It’s not about the destination, it’s about the journey. Or is it?

Trina Larsen Soles, MD

I like to travel. I like to drive and I like to fly. From the airplane I like to look down on snow-covered mountain peaks, deep valleys, mountain passes, and little winding roads. But travel isn’t always reliable. Bad weather can be notorious for causing flights to be canceled or road conditions to be treacherous. For me, the worst that can happen in these situations is that I need to cancel a meeting or event, or I arrive late. But what if the journey is time-sensitive—a life or death situation? What if we’re talking about the challenge of moving a critically ill or injured patient from a location that can’t provide definitive care to one that can? All of a sudden the terrain isn’t a beautiful view from above, but rather a transportation challenge where travel delays aren’t just inconvenient, they’re possibly fatal.

Red transfers are classified as those involving life or limb-threatening conditions. In rural communities the issues and processes around red transfers have been identified as some of the biggest stressors that rural physicians face. Dealing with any serious illness or severe trauma is stressful for most physicians, but particularly so when you practise in a low-resource environment and such cases are infrequent. The basic approach is the same—assess, resuscitate, stabilize, and arrange for definitive care. But the last item on that list generally involves a journey by either ground or air ambulance to a tertiary care hospital, and this is where we run into trouble.

Identifying the preferred destination and convincing them to take your patient is only the first step, and often there is a major impediment. We all know our hospitals are constantly overcapacity. Most often this overcapacity isn’t due to very sick patients, but rather those who can’t go home and are awaiting other sorts of arrangements. Many health authorities have developed no-refusal policies for the extremely ill, and this is a crucial requirement if we are to develop a truly patient-centred health care system. But it still takes too long to find an accepting hospital, delaying transfers in a dangerous way.

The second problem is access to and availability of the proper mode of transport and the personnel to physically move the patient from point A to B. Our ambulance system works extremely hard with the resources it has, but there aren’t enough planes in the right places, enough helicopters, or enough ground ambulances to move all the patients quickly and efficiently. We also don’t have enough of the right paramedics and other transport personnel in the right places at the right times.

A review published by the Applied Policy Research Unit at UBC analyzed best practices and generated suggestions for an evidence-based reorganization of the system. The work was supported by the Rural and Remote Division of Family Practice and the Rural Coordinating Centre of BC, both of which are funded through Doctors of BC and the Ministry of Health. Several ongoing projects arose from this work, one with Northern Health and BC Emergency Health Services, and a Rural Patient Transfer and Transport Working Group that reports to the Ministry of Health Select Standing Committee on Population Health Services. The Community Paramedicine Program is another program designed to address some of these needs. So while much work is in progress, only time will tell if the commitment to changing and improving the system in BC produces visible results.

Trauma and extreme illness are unpredictable. Too much of our health care planning involves implementing resources and personnel to the bare minimum required. It is done because of cost constraints and because in our publicly funded system we have a responsibility to account for the spending of taxpayer money. But in health, ultimately, this is a false economy. Timely initial treatment is crucial for potential recovery. The slower our response and the more delays in treatment, the more it costs us in actual health care dollars and in human suffering downstream. When it comes to patient care, the journey needs to be seamless, skilled, and efficient, because the destination matters if we are to provide the right care at the right place at the right time for all citizens in British Columbia.

As this is my last BCMJ President’s Comment, I want to say that the job of president has been an amazing journey. I want to thank you all for giving me the opportunity to travel with you this year. Together we can make these journeys for our patients better and work to transform the health care system in BC to one we can all be proud of.
—Trina Larsen Soles, MD
Doctors of BC President