As Covid case numbers grow and with thousands now isolating at home while positive, St John is dealing with a marked increase in call-outs and preparing plans for potential surges in infection rates.

As waves of Covid have surged around the world, health systems have been strained to breaking point. Ambulance services have not been spared. The American Ambulance Association last month declared a crisis born of Covid-19 and a “crippling workforce shortage”. Recent weeks have seen the army called in to drive ambulances everywhere from Scotland and Wales to the Australian state of Victoria.

The military are not yet on standby in Aotearoa, but the country’s biggest ambulance operator does have plans in place should demand surge as delta spreads in Auckland and throughout the country.

Already, St John is facing a marked growth in demand because of Covid-19. The last three months has seen about 1,600 calls a day for ambulance assistance to 111, an increase of about 100 a day. Last week that leapt to more than 1,900 a day, said Dan Ohs, deputy chief executive of ambulance operations. “It’s much higher than expected,” he said, but “still within what we would call our upper limits of workload at this time of year”.

Ambulance crews are attending about 25 Covid cases a day. “That may not sound like a lot,” said Ohs. “But because we have to wear a lot more PPE, they take a lot more time. Following the deaths of some patients that’s been widely reported in the media we’re working with Whakarongorau [telehealth service] to make sure that with anyone who’s got a clinical concern who is being managed in the community, we will pop around. So that’s generated a bit of extra workload as well. But overall, it’s not necessarily the volumes – though they are higher – that have been affecting us. It’s been the very long time it’s taking us due to the PPE and the increased pressure at the hospitals.”

In Auckland, St John is facing extra “stress and pressure”, with turnaround times at hospitals much longer than normal owing to added protocols when bringing patients to hospitals, including the rapid antigen testing sometimes required before patients can be taken out of the ambulance. “Last week in Auckland, there was almost 300 hours of excess ambulance time spent at EDs,” said Ohs. “Obviously if ambulances are tied up at EDs they’re not not available to go into the community.”

Plans for an ‘extreme environment’

With case numbers and hospitalisations only going in one direction in the short-term, plans are in place should the pressure grow further. “We have a scaled system,” Ohs explained. “Firstly, we’ve got what we call ‘Covid casuals’, volunteers who we’ve employed, who can come in in order to increase the number of ambulances on the road. We’ve also got arrangements to ensure that we have access to tertiary students if we need them. And if we got into an extreme environment – and this would only be in absolute extreme circumstances, in the kind of events that have been seen in the UK or what happened in Victoria where they called in the military – our equivalent of that would be bringing in ambulance assistants. We’d take someone like a first aid tutor, and we would train them up to be able to drive the ambulance in non-emergency conditions, to be able to lift the patient for CPR, wear PPE and that sort of thing. That would be the last resort.

“The other thing is that we have the ability, provided that the [outbreak] continues to be geographically isolated, to move our own people around. So we’ve got those sorts of surge plans in place.”

There are other strategies available, including boosting the triage capacity at the emergency communication centre, “both by putting on additional call handlers, but also putting on additional paramedics, who can help us to triage patients who might not necessarily need a face-to-face ambulance”.

Another initiative being developed is video assessment. “We’re working on a new piece of technology which would enable us to send to a mobile phone a link, so that we can visually see the patient, which means that our paramedics in the comms centre might be able to assess them on the phone to determine whether or not they need an ambulance. That would mean we can make sure we give people the same advice that we would if we were at the scene. It makes it quicker, but it also means that potentially we can work with people without putting our paramedics at risk by sending them into a Covid environment.”

‘People aren’t always giving us adequate information’

In late August, 93 St John staff went into isolation after potential exposure to a Covid-positive patient. That prompted the service to issue a public plea for people to be honest with operators about their potential exposure to the virus. “Early in the delta crisis there was a lot of fear,” said Ohs. “And people were worried that we wouldn’t be giving them treatment, or that we might withhold treatment or care from them if they declared that they were at risk of Covid.”

Following the public appeal “we saw things get a little bit better for a while”, he said. “But we are finding now that people aren’t always giving us adequate, accurate information when we get to the scene. Not giving us accurate information is often through concern that either we might leave, which of course we’d never do, or that there might be some other procedure that has to happen as a result of them having had Covid exposure. And that’s just not the case, obviously. We’re trained to work with people who have infectious disease and it only alters the way that we would approach them. But ultimately, as a result of that most of our crews are electing to wear full personal protective equipment all the time. And that’s just to keep them safe.”

All ambulance crews are now required to be fully vaccinated.

The growth of the outbreak has seen a shift in approach that means people who test positive for Covid are by default isolating at home rather than in a quarantine facility. As of yesterday, 2,210 Covid-positive people were isolating at home in Auckland and Waikato. Three deaths of people self-isolating within a week, together with a string of media reports about slow or insufficient clinical care prompted the health and disability commissioner to write to the director general of health seeking “urgent attention” to the concerns.

Ohs says he is satisfied with the public health coordination with ambulance services in managing people isolating at home.

“We’re very clear on what our role is,” he said. “We have been invited to participate in a clinical advisory group at the Ministry of Health, which is advising on how people will get managed in the community. And so as part of that we’ve got a clinical procedure and guidelines for how to keep people safe in the community. We’ve got a partnership with Whakarongorau where they can refer to us if they have clinical concerns about a patient in the community. So from a St John perspective we’re feeling fairly well connected.”

‘A horrid working environment’

The circumstances ambulance crews face are exceptionally challenging, Ohs said.

“Our ambulance crews, particularly in Auckland, but in all areas where there are lots of Covid patients, are doing an absolutely fantastic job. They’ve got a pretty horrid working environment at the moment. You can imagine as a frontline ambulance officer in Auckland, you’ve got the unknown of who’s got Covid, who hasn’t, and obviously the design of an ambulance is such that in order to make it aerodynamic and able to move quickly, it means that it’s relatively small. So our crews are in close proximity to patients in the back of the ambulance. They’re having to wear personal protective equipment all the time.”

They face added risk because they are working in ambulances fitted with ventilation systems that were “designed pre-pandemic”, said Ohs. “Now that we’ve got droplet screens to stop aerosol from getting into the front means that the air conditioning in the back isn’t as good. Our staff are working very hard, scary and unknown environment. They’re getting really hot. And they’re doing an amazing job. We recognise it’s an uncertain and uncomfortable environment for them. But they’re doing a great job of making sure that people get the right level of care and that standard of care is maintained.”