Toronto Emergency Medical Services releases findings on Alexander Street call
and confirms actions taken on recommendations. City Manager to oversee
implementation of recommendations.

TORONTO, Oct. 8 /CNW/ - This afternoon, Chief Bruce Farr released the findings and recommendations from the Ministry of Health and Long Term Care (MOHLTC) investigation into the response time of Toronto EMS to a call to Alexander Street, on June 25th, 2009.

The investigation found that there was a preventable delay in the ambulance response time to the call. The delay was caused primarily by a series of decisions that were made by Toronto EMS staff that did not follow existing EMS policy and procedures.

Prior to releasing the findings at the press conference, Chief Farr met with Mr. Hearst's family to express his sympathy and to discuss the findings of the report. "My deepest sympathies are extended to Mr. Hearst's family on behalf of the entire Toronto EMS team. I want to assure the family and all Torontonians that we have learned from what transpired and will take action to strengthen existing policies and procedures so that this situation can be prevented in the future," said Chief Farr.

The investigator made 13 recommendations. The recommendations range from providing staff with remedial training to reinforcement and review of current EMS policy and procedure. Toronto EMS has already implemented a number of the recommendations and will follow through as quickly as possible to implement the remainder.

    
    Key actions taken to date include:

    -   Preparation of remedial training programs for staff, including those
        involved in the call.
    -   Directive to all Toronto EMS managers to review and reinforce the
        existing staging policy.
    -   Improved supervision and management oversight of the staging process
        with the implementation of an "alarm" system in the Communication
        Center.
    -   A comprehensive review process of the existing staging policy and
        procedure is underway.
    

In addition, the Mayor has asked the City Manager to convene a working group with representation from EMS, the Ministries of Health and Long-Term Care and Labour, the union and the City to review the current policy regarding paramedic staging. The staging policy is used when a paramedic is in doubt about their safety and may request that police or other appropriate agency attend the scene. This policy was put in place in 2005 as a result of an order by the Ministry of Labour.

The Ministry of Health and Long Term Care Report can be found at: http://www.toronto.ca/your_health/ems.htm.

Toronto is Canada's largest city and sixth largest government, and home to a diverse population of about 2.6 million people. It is the economic engine of Canada and one of the greenest and most creative cities in North America. Toronto has won numerous awards for quality, innovation and efficiency in delivering public services. 2009 marks the 175th anniversary of Toronto's incorporation as a city. Toronto's government is dedicated to prosperity, opportunity and liveability for all its residents.

    
    October 8, 2009

     Summary of Sequence of Events Leading to Toronto Emergency Medical
     ------------------------------------------------------------------
           Services' Response to Alexander Street on June 25, 2009
           -------------------------------------------------------

    -------------------------------------------------------------------------
                                                  Time Elapsed    Cumulative
    Event Time            Toronto EMS Actions    Between Actions   Response
    HH:MM:SS                                          MM:SS          MM:SS
    -------------------------------------------------------------------------
    1. 23:04:53         Toronto Central Ambulance      00:00
       (11:04:53 p.m.)  Communications Centre (CACC)
                        received a 9-1-1 call from
                        Alexander St.
    -------------------------------------------------------------------------
    2. 23:06:18         Emergency Medical Dispatcher   01:25          01:25
       (11:06:18 p.m.)  (EMD) No.1 commits call to
                        the Computer Aided Dispatch
                        (CAD) system
    -------------------------------------------------------------------------
    3. 23:06:31         Toronto Police Services (TPS)  00:13          01:38
       (11:06:31 p.m.)  create a call to attend with
                        ambulance on a "priority 2"
                        basis
    -------------------------------------------------------------------------
    4. 23:06:48         Toronto EMS ambulance with 2   00:17          01:45
       (11:06:48 p.m.)  Primary Care Paramedics
                       (PCP's) is assigned to call.
    -------------------------------------------------------------------------
    5. 23:14:00         Paramedics advise dispatch     07:12          08:57
       (11:14:00 p.m.)  they are staging at
                        Alexander St. and Yonge St.
    -------------------------------------------------------------------------
    6. 23:14:13         An EMD contacts the police     00:13          09:10
       (11:14:13 p.m.)  and is advised that there are
                        no police available to attend
                        the call with the Paramedics
                        at 40 Alexander St.
    -------------------------------------------------------------------------
    7. 23:19:16         An EMD notifies the Paramedic  05:03          14:13
       (11:19:16 p.m.)  crews Supervisor that the
                        crew are staging, awaiting
                        the police re: 40 Alexander St.
    -------------------------------------------------------------------------
    8. 23:19:36         EMD No.5 is reached by the     00:20          14:37
       (11:19:36 p.m.)  Security Guard with the
                        patient at Alexander St. and
                        says the patient is conscious
                        and breathing with what may
                        be bruising.
    -------------------------------------------------------------------------
    9. 23:35:26         Toronto Police are assigned    15:50          30:27
       (11:35:26 p.m.)  to the call.
    -------------------------------------------------------------------------
    10. 23:36:48        An EMD receives a 2nd call     01:22          31:49
       (11:36:48 p.m.)  from the Security Company and
                        is advised the patient is not
                        breathing and CPR is in
                        progress.
    -------------------------------------------------------------------------
    11. 23:38:20        The EMD in point 10 upgrades   01:32          33:21
       (11:38:20 p.m.)  the call from Bravo (unknown)
                        to Echo (not breathing patient)
                        and the call urgency triggers
                        Toronto Fire Services to
                        respond.
    -------------------------------------------------------------------------
    12. 23:38:46        Toronto Fire pumper unit is    00:26          33:47
       (11:38:46 p.m.)  notified of call.
    ------------------------------------------------------------------------
    13. 23:38:46        2 staged Paramedics          0:00:00
       (11:38:46 p.m.)  acknowledge the call upgrade
                        and ask for Fire assistance.
                        An Advanced Care Paramedic
                        unit to assigned as well by
                        EMS Communications
    -------------------------------------------------------------------------
    14. 23:42:00        Toronto Fire arrives           03:14          37:01
       (11:42:00 p.m.)  on scene.
    -------------------------------------------------------------------------
    15. 23:43:16        Advanced Care paramedic unit   01:16          38:17
       (11:43:16 p.m.)  arrives at the scene.
    -------------------------------------------------------------------------
    16. 23:43:20        Staged Primary Care            00:04          38:21
       (11:43:20 p.m.)  Paramedics on scene
    -------------------------------------------------------------------------
    17. 23:48:30        Toronto Police arrive at       00:10          38:41
       (11:38:30 p.m.)  the scene
    -------------------------------------------------------------------------
    18. 00: 01:46       Advanced Care Paramedics
       (12:01:46 a.m.)  contact base hospital
                        physician and they advise a
                        patient with no vital signs
                        who has not responded to
                        treatment.
    -------------------------------------------------------------------------
    19. 00:07:00        Base hospital physician
       (12:07:00a.m.)   declares the patient deceased.
    -------------------------------------------------------------------------


    October 8, 2009

     Summary recommendations & Toronto Emergency Medical Services (EMS)
     action plan in response to Alexander Street investigation and report

    The following outlines the 13 recommendations from the Ministry of Health
and Long-Term Care (MOHLTC) report on the above investigation and the
corresponding actions that have been taken, or will be taken by Toronto EMS,
in response to the recommendations. A glossary of short forms is provided at
the end of this document.

    -------------------------------------------------------------------------
               Recommendation                    Toronto EMS Action
    -------------------------------------------------------------------------
    1.  That the management of Toronto      - EMD No.1 has been retrained on
        Central Ambulance Communication       the CACC policy and has been
        Center (CACC) provides remedial       scheduled to receive remedial
        training to Emergency Medical         training on return to work.
        Dispatcher No.1 (EMD) in the roles
        and responsibilities of a call      - Toronto CACC management staff
        receiver and the requirements to      will monitor EMD No.1
        process requests for emergency        performance to ensure
        medical services as required by       compliance for six (6) months
        Toronto CACC policy and procedure     which exceeds the MOHLTC
        and upon successful completion of     recommendation.
        this training that performance be
        monitored for a minimum of three    - All EMS CACC staff have been
        (3) months to ensure compliance.      reissued the CACC policy.

                                            - In addition all EMD's and their
                                              Supervisors have been told to
                                              review and reinforce existing
                                              policy and procedure.
    -------------------------------------------------------------------------
    2.  That the management of Toronto      - EMD No.1 has been retrained on
        CACC provide remedial training to     the CACC SOP (Standard
        EMD No.1 in the requirement to        Operating Procedure) with
        document all pertinent patient and    respect to documenting
        scene condition information           pertinent patient and scene
        learned while receiving requests      condition information and
        for ambulance service, including      has been scheduled to receive
        any information that there are        remedial training on return to
        individuals with a patient, and       work. Toronto CACC management
        that such documentation be            staff will monitor performance
        accurate as provided by the call      to ensure compliance for six
        and that upon successful              (6) months which exceeds the
        completion of this training that      MOHLTC recommendation.
        performance be monitored for three
        (3) months to ensure compliance.    - In addition, all CACC, EMD's
                                              and Supervisors have been told
                                              to review and enforce existing
                                              policy and procedure.
    -------------------------------------------------------------------------
    3.  That the management of Toronto      - EMD No. 1 has been retrained
        CACC provide remedial training to     on the CACC SOP with respect to
        EMD No.1 in the appropriate method    the appropriate method of
        to request police assistance on       requesting police assistance
        scene as stipulated by CACC policy    and has been scheduled to
        and procedure and that performance    receive remedial training on
        be monitored for a minimum of         return to work.
        thirty (30) days to ensure
        compliance.                         - All CACC EMDs and their
                                              Supervisors have been told to
                                              review and enforce existing
                                              policy and procedures.
    -------------------------------------------------------------------------
    4.  That the management of Toronto      - EMD No.5 has been retrained on
        CACC provide remedial training to     the CACC policy and has been
        EMD No.2 in the roles and             scheduled to receive remedial
        responsibilities of a call            training on return to work.
        receiver and the requirements to
        process requests for emergency      - Toronto CACC management staff
        medical services as required by       will monitor performance to
        Toronto CACC policy and procedure     ensure compliance for six (6)
        and upon successful completion of     months which exceeds the
        this training monitor performance     MOHLTC recommendation.
        for a minimum of 3 months.
        (90 days)
    -------------------------------------------------------------------------
    5.  That the management of Toronto      - EMD No.5 has been retrained on
        CACC provide remedial training to     the CACC SOP with respect to
        EMD No.2 in the requirement to        documenting pertinent patient
        document all pertinent patient and    and scene condition information
        scene condition information           and has been scheduled to
        learned while receiving requests      receive remedial training on
        for ambulance service, including      return to work.
        any information that there are
        individuals with a patient, and     - Upon successful completion of
        that such documentation be            remedial training, Toronto CACC
        accurate as provided by the call      management staff will monitor
        and that upon successful              his performance to ensure
        completion of this training that      compliance for six (6) months
        performance be monitored for          which exceeds the MOHLTC
        3 months. (90 days)                   recommendation.

                                            - All CACC EMDs and their
                                              Supervisors have been told to
                                              review and reinforce existing
                                              policy and procedure.
    -------------------------------------------------------------------------
    6.  That the management of Toronto      - As an Accredited Centre of
        CACC review current policy and        Excellence with the
        procedure regarding call              International Academy of
        processing and documentation          Emergency Dispatch (IAED),
        requirements and to update and or     Toronto EMS CACC maintains a
        modify such policy to ensure that     CQI (continuous quality
        all EMD's document action             improvement) process and is
        requirements pertaining to patient    required to perform call
        scene conditions.                     receiving audits daily, and to
                                              provide counsel to EMDs who
                                              fall below a 95% compliance
                                              level with the protocol. This
                                              process exceeds the
                                              requirements of the MOHLTC.

                                            - The current policy and existing
                                              Continuous Quality Improvement
                                              processes will be reviewed by
                                              an EMS management working
                                              group.
    -------------------------------------------------------------------------
    7.  That the management of Toronto      - Toronto EMS has reviewed this
        CACC and Toronto EMS review the       policy.
        police notification polices and
        amend as required to ensure that    - Recommended changes will be
        police assistance at the scene of     tabled with the City of
        a medical emergency is necessary      Toronto's 9-1-1 Emergency
        for the protection of paramedics,     Response Committee to consider
        patients and bystanders health and    impacts to all allied emergency
        safety.                               services.
    -------------------------------------------------------------------------
    8.  That the management of Toronto EMS  - PCP No.1 will be retrained and
        provide remedial training to          will receive remedial training.
        Primary Care Paramedic (PCP) No.1     upon his return to work.
        in the requirements of the Basic
        Life support Patient Care           - Upon successful completion of
        Standards as well as Toronto EMS      remedial training, Toronto EMS
        Standard Operating Procedures         management staff will monitor
        regarding the decision making         performance to ensure
        process to withhold patient care      compliance for six (6) months.
        (stage) and that upon successful
        completion of this training         - All Primary Care Paramedics and
        performance by monitored for a        their Supervisors have been
        minimum of 6 months.                  advised to review and enforce
                                              this existing policy and
                                              procedure.
    -------------------------------------------------------------------------
    9.  That the management of Toronto EMS  - PCP No.2 will be retrained and
        provide remedial training to PCP      will receive remedial training
        No.2 in the requirements of Basic     upon return to work.
        Life support Patient Care
        Standards as well as Toronto EMS    - Upon successful completion of
        Standard Operating Procedures         remedial training, Toronto EMS
        regarding decision making process     management staff will monitor
        to withhold patient care (stage)      performance to ensure
        and that upon successful              compliance for six (6) months.
        completion of this training that
        performance be monitored for 6
        months to ensure compliance.
    -------------------------------------------------------------------------
    10. That the management of Toronto EMS  - Supervisor No.1 has been
        provide remedial training to          reinstructed and will receive
        Supervisor No.1 in the roles and      remedial training upon return
        responsibilities of a Supervisor      to work.
        when notified that a paramedic
        crew is withholding patient care    - Upon successful completion of
        (staging) and upon successful         remedial training, Toronto EMS
        completion of this training           management staff will monitor
        performance be monitored for a        performance to ensure
        minimum of thirty (30) days to        compliance for six (6) months
        ensure compliance.                    which exceeds the MOHLTC
                                              recommendation.
    -------------------------------------------------------------------------
    11. That the management of Toronto EMS  - Toronto EMS is currently
        provide direction to all staff,       reviewing the 3 possible
        either by memorandum, directive or    recommended options to provide
        policy, that in any situation         this direction to staff.
        where the paramedic does not
        believe they have sufficient
        information regarding scene safety
        that they will request the
        dispatcher to provide additional
        information.
    -------------------------------------------------------------------------
    12. That the management of Toronto      - Toronto EMS CACC is currently
        CACC provide direction to all         providing direction to all EMD
        staff, either by memorandum,          staff through a Continuing
        directive or policy that in any       Education program reinforcing
        situation where it is unclear as      the situational interrogation
        to what is occurring on scene to      inherent in the protocol and
        ask pertinent questions of the        the need for documentation of
        caller in order to obtain as much     all pertinent information.
        information as possible and all
        such information will be
        documented in the call details and
        provided to the responding
        paramedics.
    -------------------------------------------------------------------------
    13. That the management of Toronto EMS
        review the current policies
        regarding paramedic withholding
        service (staging) to ensure it is
        compliant with the Basic Life
        Support Patient Care Standards as
        well as relevant health and safety
        legislation and that consideration
        is given to amending these
        policies to include;

        - immediate notification of TEMS    - Toronto EMS has implemented an
          management of any and all           "Alert Line" in the CACC to
          paramedic withholding service       provide immediate notification
          (staging) events                    to TEMS management of any EMS
                                              crew who delay patient contact
                                              as a result of a scene safety
                                              concern. This application will
                                              be applied to all delayed
                                              responses immediately. The
                                              notification will provide the
                                              CACC Management Staff and the
                                              Operations Duty Officer with
                                              the location of the delay in
                                              order to deploy the closest
                                              available Operations Supervisor
                                              to respond.

        - the immediate response of an      - July 17, 2009, Toronto EMS
          individual from TEMS management     reissued a Management directive
          to the scene to perform a scene     to all operations management
          and safety assessment               staff to establish direct
                                              communications with a paramedic
                                              withholding service (staging)
                                              to ensure the safety of the
                                              crew and provide any necessary
                                              assistance or direction. If the
                                              crew remains staged, the
                                              Operations Supervisor is to
                                              respond to the staged crew.

        - that Incident Reports will be     - A revised documentation process
          completed by the paramedics and     is being developed using
          TEMS manager involved with a        existing CAD (Computer Aided
          paramedic staging event             Dispatch) data and reporting
                                              tools to provide real time
                                              access to information and
                                              updated incident status
                                              comments. This will support the
                                              Professional Standards Unit
                                              (PSU) in collating all required
                                              documentation as CACC
                                              management staff can initiate
                                              the audit process
                                              electronically.

        - that all such incident reports    - PSU will continue to review and
          will be traced and reviewed in a    match Operations and CACC
          timely manner to ensure that all    documentation and forward for
          paramedic staging events are        review to Operations
          reasonable and necessary.           management.

                                            - In addition, TEMS has
                                              implemented working group to
                                              review and make recommendations
                                              to policy, the SOP and
                                              paramedic education, for calls
                                              where ambulance service is
                                              withheld.

                                            - TEMS will participate in the
                                              proposed City Manager's working
                                              group with the Union, the
                                              Ministry of Labour and Ministry
                                              of Health to review and make
                                              recommendations to improve the
                                              current withholding service or
                                              "staging" policy. In 2005,
                                              "staging" was put in place by a
                                              joint group of union and TEMS
                                              management in response to a
                                              Ministry of Labour order to
                                              protect the health and safety
                                              of its staff.
    -------------------------------------------------------------------------


                              GLOSSARY OF TERMS
                              -----------------

    1.  CACC - Central Ambulance Communication Center - where 9-1-1 calls are
        received, caller questioned, situation assessed over the phone, calls
        recorded and ambulances dispatched

    2.  EMD - Emergency Medical Dispatcher - the person who works in the CACC
        who takes the 9-1-1 call, questions caller, performs questioning
        according to established protocols, determines the priority of the
        call, provides the information to the paramedics and dispatches the
        ambulance

    3.  MOHLTC - Ministry of Health and Long Term Care - provincial Ministry
        provides the City funds to run the CACC and legislates provision of
        ambulance services through the Ambulance Act
        http://www.e-laws.gov.on.ca/html/regs/english/elaws_regs_000257_e.htm

    4.  PCP - Primary Care Paramedic - a health care provider who is a first
        responder to patients at a 9-1-1 call

    5.  ACP - Advanced Care Paramedic - a health care provider who is a first
        responder to patients at a 9-1-1 call who has achieved the highest
        level certification as a paramedic is able to perform advanced care
        such as intubation.

    6.  CAD - Computer Aided Device - the system that records the calls at
        the CACC and transmits the information to the paramedics dispatched
        to a call.

    7.  MOL - Ministry of Labour - the Provincial Ministry that inspects
        Toronto EMS adherence to the Occupational Health and Safety Act and
        responds to employee concerns about working conditions.
        http://www.labour.gov.on.ca/english/hs/



    Ministry of Health and             Ministère de la Santé et des
    Long-Term Care                     Soins de longue durée

    Emergency Health                   Direction des services de
    Services Branch                    santé d'urgence
    Investigation Unit                 Centre D'Investigation
    5700 Yonge Street, 6th Floor       5700 rue Yonge, 6e étage
    Toronto ON M2M 4K5                 Toronto ON M2M 4K5
    Tel.: 416-327-7068                 Tél.: 416-327-7068
    Fax: 416-327-7912                  Téléc.: 416-327-7912
    Toll Free: 800-461-6431            Appels sans frais: 800-461-6431

    Investigation Unit file: 09IU-03-141

    September 24, 2009

    Bruce Farr
    Chief and General Manager
    Toronto Emergency Medical Services
    4330 Dufferin Street
    Toronto ON M3H 5R9

    Dear Chief Farr,

    At your request I have completed the investigation of the emergency
ambulance response on June 25, 2009 to 40 Alexander Street in Toronto. I have
enclosed my Summary Report for your information.
    The evidence obtained during my investigation substantiated that there was
a preventable delay in the provision of emergency ambulance service for Mr.
James Hearst.
    As a result of the investigation it is requested that consideration be
given to the following:

    -   That the management of Toronto CACC provides remedial training to EMD
        No.1 in the roles and responsibilities of a call receiver and the
        requirements to process requests for emergency medical services as
        required by Toronto CACC policy and procedure and upon successful
        completion of this training his performance be monitored for a
        minimum of three (3) months to ensure compliance.

    -   That the management of Toronto CACC provides remedial training to EMD
        No.1 in the requirement to document all pertinent patient and scene
        condition information learned while receiving requests for ambulance
        service, including any information that there are individuals with a
        patient, and that such documentation be accurate as provided by the
        caller and that upon successful completion of this training that his
        performance be monitored for a minimum of three (3) months to ensure
        compliance.

    -   That the management of Toronto CACC provides remedial training to EMD
        No.1 in the appropriate method to request police assistance on scene
        as stipulated by CACC policy and procedure and that his performance
        be monitored for a minimum of thirty (30) days to ensure compliance.

    -   That the management of Toronto CACC provides remedial training to EMD
        No.5 in the roles and responsibilities of a call receiver and the
        requirements to process requests for emergency medical services as
        required by Toronto CACC policy and procedure and upon successful
        completion of this training his performance be monitored for a
        minimum of three (3) months to ensure compliance.

    -   That the management of Toronto CACC provides remedial training to EMD
        No.5 in the requirement to document all pertinent patient and scene
        condition information learned while receiving requests for ambulance
        service, including any information that there are individuals with a
        patient, and that such documentation be accurate as provided by the
        caller and that upon successful completion of this training that his
        performance be monitored for a minimum of three (3) months to ensure
        compliance.

    -   That the management of Toronto CACC reviews current policy and
        procedure regarding call processing and documentation requirements
        and to upgrade and or modify such policy to ensure that all EMDs
        document pertinent information pertaining to patient and scene
        conditions.

    -   That the management of Toronto CACC and Toronto EMS reviews the
        police notification policies and amend as required to ensure that
        police assistance at the scene of a medical emergency is necessary
        for the protection of paramedics, patients and bystanders health and
        safety.

    -   That the management of Toronto EMS provides remedial training to PCP
        No.1 in the requirements of the Basic Life Support Patient Care
        Standards as well as Toronto EMS Standard Operating Procedures
        regarding the decision making process to withhold patient care
        (stage) and that upon successful completion of this training his
        performance be monitored for a minimum of six (6) months to ensure
        compliance.

    -   That the management of Toronto EMS provides remedial training to PCP
        No.2 in the requirements of the Basic Life Support Patient Care
        Standards as well as Toronto EMS Standard Operating Procedures
        regarding the decision making process to withhold patient care
        (stage) and that upon successful completion of this training her
        performance be monitored for a minimum of six (6) months to ensure
        compliance.

    -   That the management of Toronto EMS provides remedial training to
        Operations Supervisor No.1 in the roles and responsibilities of a
        Supervisor when notified that a paramedic crew is staging and upon
        successful completion of this training his performance be monitored
        for a minimum of thirty (30) days to ensure compliance.

    -   That the management of Toronto EMS provides direction to all staff,
        either by memorandum, directive or policy, that in any situation
        where the paramedic does not believe they have sufficient information
        regarding scene safety that they will request the dispatcher to
        provide additional information.

    -   That the management of Toronto CACC provides direction to all staff,
        either by memorandum, directive of policy that in any situation where
        it is unclear as to what is occurring on scene to ask pertinent
        questions of the caller in order to obtain as much information as
        possible and all such information will be documented in the call
        details and provided to the responding paramedics.

    -   That the management of Toronto EMS reviews the current policies
        regarding paramedic staging to ensure it is compliant with the Basic
        Life Support Patient Care Standards as well as relevant health and
        safety legislation and that consideration is given to amending these
        policies to include:

                 -  immediate notification of TEMS management of any and all
                    paramedic staging events
                 -  the immediate response of an individual from TEMS
                    management to the scene to perform a scene and safety
                    assessment
                 -  that Incident Reports will be completed by the paramedics
                    and TEMS manager involved with a paramedic staging event
                 -  that all such Incident Reports will be tracked and
                    reviewed in a timely manner to ensure that all paramedic
                    staging events are reasonable and necessary.

    If you have any questions or require any further assistance, please do not
hesitate to contact me.

    Sincerely,

    (signed)
    Rick Brady
    Manager - Investigation Unit

    c:    M. Bates, Director - EHS Branch
          D. Brown, Sr. Manager Performance & Quality Management - EHS Branch
          G. Bragagnolo, Sr. Field Manager GTA Field Office - EHS Branch
    

SOURCE City of Toronto

For further information: For further information: Media contact: Kim McKinnon, Coordinator Public Information and Media, Toronto Emergency Medical Services, (416) 392-2255, kmckinn2@toronto.ca


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