Lives are being put at risk by British Columbia guidelines that require psychiatric patients to be heavily sedated before they are allowed on an air ambulance, according to several rural doctors who say the mentally ill are being stereotyped as dangerous.
Under the mandatory sedation guidelines, the doctors say, children, adults, people with dementia or depression and those who are psychotically violent all have to be treated the same.
About 8,000 patients are transported by air ambulance annually in B.C., and about 100 of them are mentally ill. Elsewhere in Canada, medical evacuations of mentally ill patients are rare. The numbers reflect the rugged and vast geography of the province, where many remote communities are hours from the nearest hospital.
Rural doctors saying they find moving mentally ill patients stressful because they know they will have to sedate them even when they don't want to or they will not be allowed on an air ambulance.
"You have to sedate them to the point where the B.C. ambulance people shake their shoulder and say, 'Hello, hello, wake up.' And they don't wake up. Which is dangerous," Andrea Wilhelm said.
Dr. Wilhelm, who practices on the remote islands of Haida Gwaii, has written to the B.C. Ombudsperson that the medical transfer rules amount to discrimination against the mentally ill.
"This policy, without a doubt, puts patients' lives at risk. . . . It's dangerous. And it's happening to kids and adults," Dr. Wilhelm said.
Sharmeen Mazaheri, who practices on southern Vancouver Island, concurred. "I agree wholeheartedly," Dr. Mazaheri said in an e-mail. "If patients anywhere else were unnecessarily sedated to the point of unconsciousness, it would be considered malpractice."
Other doctors – Harvey Thommasen, in Dease Lake, Peter Lake, on Haida Gwaii, and Miles Schuman, who has worked widely in northern B.C. and Nunavut, also sent emails endorsing Dr. Wilhelm's concerns.
But Paul Dagg, an associate professor of psychiatry at the University of B.C., said the flaws in the policy, drafted by the B.C. Ambulance Service in 2009 after incidents that put the safety of air crews at risk, have already been identified and are being corrected.
Dr. Dagg said a team that includes medical doctors, ambulance crews and psychiatrists is working on new guidelines, which should be in place, at least on a pilot basis, within 12 months.
"It is a challenging thing to come up with because there is really nowhere in the world that has figured out how to do this. British Columbia is one of the few jurisdictions in Canada where psychiatric patients are transferred by air ... so it's kind of ground-breaking work, and we're having to be very careful about it because there are risks for everybody involved," he said.
Dr. Dagg said the concerns raised by rural doctors are valid, but a solution can't be rushed.
The B.C. Ambulance Service wrote the guidelines after a number of incidents raised air safety concerns.
"Air transit is a high-risk undertaking with little room for error, and the consequences of under-sedating psychiatric patients could be catastrophic," Stephen Wheeler, medical director of the ambulance service, wrote in the B.C. Medical Journal in 2009, when the guidelines were introduced. "In a worst-case scenario, an agitated patient might assault the pilot and cause the aircraft to crash."
Les Fisher, chief operating officer of the ambulance service, said crews work with local doctors on a "case-by-case basis" to assess whether a mentally ill patient needs to be sedated.
The guidelines set out the "patient types who require chemical restraint." The rural doctors say that list is so broad it takes in anyone who has mental-health problems.
When the paramedics disagree with a local doctor's decision not to sedate, they can refuse to take the patient by air ambulance.
"You've got to recognize the situation they get put into. The aircraft ...are very small. They are literally shoulder to shoulder in some cases with the patient, and the cockpit is open. And at upwards of 30,000 feet there is no quick pullover if something happens," he said.
Patients turned away from an air ambulance are transported by ground, which is the way psychiatric patients are usually moved in other provinces.
"It is unique to B.C. that we are moving psychiatric patients by air," Mr. Fisher said.
He said in other provinces mentally ill patients are so rarely moved that they assessed individually.
In her letter to the B.C. Ombudsperson, Dr. Wilhelm questioned whether a heavily sedated patient can get the level of care needed on an air ambulance.
But Mr. Fisher said critical-care paramedics are trained to deal with sedated patients.
"They have transport ventilators, they have the sophisticated monitoring equipment you'd find in an intensive care unit, so I have every confidence in my staff to be able to care for these patients," he said.