From A Fort Erie Doctor – On Dying In An Ambulance

By William Hogg, MD

The people in Niagara’s southern tier are beginning to realize that dying in an ambulance today is more likely to happen than it was just a few months ago.

A most tragic death was that of 18-year-old Reilly Anzovino a couple of weeks ago (this past Boxing Day) during her college break. She was badly injured in a car accident on the Garrison Road. It was a wintry-slippery, foggy night.

She died in the ambulance as it pulled into Welland hospital’s ER. If that ambulance had been able to go to her own home town’s hospital in Fort Erie, she would have been alive on arrival – not DOA. 
The ambulance was forced to bypass DMH because the bureaucrats who run the Niagara Health System (NHS) closed her hospital’s ER just short of three months earlier (on 28 Sept. 2009).

What the good people of Fort Erie don’t yet know is that the bureaucrats who run the Niagara Health System were warned about deaths like Reilly’s away back in June of 2009. Yes, those bureaucrats knew about the possibility well before they went ahead – against all sound advice – and shut down the emergency departments in both of these two southern tier towns. As a matter of fact, by shutting down the Douglas Memorial Hospital ER in Reilly’s home town of Fort Erie, they probably indirectly caused Reilly’s death. And there will be more deaths of this kind. A new slogan: NHS = DOA !!! \

Now this is a very serious accusation. But it can be proved. How? I was the doctor that warned NHS of the possibility of “time-critical” emergency deaths similar to if not exactly like Reilly’s (by email and in writing). And I was totally ignored. Here is the story. But first, let me lead up to it by stating that I have no personal axe to grind with NHS.

A native of Fort Erie, I once taught at McMaster medical school. In the 1970’s I was VP of medical staff and chief of paediatrics at DMH in Fort Erie. Since then, my work has taken me far afield, but Fort Erie has remained home base. I have been retired for some ten years (since before NHS came on the scene) and am now 78 years old.

After I learned of NHS’s local health-disruptive plans at a big public get-together in the Fall of 2008, I wrote Fort Erie’s Mayor commending him on his intent to fight for the preservation of the town’s small but excellent hospital. Then I posted “A Small Town Horror Story” on the Net. Next, as an ordinary citizen, I aligned myself with Mrs. Sue Salzer and her Yellow Shirt League. We all trooped to Toronto together by bus to ‘protest’ the Ministry of Health. But NHS simply forged ahead like an unstoppable dreadnought. It was a rude awakening to see a public service corporation at war with its own people. So, I decided, to politely but firmly educate this NHS warship with an old doctor’s bag of medical info. Being appalled at NHS’s declared intent to relocate all of Niagara’s obstetrics to a place far off in the peninsula’s northwest corner, I sent my first email to their media department exactly as follows, openly under my own name:

By email #1: Information service from the people of Fort Erie trying to help NHS…
Obstetrical emergencies can be the most critical of all. A woman who’s already had 4 babies with ease, no complications, goes into labour 6 weeks early. The top of the baby’s head starts showing, but then suddenly it pulls back. The mother involuntarily pushes. But the baby’s head, after a brief appearance, again pops back inside. This can be a recipe for disaster. For the umbilical cord may be prolapsed, wrapped around the baby’s neck, twice around it. Every time she pushes the cord tightens, strangling the baby, holding it back. But that’s not all. Every time she pushes, and she cannot help doing so, the cord stretches, trying to pull the placenta off the wall of her uterus where it’s attached. If that happens it’s curtains. If the placenta is torn off, it leaves a gaping, blood-engorged wound behind. It’s like flushing a toilet – all, every bit of her blood and the baby, will gush out in a flood from below. She will be dead in a minute. And most likely the baby too. Right at the intersection of the QEW and the Sodom Rd. This is the sort of situation in which the right doctor in an emergency room very close by can make all the difference. Paramedics are not equipped to diagnose and correct this double life threatening emergency. But any small town ER with an emergency physician can! At the same time: prevent two deaths, and save two lives. Think on it.

June 18, 2009. If there is one, just one, death like this – you at NHS will be held legally responsible. You are no longer ignorant. You have been informed and warned.
Over the rest of the month similar missives – combining emergency information with a statement of consequences – were sent, with copies to EMS (ambulance), LHIN, the Yellow Shirt Brigade. A paper original of everything pulled together was handed to Mr. Russ Wilson (for the Mayor) during a Yellow Shirt meeting.
At this point it might be helpful to clarify the different categories of medical emergencies. Basically, an emergency is a threat to life or limb. There are ordinary everyday emergencies and then there are time-critical emergencies. Time-critical emergencies require rapid attention, else death is an imminent risk. Along with all other emergencies, the time-critical ones routinely came directly to the ER where they were promptly moved to the head of the line and dealt with, within minutes, without fanfare. Hence they were next to ‘invisible’ as a type. By downgrading and bypassing ERs, forcing these problems out onto the highway in an ambulance, the non-medical managers have ‘created’ a new and visible time-critical type of emergency. These new time-critical emergencies are really bureaucratic artifacts.
Specifically, people with gunshot wounds in vital areas, unconscious people with difficulty breathing, people in shock bleeding massively, people with drug overdoses, people in anaphylactic shock, people with head injuries, and many more (I cant list them all), are the ones that would ordinarily be those moved to the head of the ER line. If they cannot be put at the head of the line because they are on an ambulance that has bypassed the hospital and is out there somewhere on the highway on a trip to a place too far away, they may just die in that ambulance. And that is in spite of all the good intentions of fine paramedics, for there are still certain things that only a doctor at a hospital can do. The emergency problem that most people think of is a person having a heart attack. Here is the exact clinical vignette that I sent on to NHS last June:

By email #2: ‘DMH educates NHS’ – a workaday information service from the people of Fort Erie in an effort to prevent unnecessary deaths by ‘trying’ to improve and help NHS…
The usual emergency that people think of where time is of the essence is heart attacks. True up to a point. Sadly, some people will die on the spot. Nothing can be done. Even CPR is too late. Others will survive long trips by car or ambulance and, luckily, arrive more or less intact at a ‘centre of excellence.’ Some, and this is the key point, will have an irregular heart beat and die halfway – in the ambulance. So? All people with suspected ‘coronaries’ should be speedily brought to the nearest emergency, even a rural one, for immediate assessment, life support and stabilization – ASAP – before transportation to a far away place. OK? We all have an idea about what ‘life support’ is all about: CPR, intubation, oxygen, etc. But what is stabilization? It is designed to prevent further progression of an active heart attack. In people with a coronary blockage type of heart attack, a timely ‘clot-buster’ can be life-saving as well as stopping the spread of heart muscle death. Any concurrent arrhythmia of the heart beat, is an immediate and imminent threat to life. It can go on to ventricular fibrillation and sudden death. Morphine for pain and an intravenous bolus of xylocaine can calm the heart and calm the person and get the person safely past the long trip to a distant intensive care unit or a ‘centre of excellence.’ To my present knowledge, paramedics in ambulances do not inject xylocaine boluses or start clot-buster medication. Emergency room doctors do, as can even family MD’s and GP’s in small town and rural hospitals. So, and it needs repeating, all persons with suspected coronaries, especially with an irregular heart beat, should be taken immediately to the very closest hospital, even a small town rural one, before further transport. Think on it. For otherwise there will be unnecessary deaths.

Dated: June 19, 2009. If there is one, just one, death like this – you at NHS will be held legally responsible. You are no longer ignorant. You have been informed and forewarned. /cc: ambulance service
Many readers may recall that one Port Colborne man already has suffered the “NHS = DOA” fate – last fall. I could cite 50 hypothetical examples of time-critical emergencies. And I will if necessary and if you want more. But I believe you have my point. To be certain, I’m going to give one example of a common emergency that is NOT necessarily time critical. This is also exactly as it went to NHS:
By email #6: Information service from people in Fort Erie ‘trying’ to help NHS…
An older person with fragile bones may trip, fall and break her hip (or snap her hip and then fall down – in that order too). It’s a potential life threatening emergency, but, without any treatment at all, the victim may last a week or so before dying. Cruel thought, but it goes on all the time in US-America! We’re luckier, or more prudent, in Canada. Here, the idea is to ‘splint ’em where they lie’ and ensure a slow, safe ride to hospital, without bumps or jolts. Even so, slow ride and all, it’s a genuine emergency as there is usually bad pain and often bleeding into the soft tissue that surrounds the fracture. That is, there is a possibility of onset of traumatic shock, with all the dangers that poses. Therefore, the person may need IV’s and perhaps a blood transfusion. But there’s no need for screaming sirens. Hence, if this older lady lives in an outlying area, it’s a wise idea to make a short stop at the local emergency room, for rapid assessment, pain relief, IV’s etc., before subjecting her to a much longer trip to the ‘centre of excellence’ where, at more leisure, surgical hip pinning is done. Nice scenario? Oh Canada, our home and native … gracious? not always … land. NHS with its HIP (hospital ‘improvement’ plan) would risk this older person’s life.

Dated: June 25, 2009. If there is one, just one, death or disability like this – you at NHS will be held legally responsible. You are now no longer ignorant. You have been duly informed and forewarned. /cc: EMS ambulance service, LHIN J. Gledhill, Yellow Shirts Sue Salzer
Here is another way of looking at the idea of a time-critical emergency: time-critical is an old concept now seen in a new context. It will emerge into bold relief when the local ER lineup is completely removed and the ambulances must take time-critical emergencies to a different (distant, longer) lineup. This is exactly what happens when bureaucrats close outlying emergency rooms, change their name to a UCC, and divert all ambulances carrying real emergencies away and out of town. An ER by any other name, that does not accept ambulances with emergencies on board, is a cruel cover-up and bureaucratic hoax.
For more clarification: Although many time-critical emergencies can be anticipated, others may happen out of the blue; they range right across the whole medical spectrum – surgical, obstetrical, psychiatric, paediatric, geriatric. They obviously are less frequent than ordinary run of the mill emergencies, but when they do happen fur really flies. Time is of the essence. As is a good doctor – not a paramedic in an ambulance. If they are overlooked or neglected the poor patient dies.
Now I hate to be a fear monger or leave the reader in uncertainty. There’s enough of that going on in both countries these days. So what can you, as a local resident or as an American visitor to Niagara’s Southern Tier or Lake Erie’s beaches, actually do? We’ll come to that in a moment.
But first, what should NHS do? NHS should swallow its pride (or whatever it is) and immediately, without delay, put the Fort Erie and Port Colborne hospitals back into proper running condition. That is, NHS should dismantle its “UCCs” (whatever artificial concoction they are) and reopen the Emergency Departments. That would solve the problem of ambulances racing around the highways carrying time-critical human time bombs that could die any minute.
Should NHS refuse to do that, then the EMS (ambulance service), which is separate from NHS, should cut the red tape that forces them to bypass rural and small town hospitals (only if they have a real emergency on board (think of that crazy regulation!)) and go directly to the Fort Erie or Port Colborne hospitals anyway. There will be trained doctors there at those new-fangled UCCs. NHS has guaranteed that much. The time-critical patient will get timely treatment and wrongful deaths will be prevented.
If NHS and EMS both fail to respond rationally, as recommended, we come back to what you can do in case of an emergency. Now this is hard advice to give and a difficult decision for you to make. But here it is anyway. Get yourself or your relative as quickly as possible – on your own – to the nearest hospital that recently had an ER. Do so, especially if you think the emergency might be time-critical. (I made a suggestion recently that taxis gear themselves up to do a bit of ‘ambulance’ work!) Do not let yourself or relative or friend die somewhere out there on some rural road.

(William Hogg is a retired physician living in Fort Erie and a former teacher at McMaster University’s medical school.)

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