Where Are You On The Spectrum?

We all are somewhere on the spectrum of grief.

Grief is a natural response to a loss. We generally associate grief with death, however, we can encounter emotional suffering over various types of losses related to relationships, career, health, etc.

If life is perceived as a book, then my work as a chaplain at a long-term care facility allows me to be part of the last chapter of people’s lives, and also gives me the privilege to read some of their life’s previous chapters. They, or their family and friends, share their stories with me, and when they can’t speak, the pictures hung on their walls silently narrate their accomplishments and life journey.

My bedside conversations with the ones living out their last chapter of life, often consist of the residue of unprocessed grief related to losses they experienced over their lifetime. As they share with me their loss of loved ones to death, distance, or conflict, loss of possessions and statuses which brought them joy, a sense of pride and identity, and loss of abilities that once strengthened or enriched them, I witness their deep pain that accompanies their words.

I recall one elderly man who said to me, a few days before his death, “life has given me both great joys and great sorrows,” as he reflected on his life. Succinctly, he had described what life looks like for many of us.

Borrowing the hindsight of the elderly, I have noticed that our skills in celebrating our joys and successes outweigh our knowledge and endurance to process grief. It is especially true when our grief is not understood by our family and friends. When we experience an overload of multiple losses, its cumulative impact on us is harder to navigate. In my work, I regularly come across families dealing with ambiguous grief related to their loved ones with Dementia/Alzheimer’s – losing them mentally and emotionally while they are still present in the body.

One of the wisdom books in the Hebrew scripture and the Bible says, “there is a time for everything…time to weep and a time to laugh, a time to mourn and a time to dance” (Ecclesiastes 3:1- 4). Yet, with our constricted schedules and busy lifestyles, we frequently rush the grieving process – we are uncomfortable to take time to weep and mourn.

When I read verses in the Bible like “Jesus wept” (John 11:35); “Blessed are those who mourn, for they will be comforted” (Matthew 5:4); and several other Biblical passages related to grief, I find an encouragement to acknowledge our grief and to work through the series of difficult emotions that go along with that ride.

I think to live well, we need to grieve well. Each unaddressed grief cumulates and may erupt like a volcano in the last chapter of our life. Prayer, reflection, nature, and talking to someone are a few of the tools of grief work, however, asking ourselves where we are on the spectrum of grief is conceivably the beginning of grieving well.

BY KEN DE JONG, TORONTO FIRE CAPTAIN, STATION 445-A

“Roll the Heavy” is a series of articles to inform the members of the capabilities, equipment and limitations of the Heavy Rescue Squads. This is a special edition to present the services and training of the Ornge Air Ambulance Service. They are (loosely) the Heavy Rescues of the Paramedic world. By sharing this information, we can better serve the citizens by fostering a professional, team approach. This will improve the chances of a successful outcome in the many complicated and technical emergencies that we respond to.

Introduction

In past articles, we have presented the different attributes of the Heavy Rescues. I recently completed the TFS Vehicle Extrication course, and the TFS uses a video from the Ornge air ambulance service to show how to prepare for their helicopter arrival. I know one of the Critical Care Flight Paramedics (CCFP) at Ornge, Mike Tesarski, so I reached out to him and asked him what, if anything, we can do to improve the level of care for the patient. I invited him to be part of an article for this magazine, and he and Ornge graciously turned it into a ride-a-long experience. I, personally, have had only four other experiences with Ornge. When I was on the volunteers in the Parry Sound area, they magically showed up during a complicated extrication. During my career on TFS, I saw them once land on the Gardiner Expressway and once in a parking lot in southern Etobicoke – again, for auto extrications. Years ago, when my father was experiencing an aortic aneurysm, he was flown from the Parry Sound Hospital to Toronto General Hospital for emergency open-heart surgery – it saved his life. My hope for the ride-a-long shift was to learn and share information that could help first-responders improve the care of patients in need of Ornge and their CCFPs. During my shift with them, I was constantly reminded of the similarities between their world and ours. Some uninformed person may think that Ornge is just an “ambulance in the sky”. That is like people thinking we, as firefighters, just put “water on the fire”. There is a much larger and impressive service that Ornge and the CCFPs do.

A Little Background

Ornge’s mission is to provide safe and timely care, transport and access to health services for patients in Ontario. The service was renamed “Ornge” in 2006, but the air ambulance program has been operating since 1977. Fun fact – the altered spelling is partly to make people stop and take a second look, but it is also a nod to the legacy orange colours on the helicopter - and because you can’t trademark a colour, they dropped the “A”.

Some of their operational statistics are as follows:

• They have over 600 employees

• They have 10 Helicopters, 8 Fixed-wing aircraft

• They have their own land ambulances

• They have 13 dedicated bases across Ontario

• They conduct more than 20,000 patient-related transports annually

• They cover an area of more than 1,000,000 km2

• They serve 14,000,000 residents

Ornge is structured as a non-profit, charitable organization with the government of Ontario as its largest client (working with them through a performance agreement). Ornge is not accessible to the public through 9-1-1. They are usually requested through a medical facility, Central Ambulance Communications Centre or land paramedic service, and deployed through their own Operations Control Centre.

What Do They Do?

As mentioned earlier, Ornge can be dispatched, under certain circumstances, by paramedics in the field or by hospitals. The transporting “up-service” is speed over a distance. Someone in need of high level care, especially in remote locations, needs that care as fast as possible. A land ambulance may be able to transport, but the distances, especially in the northern reaches, can be a huge factor.

Smaller, community hospitals have less complex trauma calls than in the city centres and therefore less experience. The doctors are knowledgeable, but having the CCFPs provide advice, based on dozens, if not hundreds, of complex trauma calls, makes the care for the patient that much more successful. This was my first thought about the similarity to the fire service. Awareness level firefighters will respond to complex technical rescues, and they will do their best, but having trained and experienced technicians available improves the chances of a positive outcome.

The second similarity happened twice during my ride-a-long. There is a friendly nickname for the heavy rescues in Toronto. They are sometimes known as the “turn around truck”. I had to smile a little when, during my shift, we were waved off of a call to a northern community for a patient who had fallen about 50 feet. They had only pulled the helicopter half way out of the hanger when the PA announced the cancellation. An hour later, we were dispatched to another trauma call in the north, and we were airborne over the downtown core when we were “turned around”. This obviously happens because the updates from the scene or hospital deem the crew and helicopter unnecessary, and they can be freed up for another dispatch.

The Ride-a-Long

The ride-a-long shift felt very familiar to me because it was similar to our fire department routine. The CCFPs and pilots work a 12-hour shift, from seven until seven, and their “change-over” happens around a kitchen table. There are also engineers (flight mechanics) and management/training staff at the facility. They have an element of “stoking”, where the pilots do their daily checks, the paramedics go over their supplies and equipment, and the staff ensures everyone has clocked in and the place operates smoothly.

An added element of the routine is the “AMRM” (pronounced am-ram”). AMRM stands for Air Medical Resource Management and is used to optimize the human/machine interface and related interpersonal issues, focusing on communication skills and team building. The part of it I saw was what most would describe as a “tail-board” safety and communication session out in the hanger. Each party had a chance to update information about their world and how it would affect each other. I was introduced and the whole session set the stage for everyone being knowledgeable about the day’s status and plan.

The professional approach continued from there. I had been given quite a bit of background information before even showing up, but during the morning, I was given safety training on the helicopter, PPE, briefings on how to act in the hospital settings or at “scene calls” - which are when they land right on the highway, at a parking lot, a soccer field, etc. The furthest we, as TFS rescuers may get from a patient, is down an embankment or deep inside a building. With Ornge, they may have to land and then get shuttled by land ambulance, snowmobile, side-by-side or on foot to the scene of the patient. Their gear is not unlike our rope equipment bags – backpack style, all lettered and organized so they can grab it and go when needed. Mike told me that sometimes when they are flying a patient from a scene call to a hospital, the inside of the helicopter looks like a “bomb went off” in the cabin! There are pieces of equipment, wrappers, blood and clothing everywhere and the paramedics are juggling about a half dozen high-intensity issues all at once. Issues like time to the ER, weather affecting the flight smoothness, patient needs, communicating with the receiving doctors, strict maximums on pilot and paramedic duty shifts, among other issues, have to be weighed, while keeping the patient stable and comfortable.

Like my shifts at the TFS, I don’t want bad things to happen to people, but if they are going to happen, I want to be there. As I mentioned, we were turned around twice, but eventually got dispatched to a transport of a 2-month-old heart surgery patient. The land ambulance ride would have been about two and a half hours one-way and there was a critical need to keep the patient stable. The helicopter ride was 40 minutes and having the CCFPs involved was really like having a doctor at the patient’s bedside the whole time. The professionalism shown to the hospital staff and the parent (who rode along as well) was bar-none, and I was proud to see it unfold in front of me. As I mentioned, my dad had a flight and he remembered how calming and “enjoyable” the experience was, considering his life was in danger; kudos to the paramedics for this.

The Critical Care Flight Paramedics

Ornge Critical Care Flight Paramedics function with a greatly expanded scope of practice, designed to maintain the high level of treatment from an intensive care sending facility, during the out of hospital transport, and until delivery at the receiving facility. They carry many more medications (212 vs 34 drugs) over the Advanced Care Paramedic and have equipment that includes medication infusion pumps, invasive mechanical ventilation and arterial line monitoring.

The biggest game-changer to their scope of practice came about a year ago: blood. They carry blood with them to all of their calls, and this can make or break the situation. Blood allows proper oxygenation, clotting and perfusion to the brain and organs, and without it, you are just watering down the circulatory system. They also carry drugs that can stop the bleeding-out process, to give the patient time to get to the hospital ER.

During my shift, there was a second ride-a-long person who was an ER doctor (they operate two helicopters at the Toronto Island base). The conversations he had with the paramedics were impressive. I felt like a 6-year-old listening in to adults talking about a complex topic. I could string together enough of their words that I could follow the conversation, but my first responder background just couldn’t allow me to participate. It reminded me that at a rescue call, we need to get these and the TPS paramedics into the fold of the rescue to affect a good outcome. The on-going training of the CCFPs is also impressive. Structured in a quarterly training model, the paramedics must attend or complete certain training modules in each quarter to stay certified. During my shift, a trainer dropped in to encourage Mike, and a number of the other paramedics to complete some of their “Q3” requirements. His office was next door, and two sessions were prepared. One was a crashing cardiac arrest, similar to our CPR / Defib scenarios – with the added elements of drug management and varying shock levels. The other session was an emergency childbirth. Where we get training in the basics, they do complicated scenarios like shoulder dystocia - when the shoulders are stuck. It is very impressive training. I had a chance to talk to the pilots as well, and again, you get the best of the best. Not unlike joining the fire service, the minimum standards are just that – minimum. These pilots have thousands of hours of flight time and accreditations to fly by instrument only (for darkness and bad weather). Many have been instructors in the military or flown in highly technical work environments in the mining or lumber industry. They are an integral part of the team, as they have the lives of the patients and the paramedics (and me!) in their hands. An interesting note is that when the dispatch comes in, the pilots are not allowed to know the details of the trauma or transport, other than the location. This is to create a sterile cockpit so that they will not use emotions to decide whether it is safe to fly. You can imagine that if they knew it was life or death for a young child, they might push the envelope if the weather was bad. We all want what’s best for the patient, but sometimes we have to make hard decisions, and this protocol at least removes that burden.

What Are the Take-Aways?

The number one take-away, when talking to the paramedics, for us and all health-care levels, was communication. If they are given detailed information about the patient, the mechanisms of injury, the location, the current status of the rescue, etc., they can start to formulate a plan for their care and hit the ground running. If they need to move from the landing area to the scene itself, they must choose what bags to bring. This is not unlike my needs as a Squad Captain. If the first-in crews give a detailed description of the situation, I can start to plan and organize the crew on-route and be more effective and efficient with the rescue. The CCFPs usually get their communication from the on-site paramedics, but we can be part of that communication chain.

The second, and more direct take-away, came directly from Mike. It was a simple request…warm, warm, warm. Any patient that is trapped in a prolonged traumatic scene NEEDS to be kept warm. The cold of an auto-ex entrapment, water rescue, trench rescue (soil), structural collapse, or machinery rescue will directly affect the bodily functions of a patient, which can seriously affect the survivability. The CCFPs showed me their IV “blood warmers”, but they said it was as simple as blankets and chemical-type warming packs.

The third take-away was what we really already know. We are a team. Interagency partnership has had its ups and downs, but we can all agree that we are here for the patient. The CCFPs spoke very highly of firefighters, provincewide, and completely admit they’re not experts in rescue. I don’t know too many firefighters that would question the knowledge and professionalism of the flight paramedics. I have a new appreciation for what is happening when I see that orange helicopter flying overhead. I hope, with this article, you do as well. Stay safe.