Stranded in the Emergency Department

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.

The comments section is closed.

  • Louisa McCutcheon says:

    This is digraceful.our goverment is falling us all. Hospitals and Shcool clousings should be top piorities

  • Sheila O'Reilly says:

    Hi Heather
    Well written.
    Sad and true.
    Wondering if you could check out the website for Nurse On Board Ottawa when you have a minute?
    I have sent your article to Susan Hagar. Owner/Ottawa
    Sheila O’Reilly RN
    OTMH Oakville/Nurse On Board Oakville

  • ED says:

    Looks like the Canadian Health care system has its flaws. That waiting is a farce. That does not happen in the USA.

  • Mdwyer says:

    The need for a place in between E.R. And long term care homes. Call it the “waiting room” for those in need of care, in all walks of life, and use “Emergency room” for just that. The family physician should identify where this pt needs to go at that time.

  • Lori Baker says:

    Unfortunately the system is broken. Those of us who have worked in it for years (43) recognize that. The staff are wonderful, but it is run as a business and I know of no business that can survive or thrive on cutbacks alone. They all need revenue. When the only “revenue” comes from our taxes, it is not sustainable.

  • Sara Ahronheim says:

    You are spot on.

  • Kathleen says:

    So disheartening yet so true….left a young man who has seen 8 doctors in past few months with purulent discharge from his eyes who had patiently waited 5.5 hrs to see an ERP. Eyes glues shut. Hoping tonight he will finally get his specialist referral…

  • Wendy says:

    So what has been done about this? This is over 2 years later. Anyone?

  • Kathleen says:

    So disheartening yet so true….left a young man who has seen 8 doctors in past few months with purulent discharge from his eyes who had patiently waited 5.5 hrs to see an ERP. Eyes glues shut. Hoping tonight he will finally get his specialist referral…

  • Alynn MacLean says:

    This happened in Owen Sound this week, when a patient came in from an outside hospital with ? apparent heart failure. They took 1 1/2 litres of fluid off his lungs and sent him back to the feeder hospital, saying that he had cancer in both lungs. How did they determine that? Did they swab for RSV? Within hours, this octogenarian had died, and we are left to wonder “Was that needless?” Two days prior, he had been enjoying life.

  • Terry Hill, PhD says:

    Well summarized. It begs many questions, not the least of which is “Are we, as a hospital, truly patient centered?”
    The traditional flow chart for making changes is patient to nurse/doctor, nurse/doctor to department manager/chief of staff, department manage/chief of staff to senior administration, senior administration to the CEO, CEO to the Board, Board to the Ministry.
    This bureaucratic road to Oz is fraught with issues of: resource scarcity, questions along the way of “Whose job is it”, outdated policies, ‘too many patients – too few beds’, regular public accountability reports, staffing turnover and burnout, treatment error, lack of follow-up, insufficient space, long-term care patients, e.g., mental health/alzheimers in oncology (or other irrelevant) wards, ignorance of ethnic culture needs, inter- and intra-group status conflict, etc.
    We forget that hospitals are communities. We work within them, and treat them, like a business, where performance management reviews are lunchroom discussion priorities, and corporate goal displacement puts the nuisance patient-client at the perifery of care by accident, and not at the centre by design.
    A structural ‘revolution’ is needed in healthcare settings, from top to bottom.

  • Donna Young says:

    Thank u Heather Murray

  • Lise Millard says:

    Well said! Someone in charge “government” needs to do what is required now!

  • Tony Dempsey says:

    I would think our beautiful country should assist. Or is it too dire?
    Maybe I don’t have all the info but I think everyone deserves a long reach…….In a time of need! When it’s life threatening.
    Or maybe they don’t, only god knowns.

  • Sabra Gibbens says:

    Thank you for sharing that heart-breaking and all too common scenario. We certainly have systemic issues that are exceedingly complex, but there may be one simple tool that we aren’t utilizing as much as we could for coordinated patient care: the back office line at the family doctor’s office. Is there a way for all the emerg physicians and other specialists to have my back office (physician’s line) number easily available? I am often here until late at night and on weekends, not just M-F 9-5. When I send someone to emerg, I always call and speak to the physician personally. I am thrilled when a hospital-based colleague calls me to clarify background or come up with a discharge plan, even if it disrupts the flow of my busy clinics. Have other physician communities tried this and found it to be helpful?

  • Maureen Dunn (Moiseshyn) says:

    Very well said, Heather. It was problematic and heart wrenching 10 years ago when I was a staff nurse in emergency. I just can’t imagine what it is like now. The overwhelming feeling of helplessness that emergency staff feels is but a tiny drop in the bucket compared to what the sick and hopeless feeling that these very ill people feel.

  • Ken Wightman says:

    You need an editing button so that those leaving comments can correct errors. I’m not a editor and I made some grammar and spelling errors. They take away from my comments.


  • Ken Wightman says:

    I have has a lot of contact with the healthcare system in recent years. I have begun to wonder if we should be expanding the ER and restructuring our hospitals to reflex a stronger ER leadership role. I recently needed emergency surgery. I spent a full 16 hours in the ER — but during those 16 hours a lot was accomplished: EKGs, X-rays, a CT scan and more. I went directly from the ER to surgery. Thankfully no time was wasted moving from the ER to a bed on a ward floor.

    This is not the first time I have spent a lot of time in the ER. Nor is this the first time that a lot was accomplished by the amazing ER medical staff. I’m not as quick at damning the long ER times. I’d just like to see them become a positive part of the system.

    • Dee Leffers says:

      The ER does amazing work but they shouldn’t have to – this patient should be able to be referred by her family doctor for appropriate care by the cancer clinic. She should be assessed quickly and a plan developed. Unfortunately, her family doctor can only make referrals and phone calls and hope that someone takes pity on this patient at the expense of some other. The people, the knowledge and, for the most part, the infrastructure exist for this to happen but if we cannot pay the oncologists or the imaging techs or the hospital doesn’t have any more OR time because they have gone over budget – it is all for naught. Health care workers have been holding the system together with bandaids and prayers for a long time – that can only work for so long.

  • JP Graba says:

    A change in dogma is required. How and where we fund – not how much more…throwing more money at those grand edifices (hospitals) ONLY is not the answer. Infrastructure within the community, long-term care homes, way more PSWs and visiting nurses can aid in keeping IP beds available for the acute medical conditions for which they were designed. Oakville’s new institution will be close to $1B by the time its completed; St Catharines moved into their $300M facility 1y ago (not to mention the ongoing talks to construct a new Niagara south hospital). How many less costly chronic care facilities are currently planned or under construction (which aid in decompressing ERs and hospitals in general)?

  • Kieran Quinn says:

    Hi Heather,

    A fantastic story about an all too common scenario in our hospitals. Even as a junior resident, I find myself trying to explain the complexity of our system to many of my patients (something I struggle with myself!).

    I hate to ask it – but where should we target our solutions to a patient like the one you described above? I’m at a loss and don’t know what to tell my patients when I send them home because we simply don’t have the bed resources to expedite the care they need.

    • Joy Walsh says:

      What the system needs again are the senior dedicated nursing staff who took on the role of patient advocate.they got things moving. I know because i was a dedicated nurse for many years and fought to make things better for the patient.unfortunately they have replaced those nurses with managers who know nothing about patient care

  • Peter G M Cox says:

    Great article – and comments. Can it REALLY be true that the number of administrators has increased by 700% over the past 30 years? (I’m not doubting it; I read that admin increased 60% in a five year period in the 1980’s and have been trying to find reliable statistics since then; I should appreciate being “pointed in the right direction” – an accurate and authoritative source for this.)

    We are constantly hearing about cuts to nurse staffing in hospitals and we already employ 40% fewer doctors per capita than Continental Europeans – while our healthcare spending per capita is comparable. I have speculated that one reason for this is excessive bureaucracy but we rarely, if ever, hear of cuts to administrative staffing. I have even seen a “research report” that “proves” that the number of doctors per capita has no impact on health outcomes! I’m waiting to see one that shows that more admin does!

    To quote from the Euro Health Consumer Index report 2012 – “… one important net effect of the (Netherlands) healthcare structure would be that healthcare operative decisions are taken, to an unusually high degree, by medical professionals with patient co-participation. Financing agencies and healthcare amateurs such as politicians and bureaucrats seem farther removed from operative healthcare decisions in the (Netherlands) than in almost any other European country. This could in itself be a major reason behind the (Netherlands) landslide victory in the EHCI 2012”. Possibly there is something we could learn from them?!

    In the meantime, perhaps we SHOULD require not just hospital CEOs but Health Ministers and senior health department bureaucrats to take the Hippocratic Oath!

  • Rick Janson says:

    Great article — makes me further despair over Murray Martin’s comments this week that suggest the way forward is more rationing and more expensive hospital mergers. This from a guy who was last reported to be earning close to $700k a year as CEO of Hamilton Health Sciences. Not sure how repeating all the things that got us into this mess is somehow going to solve our problems. We’re told we can’t afford our present system, but Scarborough-Rouge was, with additional provincial dollars, willing to plunk down an absolute minimum of $35 million to effect a corporate merger that wouldn’t have created one more minute of patient care. We have a boom in hospital construction, often an inflated P3 prices. These P3s will often open with fewer beds than the hospitals they are intended to replace. We have complex schemes for operational funding that don’t seem to have any logic to them — penalizing hospitals with demographics that call out for significant intervention. Since 2010 we’ve had the evidence that a public pharmacare system will not only save billions in drug costs, but also go a long way to alleviate pressures on our ERs by non-compliant patients who cannot afford their medications. Yet where is the political will to move towards such a system? It’s no surprise that beds are so precious — Ontario cut 38 per cent of the beds we had in 1990. We’re told, don’t worry, all these services are now in the community, but clearly they aren’t. The system is poorly organized. Problem is, rather than assessing and addressing the change that has taken place, we seem to be racing towards more of the same. Heather’s piece is a great intervention on how the wheels have truly come off the bus and how we really have lost sight of what patient-centered care really is.


  • Jennifer Dee says:


    This is an excellent explanation of the loop that many people find themselves trapped in when they arrive in an Emergency Room. Emergency Rooms are frequently in grid lock and seem paralized because of all of the other pressures the health care system faces. Increasingly patients with complex and chronic care requirements end up in emergency rooms for days on end waiting for admission. In the case you have provided, someone gets some serious news about their health and is then left in the aybss waiting for that referral that may or may not materialize.

    When we start to think about what the system needs it must be a radical reinvention of care and a new delivery model. A common communication platform across all care providers and allied health professionals including pharmacies would certainly be a good starting place. A national health care model could mean one standard of care from coast to coast.
    Someone needs to have the courage to take on the task of delivery of care reform and not add-on to a broken system but start at the beginning and find a way to provide the correct standard of care at the most appropriate location and by the most appropriate care provider (Dr. nurse, nurse practioner, EMT). Finding real solutions to the crisis in care is so political that it seems we are relegated to what we have currently. That means we all suffer, especially those who work in Emergency Medicine, as every day is a crisis.

  • Shawn Whatley says:

    Thanks for writing this, Heather!

    You did a great job capturing the terrible situation patients experience, and the demoralizing effect it has on front-line providers. I only wish that we could take your passion and translate it into real change.

    Medicare needs fundamental change in structure, leadership, and funding. It does not need more money; it needs new governance. It can be accomplished and still funded with tax dollars.

    Thanks again. Keep putting patients first!



    • Dr Merrilee Fullerton says:

      You see things clearly, Shawn.
      The reality is that with fewer than average per capita MDs than most developed countries, a productive MD is absolutely necessary.
      Farncombe needs to consider the cost of squandering the health human resources we have that could be helping patients.
      It is far more valuable to Canada to have a productive specialist providing care to patients than having to produce more MDs to divide the work amongst them.
      It is twisted logic to think that when MDs provide expensive procedures in greater amounts that they are somehow greedy.
      If an MD who is in short supply invests in equipment to help more patients and is willing to work hard to help more patients they should be seen as positive to society.
      Stop the self-flagellation and jealousy and get on with finding realistic ways for patients to get care.

  • Farncombe says:

    Our system is bloating under its own weight. These poor patients need care, yet they cannot receive it because of systemic underfunding or misallocation of funds.

    As an example, why do cataract removal surgeries pay so goddamn much (I don’t blame the ophthalmologists; they don’t set the fee schedule) while patients can’t even get in to see a surgical oncologist because there aren’t enough ORs for the newly trained surgical oncologists to work in? Why not take that money we’re paying for an overvalued procedure and put it towards opening new infrastructure so people like the patient in your article can be seen?

    Why has the number of hospital administrators increased by 700% over the last 30 years, yet the number of physicians and other providers of care increased at a far lower rate.

    We love talking about bull and buzzwords like “patient centered care” and “medical home” and other such garbage, but we have nothing to show for it.

    It’s our own fault as physicians. We are letting the people down because of our spinelessness and inability/unwillingness to take charge of things on an administrative level. Hospital CEOs did not take the Hippocratic Oath!

    • Solutions required says:

      Unfortunately the underfunded medical system continues to creak and crumble and patients are skipping through the cracks. Why you would pick one procedure from the multitudes to single out is quite astounding.
      Do you know how much a hospital gets reimbursed to do a cataract? Do you know that the funding to institutions doing cataract ORs have been reduced by 50% per procedure recently. Do you know that the number of cataracts performed on this province have been reduced by 20% in the last 2 years? Do you know the province has introduced legislation to move low intensity procedures like cataracts and endoscopies to community based independent health facilities?
      Maybe you were commenting on the amount the physician gets reimbursed to do this sight saving ” over valued” procedure? That amount has been reduced by over 25% in the last 4 years?
      With these cuts has patient care increased? Have more surgical oncologists been hired? No. The problem is not what you perceive as over valued procedures but rather our province has squandered away billions and is so in debt that it cannot afford the infrastructure and procedure costs. Look at all the new surgical grads who cannot get jobs.
      Next time think through your comments before picking on one group or procedure. All you are doing is perpetuating a stereotype.

      BTW if the province was really interested in improving things they would look into increasing long term care beds so that patients that don’t need acute facilities would have a place to go. In addition ORs work only 7 hours a day, no thought about expanding hours to handle the increased need, nope let’s just slag cataract procedures again.

      • Farncombe says:

        Cataracts are overvalued, and I have not seen evidence to the contrary. The technical fee for cataracts has been lowered (as it probably should be), but that still doesn’t change overvaluing of the professional component in relation to other things. What’s more important – an appendectomy for acute appendicitis or a cataract removal? The answer is subjective (many people would rather die than be blind), but the fee schedule certainly values cataracts.

        I am saying that such overvalued procedures are paying out too much when that money could go towards infrastructure. Cataracts are just one of these.

        The province of Ontario has certainly squandered away money and we as physicians should be more demanding of government accountability. That still doesn’t change the fact that some procedures are overvalued.

        We must also take control of bloated hospital administration, and whittle things down. Every day on the way to see patients I spy corporate suits sitting at the big table in the big boardroom sipping coffee and eating food paid out of the hospital budget! Yet patients can’t get seen in a timely manner. Something is wrong.

      • Solution required says:

        So you have not seen any evidence to the contrary. Well have you looked? All those facts that I stated above are true yet you go and look in the schedule of benefits and compare two services. Did you look at the last 4 years how the professional component has decreased for cataract surgery? Has the amount for appendectomies decreased or for that matter increased?
        How about the 50% reduction to the hospital to perform cataract surgery? Did you know some hospitals divested themselves of ophthalmology when the technical component was deemed below the cost to perform the procedure?

        I am not going to debate with you about what you perceive as over valued. You have your bias and that’s not going to change as you continue to perpetuate a stereotype. The OMA through their program of equality will balance things out.

        Unfortunately, even though I agree with you regarding the multiple bloated levels of overpaid bureaucracies within and outside of hospitals you still miss the bigger picture that we, as a province, are broke. We cannot continue to finance healthcare by picking on small amounts. Any savings are channeled back into feeding the poor Liberal decisions and increasing debt. No expansion of programs are possible in this fiscal reality even though the need is apparent.

        Face it, all that we are doing is rearranging the deck chairs on the sinking healthcare ship titanic. New solutions need to be brought to light. Until that is looked at those patients in need will continue to slip through the cracks

  • Aleem Bhanji says:

    Great Article Heather. A few thoughts. Wouldn’t it be great if primary, specialty and community care could engage and have a joint discussion with the patient and their family about the status? What’s most important for the patient and their family? Can we have one care plan? This way the entire team would be on the same page as to what would constitute an exacerbation and necessitate escalation. In addition it could possibly by-pass the emerg which would definitely reduce the anxiety for patient and reduce one repeat patient coming into the ED.

    My second thought for your consideration is this. Where is the home and community health fit into this scenario? Is there anything they could do in terms of continuous monitoring to support the team in case of an escalation? We talk about the need for home and community to take on a larger role… So what is its role? This could also help to reduce patient / caregiver anxiety.

    Finally, this story highlights a glaring hole/opportunity with our system. Specialist clinics within hospitals all run independently without coordination or a centralized online booking mechanism. If KGH’s clinic is fully booked for months but Quinte or Peterborough or Ottawa have a shorter-wait time, maybe the patient wouldn’t mind the short drive if it meant that she could be seen quicker. That would be a great step towards patient-centered access to care.

    Appreciate your thoughts.


Heather Murray


Heather Murray is an emergency physician and medical educator in Kingston, Ontario.

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