By Anna Ding and Elysée Nouvet (PhD)
More than 500,000 cases of COVID-19 have been documented in Ontario since the start of the pandemic, placing immense strain on society (Queen’s Printer for Ontario, 2021). Paramedics on the front lines of Ontario’s pandemic response constitute a crucial part of patient care and infection management, taking measures to limit risks of contamination to themselves, other patients and providers as they deliver essential healthcare services. Their work as healthcare professionals is unique, inherently risky, and imperative as a bridge between the province’s healthcare system and the public. Despite this reality, paramedics largely operate under the radar of the communities they serve. While services have faced higher call volumes and new stressors during this pandemic, paramedics did not appear on Ontario’s List of Essential Services alongside police and fire when this list was first published in March 2020 (Ontario Paramedic’s Association, 2020).
Researchers based in Health Sciences and the Schulich School of Medicine and Dentistry at Western University interviewed 21 paramedics in Ontario between June to August 2020, exploring their experiences of risk and safety while working in emergency response. The rapid study aimed to understand how paramedics were living and navigating any perceived added pressures of work in this global pandemic, with an eye to informing improved supports for this group of healthcare workers moving forward.
Like so many around the world, Ontario paramedics did not know exactly what they were up against as they began to respond to calls for assistance in March 2020. With unprecedented stay at home orders in place, global shutdowns, limited understanding of the novel COVID-19 and debates on the effectiveness of masking to limit infection, being on the front lines of the pandemic did require adjusting practice and mind to new safety risks. While paramedics are skilled at adapting quickly to unforeseen circumstances, COVID-19 represented a whole new level of uncertainty for these emergency responders.
“I can say this for sure, this is the first time in my 27[year] career that I’ve been scared” (Participant 5)
As the rates of infection and hospitalization rose across Canada in Spring 2020, several precautions were adopted within paramedic services. Participants in the Western University study described efforts locally and across the province to ensure their safety, but also described the stress of the new normal. Access to personal protective equipment (PPE) across the province was not uniform or easy across municipalities in the early days of the pandemic. The risk of shortages was real. Communications on what PPE was essential to stay safe kept changing, leaving some paramedics, by their own accounts, uncertain that they were indeed dressed as safely as possible to respond to calls. Getting PPE on slowed patient response time, escalating patient and family emotions in already stressful crises. PPE does need to be put on upon arrival at a scene: goggles fog, and gowns are too restrictive for driving. Climbing down flights of stairs with patients in PPE felt treacherous at times, but also posed risks that PPE would slip out of place.
The dynamic nature of a public health emergency also meant that internal policy was constantly changing. Best practice for safety and patient screening criteria could and did change frequently, and sometimes even between shifts. With every call, patients needed to be screened for potential COVID-19 exposure or infection. But with so many potential symptoms, participants in the study noted how difficult it was to screen patients out of the “at risk for COVID-19” category.
Tending to patients in crisis also looks different in a pandemic. To lower paramedics’ risk of exposure to potential infection, the option of engaging in aerosol generating procedures to treat shortness of breath was removed. Since paramedics have the public-facing role in emergency response, they also faced the difficult task of explaining to families of patients in crisis that they could not accompany their loved ones to the hospital. No paramedic interviewed questioned the importance of new safety precautions, but that did not make it easier to uphold them. As defined by Elisabeth Fortier (2019), moral distress often arises when system-level limitations constrain healthcare providers from doing what they know under different circumstances could have been done for a patient.
Paramedic teams began to develop their own wipe down protocols for ambulances, being vigilant to maintain cleanliness between calls. Eating in the lunchroom felt reckless to some. One individual decided in dialogue with their spouse that they would sleep in a trailer parked outside their home for the duration of the pandemic. Others had started in March 2020 to avoid all physical contact with family members and had still not hugged their kids or shared a bed with their partners at the time of interview several months later.
Paramedics generally service numerous base hospitals within one region. Each hospital developed its own procedures. Different hospitals had separate rules for donning and doffing PPE, and rules for entry and transfer of patients. At times, they had to wait in hospital parking garages without air conditioning, in layers of PPE, and with patients unaccompanied by loved ones. Shifts were often truly exhausting.
“I think we’re kind of just being expected to keep on showing up…when this is over I think you’re going to see a little bit of [a] mass exodus out of healthcare in general.” (Participant 17)
The mental health impacts of the pandemic are becoming more recognized, for its effect on healthcare workers who have had to work through this global emergency. Multiple participants in interviews described a sense of emotional exhaustion and distance from their job, especially when call volumes increased to a level where they were sacrificing their breaks. This was intensified by a constant worry about spreading COVID-19 to their family, with many choosing to self-isolate due to the heightened danger of infection.
For such a high-risk profession, there is a lack of adequate mental health support and concern in whether paramedics are easily forgotten and under considered in public health. This could be rooted in the relative novelty of their occupation, as the field has rapidly evolved from their role as ambulance drivers to the highly skilled and college educated healthcare professionals they are today. Paramedics choose this profession for the fast-paced environment and flexibility, along with the ability to help patients and continuously learn. As the field expands, it is imperative that current policy reflects their responsibilities.
“Between the mental health aspect and then the physical aspect, most people didn’t retire from the job.” (Participant 24)
Healthcare workers worldwide have been fighting tirelessly against the COVID-19 pandemic. Paramedics are undoubtedly essential to the public and as individuals themselves. At the time of study interviews, participants were grateful for the support received by their management, who face additional stresses when leading during crisis. For example, holding weekly town halls allowed continuous feedback to be given. For public health long-term, it is salient to acknowledge and continue to work to alleviate and understand the pressing reasons of why so few paramedics reach retirement. These lessons of the COVID-19 pandemic should be applied to future public health emergencies, so that policy can be proactive, rather than reactive.
Elysée Nouvet is a medical anthropologist and assistant professor in the School of Health Studies at Western University, in London, Canada. She has received funding as Principal Investigator from ELRHA’s Research for Health in Humanitarian Crises fund (U.K.), the Canadian Institutes of Health Research, and the International Development Research Centre of Canada to explore experiences and ethics of research and care in public health emergencies across the world.
Anna Ding is a research student in the Faculty of Health Studies at Western University.