It’s a weekend shift in a Canadian Emergency Department. On a stretcher lies a woman in her sixties. She has, just this week, been diagnosed with an advanced cancer. Her symptoms crept up on her, unnoticed or passed off as the result of inactivity during a long cold winter. These multiple niggling things had finally announced themselves earlier in the week, and she went to her local ED to be seen. Through a series of investigations, she received the unwelcome news of a serious illness, and arrangements were made for her to have an urgent appointment with the appropriate specialty service in the next few days. She would get a call, she was told.
Frightened and shocked, she went to see her family doctor, who made numerous calls on her behalf in order to pin down the exact date of this referral. However, the service is short staffed, the clinic overbooked and the appointment has been delayed – it will be the next week, the secretary says. Perhaps. They will try.
The family doctor told the patient not to ignore any new or different symptoms, and to come to the ED if she gets any worse. He knows that this patient needs surgery. She also needs to be seen by several different specialists to coordinate her management, and help her through her treatment. She is teetering on the edge of a number of serious disease related complications. And now she is in the ED, for the third time this week. She’s finding it harder to breathe, and she is having more pain and a few other problems. None of these symptoms are new. Her visit today is due to a steady worsening of things that are now ominous and terrifying to her.
The service is called, with a request to admit this patient, to facilitate her workup, to coordinate the multiple specialists who will need to be involved, and to get moving on the surgery that she needs. The resident, under pressure to keep the service’s beds moving, believes that this is a ‘weak’ consult. “We’re going to send her home. Her bloodwork hasn’t changed. She’ll be seen in clinic.” After the resident reviews the case and talks with the patient, she is again promised an urgent clinic appointment. She shuffles out the door with her husband. They stop a few times on the way to the waiting room so that she can catch her breath and then they head home to wait by the phone.
This story repeats itself over and over in every Canadian Emergency Department. Our system is trying to maximize efficiency, which means that every clinic, department and inpatient service is being asked to do more with less and to account for every minute spent. These groups each defer patients with complex, non-emergent problems to other places. The service can’t admit the patient to speed up her surgery because they don’t have any unbooked operating room time – someone else will need to be cancelled. Hospital admission flow algorithms don’t have a line for “sort out new cancer” and she will “take up a bed” while her problems get solved. Hospital beds are a scarce resource, fiercely protected by the services that use them. The clinic can’t take her either – not for a while. There are too many other patients waiting, and too many other not-quite emergencies are trying to be seen there too.
The Emergency Department has become the refuge for these desperate patients, the last hope for the worried, frustrated people who are waiting for procedures and specialists. My emergency physician colleagues across the country all recognize this patient, this scenario. Timely response to complex problems often now requires aggressive advocacy from family, friends and physician allies. Excellent care from outstanding, compassionate health care teams is still the norm, once the pathway is established. But patients have to navigate an increasingly fragmented, complex system to obtain it.
Emergency Medicine used to be about providing urgent or emergent medical care, but more and more it is about interacting with sick, frightened and frustrated people who are waiting for something they need from the system. And more and more our Emergency Department ‘care’ consists of trying to explain to these patients the complexities of a system that looks like it doesn’t care about their problems.