British Columbia Ambulance Service

History

Prior to 1974, ambulance services in British Columbia was provided by a mixture of volunteer ambulance brigades, fire departments, funeral homes, and private operators. As a result of recommendations made by the Foulkes Commission's report on health care, titled "Health Security for British Columbians" released in 1973, the Government of British Columbia created the Emergency Health Services Commission (EHSC), which in turn created the BC Ambulance Service on July 4, 1974.

Governance

In British Columbia, responsibility for the provision of ambulance services is granted to British Columbia Emergency Health Services (BCEHS) under the auspices of the Emergency and Health Services Act. BCEHS reports to PHSA. The members of the Emergency Health Services Commission act as a Board of Directors to the BC Ambulance Service. The commission membership consists of health service administrators, medical professionals, and government representatives. BCEHS is also responsible for the operation of the BC Patient Transfer Network, which assists physicians when it is necessary to transfer a patient to a higher level of care.

The Emergency Medical Assistants Licensing Board is an independent regulatory body responsible for licensing Paramedics.

Organization

There are 183 ambulance stations in British Columbia, including the transfer fleet. Stations may be staffed with part-time paramedics, part-time and full-time paramedics, or only full-time paramedics, depending on where the station is located and the number of calls its crews are dispatched to. Each station is headed up by a Unit Chief, who acts as supervisor for the crew at the station. The Unit Chief also handles the day-to-day administrative duties required by the station, including payroll management, overseeing station and ambulance maintenance, and crew scheduling.

Each station falls under the responsibility of a District Superintendent. The District Superintendent has responsibility for the operations of all of the stations within a given district. The size of the district, and the number of stations it encompasses, varies depending on factors such as geography, station size and number of paramedics.

Each BCAS district is part of a larger region, which is headed by an Executive Director. Each District Superintendent is accountable to the Executive Director for that specific region. In some regions, a Director of Operations assists the Executive Director with day-to-day activities. The District Superintendents are accountable to the Executive Director of the region, who in turn reports to the Chief Operating Officer of the BC Ambulance Service.

The BCAS provincial headquarters is located in Victoria, BC. It is staffed by an executive management team, and other support services. The final responsibility for BCAS operations lies with the service's Chief Operating Officer. The Chief Operating Officer is accountable to the Executive Officer, BC Emergency Health Services, who in turn reports to the Board of BC Emergency Health Services.

Staff

As of November 2015, the BCAS employs 4,300 part-time and full-time paramedics and dispatchers. This includes management and administrative employees in the BCAS.

Emergency medical communication centres

The BCAS operates four Communication centres located throughout the province. The Vancouver Island Communications Centre (VICC), located in Victoria British Columbia is responsible for all ground ambulance deployment for Vancouver Island and the Gulf Islands; the Lower Mainland Region Ambulance Communication Centre (LMRACC) deploys all ground ambulances in the Lower Mainland (i.e., Metro Vancouver & the Fraser Valley Regional District), the Sunshine Coast, as far east as Boston Bar and as far north as Pemberton; and the Interior and Northern BC Communications Centre (INBCCC) deploys resources to the remainder of the province, including the southern interior (Okanagan, Cariboo & Kootenays) and northern BC (Skeena, Northern Interior & Peace Regions, representing west-central, east-central and northern areas of the province, respectively). The fourth Communication centre, the Provincial Air Ambulance Coordination Centre (PAACC), is located in Victoria and has responsibility for coordinating and deploying of all air ambulance resources, whether they are used for scene responses, or for inter-facility transfers.

Each Communication centre is staffed with a mixture of Emergency Medical Call Takers (EMCT) and Emergency Medical Dispatchers (EMD). The Vancouver Communication system is the largest of the four Centres. A Communication Supervisor who is a barganing unit member, provides line supervisory support to Communication centre staff, with a Director and a Communication Superintendent managing the centre. Other centres have a Charge EMD in the role of Supervisor, with a Superintendent managing the Centre. Training for EMCTs and EMDs is provided in-house by the BC Ambulance Service.

The BC Ambulance Service utilizes the Advanced Medical Priority Dispatch System (AMPDS) to triage calls and a customized Resource Allocation Plan (RAP) to allocate First Responders, Primary Care Paramedics, and Advanced Care Paramedics to calls as needed.

Within the Metro Vancouver region, BCAS utilizes the E-Comm Wide-Area Radio Network for one-stop communication between police and fire agencies.

Airevac response

The BCAS is responsible for the delivery of air ambulance services throughout the province of British Columbia. Critical care paramedics are deployed from bases in Prince George, Richmond, Kelowna and Kamloops, Nanaimo, Langley and Vancouver.

Each team is composed of two CCPs who transport all Adult patients and some pediatric patients. The Infant Transport Team (ITT) based out of BC Children's Hospital in Vancouver handles the critical care infant, child, and maternity transports. The ITT have completed advanced training and provide emergency medical care to pediatric, neo-natal and high-risk obstetric patients.

The BC Ambulance Service air ambulance fleet consists of six fixed-wing aircraft, five Beechcraft Super King Air 350 turboprops and one Cessna Citation Encore jet. Additional aircraft are chartered on an as-needed basis. The BCAS also operates four dedicated air ambulance helicopters, two based in Vancouver and one based in both Prince Rupert and Kamloops. BCAS also utilizes approximately 40 pre-qualified charter carriers throughout British Columbia.

Shifts

There are four different part-time shifts, and five main full-time shifts used at BC Ambulance stations. The two main part-time shifts are designated Kilo and Foxtrot, but Juliet and Mike are also used. The five full-time shifts are Alpha, Bravo, Charlie, Delta and Echo.

Full-time shift patterns

An Alpha shift pattern provides continuous coverage with one ambulance and is divided into two 12-hour shifts (0630-1830 & 1830-0630), or a 10-hour day-shift plus a 14-hour night-shift (0800-1800 & 1800-0800), depending on the station.

Bravo and Charlie shifts are 11 hours long, with Bravo starting in the morning (e.g., 0730-1830) and Charlie starting in the afternoon (e.g., 1300-0000). At busier stations, paramedics may work a Bravo/Charlie pattern where the first two days of the block are on Bravo and the final two days of the block are on Charlie; Charlie patterns are always supplemented by Bravo for peak coverage in the afternoon. Alpha, Bravo and Charlie patterns operate on a platoon cycle of four days on and four days off in a 56-day cycle. This means a 48-hour block for Alpha but, since it is over a period of eight days, averages out to a 42-hour work week. Similarly, for Bravo and Charlie, the block may be 44 hours in duration but the average work week is 38.5 hours.

Delta and Echo patterns differ in that they do not necessarily follow the standard platoon cycle of 'four and four'. Delta, for example, is on a 70-day cycle and provides a 35-hour work week, through various patterns. These shifts may be 12.5 hours long with a "four and six" pattern, a 7-hour shift on a standard Mon-Fri work-week or a 10-hour shift on a "four and three" alternating with "three and four" pattern. Lastly, a Delta pattern may be 10-hour shifts following the regular platoon cycle of "four and four". Delta patterns are almost exclusively reserved for Dispatch but are also used on two Transfer Fleet shift patterns (X-Ray and Uniform). An Echo shift, on the other hand, is 10 hours long and can start at any time during the day depending on the area's needs. If scheduled, it is usually a day shift at a smaller station and is reserved for a full-time Unit Chief and their partner. Echo is also the standard shift pattern for Transfer Fleet but these shifts are called different names according to start time. Echo patterns are typically Tuesday through Friday or Monday through Thursday, providing a 40-hour work week on a 56-day cycle.

Part-time shift patterns

Kilo shifts are strictly on-call and paramedics respond to a pager. A kilo-responding paramedic must answer a page by calling dispatch within two minutes but there is no requirement to arrive at the station within a set time. However, most on-call paramedics carry their uniform with them and do not engage in any activity that they cannot drop at a moments notice (including other employment obligations). Each Kilo call-out generates a minimum of four hours of pay, as long as the crew returns to the station before each successive call. The Kilo stipend, called "pager pay", is currently set at $2.00 per hour and is paid regardless of whether work is performed during the shift. There is no pager pay for working past the end of a shift, unless the same paramedic is scheduled for back-to-back kilo shifts. On-call paramedics are not expected to perform any duties and need not even be at the station until they receive a page out.

Foxtrot is a compromise between a full-time shift and a Kilo shift. Paramedic crews on this shift pattern are said to be on "standby" and are required to be in their ambulance within 90 seconds of the page or phone call, just like a regular full-time unit. The Foxtrot stipend is currently $11.67 per hour and is increased to the full hourly wage for a minimum of three hours when a call is dispatched to the crew. As with Kilo, the crew is not expected to perform any duties while on standby. Should a call come in, the crew is considered to be "activated" for 3 hours and is under the direction of your dispatcher for that time. Unlike Kilo, if another call is dispatched to the crew within those three hours, no further pay is accumulated. After the three-hour window or on returning to the station past the three-hour activation period, the crew returns to standby status until another call is dispatched.

Mike patterns are uncommon but they behave like Kilo cars that are pre-booked for transfers in busy regions or for event upstaffing so their shifts tend to be quite long and involve a lot of overtime. Scheduled Mike cars get $2.00 per hour Pager Pay.

Juliet shifts are 12-hours long and are normally prescheduled but may be authorized as a last-minute stopgap measure. They are staffed by part-time or irregularly-scheduled full-time paramedics and may begin at any time. Typically, Juliet shifts are used to up-staff a station or region in cases of expected high call-volume or to back-fill for a crew that has left on an airevac.

Transfer Fleet patterns

The Transfer Fleet that operates out of many Vancouver Post and Fraser Valley stations is used for routine and stat transfers. It is its own separate post, called B88 (B = 2, for Region 2). In principle, these units are meant to ease the workload of the Emergency Fleet and ensure those are available for emergency calls. At the inception of the Transfer Fleet, all units were designated Tango but they are currently called by different names, depending on their start time. With some exceptions, their shifts follow the Echo pattern, as outlined above. Notably, Papa imitates the Bravo pattern, as it is an 11-hour shift on a platoon cycle.

In smaller posts, Kilo is first choice for transfers so that the duty car (Alpha, Bravo, Charlie, Echo or Foxtrot) can be available for emergencies. In practice, the duty car may be used for short transfers within the normal response area, especially if Kilo (or Foxtrot) are occupied.

Training

Paramedics in BC obtain their initial training before employment by pursuing either their EMR or PCP License at their own cost.

EMR training is available through a variety of instructional agencies throughout the province. EMR courses that are approved by the EMA Licensing Board include those offered by the College of the Rockies, Paramedic Academy of the Justice Institute of BC (JIBC), St. John Ambulance SJA, the Academy of Emergency Training, EMP Canada, First Aid Certified Training Systems, Vancouver Island University Centre for Continuing Studies and Okanagan College Continuing Studies.

Primary Care Paramedic training is offered by the Paramedic Academy under the School of Health Sciences at the Justice Institute of BC. Advanced Care Paramedic training is only available through the Paramedic Academy.

All ITT and CCP training is conducted 'in-house' by BCAS Clinical Education Division in conjunction with BC Women's, BC Children's, Vancouver General, St. Paul's hospitals and BCIT.

The EMA Licensing Board maintains a list of approved training agencies available to potential students. Those students who do not complete one of the approved courses will not be permitted to apply for a licensing examination.

Clinical Education is the Division of BC Ambulance Service that provides Paramedic development once a Paramedic has been hired. The main goal of the Clinical Education Division is to support the delivery of quality patient care through curriculum development and course presentation. A new employee can expect to be offered about 11 courses of paid training in their first six months of service. These courses may include:

In addition, new employees must pass a driving preceptorship prior to being allowed to drive Code 3 (lights & sirens). BCAS fosters an environment of lifelong learning and offers a combination of face-to-face and online educational opportunities for Paramedic development.

Licensing and qualifications

Paramedics qualified in British Columbia are broadly referred to as Emergency Medical Assistants and are licensed by the Emergency Medical Assistants (EMA) Licensing Board (EMALB), a government regulatory agency, under one of five categories:

EMR and PCP are Basic Life Support (BLS) qualifications while ACP is an Advanced Life Support (ALS) qualification; ITT has some pediatric advanced protocols; CCP has a whole different scope of practice. BCAS treatment guidelines are universal, which a qualified practitioner may employ at any time, up to his or her license qualification, within the provincial borders, given that the required equipment is at hand. Licencing qualifications and endorsements can be found in the EMA Regulations under Schedule 1 and Schedule 2.

Emergency medical responder (EMR)

An EMR licensee is qualified to deliver a limited number of medications, under the class of 'symptom relief', including ASA, Nitrous Oxide, Nitroglycerin SL and oral Glucose. They are also qualified in the use of an Automated External Defibrillator (AED) and may monitor an existing IV line. Their protocols include Cardiac Arrest, Cardiac Chest Pain, Diabetic Emergencies and management of pain using Entonox. The "Schedule 2" endorsements appear as "Symptom Relief" and "IV Maint".

Schedule 1 - EMR Licence Qualifications:

Schedule 2 - EMR Licence Endorsements:

Primary care paramedic (PCP)

The vast majority of Paramedics in BC practice at this level.

In addition to the EMR guidelines, PCP licensees have treatment guidelines for Shortness of Breath (SOB), Anaphylaxis, Narcotic Overdose, an expanded Diabetic Emergencies and a catch-all for patients with a decreased level of consciousness Not Yet Diagnosed (NYD) that combines the Diabetic/Hypoglycemic and Narcotic OD guidelines. PCP-qualified paramedics may also be endorsed for intravenous cannulation (PCP-IV) and will have an additional guidelines for Hypovolemia as well as enhancements to the anaphylaxis, diabetic, narcotic OD and NYD guidelines. Additional PCP-level medications include Salbutamol (Ventolin), Naloxone HCL (Narcan), Glucagon, Epinephrine HCL (Adrenaline), Diphenhydramine (Benadryl), Thiamine (Betaxin)(thiamine has been removed as treatment), Dextrose 10% (D₁₀W), TXA, Dimenhydrinate and Normal Saline. BCAS Medical Leadership has introduced 'Treatment Guidelines', which is a more generalized framework within which paramedics can operate with more flexibility and clinical decision making.

The "Schedule 2" endorsements appear on the PCP licence as "IV" or "ET". Normally, an ET endorsement is not awarded unless the paramedic practitioner has voluntarily downgraded from ACP to PCP and there were no previous issues with field intubations. At this point, the PCP-ET would simply have an adjunct to assist in Cardiac Arrest management. With increased labour mobility between the provinces, some paramedics from other jurisdictions will see restrictions such as for Narcan, Thiamine, Antihistamine or Entonox. Former EMA 2 Paramedics will also see an IM restriction since they were not technically trained how to perform an intramuscular injection.

Schedule 1 - PCP Licence Qualifications

Schedule 2 - PCP Licence Endorsements

Infant Transport Team (ITT)

ITT paramedics are specifically trained for critical care of perinatal, neonatal and pediatric patients. They respond as an equally qualified team of two and sometimes take a physician with them for critically ill patients. When dispatched on street calls these are targeted response ambulances that often assist or intervene when necessary, but can hand a more stable patient off to a layered or co-responding PCP ambulance. The team currently consists of only 26 specially trained paramedics for the entire province.

In addition to the PCP protocols and medications, they may also administer Acetaminophen, Adenosine, Atropine Sulphate, Calcium Chloride, Dextrose 50%, Dimenhydrinate (Gravol), Hemabate, Indomethacin, Lorazepam, Magnesium Sulphate, Midazolam (Versed), Morphine Sulphate, Ondansetron, Oxytocin, Sodium Bicarbonate and Out-of-Scope medications with orders from a CCTA. ITT paramedics have their own unique set of prehospital treatment guidelines that mirror ACP guidelines in the areas of pediatrics, having the ability to treat respiratory/cardiac arrest and disrhythmias. The ITT practitioner also has adult ACLS guidelines and intubation in the event they encounter an adult cardiac arrest.

Their additional training and skills include the use and monitoring of Incubators, Endotracheal (ET) Intubation, Intraosseous (IO) Access, nasogastric (NG) tube insertion and suctioning, manual defibrillation, cardioversion, chest decompression, Venous pressure monitoring, Arterial & Central Line Monitoring, Chest Tube Management, transthoracic pacing, Blood Product Infusion, IV Infusion Devices, 'IV with Medication' Maintenance, Mechanical Ventilation (using the LTV 1000 and 1200 and BMD CrossVent), Foreign body removal with laryngoscope, ET/IO/PR drug administration, Central & Parenteral Line Management, Venous & Arterial blood sample collection, point of collection analysis of ABG's and chemistry using the I-Stat, Lab & X-ray interpretation.

The ITT paramedics also transport pediatric and adult ECMO (Extracorporeal Membrane Oxygenation) patients with a perfusionist from BC Children's.

While there are some areas of overlap between ACP and ITT, the additional ITT 'Airevac' class of skills that are not included in the standard ACP skill-set are Venous Pressure Monitoring, Arterial & Central Line Monitoring, Chest Tube Management, Blood Product Infusion, Mechanical Ventilation, nitric oxide delivery systems and Out-of-Scope Medications by orders.

Schedule 1 - ITT Licence Qualifications

Schedule 2 - ITT Licence Endorsements

Advanced care paramedic (ACP)

Although there are relatively few ACP-staffed ambulances compared to PCP, the majority of the population is covered by ALS service. These are targeted response units with two ACP-qualified paramedics. They are able to defer transport of a more stable patient to a layered or co-responding PCP ambulance. This ensures that most patients have access to ACP but that the resource is not tied up on a call they are not needed on. It also ensures that ACP-qualified paramedics treat a "critical mass" of the most acutely ill patients, thereby maintaining their high skill level.

ACP paramedics have protocols to administer all PCP plus Adenosine, Calcium Chloride, Dextrose 50%, Dimenhydrinate (Gravol), Ipratropium Bromide (Atrovent), Lidocaine, Morphine Sulphate and Amiodarone (Cordarone). Their additional skills include synchronized cardioversion, airway isolation devices, endotracheal intubation, end-tidal CO₂ monitoring, external jugular vein cannulation, transcutaneous pacing, IV colloid/crytalloid volume expanders, nasopharangeal airways, needle thoracentesis and surgical or needle cricothyrotomy.

Schedule 1 - ACP Licence Qualifications

Schedule 2 - ACP Licence Endorsements

Critical care paramedic (CCP)

CCPs are paired in British Columbia.

To become qualified at this level, experienced ACP paramedics take further training consisting of a portion of the CCRN program through BCIT, followed by an intensive hospital-based program through St. Paul's Hospital. Next, there is a work experience portion, and finally, CCP licensure. Formerly, an ACP could take a much shorter course and receive a "Full Schedule 2" endorsement.

CCP's have standard operating guidelines for common critical patients; SIRS/Sepsis, RSI, Chest decompression, Ventilation strategies using the LTV 1000 and 1200, ACS and coronary care, etc. CCP paramedics sometimes take an intensivist with them, but consult with Critical Care Transport advisors.

CCP qualifications follow the NOCP guidelines as endorsed by the Paramedic Association of Canada. In addition to standard ACP protocols, the CCP can perform Schedule 2 ACP skills and procedures as well as administer virtually any medication following assessment and consult with the Critical Care Transport Advisor (CCTA). CCTAs are essential to both the air-evacuation and ground critical care transport programs.

Schedule 1 - CCP Licence Qualifications

Schedule 2 - CCP Licence Endorsements

Labour Mobility

With the introduction of the Trade, Investment and Labour Mobility Agreement (TILMA), the process of transferring one's license between provincial jurisdictions has been streamlined.

Hiring process

The basic requirements to become employed by the BCAS as of August 15, 2007 are:

At this time, EMR-qualified staff are only permitted to work in remote and rural stations and must upgrade to PCP if they wish to further their career with the BCAS, including lateral transfers to an Urban or Metro-designated station on a part-time basis or application for a full-time posting. The exceptions to this rule include applications to one of the Dispatch Centres or to the Metro Vancouver Transfer Fleet, both of which require only an EMR qualification; these are internal applications for current BCAS employees only.

The interview consists of a behavioural interview with a panel of two to three Unit chiefs (and may include a Regional Superintendent or HR personnel) and is approximately 1 hour long. It may be held at a regional Human Resources office or at a given ambulance station where the applicant is under consideration. The interview follows the STAR (Situation, Task, Action, Result) format. After an applicant completes the interview he or she will not find out the results for another 1–3 months. If unsuccessful at the interview stage, the applicant may be told he or she cannot re-apply for a period of 6 months.

If the applicant passes the interview, they are entered into the hiring pool and ranked according to their score on the written exam and interview. From this point, the prospective employee may be contacted by a Unit chief that is hiring. After passing the interview stage, a physical fitness assessment, a medical assessment and two criminal record checks will be conducted. Assuming all goes well, the applicant is then hired into the service at a specific ambulance station, called a 'primary operator'. Once issued an employee number, they are deemed eligible to work and the employee enters into a six-month probationary period. If the applicant is hired as underqualified (i.e., hired without a Class 4 driver's license or other specific training), conditions of probation may be imposed such that the person must obtain certain qualifications before their probation is up or they may be released from the service. During probation, a paramedic may not move to another station (called a lateral transfer) or work at any other BCAS station (often called working at a 'secondary operator'). The probationary period may be extended at the discretion of the Executive Director; this requires both the signature of the Unit Chief and the District Superintendent, as well as notification to the individual prior to the extension.

Rank and qualification insignia

The BC Ambulance Service is a uniformed organization and as such, has a similar rank structure to most police or fire departments. The medical qualifications of a uniformed member are denoted with collar insignia, commonly known as 'collar dogs', while rank is denoted using epaulettes. Excluded management and administrative employees in regional offices and provincial headquarters do not wear uniforms.

Current qualifications designated by collar dogs include EMR, PCP, ACP, ITT, EMCT and EMD. The EMR and PCP levels are shown on bronze and silver circles, respectively, forming the BCAS logo, along with a circumform bar below, denoting the EMR or PCP qualification. ACP and ITT (Infant Transport Team) paramedics are recognized with gold cauducei, with either "ALS" or "Neonatology" imprinted upon them. CCP (Critical Care Paramedics) have a gold coloured shield with blue star of life and CCP on it. Within the Communication Centres, EMD (Emergency Medical Dispatcher) and EMCT (Emergency Medical Call Taker) are designated by gold and silver shields, respectively.

For rank insignia, Paramedics and dispatchers who hold the position of Unit Chief or Charge Dispatcher wear a black epaulette with three gold stripes. District Supervisors and Dispatch Supervisors wear the same coloured epaulette with four gold stripes while Dispatch Officers wear two gold stripes. Ranks above District Supervisor are management positions and are distinguished by a varying number of pips on their epaulette. District and Platoon Superintendents wear an epaulette with three pips, Managers wear one pip and one crown, Directors wear two pips and one crown and the Executive Director of a region will wear three pips plus a crown. Each station and dispatch centre has a staff member designated as its Occupational Safety & Health (OSH) representative. These paramedics and dispatchers are identified with a black epaulette with a single royal blue bar. Staff who are designated as OSH representatives hold no supervisory authority, but are available to assist staff with safe work practices. BC Ambulance instructional staff wear a black epalette with the word "INSTRUCTOR" embroidered in gold, facing laterally.

Shoulder flashes for field staff arenavy blue with a navy blue trim, and include the British Columbia Coat of Arms, with the words "Ambulance" above, and "British Columbia" below, both in white.

Other pins and insignia

Labour relations

Ambulance paramedics, emergency medical call-takers, and emergency medical dispatchers are members of the Ambulance Paramedics of British Columbia (APBC) Local 873 of the Canadian Union of Public Employees (CUPE). Provincial headquarters and administrative staff are members of the British Columbia Government Employees Union (BCGEU).

Community involvement