In the context of a 28-year-old man and a 61-year-old woman who died in less than ideal circumstances during an air ambulance transport, two coroners are recommending that the Ministry of Health set up a call centre within six months.
This center would report to the Provincial Coordination Center for Air Transfers, which would include the Intensive Care Bed Occupancy Optimization Center and the Quebec Aeromedical Evacuation Service. This is also what is planned in the Government Action Plan for the Pre-Hospital Emergency System 2023-2028, but at the beginning of August the process had not started to be deployed, according to coroner Me Francine Danais.
“I will insist that this be implemented quickly to allow doctors to concentrate on their patients rather than taking steps that I would describe as administrative,” wrote M.e Danais in his report.
The Government Air Service (SAG) has four aircraft. “In the last five years, there has been an increase in the number of transfers of about 38% and sometimes all four aircraft are in service at the same time. Given these facts, it becomes clear that the air fleet must be increased,” says Mr.e Danish.
The coroner also notes that the SAG is facing a shortage of pilots “who are moving to the private sector for better working conditions.” This issue means that sometimes a plane is available, but no pilot is.
With Me Julie-Kim Godin, the two coroners published their conclusions on Wednesday concerning two deaths that occurred in the context of emergency air transfers.
In order to improve air medical transport service in remote areas, including the territories of First Nations and Inuit communities, Me Godin recommends that the Ministry of Health ensure that sufficient personnel and equipment are available.
Me Danais also makes other recommendations to the Ministry of Transport. She asks it to put in place “measures to promote the attraction and retention of pilots, in order to allow for faster emergency air transfer for patients from remote areas.”
The Ministry of Transport is also called upon to accelerate the replacement of obsolete equipment in the current fleet and to improve it as soon as possible if necessary.
First case: death of a 28-year-old man
The case that M.e Danais concerns a 28-year-old man who died on January 4, 2024 in Val-d’Or during an attempted air transfer.
On the morning of January 3, a land ambulance was requested for the Val-d’Or Hospital because the man had been vomiting blood for three days, was unable to eat and was having difficulty breathing.
Upon arrival at the hospital, his condition deteriorated rapidly and he was transferred to the intensive care unit. He was intubated to facilitate his oxygenation and a little later, chest X-rays confirmed that he needed extracorporeal membrane oxygenation (ECMO) treatment, but unfortunately, this device was only available in large urban centres (Montreal, Quebec City, Sherbrooke and Chicoutimi).
The Sacré-Coeur Hospital in Montreal was identified to receive the patient. After stabilizing him, the air medical team was finally ready to take off at 4:30 a.m. on January 4.
It should be noted that the SAG had been informed earlier of the absence of pilots available for the night shift for an aeromedical transfer. He ensured the availability of a relief aircraft which unfortunately left for another urgent mission. It was necessary to request a second relief aircraft.
During the night, this relief plane is positioned at the Quebec airport. The patient is transferred to the tarmac while the temperature is minus 22 degrees Celsius. In the plane, equipment has frozen. Given the situation, the air medical team decides to return the patient to the Val-d’Or Hospital.
Shortly afterwards, the man suffered a cardiorespiratory arrest and resuscitation was successfully attempted. Back in the hospital’s intensive care unit, he suffered another cardiorespiratory arrest from which he succumbed.
Second case: death of a 61-year-old woman
The second case, which Me Godin analyzed, concerns the death of a 61-year-old woman in August 2022. At the time, the lady ended up at the CLSC in Salluit because she was vomiting blood.
Medical staff conclude that the blood discharge is coming from the respiratory tract and pneumonia or tuberculosis is suspected (given his history). An air transfer to the Inuulitsivik Health Centre is planned.
Six hours later, the patient took off with the medical team, but during the transport, she coughed up “a massive amount of blood”. She went into cardiorespiratory arrest and manoeuvres were performed on her by the team in the plane and continued by the medical staff once they arrived at the Inuulitsivik Health Centre. She was unfortunately pronounced dead at the centre.
It should be noted that the woman’s transfer was managed by the Inuulitsivik Health Centre and not by the Department of Health. Coroner Godin points out in her report that Salluit is a remote region where the weather can make travel difficult.
Me Godin, however, states that the six-hour delay is due, among other things, to “issues of service organization, prioritization of requests as well as the availability of human and material resources.”
The coroner indicated that it would be “relevant to standardize approaches and group services within a single coordination center, while respecting regional realities.” She specified that the Ministry of Health and Social Services has shown itself to be open to this.
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