine residents through the Toronto Base Hospital program, it has also permitted paramedics to function as supporting and as lead researchers, and in some cases, as the principal researcher of their own projects.^[16] All research conducted at Toronto EMS is pre-approved by the University of Toronto Research Ethics Committee, and the findings of research conducted at Toronto EMS, by both physicians and paramedics, has been published in respected, peer-reviewed, international journals.^[17]

Community involvement

Toronto EMS paramedics are heavily involved in various community programs and partnerships. Toronto's paramedics are active participants in the community which they serve. At the 'grass roots' level, Toronto's paramedics and EMDs fund a children's breakfast club, ensuring a nutritious breakfast for the children who live in several of the city's housing projects. Paramedics also participate in a variety of other events in the community, including their enthusiastic (and occasionally successful) participation in the dragon boat races staged annually by the city's Chinese community.^[18] As another little known fact of community involvement by paramedics, all of the floats in the city's annual Santa Claus Parade (one of North America's largest), are driven by volunteers from Toronto EMS, including both paramedics and a variety of other staff.^[19]

See also

• York Region EMS
• Durham Region EMS
• Peel Regional Paramedic Services
• List of EMS Services in Ontario

References

1. ^ "Ambulance Act, R.S.O. (1990) (Law Society of Upper Canada website)". http://www.canlii.org/on/laws/sta/a-19/20080821/whole.html. Retrieved 2009-02-04. 
2. ^ "History (Toronto Police website)". http://www.torontopolice.on.ca/publications/files/misc/history/1t.html. Retrieved 2009-02-04. 
3. ^ "History of Toronto Emergency Medical Services (website)". http://www.torontoems.ca/main-site/about/history.html. Retrieved 2009-02-04. 
4. ^ "History of Ambulance Dispatching (website)". http://www.andrewjohnpublishing.com/Wavelength/Wave%20Volume%2020%20Issue%202/Wavelengthvolume20issue2AmbulancedispatchingpartII.html. Retrieved 2009-02-04. ^{[dead link]}
5. ^ "City of Toronto Act, R.S.O. (1997) (Law Society of Upper Canada website)". http://www.canlii.org/on/laws/sta/1997c.2/20030205/whole.html. Retrieved 2009-02-24. 
6. ^ "Advanced Care (Toronto EMS website)". http://www.torontoems.ca/main-site/about/history.html. Retrieved 2009-02-04. 
7. ^ ^{a b c} As reported by Toronto EMS in their Service Information Profile (internal document)
8. ^ "Paramedicine (Canadian Medical Association website)". http://www.cma.ca/index.cfm/ci_id/50602/la_id/1.htm#PARA-ON. Retrieved 2009-02-05. 
9. ^ "Medusa Technologies corporate website)". http://www.medusamedical.com/SirenOverview/Features.html. Retrieved 2009-02-05. ^{[dead link]}
10. ^ "Toronto achieves excellence in emergency medical dispatch (Toronto EMS website)". http://www.torontoems.ca/main-site/news/stories/cacc-accreditation.html. Retrieved 2009-02-04. 
11. ^ "Toronto HUSAR Team website". http://www.toronto.ca/wes/techservices/oem/husar/index.htm. Retrieved 2009-02-02. 
12. ^ "ED Overcrowding & Ambulance Offload Delay". http://web.management.mcgill.ca/verter/ED%20Workshop/Brian%20Schwartz.pdf. Retrieved 2009-02-04. ^{[dead link]}
13. ^ "EMS in Ontario Today (AMEMSO website)". http://www.emsontario.ca/about/ems.htm. Retrieved 2009-02-05. ^{[dead link]}
14. ^ "9-1-1=Emergency in any language (City of Toronto website)". http://www.toronto.ca/emerg/911.htm. Retrieved 2009-02-04. 
15. ^ Axworthy, Thomas (2007-04-22). "Canada's Looming Health Care Crisis (Toronto Star website)". The Star. http://www.thestar.com/comment/columnists/article/205571. Retrieved 2009-02-05. 
16. ^ "Toronto EMS and the Sunnybrook-Osler Centre for Prehospital Care take top honours at international EMS conference (City of Toronto website)". http://wx.toronto.ca/inter/it/newsrel.nsf/3257dc890938d23b85256dde005a446b/85db7b96532716ea8525717700635ac0?OpenDocument. Retrieved 209-02-04. 
17. ^ "The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity". http://www.cmaj.ca/cgi/content/full/178/9/1141. Retrieved 2009-02-04. 
18. ^ "dragonboats.com website". http://www.dragonboats.com/documents/DB09-sponpack.pdf. Retrieved 2009-02-04. ^{[dead link]}
19. ^ "Send in the Clowns". http://gapopensource.com/?p=242. Retrieved 2009-02-04. 

External links

• Toronto EMS - official Website
• Toronto Police Services
• Toronto Fire Services