Ambulances in Metro Vancouver are getting to the most life-threatening emergencies, like heart attacks, a bit faster than they used to, but at the expense of thousands of patients with less serious ailments who are waiting significantly longer for help to arrive. That's according to an exclusive analysis by The Vancouver Sun of more than 600,000 ambulance calls over the past five years in Vancouver, Surrey, Burnaby, Richmond and Langley. In October 2013, B.C. Emergency Health Services, which operates the ambulance service, downgraded 74 call types, including abdominal pain and assaults, from "Lights and Sirens" to "No Lights and Sirens." The move was criticized by several Metro Vancouver mayors and fire chiefs who said it led to longer response times for many serious incidents and forced first responders, like firefighters, to spend more time tending to patients than in the past. BCEHS argued the decision reduced the risk of accidents and allowed it to improve response times for the most serious calls.

If you're on a mobile device, please

If you're on a mobile device, please click here to see the chart. According to the data analyzed by The Sun, response times for those 74 downgraded call types - which make up nearly one in every five calls - did get significantly worse following the change, from a typical response time of 9.8 minutes in 2012 to 14.4 minutes in 2014. At the same time, response times for the most life-threatening calls improved. But those calls are far fewer in number and the change was much less dramatic. Only about one per cent of all calls are categorized as "Echo" calls, meaning the medical condition is immediately life-threatening: things like heart attacks and airway obstructions. The typical response time for those calls did get better between 2012 and 2014, but only by half a minute: from 8.1 minutes in 2012 to 7.6 minutes in 2014. On its face, that might seem like a poor trade-off: Thousands of patients waiting longer for help so the ambulance service can shave a few seconds off a handful of its most serious calls. But Dr. William Dick, vicepresident of medical programs for BCEHS, said numerous studies show that for those handful of life-threatening cases, seconds really can make the difference between life and death. "That tiny percentage of calls are the most critically ill patients. And anything we can do to get those response times down is ethically the right thing to do," he said. "Don't think it doesn't weigh on me that I have to make people wait. ... (But) if even a thousand people wait 15 more minutes, and they're in pain, and I've saved one person from not dying, who can go home (to) his family, I'll make that trade every day." In addition to getting overall response times down, the ambulance service has also increased the share of "Echo" calls it's getting to in less than five minutes, from 11 per cent in 2012 to 16 per cent in 2014. "They're robbing Peter to pay Paul," Bronwyn Barter, president of the paramedics union, wrote in an email. "Saving lives should be a top priority but should not come at the expense of hundreds of thousands in need of assistance. ... Every British Columbian is entitled to a timely response by the ambulance service." Barter said the number of ambulances and paramedics needs to be increased to keep up with the province's growing and aging population.

"The data does show a small improvement to some of the more serious call types," said Surrey fire Chief Len Garis. "However the question is whether the small improvement to a very few calls is worth the cost of lengthier delays for all the other call types." For example, he said, firefighters are often on the scene of a heart attack before an ambulance is and can administer much of the same initial treatment. "If first responders are providing CPR, (automatic) defibrillation and airway management, then it is unclear if having a transport ambulance arrive a minute earlier would make a difference," Garis wrote in an email. Garis acknowledged that having an Advanced Life Support (ALS) ambulance - which is equipped with more highly trained staff with more drugs and equipment - on scene faster would probably increase the chances of survival. Dick said the changes have resulted in more ALS ambulances getting to high-priority calls quicker. But he argued a faster response by even a basic ambulance team can make a difference as they have more tools than firefighters do for clearing a patient's airway and can start an IV line. A faster response also means the patient will get to hospital quicker, said Dick, which increases their chance of survival. Dick said he's confident the changes BCEHS has made have saved lives, based on the experience of ambulance services in other places. But he concedes he doesn't yet have solid proof. BCEHS recently entered a data-sharing agreement with the Ministry of Health, which should allow it to track what happened to ambulance patients after they got dropped off at hospital. Once that analysis is complete in a couple of months, said Dick, the agency should know if the changes are actually saving lives. "If our experience is the same as every other published paper on this topic, we should see some fairly robust outcomes that are good. But I look at it with an open mind," he said. "(And) if the data shows we have to make changes, we'll make them." Even if the changes are saving lives, though, one expert said that doesn't necessarily mean BCEHS made the right decision. Craig Mitton, a health economist at the University of B.C.'s school of population and public health, has done extensive research on priority setting in the health care system. Mitton said his research shows that while those directly involved in health care delivery - doctors, nurses, paramedics - tend to focus on saving lives above all else, the public takes a broader view. While he hasn't specifically studied ambulance response times, Mitton said research in other areas - like end-of-life care and expensive drugs - suggests the public wants more of a balance between reducing mortality and things like quality of life and shorter waiting times. "While recognizing it's important, the single focus on saving lives isn't the only thing the general public is interested in," said Mitton. And, in fact, while BCEHS has maintained that its decision to prioritize life-threatening calls is the right one, it has made some concessions to its critics.

In October, seven of the 74 calls the agency downgraded in 2013 were bumped back up again to "Lights and Sirens." Most of those upgraded calls are for falls, a call type that is not usually lifethreatening but disproportionately affects the elderly and can be extremely painful. "Pain management is not necessarily impacting the ultimate medical outcome because a broken hip is still a broken hip," said Linda Lupini, executive vicepresident of BCEHS. "But with some calls you do have to take into consideration pain." She noted the ambulance service already responds faster to calls involving children than those involving adults, even for the same type of medical condition. "We do feel that very vulnerable patients are a high priority," she said. "Maybe a 30-yearold in pain is something society thinks is a good trade-off, but an 80-year-old in pain or a fouryear-old in pain is not." One of the most interesting findings in The Sun's analysis is that the changes made by the B.C. Ambulance Service have had a much bigger impact on the most extreme cases than on the typical ones. Take the 74 downgraded calls as an example. The median response time for those calls - meaning half of patients waited longer and half shorter - went from 9.8 minutes in 2012 to 14.4 minutes in 2014, a 47 per cent increase. In contrast, the 90th percentile response time - meaning one in 10 patients waited longer - went up 84 per cent, from 18.3 minutes to 33.7 minutes. Looked at another way, in 2012 fewer than one in 50 (1.4 per cent) of those patients waited more than half an hour for an ambulance to arrive. By 2014, it was nearly one in seven (13.1 per cent). The reason for that is that downgrading a call from "Lights and Sirens" to "No Lights and Sirens" actually does two key things. The first, and most obvious, is that the ambulance doesn't use its lights and sirens while heading to a call. That might seem like a big deal, but it may only add a few minutes to a typical response. "It's not about the ambulance being stuck in traffic," said Dick. "In a lot of the areas, it doesn't make a huge difference in the actual driving time." The second, and much bigger, factor is that downgrading a call to "No Lights and Sirens" means that, if a more serious call comes in while the ambulance is on its way, it can be diverted. During particularly busy times, several ambulances can be sent to the same low-priority call, and be repeatedly diverted, before one finally arrives. This may help explain some of the stories that have emerged of people waiting 45 minutes or an hour for an ambulance to arrive. While such cases are not the norm - ambulances still get to the vast majority of routine calls in less than 30 minutes - there are a lot more long waits now than there used to be. In addition to providing an overall picture of the impact of the decision to downgrade calls, the data analyzed by The Sun also reveals how response times vary between Metro Vancouver cities.