Pre-hospital chain of care

The pre-hospital chain of care corresponds to all the actions and interventions undertaken by various care providers to assist a person in an emergency situation.

The 911 emergency service and ambulance services are essential elements in the pre-hospital chain of care and are probably the best known. However, they are surrounded by other services that play an equally important role in an emergency situation.

In the event of cardiopulmonary arrest, the actions of the first persons on the scene have a major impact on the victim's survival. The victim's chances of survival decrease by 7-10% per minute after cardiopulmonary arrest, but can be tripled if resuscitation is performed quickly.

Until paramedics arrive and the patient is taken to hospital, rapid and effective intervention (call 911 and start resuscitation) by the following people can save a life:

• Citizen first responders
• Police first responders
• First responders

The pre-hospital chain of care includes:

• the lay responder or designated first aider (if on site);
• the 911 emergency service;
• the health communication centre;
• first responder services;
• ambulance services;
• hospitals.

Anyone present at the scene of an emergency becomes a first responder and must call 911 as soon as possible if emergency assistance is needed. A first responder could be a witness, a passerby, a family member, a friend, a colleague, a first aider, etc.

Be aware that Québec laws protect all citizen first aiders when they provide assistance in good faith. Citizens who provide first aid are not responsible for any harm done to the victim unless there is gross fault. Gross fault refers to gross carelessness, gross negligence, or intentional fault.

See the page What to do in an emergency requiring an ambulance for the steps to follow in an emergency and the specific steps to take during a cardiac arrest.

In just a few seconds, a call to 911 emergency services can determine whether the situation requires the assistance of the police, firefighters or ambulance services. When ambulance services are required, the call is immediately transferred to the health communication centre.

During each call, the emergency medical dispatcher at the health communication centre asks simple questions to establish the priority of the dispatch of ambulance services. It is important to answer the dispatcher’s questions calmly and clearly.

If the case seems urgent, they contact paramedics or first responders, if the municipality has this service, during the first seconds of the call. If necessary, they stay on the line with the caller to give their useful advice while they are waiting for help to arrive.

Some municipalities have a first responder service. This local service means that someone can be sent to the scene quickly in emergency situations. This person makes sure that the condition of people in distress does not worsen while waiting for the ambulance attendants to arrive.

First responders are trained to:

• administer first aid;
• use an automated external defibrillator when a person is in cardiac arrest;
• give medication in the event of a severe allergic reaction, medical symptoms of a diabetic person or possible intoxication by opioid medication depending on the level of training obtained.

Once the ambulance arrives on the scene, the first responders leave the paramedics in charge of the situation. They remain present to provide support if needed.

Not all Québec municipalities have a first responder service, but new services are added every year. Québec has around 6,270 first responders in more than 384 municipalities. For example, the Montréal territory has around 1,700 first responders. To find out if there is a first responder service in your municipality and how it works, contact the integrated health and social services centre (CISSS) or integrated university health and social services centre (CIUSSS) in your area. For the Montréal and Laval areas, contact Urgences-santé .

The paramedic is responsible for checking the person's health condition, providing them with the necessary care and offering transport to a hospital. They must also inform the hospital centre of the patient's condition using the pre-hospital intervention report. This report is added to the patient's medical record.

A medical technician can:

• administer medication in the event of a severe allergic reaction,  medical symptoms of a diabetic person, difficulty breathing, possible intoxication by opioid intoxication, heart problems and severe pain;
• use a semi-automatic defibrillator during a cardiac arrest;
• check the heart’s activity if heart problems are suspected;
• improve the patient’s ventilation and breathing using mechanical devices.

Paramedics receive rigorous pre-hospital emergency care training that allows them to respond effectively to people in distress in any emergency situation. Several CEGEPs and some private colleges provide this training. All active paramedics must also complete a mandatory continuing education program each year. Through this training program, paramedics keep their skills up to date.

In Québec, ambulance services are provided by:

• private companies;
• companies incorporated as worker cooperatives;
• the public sector company Urgences-santé for the Montréal and Laval territories.

Ambulance services must transport the patient to the hospital that can meet the patient’s needs within the shortest period of time. The following criteria are considered when choosing where to transport the patient:

• the patient’s health condition;
• the distance to be covered or the quickest access;
• the specialized services offered by the hospital centre;
• the institution's emergency room capacity.

Triage involves prioritizing the care of patients who come to a hospital’s emergency department based on the severity of their health condition. Arriving at the emergency room by ambulance does not guarantee priority treatment. A person who arrived in an ambulance but whose condition is stable may be treated less quickly than a person who arrived in the emergency room by another means. If the second person’s condition requires immediate care, their treatment will be considered a priority at triage.