An Impossible Scenario

Can you imagine if the Montreal police depended on private placement agencies to staff its patrol cars? 

Or had to request, on a daily basis, help from police forces in the Laurentians, Lanaudiere and the Monteregie to respond to calls on its territory. Or what if the fire department routinely had dozens of 911 calls on hold, creating such a bottleneck that buildings might burn for hours before a team of available firefighters would be able to reach them?

Both scenarios are, quite frankly, unimaginable because they would be indicators that each of those essential public safety agencies couldn’t fulfill its primary mission. In this life and death crisis, steps would immediately be taken to address the situation. 

And yet, that’s exactly the situation confronting Urgences-santé, the government-owned and managed corporation which has a monopoly on providing ambulance service for all of Montreal and Laval. 

LOCAL JOURNALISM: NOT DEAD YET

When every day is a crisis

Urgences-sante relies on their emergency measures plan in order to keep as many paramedics on the streets as possible – even if that means cutting their meal breaks and extending their shifts with mandatory overtime and extra calls.

While Urgences-santé has as its mission to respond to, care for and transport people in all forms of health-related emergencies, the corporation itself is supposed to be relatively crisis-resistant.

As data released via an Access to Information request by The Last Ambulance indicates, Urgences-santé has been in operational crisis mode almost every day since the beginning of 2024.

Urgences-santé has something they refer to as their Protective Measures Plan which is triggered when the number of people who need help outpaces the number of paramedics on the streets – and the number of emergency medical dispatchers needed to triage all those calls based on priority. 

The Protective Measures Plan or, as it is known familiarly, MAP is designed to protect the organization from collapsing under the weight of the mission it was created to fulfill. The MAP was established as a tactic of last resort to be pulled out of the metaphysical toolbox that resides in the Operational Command suite next to, presumably, a whole lot of real-time data used to monitor the vital signs of the organization.

MAP is supposed to be triggered when Urgences-santé is in critical need of placing as many paramedics on the streets as possible. An Operational Commander analyzes the situation-at-hand and decides to implement MAP. MAP 1 means that the corporation can cancel personal, union, and administrative leaves – as well as recalling paramedics who were assigned to other tasks, e.g., teaching their peers at the training center.

It is during MAP when paramedics from the lower Laurentians and in the Lanaudiere region respond to calls in Laval while their counterparts from the South Shore respond to calls on the West Island.

MAP 1 is supposed to mean all-hands-on-deck or battle stations or whatever terminology you can imagine that would bring a large organization to a ready alert status and focus all of its energies on ensuring it fulfills its mission.

During the month of January 2024, Urgences-santé was in MAP 1 mode a stunning 36 times. On January 7th, the organization was in crisis mode for 13 hours and 32 minutes. On Jan. 8, the number of hours in MAP 1 (with a brief 13-minute stint in MAP 2) rose to 20 hours and 2 minutes.

“For MAP level 1, it doesn’t affect me much. It’s so frequent that it’s business as usual in my head,” one paramedic told me on the condition of being cited anonymously. 

If you’re wondering about just how frequent an emergency plan would need to be deployed that it has become ‘business as usual’ for a paramedic, MAP mode was implemented 126 times from Jan. 1 through March 14th, 2024. There were 74 days in that time period.

On Feb. 9, 10 and 11, Urgences-santé was in crisis mode 99.9% of the time. All day – 24 hours a day – for three consecutive days.

On Feb. 16 and 17, it happened again. Urgences-santé was in MAP mode 99.9% of the time for two consecutive days. On Feb. 18, they managed to squeeze in 47 minutes of normal operations and finished the day having been in crisis mode 97% of the time.

How MAP is implemented remains a mystery to the paramedics in the employ of Urgences-santé.

“If I had to summarize it in one word, it would be frustration,” another paramedic, speaking to me under condition he remained anonymous.“There’s no consistency as to when the MAP’s are applied. There are times where we will be running with 20, 30, 40 plus calls waiting and no vehicles available and where no MAP has been triggered. 

“Other times we will remain in a MAP 2 situation with four Priority 7 calls, a series of transfers, and maybe a priority 3 call waiting. There’s no clarity from management as to why certain situations require or not the application of a MAP.” 

MAP 2 is triggered when MAP 1 isn’t enough and there are significant delays for high-priority calls.

When MAP 2 is implemented, Urgences-santé unilaterally reduces the duration of meal breaks to 30 minutes for 10 and 12-hour shifts. This, in theory, is designed to increase the availability of resources. Of course, paramedics themselves are only one element in a complex system which goes into cascading failure mode when it is overtasked – which is a frequent occurrence.

In January 2024, Urgences-santé triggered MAP 2 a total of nine times. In February, the number of times MAP 2 was implemented jumped to 20. From March 1 through the 14th, MAP 2 was implemented once.

The lengthiest period in MAP 2 on a single day occurred on Jan. 11 with more than eight hours in MAP 2 and two hours in MAP 3 (morethat later). On Feb. 17, Urgences-santé spent six hours and 44 minutes in MAP 2 mode. And on Feb. 9 and 10, the organization was in MAP 2 mode for more than 12 consecutive hours.

“Well, I’ve experienced all three forms of MAP. Nobody cares anymore about MAP 1. We’re always in it,” a paramedic told me on the condition of anonymity. “It doesn’t necessarily affect us, and it’s a bit like the boy who cried wolf. MAP 2 pisses us off. I only get 30 minutes of break on a 12-hour day. Most of the time, we’re in MAP 2 because of low-priority calls that stack up.”

One of his colleagues added, “It’s more at the MAP level 2 that the frustration is well palpable since it’s often activated at specific times to target the (lunch) of certain shifts. Thirty minutes of break is really little time to eat and try to relax. Even worse if we’re in the middle of nowhere with a meal to heat up. 

The implementation of MAP also has an outsized impact on the emergency medical dispatchers who handle each of the calls coming in via the public or the health care system.

“The atmosphere is more tense, and it’s more stressful,”said an emergency medical dispatcher speaking on condition of anonymity. “Sometimes there are disputes between dispatchers because we have to manage the thousands of calls, radio waves, talk to (fire service), the (police), call back to the scene because patients don’t respond (when the paramedics arrive), find patients when they’re outside, etc. 

“When we’re in MAP … the territory (we cover) is larger, and the calls are more numerous,” one dispatcher said. “Regarding call-taking, we have to hang up quickly with the callers because we see that there are calls waiting. Calls are not always compliant because of this. Information is often missing, so dispatch has to call back, and that adds more work. 

“Paramedics are not always kind and understanding, it’s difficult. We are surprised when we’re not in MAP.” 

MAP 3 is catastrophic. 

MAP 3 means that the demand for services has far outstripped the availability of resources and that demand continues to deepen. Fortunately, the number of times MAP 3 is triggered over a year can be counted with the fingers on one hand.

From Jan. 1 through March 14, there was only one period of MAP 3 at Urgences-santé. That occurred on Jan. 11as the organization plunged into a crisis unable to keep pace with the hundreds of calls coming in after the city was coated in ice.

For paramedics, however, how Urgences-santé decides to implement MAP 2 or MAP 3 remains a mystery and is the source of deeply felt frustration.

“MAP 3 is a different beast. It’s rare, but when it happens, it’s one of two things: either a major catastrophe that everyone is ready to deal with and that we recognize as part of the job,” said a paramedic who wished to remain anonymous. “Or it’s total crap and just tons of Priority 3 calls, most of which are upgraded low-priority calls that waited too long, or the call volume is too high, and Emergency Medical Dispatchers can’t evaluate, so all calls become Priority 1, which increases the amplitude of the vicious circle. 

“Last time, it was an insult. We were basically told: ‘Here’s your 16-hour shift with a legal 30-minute break. It doesn’t matter that you have a life, a family, or anything outside of work. You’re our prisoner and do what you’re told.’ It was really pathetic. 

“I’ve only experienced MAP 3 once, but in my opinion, once is too much. It just shows how much the prehospital system is struggling in the metropolis and generates a lot of frustration among the teams who see their end-of-shifts canceled.”

How many paramedics are actually on the streets?

This is the latest request for paramedics available to work shifts that remain unfilled at Urgences-santé: 

Active paramedics vs employed paramedics 

There is a lack of transparency when it comes to Urgences-sante reporting the number of paramedics on parental leave, sick leave or assigned to activities other than patient care. 

The number of active paramedics impacts the ability of Urgences-sante to deliver all of the hours of service authorized and financed by the provincial government. But Urgences-santé’s reporting doesn’t indicate the real depth of the shortage of paramedics.

In its 2020 annual report, Urgences-sante reported that only 750 of its 1002 paramedics were active. All subsequent reports no longer make the distinction between active and inactive employees. By merely including the total number of employees, they give the impression there is no staffing crisis (highly unlikely, but hey, if no one is looking, it’s all good).

On April 2, I asked Urgences-sante:

Could you tell me the number of paramedics employed by Urgences-santé for each of the following years: 2022 and 2023?

Can you tell me the number of active paramedics* for each of these years? *’Active’ defined as being assigned to patient care and not on parental leave, CNESST, sick leave, or assigned to other activities within the organization. It would be nice if, rather than an exact number, you could tell me what percentage of paramedics were inactive for each of those years.

On April 10, Urgences-santé responded: 

“Here is a document that was produced as part of the 2024-2025 credit study. There are no percentages with inactive employees but it contains the most recent figures for our staff, by employment category.”

The total listed for paramedics is 1015.3 — broken down as 860.9 full-time paramedics and 154.4 part-time paramedics. 

On April 11, I replied to Urgences-sante : 

Unfortunately, this is not the information I requested and I do not believe that it reflects the reality of staffing at Urgences-santé. Because if all the paramedics employed by the company were actively involved in patient care, the contracts that Urgences-santé signed with — (how many are there now?) — private employment agencies wouldn’t be necessary.

And there’s the rub.

Urgences-sante has multiple contracts in place with private placement agencies – and some of those contracts have been in place for more than a year, because they do not have enough active paramedics to staff all of their shifts.

Perhaps it’s time for a thorough investigation into the management practices of the largest ambulance service in Quebec.