The union representing ambulance paramedics is questioning how the provincial government allowed Vancouver and Surrey firefighters to begin injecting a life-saving drug into overdose victims.
Bronwyn Barter, provincial president of the Ambulance Paramedics of B.C., said the union was not properly consulted about the type of training for firefighters to administer naloxone, the protocols for handing off a patient at a scene or the medical evidence showing the need for firefighters to use the medication.
“I know a lot of people would like to characterize this as a turf war, when really there’s more going on, in our view, with the way that this was handled,” Barter told the Courier. “When we normally do something like this -- when we add a protocol or something -- there’s some work done to make sure everybody is safe, the patient’s safe, the people using the protocol are safe. And this never happened with this issue.”
In January, the B.C. government announced that firefighters in Vancouver and Surrey could use a syringe to inject naloxone, or Narcan, into overdose victims. The government, via a ministerial order from Health Minister Terry Lake, also expanded the number of paramedics certified to use the medication, which quickly reverses the effects of opiods such as heroin and fentanyl on the body by restoring breathing within two to three minutes.
That announcement came after the B.C. Coroners Service released a report the same month showing 465 people died in B.C. last year of an apparent illicit drug overdose, which was an increase of 27 per cent from the 366 people who died in 2014.
So far, Vancouver firefighters have administered naloxone nine times and their counterparts in Surrey used it eight times, said Vancouver Fire Chief John McKearney, noting 230 of his firefighters are trained to inject the medication.
“At the street level, I’m told by my staff that it’s positive, it’s not negative,” said McKearney of the firefighters’ relationship with paramedics when using naloxone. “In fact, there were a couple of instances where paramedics have arrived on scene where we hadn’t yet administered naloxone and they’ve said, ‘You just go ahead and keep doing it.’ So it’s working out quite well.”
No longer prescription drug
Linda Lupini, executive vice-president of the Provincial Health Services Society and B.C. Emergency Health Services, said she met with Barter and the union’s executive team in June of last year to discuss firefighters using naloxone. Lupini said the rationale for firefighters being equipped with naloxone was in reaction to the spike in overdose drug deaths. She noted Vancouver and Surrey account for more than 80 per cent of overdose drug deaths and that firefighters in Metro Vancouver are first to respond to emergency calls 70 per cent of the time.
Prior to firefighters using the medication, Lupini said, the B.C. Centre for Disease Control trained more than 6,000 people, including shelter workers, drug users and other health care workers on how to administer naloxone. The medication is also available in 160 clinics and is no longer a prescription drug.
“It’s understandable that [the paramedics’ union] prefer to have an increased head count in their own union with their own paramedics doing this work,” Lupini said. “But we have to look at this crisis and we have to say the most important thing to look at here is saving lives.”
Added Lupini: “The ambulance paramedics of B.C. are probably not ever going to support an expanding role for firefighter first responders. Because, in their defence, they want more paramedics, so that they can always get to the scene first.”
Barter wouldn’t provide a yes or no answer to the Courier when asked whether her union supported firefighters being equipped with naloxone, saying “they’re doing it now. It is what it is.”
Barter said she was never informed by B.C. Emergency Health Services about the ministerial order that allowed firefighters to use naloxone. Although Lupini said she sent Barter a text message around Christmas time informing her of the order, Barter said she never received it.
“In the past when there’s been a ministerial order, there’s been a lot of collaboration, it’s had the interested parties, it’s had firefighters at the table, it’s had the paramedics at the table, they involved the politicians,” Barter said. “But something was off about this ministerial order. It feels like there was a bit of a cart before the horse.”
Letter to city council
In a letter she wrote to Vancouver city council last week, Barter cited the World Health Organization’s recommendation for managing an opiod overdose. It says the primary focus should be “to address respiration and oxygenation,” including assisted ventilation with rescue breathing or bag and mask with supplemental oxygen.
“These are skills that first responders already have,” she wrote. “There is no evidence to indicate that patients in Vancouver died on scene as a result of naloxone not being given by fire first responders.”
She said administering naloxone to a chronic drug user can bring on symptoms of withdrawal, including a patient becoming combative, a rapid and significant change in blood pressure, increased heart rate and heart failure.
“A first responder has limited skills to adequately manage a patient experiencing sudden withdrawal symptoms,” she said in her letter.
That letter was read to council by paramedic Sophia Georgas, who is the union’s executive government liaison. Georgas raised concerns about how such a move by government to allow firefighters to administer naloxone could be seen as downloading costs and services on city taxpayers.
The cost of each ampoule of naloxone for Vancouver firefighters was $1.86. A complete kit, which includes retractable syringes, is under $5. All training, except for the initial instructor training done by Dr. William Dick of emergency health services, was done in-house.
Vancouver Coun. Geoff Meggs, who received a copy of the letter, said he recognized there is tension between paramedics and firefighters over the scope of practice for delivering emergency medical services. He pointed to B.C. Emergency Health Services decision in 2014 to downgrade 39 types of calls to routine that were once classified as emergency.
Waiting for ambulance
The result of that change, as told by Chief McKearney in a presentation to council in March 2014, was that firefighters – who are not as highly trained as paramedics and not allowed to transport patients to hospital – were responding to calls such as falls, assaults and motor vehicle accidents and waiting an average of 21 minutes for an ambulance to arrive.
“Municipalities pay for firefighters and the province pays for ambulance paramedics,” Meggs said. “So if there’s going to be a reallocation of duties, that’s fundamentally, in my view, a medical question and I would defer to the professionals on that. But I think that these medical services should be paid for under the medical services plan, not the property tax base.”
But, Meggs said, he supports the government’s decision to allow firefighters to administer naloxone.
“It’s a practical thing to do, they’re usually first on the scene,” he said.
Vancouver Police Chief Adam Palmer has told the Courier that he is interested in having his officers using the nasal spray form of naloxone, once it becomes available and is approved by Health Canada. Police departments in the United States use both the nasal spray and syringes.