In September, the Tallinn Ambulance service (Tallinna Kiirabi) celebrated its 100th birthday, but at the same time one of the most prestigious medical institutions in Estonia is facing serious accusations, namely that a number of former and current employees claim that they have for years been forced to falsify documents in order to paint a better picture of emergency response speeds than is in reality the case. 

Management states that this relates to an IT technological error and will not result in any public harm.

Two current employees, Argo and Toomas (names changed), may very well have been risking their jobs and careers by giving an interview to Pealtnägija, the show says.

Toomas said: "What is happening at the moment is not in patients' interests. When we know inside the organization that we have a problem getting to the ambulance in one minute, then instead of resolving this issue, we alter the recorded times."

Pealtnägija had already received the first hints on how Estonia's largest ambulance service institution allegedly regularly changes the times related to challenges in the databases and distorts statistics in springtime, but the service's management did not seem to be interested in this.

Last year, a former ambulance service employee, Joona Sõsa, who was fired over Covid vaccination refusal, wrote a letter of no confidence to the Mayor of Tallinn on behalf of the Estonian Ambulance Workers' Union (Eesti Kiirabi Töötajate Ametiühing), accusing Raul Adlas, the chief doctor of service, accusing him of a dictatorial management style and of persecuting employees, and also referenced the alleged falsification of documents. One year on, Sõsa stands by his words.

Start times and time taken to reach those in need both recorded

It is understandable that the field of emergency care is precisely regulated and controlled, since it relates to preserving lives over time. One of the most important yardsticks is the time of departure and arrival, whereby separate records are kept of both when an emergency crew set out and when they reach the site to which they are called out.

The norms established by law require that a brigade must set off on an emergency call within one to 10 minutes after receiving the notification, depending on the priority of the case. The highest level or "delta" challenge, for example in the case of cardiac arrest, must be underway within one minute. 

In terms of journey time it should take seven to 14 minutes to reach a scene, depending on the location of call-out.

This is where the alleged skeleton in the closet is located. Sõsa and other whistleblowers actually submitted concrete evidence to the City of Tallinn, in formal terms the customer of the ambulance service, a year ago, which seems to imply that the departure times in the database are being falsified and that organizers of this alleged fraud are the management and middle-level employees of the ambulance service. 

For example, Sõsa provided the city with 13 SMS text messages in which field commanders had given specific instructions to brigade commanders and which could be considered as leaning towards fraud, and claims that such orders were almost daily.

Sõsa said: "Either during the shift or after it has ended, a nurse, brigade leader or doctor may receive a message from the feedback field manager to the effect that this or that trip is too long. For example, it is three minutes, but it should be one minute, and the message states that the brigade leader should to improve this time."

"Pealtnägija" was lucky enough to get hold of 20 such messages, mostly from the summer of this year. For example, last January 10, the field commander sent an order to subordinates to "check and amend" the departure time of a "Charlie" (ie. second-highest priority – ed.) category callout.

Instead of the stipulated three minutes, the brigade left the depot after four minutes, i.e. the departure was delayed by a minute. On April 9 of the same year, the field commander issued a brigade a German greeting, "Guten morgen" and informed them that the call-out departure from a previous evening had been delayed by three minutes.

Speed of response is regulated by legislation and contracts

On the one hand, the law stipulates the speed of response, on the other, a contract with the Health Insurance Fund (Haigekassa), which was in force at the time, stipulated that an ambulance would arrive at an incident within a certain average time. 

Legally speaking, while the brigade might not have been late on the scene, since their start was too slow, they could actually have reached the patient much earlier.

"Pealtnägija" presented these statements and questions to the ambulance manager Raul Adlas and the head of the Tallinn Social and Health Board (Sotsiaal- ja tervishoiuamet) Raimo Saad, who Adlas is strictly subordinate to. According to both parties, the main issue is not the time of departure, but the time of arrival, while there are certainly no problems with the latter. Moreover, a record of each call is also saved in the alarm center (Häirekeskus) system, and if doubts arise, data can always been checked from there. Overall, both Saad and Adlas say the suspicions were malicious and taken out of context.

The City of Tallinn even conducted a separate inspection following Sõsa's complaint, which did not detect any irregularities. According to Adlas, there were no discrepancies in the databases, so the claims were not based in fact.

On first glance then this might seem to have been an attack by disillusioned former employees, and all the more so given that at the same time the matter reached the editors at "Pealtnätgija", a similar tip-off was also sent to the Health Board, at the beginning of June this year, which was not taken on, but instead the whistleblower was asked to provide more evidence. 

"I would venture to say that a systematic review of such emergency schedules in general is appropriate. There are also quality managers who can overestimate whether the treatment that was offered there, when the ambulance was summonsed, is appropriate, whether it is appropriate in accordance with the algorithms, in accordance with the treatment manual etc.," head of the Health Board's Department of Health Management Ragnar Vaiknemets told the show.

"Pealtnägija" contacted a dozen former and current medics in the summer, and found it transpired that the problem not only really exists but is also considerably more extensive than previously thought.

"Argo" said the practice has been going on for a long time, hence why it is not talked about much any more. "It's starting to become somewhat of a daily part of our job," he said. "Toomas" added that it is not clear why it is necessary to do this.

'Phone conversations with several medics still working at the Tallinn Ambulance Service also confirmed that there is constant manipulation of recorded times.

Changes in the system are not visible to the patient

"Pealtnägija" found that it is clear that the computer system allows brigades to change data related to their own challenges. A user with rights can edit essentially everything, from the time of day to the content of the callout, while there is no visible trace of the changes visible to the patient.

"Yes, we have something like 'card checkers', if I'm not mistaken; three people have been selected for this. These are smart brigade leaders with lengthy work experience who know how to read these records, interpret them and identify errors very well. They then give feedback to the brigade leader when they they see some anomaly there which doesn't fit together," Toomas described.

According to Adlas, whether the terms have been mistaken or the patient's statements have been misinterpreted will be the subject of review. "Sometimes the challenges facing an ambulance crew are so tense, nervous that this arises later."

However, whistleblowers sometimes relate quite startling details. With the post-pandemic manpower shortage, staff have been doing several shifts in a row, in defiance of the law, while the brigades are led by medics who lack the necessary qualifications.

There are more objections and criticisms than could be processed in one segment, "Pealtnägija" added, starting with the lack of staff and even chronic heel-draggers, who have to be searched out high and low in the building during an emergency, and culminating with the fact that during peak times half of Tallinn's ambulance resources are sitting in line outside the doors of the hospital's EMOs. This in turn leads to lateness to challenges, employee fatigue and burnout.

However, some of the allegations seem particularly unsettling, "Pealtnägija" found. For example, it is actually physically impossible to exit some Tallinn Ambulance buildings as quickly as the law requires (see above).

"One of the classic cases is the Mahtra station, so if someone locates it, it's worth coming to take a look at it in the thawing winter weather. It is the case that euro-pallets are often used in order to reach the ambulance with dry feet. If this brigade gets across the pallets, and they have to get into the car in one minute – which is basically doable – all it takes is for one member of the brigade to trip and fall, and they could sprain their ankle. You have to ask, but what about the [original] patient?" Toomas said.

"Argo" noted the example of the Haabersti health center, where an emergency journey starts from the second floor. "There are several doors locked which require a smart card to open, there are stairs, and the front door is locked. This certainly cannot be done immediately within the minute."

According to "Toomas", this can also be a matter of life and death for the patient. "In the case of a delta call, say, a resuscitation - if you think about it on the lines of how much difference does it make to the patient whether we get there in seven minutes or six minutes, in fact the outlook for the patient, how they're going to continue their life after CPR, actually is a very big difference."

Adlas said the best is made of the small budget opportunities.

Call-out is set before ambulance is on its way

According to the two medics, one trick to avoid reformatting documents later is to fictitiously fix the departure time at the very start, in other words, the start of the brigade's trip is not registered automatically but manually.

"We have two options for pressing the call-out button. One is where you physically enter the ambulance, look at the screen, press exit, and the other option is one where you have a handheld station in your pocket, which is always with you 24/7, even when you go to the toilet, you always have it with you. So if you get a delta call-out, you can immediately press departure on the X and then it will register there automatically and you can register in nicely in one minute," explained Toomas.

Adlas said however that the latter is prohibited and if anyone does this, this is a serious matter which must be discussed.

"Toomas" said: "It is possible to cheat this system, so to speak, precisely because we don't bother to change these cards afterwards. We often press exit immediately at the manual station and then calmly get into the ambulance and continue doing our work."

"Pealtnägija" met Adlas on several occasions, and while the ambulance manager initially claimed that changing the times was a rare occurrence, later he claimed that the times were often specified due to technical errors in the databases

In essence, Adlas, who previously spoke first and foremost about embittered, disillusioned ex-employees fabricating stories, later stated that there were always technical problems and interruptions between national databases, causing servers to crash and work to be halted. 

When the system recovers, the times or other information is either lost or incorrect, and therefore laborious follow-up checks must be made, he said.

Tõnis Jaagus from the state Health and Welfare Information Systems Center (TEHIK), which manages the databases in question, said outright that Adlas' talk about constant disturbances was "ignorant" and "false". Temporary failures and regular maintenance happens, but in no case, Jaagus said, can this hold-up ambulance work to such an extent, even less to the extent that the data gets lost, as Adlas claimed both last year before the city authorities and now to "Pealtnägija".

TEHIK is responsible for the system and therefore it must be a fault on their part, Adlas said.

Jaagus responded that: "No, this not that the departure time itself which could be wrong. Second, I think that if it were actually the case that there were constantly some kind of problems, we would come under much more scrutiny."

Changes were made in the thousands

At the end of the summer, this story took a surprising turn. One may only speculate on whether it is a coincidence, but just at the same time that "Pealtnägija" started quizzing officials on the issue, the Health Board started a monitoring procedure on the Tallinn Ambulance at the beginning of September, a procedure which opened a veritable Pandora's box of delights.

According to Ragnar Vaiknemets, ambulance travel time records were changed in the order of thousands. "Thousands of departure times have been altered on ambulance cards, which is why we want you to take a deep dive into why so many have occurred," he said.

Vaiknemets, who himself is a former emergency medic, said that this had come as an unpleasant surprise and pledged to find out what is behind the massive data change by the end of October at the latest. It raises questions as to how could this not have been noticed earlier, especially since a year ago a similar investigation had already taken place in the city of Tallinn.

"We're making it very clear what was changed and to what extent, how it was changed and why, and what the implications are," he said.

In conclusion, first, it is important not to over-dramatize things, "Pealtnägija" reported - there is no information to suggest that anyone actually died or suffered due to the alleged delays. This can be speculated about, but without a separate in-depth study it is not possible to confirm or disprove either way. Second, even if thisis a slip of the tongue, a considerable number of employees of the Tallinn emergency room believe that they are participating in a fraud.

Finally, even in the best-case scenario, if the issue is just an IT technology problem, changing the practice of applying already overworked emergency staff to manually fix times seems like a no-brainer.

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