System barriers subthemes, with illustrative quotations
| Subtheme | Description | Illustrative quotation |
|---|---|---|
| Access to care | Participants described issues in availability of alternative care options as driving EMS use | The health care system as a whole needs to look at how they’re providing that primary care. It is a really rational decision for patients to call for these low acuity complaints because EMS is there 24/7 and the emergency and urgent cares are there 24/7, so they are reaching out to the only care available. — P14, community paramedic |
| Navigation issues on First Nations | Participants described paramedics having difficulty finding locations on First Nations, particularly where First Nations lands do not follow road and address formulas that are used elsewhere in Alberta | There’s been several times where they [paramedics] don’t know where they’re going because they don’t know the reserve. They’re not able to find houses; they’ve pulled into houses and asked, “Is this the place we’re supposed to be at?” And they’ll be way off route. These kinds of things are very concerning to a member on the Nation when it comes to life-and-death services. — P8, First Nation community member |
| Reporting concerns | Participants described a lack of effective mechanisms to report discriminatory behaviour or a lack of such mechanisms | A lot of our people won’t go through that [complaints] process to make that person accountable or their health care team [accountable]. It doesn’t matter what team, like, EMS, nurses, doctors. You call a 1–800 number and then you’ll get a call back and then again, it’s back and forth, just too overwhelming. — P1, First Nation community member |
| Response and transport issues | Participants described negative experiences related to ambulance response and barriers to transportation home | The people [First Nations community members] can be frustrated because it does take 45 minutes, 2 hours, maybe 4, if they [paramedics] are coming from another community, and people can meet immediately with frustration. “How come it took you guys so long?” And we’ve got to do our best to de-escalate that situation. — P19, paramedic I do know with Health Canada — they used to pay us to actually do a transport home by ambulance. Then they realized maybe that’s too expensive. Hence that’s how that medical transportation program kind of got born out of that, which is a great idea. But trouble is, a medical transportation tends to go from 8 to 5 type of thing, not so much after hours. — P6, First Nations EMS manager |
| Finance and billing | Participants described difficulties that arise for patients when they are billed for paramedic services that are covered by their Health Canada Non-Insured Health Benefits, and these bills are sometimes sent to collections | I’m seeing a lot of clients who have EMS bills. They’re getting billed for their transport to the hospital, and a lot of these bills are already gone to collections for a nonpayment. There’s a big lack of communication possibly with the paramedic team and the client. There’s no questioning or indicating “Are you First Nation? Do you have a status number?” or anything like that. All they ask for is the Alberta Health Care [Insurance Plan number]. As a result, we have quite a [few] clients who are getting these invoices for ambulance services without being aware that it’s covered by the Non-Insured Health program or Non-Insured Health Benefits program. With that being said, they [bills] are going unpaid, and then they’re being submitted to collections. — P28, First Nation community member |
| Avoidance and delays in care | ||
| Owing to discrimination | Participants described patients’ declining paramedic care or hospital care owing to prior experiences of discrimination | I really don’t like [name of hospital, about 60 km away] because they’re so very difficult with our people. I wanted to go to [name of hospital, about 140 km away] or [name of hospital, about 100 km away], but they [the paramedics] said no. I said, “Okay, I want to stay here and die at home.” — P33, First Nation community member The main reason the person [who declined transport a few hours before their death from a treatable condition] expressed that they did not want to be transported was because of the discrimination they had experienced in previous visits to the hospital. — P22, EMS manager |
| Owing to system barriers in returning home | Participants described patients’ declining hospital transport owing to difficulty securing transport home following EMS transport to hospital | We find ourselves trying to convince sick [people] to come with us for medical attention, and that is the priority. Finding the way home is something that people should not be worried about. — P27, paramedic Just that aspect [return transport to community] alone unfortunately is a deterrent for some people. I know in the past, people have tried to walk home. That’s a 50-kilometre walk from [name of hospital] back to the Nation, depending on where they live. Some people have tried to do [that] when it’s 40 below outside, which is just insane, but yet that’s what they’re faced with for whatever reason. — P6, First Nations EMS manager |
| Paramedic moral injury and advocacy | Paramedics described negative impacts on them personally and professionally when issues of systemic discrimination affected patient care, and also described efforts they make to advocate for patients | Of course, we can’t force people to come with us, unless we [have a mental health form for] them, and that’s a very narrow window of opportunity. This patient did not come anywhere near the criteria for that to be able to happen. In the end, after about an hour and a half–long interaction, the crew signed the patient off and left him in the care of the family and returned back to the station … to be called back 5 hours later to find that the patient had taken their own life. It was a very traumatic experience for our crew. Of course, a lot of blaming themselves for not having transported that person. So, that was a very early introduction to the consequences of the systemic discrimination and racism that First Nations people face. — P22, EMS manager We’re advocating for our patients relentlessly. What we’re talking about earlier and what [name of participant] was talking about earlier — we’ll go toe to toe with anybody. If we see our patients being mistreated, we’ll gladly step in there. But it’s still out there; it’s every day. — P15, First Nation paramedic I vividly recall dropping off a male patient to one of the Northern hospitals, from one of the isolated First Nations communities. … I remember relaying that this patient was just quite ill, their presentation — it just, it was either leading toward sepsis or some sort of a gastrointestinal issue. [Then in the ED], to have it downplayed and disregarded … unfortunately, just referencing stereotypes, be it just addictive substances consumption or just self-neglect … it was really unfortunate being an experienced health care provider to have our experience written off when we’re trying to do patient advocacy for the receiving facility. — P27, paramedic So, when I’m picking a shift up, my mindset is, “Am I going to have a good shift or a negative shift, because of my partner? Are people going to be rude to me at the hospital?” I want to go in with good intentions and to be a good advocate for my patient, but I want to enjoy my workday. — P12, First Nation paramedic |
Note: ED = emergency department, EMS = emergency medical service.