British Columbia Ambulance Service

The British Columbia Ambulance Service (BCAS) is the sole ambulance service and provider of pre-hospital emergency care in the province of British Columbia, Canada, and is one of the largest Emergency Medical Services (EMS) services in North America. The BCAS also provides inter-facility patient transfer services in circumstances where a patient needs to be moved between health care facilities. The BCAS has a fleet of over 450 ground ambulances operating from 190 stations across the province. Dispatch centers in Vancouver, Victoria, and Kamloops provide call-taking and ambulance dispatching services to the entire province. In addition, BCAS operates an airevac program that utilizes both fixed-wing and rotary aircraft. As of September 11, 2007, the BCAS employs 2,008 part-time paramedics and 1,396 full-time paramedics for a total of 3,404 paramedics. These figures include paramedics that work in dispatch and on the transfer fleet, but do not include upper management. There are approximately 315 management employees in the BCAS.

History
Prior to 1974, ambulance services in British Columbia were generally uncoordinated. Service 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" and 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 ambulance services is granted to the Emergency and Health Services Commission (EHSC) under the auspices of the Health Emergency Act. Under the terms of the Act, the EHSC is considered an agent of the government and as such, holds all responsibility for the provision of ambulance services across the province. The members of the 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. The commission meets regularly to provide direction to the BCAS Executive Management Team.

The EHSC has recently taken over responsibliity for the operation of HealthLines Services BC (HLSBC). This includes the BC NurseLine telephone triage service (separate from 9-1-1 services), BC BedLine, which assists physicians when it is necessary to transfer a patient to a higher level of care as well as BC HealthGuide, BC HealthFiles, BC HealthGuide OnLine, and Dial-A-Dietitian.

While the EHSC, and consequently the BCAS, are agents of the government and are able to operate independently, in practice they are part of the BC government's Ministry of Health, which provides one-hundred percent funding for operations.

Organization
There are 190 ambulance stations in British Columbia, including three seasonal stations and 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. Each station is headed up by a Paramedic Chief, who acts as supervisor for the crew at the station. The Paramedic 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, number of paramedics and others.

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.


 * Vancouver Island Region (Headquarters: Victoria, BC)
 * Lower Mainland Region (Headquarters: Vancouver, BC)
 * Interior Region (Headquarters: Kamloops, BC)
 * Northern Region (Headquarters: Prince George, BC)

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, Emergency & Health Services Commission, who in turn reports to the Board of the Emergency & Health Services Commission.

Dispatch Centres
The BCAS operates four dispatch centres located throughout the province. The Victoria Communications Centre is responsible for all ground ambulance dispatching for Vancouver Island and the Gulf Islands; the Vancouver Communications Centre dispatches 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 Kamloops Communication Centre dispatches crews 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 dispatch centre, the Provincial Air Ambulance Coordination Centre (PAACC), is located in Victoria and has responsibility for dispatching of all air ambulance resources, whether they are used for scene responses, or for inter-facility transfers.

Each dispatch centre is staffed with a mixture of Emergency Medical Call Takers (EMCT) and Emergency Medical Dispatchers (EMD). A Dispatch Supervisor provides line supervisory support to dispatch centre staff, with a Director of Communications and Dispatch Superintendents who manage the dispatch 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 classify calls and dispatch resources.

To report a medical emergency, dial 9-1-1, the emergency telephone number in British Columbia. When dialed from a land line or mobile phone (excluding satellite phone and VoIP service), your phone number and address will be provided to the EMCT and EMD. In the case of cellular phones, only your phone number will be made available, although GPS technology will soon make it possible to locate the nearest cell site and possibly your exact co-ordinates.

Deployment
The current system designates a given station (or 'Operator') as either Metropolitan, Urban, Rural or Remote. A Remote-designated station typically has a call-volume of less than 500 calls per year and is staffed entirely by part-time EMR and PCP-qualified paramedics; Rural-designated stations usually have a range between 500 to 2000 calls per year and may have a full-time or part-time Paramedic Chief and might also have a full-time shift pattern for four full-time paramedics during daytime hours. Urban-designated stations generally have call volumes greater than 2000 calls per year and may range up to and over 10,000 calls. A 'Post' is a station or group of stations that are grouped together based on operational needs. The basic difference between Urban and Metro is that metropolitan posts consist of groups of neighbouring urban posts, each of which has a very high call volume; for example, every station in Vancouver Post is designated Metro. When a post incorporates more than one station, it functions as a unit for the purposes of irregularly-scheduled paramedic deployment (including part-time paramedics attached to the post).

In larger Urban and Metro-designated posts, including stations in Metro Vancouver, the Fraser Valley Regional District (i.e., Abbotsford and Chilliwack), Victoria, Nanaimo, Kelowna, Kamloops and Prince George, ground ambulance service is provided by a mix of PCP and ACP-qualified paramedics. In smaller Urban-designated posts (such as Cranbrook, Nelson, Prince Rupert, Terrace, Fort St John, Vernon, Salmon Arm, Penticton, Campbell River, Port Alberni, Squamish, Whistler, Powell River, Sechelt, Williams Lake and Quesnel) there is a core of four to eight full-time, regularly scheduled paramedics at the PCP level but there is also a heavy reliance on part-time, irregularly scheduled paramedics who are also trained to the PCP qualification. These auxiliary staff traditionally rely on paged call-outs and need not stay at the station but should remain in relatively close proximity in case of a call.

The first step toward a Metro designation (from Urban) requires a population base of 70,000 to 80,000 people. This will maintain a call-volume around 10,000 calls per year and will warrant the addition of Advanced Life Support (ALS) resources to the station (e.g., Chilliwack). The next step would be to split the calls between two separate stations serving a single community (e.g., Kelowna, Kamloops, Prince George & Nanaimo). Finally, as in the case of Abbotsford, when the call volume for the two stations combined reaches in excess of 20,000 calls, the station is re-designated as a Metro Post. When there are enough Metro Posts in a given region, they are reorganized into a larger comprehensive post like Metro Vancouver or Greater Victoria. This will likely be the case for the Fraser Valley Regional District; that is, Abbotsford, Chilliwack, Mission, Agassiz and Hope may well become a 'Fraser Valley Post'; Kelowna and Nanaimo may not be far behind.

Air Ambulance
The BCAS is responsible for the delivery of air ambulance services throughout the province of British Columbia. There are four dedicated air ambulance bases in BC, located in Richmond, Kelowna, and Prince George at their respective airports (YVR, YLW, & YXS) while the Infant Transport Team (ITT) is based out of BC Children's Hospital in Vancouver. ITT paramedics handle all of the high-risk infant, child, and maternity transports that take place in BC. The ITT is unique in North America, as the first team to use paramedics to perform transports of these critical patients.

The BC Ambulance Service air ambulance fleet consists of six fixed-wing aircraft, five Beechcraft Super King Air 350 turboprops and one Bombardier Learjet 31 jet. Additional aircraft are chartered on an as-needed basis. The BCAS also operates three dedicated air ambulance helicopters. Two Sikorsky S-72 helicopters are based in Vancouver, with a Bell 222 helicopter based in Prince Rupert. In addition, patient transfers are routinely performed by BLS crews in charter aircraft (e.g., Beechcraft King Air 100 turboprops).

Licensing & 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 agency, under one of five categories:


 * Emergency Medical Responder (EMR)
 * Primary Care Paramedic (PCP)
 * Advanced Care Paramedic (ACP)
 * Critical Care Paramedic (CCP)
 * Infant Transport Team Paramedic (ITT)

EMR and PCP are Basic Life Support (BLS) qualifications while ACP is an Advanced Life Support (ALS) qualification; ITT and CCP include additional ALS endorsements. EMALB protocols are universal protocols 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.

Since BC EMAs are not governed by a college of paramedics, the EMALB controls all aspects of licensing including protocols, evaluations and fees. There is a new fee schedule (effective April 15, 2007). Written exams now cost $50.00 per attempt and practical exams at the EMR and PCP qualifications cost $400.00; practical exams for ACP qualification cost $500.00. There is also a licensing renewal fee of $50.00, due every five years. There is no cost for licensing at the ITT or CCP levels although so-qualified paramedics are still subject to the 5-year license renewal fee. Legislation exists to allow CCP licensure; however, there are currently no CCP-qualified paramedics in BC.

Emergency Medical Responder
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.

Primary Care Paramedic
In addition to the EMR protocols, PCP licensees have protocols 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 protocols. PCP-qualified paramedics may also be endorsed for intravenous cannulation (PCP-IV) and will have an additional protocol for Hypovolemia as well as enhancements to the anaphylaxis, diabetic, narcotic OD and NYD protocols. Additional PCP-level medications include Salbutamol (Ventolin), Naloxone HCL (Narcan), Glucagon, Epinepherine HCL (Adrenaline), Diphenhydramine (Benadryl), Thiamine (Betaxin), Dextrose 10% and Normal Saline.

Infant Transport Team
ITT paramedics are specifically trained for intensive perinatal, neonatal and pediatric care. In addition to the PCP protocols and medications, they may also administer Acetaminophen, Atropine Sulphate, Magnesium Sulphate, Midazolam (Versed), Sodium Bicarbonate and Out-of-Scope medications with orders from a Transport Advisor. 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, Arterial & Central Line Monitoring, Chest Tube Management, Blood Product Infusion, IV Infusion Devices, 'IV with Medication' Maintenance, Mechanical Ventilation, Foreign Body Removal with Laryngoscope and ET/IO/Rectal Drug Administration.

Advanced Care Paramedic
ACP paramedics have protocols to administer all PCP and ITT medications plus Adenosine, Calcium Chloride, Dextrose 50%, Dimenhydrinate (Gravol), Furosemide (Lasix), Heparin, Ipratropium Bromide (Atrovent), Lidocaine, Morphine Sulphate and Procainamide (Pronestyl). Their additional skills include Cardioversion, Combitube, ETT - CO2 Monitors, External Jugular Vein Cannulation, External Pacing, IV Colloid/Crytalloid Volume Expanders, Nasopharangeal Airways, Needle Thoracentesis and Surgical or Needle Cricothyrotomy.

Critical Care Paramedic
ACP-qualified paramedics can perform advanced protocols under an 'Airevac' endorsement that roughly equates with a CCP qualification. Airevac-endorsed ACP paramedics may also administer Nitroglycerin IV, Meperidine HCL (Demerol), Nitroglycerin Paste, Pancuronium Bromide (Pavulon) and Out-of-Scope medications with orders from a Transport Advisor. Their additional skills include Bladder Catheterization, Central & Parenteral Line Management, Venous & Arterial Blood Sample Collection, Lab & X-ray interpretation, Transvenous Pacing, 12-Lead ECG, Venous Pressure Monitoring, Arterial & Central Line Monitoring, Chest Tube Management, Blood Product Infusion, Mechanical Ventilation.

Note that, 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 Arterial & Central Line Monitoring, Chest Tube Management, Blood Product Infusion, Mechanical Ventilation and Out-of-Scope Medications by orders. Strictly speaking, the only skill not performed by Airevac-Endorsed ACP (i.e., CCP) paramedics is Incubator usage and monitoring.

Training
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 Paramedic Academy of the Justice Institute of BC, the Academy of Emergency Training, and EMP Canada.

Primary Care Paramedic training is offered by both the Paramedic Academy and the Academy of Emergency Training. Advanced Care Paramedic training is only available through the Paramedic Academy. All ITT and Airevac training is conducted 'in-house' by the BCAS.

The EMA Licensing Board maintains a list of the approved training courses 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.

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).

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


 * A valid EMR, PCP, ITT or ACP license issued by the Emergency Medical Assistants Licensing Board;
 * A valid Class 1, 2 or 4 BC Driver's License. If Class 4, then 'unrestricted' is preferred.
 * Proof of a 'safe and competent' driving history as demonstrated by a Driver's Licence Abstract;
 * A CPR Level 'C' (or HCP) certificate, valid within one year, also known as "BCLS";
 * Legal entitlement to work in Canada;
 * At least 19 years of age;
 * Grade 12 Graduation Diploma or equivalent;
 * Satisfactory Criminal Record Search and Criminal Record Review Act Search;
 * Fit to safely perform the duties of a paramedic as measured through a medical and physical pre-employment assessment;
 * Be of good character;
 * Be available on a regular basis for ambulance duty.

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.

If the above requirements are not able to be fully met, the applicant can still contact a paramedic chief in their local community for further information on applying. For example, in cases of extreme staff shortages, an attendant may be hired as a "Driver Only" if he or she holds only a Level 3 Occupational First Aid (OFA 3) Certificate or equivalent (OFA 3 is not a prerequisite for an EMR license but it is the current industry standard in BC for remote or high-risk workplaces).

With the imminent abolishment of mandatory retirement, paramedics may work past the age of 65 as part-time employees. Once they retire from service, they must be off work for a period of one month after which they may reapply to become employed by the BCAS in a part-time capacity; it is the pension corporation that requires a formal severance of employment prior to the pension benefits being activated. The details of this process have yet to be fully fleshed out.

On average, it takes approximately 3 to 6 months before an applicant is granted an interview. The interview consists of a behavioural interview with a panel of two to three paramedic 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. If the applicant has not yet completed a PCP program, there will also be a written exam based on OFA 3 knowledge of first aid and anatomy. 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 paramedic 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 Paramedic Chief and the District Superintendent, as well as notification to the individual prior to the extension.

Rank & Qualification Insignia
The BC Ambulance Service is a paramilitary 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. BCAS qualification insignia has not yet caught up to the new license levels of EMR/PCP/ACP/CCP and as such, current collar insignia is out of date. Past insignia had paramedics qualified at the EMA 1 or EMA 2 levels provided bronze and silver circles, respectively, forming the BCAS logo, along with a bar below denoting the EMA 1 (now EMR) or EMA 2 (now PCP) qualification. EMA 3 - Advanced Life Support (now ACP) and EMA 3 - Infant Transport Team paramedics were recognized with gold cauducei, with either "ALS" or "Neonatology" imprinted upon them. Emergency Medical Dispatchers (EMDs) and Emergency Medical Call Takers (EMCTs) presently wear gold and silver shields, respectively.

For rank insignia, field paramedics and dispatchers wear a blank epaulette holder. Paramedics and dispatchers who hold the position of Paramedic Chief, Dispatch Officer or Charge Dispatcher, wear a black epaulette with three gold stripes. District Supervisors, Dispatch Supervisors, Provincial Special Program Managers/Advisors wear the same coloured epaulette, with four gold stripes. Ranks above District Supervisor are management positions and are distinguished by a shoulder flash that is navy blue, with a navy blue trim, as well as a varying number of pips on their epaulette. District and Platoon Superintendents wear an epaulette with three pips, Directors of Operations wear one pip and one crown and the Executive Director of a region will wear two pips plus a crown. Shoulder flashes for field staff are royal blue with yellow trim, and include the British Columbia Coat of Arms, with the words "Ambulance" above, and "British Columbia" below, in white. Shoulder flashes for management personnel are navy blue with a navy blue trim. The layout of the shoulder flash is the same for both. Each station and dispatch centre has a staff member designated as its Occupational Safety & Health representative. These paramedics and dispatchers are identified with a navy 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.