A new kind of paramedic

Happy EMS Week! Today we are excited to feature one of our members, Canadian community paramedic, Jeff Orr. Based in Ontario, Jeff has worked as an emergency paramedic for over 30 years and has recently transitioned within his service to their new Community Paramedicine (CP) program. If you are not yet familiar with this new model, Jeff’s interview will bring you up to speed on community paramedicine and how the role of paramedics has evolved over the years.

Community paramedicine was initiated in Nova Scotia, Canada, on Long and Brier Islands in 2005. Even now, there is no hospital on either island, and until 2005, the only way for residents to access healthcare services was by taking a ferry ride. To better serve this population, Nova Scotia health authorities implemented a local clinic operated by a nurse practitioner and community paramedics, with offsite physician consultation as necessary. Since then, community paramedicine has spread across Canada and worldwide, with 54 community paramedicine programs in Ontario alone. The Canadian community paramedicine model has attracted a lot of attention both at home and abroad. While Canadian healthcare bodies are still keeping a close eye on the outcomes of this new initiative, foreign paramedics consider this new service to be a model to study and follow.

Last week, there was a big conference in Toronto, about community paramedicine. Our superintendent went and met people from the UK, Australia, Ireland, and the US. And they're all really looking at Canada as the community paramedic hub model.

Besides serving more rural and isolated areas, community paramedics aim to decrease the number of non-urgent patients calling 911, ease the burden on emergency departments and paramedic services, and improve the quality of life of local residents. Under this program, paramedics assess senior citizens and high-risk individuals to identify and address potential health issues before they escalate into emergencies. They provide home and office visits, remote monitoring, vaccinations, risk assessments, and a list of other services that will grow as the program continues to develop. 

Jeff is a veteran paramedic with 32 years of experience based in Sault Ste. Marie, Ontario, Canada. As a kid, he was fascinated by his father's job as an internist and by a TV show which featured two fire medics in Los Angeles. These two elements sparked his love for medicine—and emergency medicine in particular. Jeff put his passion for coming to the rescue into practice very early. As a teen, he worked as a lifeguard and then moved on to volunteer with the Canadian Ski Patrol, which involved basic medical tasks such as bandaging and dressing wounds. Jeff later decided to pursue a career as a paramedic and attended paramedic school. When he first started, paramedics were called ambulance attendants, and they were only allowed to drive very fast with sirens on, do a quick assessment, put oxygen on the patients, and transport them to the hospital. 

I enjoyed the adrenaline rush, the unknown, and being able to get to a patient who is in some sort of distress…who is having some medical crisis. They're basically having the worst day of their life. I love that I am able to walk in and get them from that crisis moment to a more level, safe place. 

From the SARS outbreak in early 2000 to COVID-19, Jeff has witnessed it all in his 32 years on the job. Over time, his role has evolved dramatically, allowing him to bring more and more advanced care to his patients. In September 2022, Jeff volunteered to work in the new Community Paramedicine program in Sault Ste. Marie. This decision completely changed his way of approaching and working with patients. As a community paramedic, Jeff can now schedule appointments and provide medical services to patients in his office. So, instead of waiting for an emergency call, he now waits for referrals from emergency paramedics, hospital discharge planners, and community services requesting medical care for their patients. 

Emergency care is directed to those patients who need immediate care, and the ultimate goal is to stabilize them and transfer them to a hospital as quickly as possible. In his previous role, Jeff was always aware that a few seconds could make the difference between life and death. Undeterred by the great responsibility and pressure, Jeff felt incredibly gratified by helping his patients survive the most unpredictable situations, not all of them negative.

I've been involved in five deliveries. The very first one, I was on an adrenaline rush for a day and a half. I worked the whole night shift, we delivered the baby at five in the morning, and I couldn't sleep for another day and a half because of the adrenaline rush. 

Many times, however, Jeff was called to assist patients who didn’t have a real medical emergency. It was not uncommon for him to encounter patients who lacked social support and, as a result, called for assistance frequently. Such cases can now be addressed through community paramedicine, where paramedics can provide social support to patients and assist them in finding long-term care options. One example was a regular patient who made about 50 calls per week to emergency services for non-medical needs. One of the paramedics took her on as a client and helped her transition to a nursing home, where she has more social support, and her reliance on emergency care was eliminated. This is just one non-medical example. The community paramedics also meet with patients during structured appointments to assist with continuity of care following discharge from the hospital or at the request of their primary care provider. Joining the Community Paramedicine program allowed Jeff to get involved in the long-term care of this kind of patient, which can be both rewarding and challenging. Many people would think that transitioning to community paramedicine is an effortless way to ease into retirement. This is not the case for Jeff, who sees his new role as an opportunity to contribute to the development of a program that could benefit him as a member of the community in the future. Supervised by the program's independent medical director, Jeff and his colleagues are gradually expanding the scope of practice of community paramedics. As exciting and empowering as this is, this change requires them to acquire new clinical skills, which is not always a straightforward process.

Being a paramedic requires the ability to adapt quickly to new skills and situations, such as delivering a baby. Although paramedics receive some training, they often find themselves in chaotic situations that they are not specifically trained for, with only their partner for support. Learning is a continuous process, and paramedics are responsible for their own education. A lot of the education for paramedics in Ontario happens on the job or is provided by the Ontario Base Hospital. Physicians who want paramedics to be able to perform specific diagnostic tests or treatments teach them how to do so. The same thing happens with medications. Paramedics are educated on the contraindications, indications, and side effects of the drugs they are allowed to administer. However, the education available is not always relevant or applicable to paramedics. 

A lot of the education is not directed to, or created for, paramedics. Especially in my younger career, the education that we received was all for nursing and physicians. So to bring it to a paramedic level is a challenge. 

There is a growing recognition of the need for more paramedic-specific education, but it is still a work in progress. Paramedics may need to reach out to other colleges or healthcare professionals for education and training opportunities. The learning process can be overwhelming, and it can be challenging to find the right balance of relevant information without overload. There are also various aspects to being a paramedic beyond the technical skills, such as the social and mental health components. It's crucial to be able to connect with people, show empathy, and maintain a professional demeanor. One valuable piece of advice Jeff gives to new paramedics is to always keep an open mind and be prepared for any medical condition that may arise. Failing to do so can result in tunnel vision and being unprepared. Mental health comprises a large percentage of the calls that paramedics attend to, including within the paramedicine sector, and whether it’s anxiety, depression, suicidal ideation or previously diagnosed psychiatric conditions, how paramedics manage the patients varies and takes sensitivity. 

Talking specifically about community paramedics, the learning challenge is twofold. As mentioned earlier, the community paramedicine program enables its members to expand their scope of practice, which implies learning new clinical skills to fit their new objectives. For example, emergency paramedics in Ontario are not allowed to perform point-of-care testing. On the contrary, community paramedics are required to test patients for different pathologies and have to learn how to do so. Acquiring new skills is not the only challenge for Jeff and his colleagues. As emphasized by Julie Cole, Sault Ste. Marie’s Community Paramedicine Program superintendent, becoming a community paramedic requires a complete mindset shift. 

I often describe Community Paramedicine (CP) as the "preventative" side of EMS. Historically, ambulance response has always been reactive, and CP allows us to get involved before a crisis occurs in patients with chronic health conditions and various comorbidities. The biggest challenge for paramedics like Jeff—myself included—[who] have made this transition is re-framing our instinct to respond from an emergency perspective. Managing chronic illness is very different than emergency response. Paramedics generally have a 20-minute relationship with their patients. Although we may see other contributing factors (such as social isolation, mental health concerns, food or financial insecurity) that are causing patients to further decline in their health and wellbeing—from the 911 side, they are outside of our purview with regards to [acting on] these concerns. CP can act on these concerns. CP is about collaboration and integration; removing the traditional "silos" involved in healthcare, navigating the healthcare system, and liaising with other healthcare providers to find the best, sustainable solution for patients.

Jeff and his colleagues in the Community Paramedicine program in Sault Ste. Marie are only expected to complete one year. However, he’s already considering extending his participation as positive new developments in the program are on the horizon, such as the possibility to diagnose and treat pathologies like congestive heart failure.

I'm very happy that I'm able to be part of this new program. We don't have enough stats to really show how beneficial it's been, but just preliminary figures have been unbelievable.

Jeff also hopes to see more educational resources supporting the program's growth. He would love to see community paramedics in Sault Ste. Marie developing new clinical skills and identifying areas where they can administer medication or provide additional support. Jeff believes that additional courses and paramedic-specific materials would help them tremendously to increase their competence when dealing with patients and communicating with other healthcare professionals. 

I did the one [Medmastery course] on atrial fibrillation. I really enjoyed it because it was short, compact, and to the point. Say I have somebody [a patient] who's got A-fib. What should I be looking for? It also makes me look much better when I'm writing out a clinical note to the physician, the family MD, or even a specialist—These are my findings. This is what it looks like. It sounds like A-fib—to let them know what, and how severe it is, and all the fine details. 

Listening to Jeff talk about his experience as a paramedic was incredibly inspiring for us. His enthusiasm and dedication to his job are contagious! Thank you Jeff for sharing your story and for helping us understand how Medmastery can better meet paramedics’ educational needs.