Karen has been an emergency physician for over 20 years. She’s fed up with the impact of emergency department overcrowding on her and her patients.
How has emergency medicine changed over the last 20 years?
“The patients are more complex and elderly. Overcrowding is the biggest change. When I first started 20 years ago, if one or two patients were in the department for over 24 hours, that would really have caught our attention. We’d be like, ‘What’s going on?’ Now there are 30, sometimes more.”
I think there’s a misunderstanding about what the problem with overcrowding is. As a country we are high users of emergency departments. However, the sore throats and ankles are not a problem for us to deal with. They don’t occupy beds for a long time. It’s the admitted patients who get parked in emerg who are the big problem.
“We’re a department of 38 beds and we often have up to 30 admitted patients. We see a volume of about 170 a day, which means we are trying to see 170 people in eight beds. So, we are doing a lot of hallway and make-do medicine.”
“Overcrowding causes real morbidity and mortality, and there’s an incredible toll on the staff trying to deal with it.”
“I saw an elderly man who had a severe infection and ended up in the ICU. I realized that he had been in the waiting room the day before and left after five hours without being seen by a physician. I read the nurse’s notes from the evening before, and he had symptoms of a urinary tract infection. I felt so bad because if he had just been given an antibiotic then, he might have been fine. The people who leave our waiting room are sometimes the sick older patients who need to be seen, but who feel too unwell to stay.”
“Another 70 year old man fell down the stairs. He waited, I think, four hours and then left. He came back the next day, and had a fracture of his foot that needed surgery and a wrist fracture. He had walked around on the foot fracture for 24 hours. I guess it’s not the end of the world, but you don’t feel good about that.”
“I could tell you about deaths too – people who deteriorate while sitting in the waiting room or who leave without being seen and then come in having suffered a cardiac arrest.”
Overcrowding makes us cut corners. Like not doing a rectal examination or a pelvic exam, or not taking a sexual history because there is no private space. Whispering to a 14 year old, ‘Are you sexually active?’ because you are in the hall.
“I cared for a girl who likely had appendicitis but there was no bed to examine her in. So I found a Geri chair in the hall and put her in that. We had just let someone with kidney stones who was in that chair go. We were so crowded that we had run out of IV poles. The nurse had taped the IV bag for the previous patient to the wall. When he left no one stopped the IV, so there was a puddle of water on the floor. Her mom asked if I could examine her in a private area. I said I would like to but I just didn’t have beds. I said I wouldn’t lift her shirt. So I did a subpar exam. Her mom, who was very reasonable, looked at the IV bag, the puddle and the crowded hallway and said, ‘This is like third world medicine!’”
“The lack of resources in the community is a real problem. People are parked in our department for literally days because no one wants to admit them and they can’t go home without help. Like someone with a stable pelvic fracture who with a bit of help could probably manage at home. That’s a daily occurrence.”
“I feel guilty that I am part of a system that does this to people. Patients are angry, and rightly so. I can think of umpteen dozens of patients where I just feel like I am constantly apologizing. Personally, it’s taken an emotional toll.”
I’ve even given up apologizing. I just agree with patients that this isn’t good care, and ask them to complain to others because I am not having any luck.
“Some hospitals have made the move to hallway medicine, which is to unload the emergency department and share the load with other parts of the hospital. If we are stacking 30 patients in our department surely every floor could have two or three in their hallway too.”
“Studies show that it’s safer to do that. And it might be a driver of change. Do you really have to do teaching rounds first thing in the morning? Could you do discharge rounds and then do your teaching? Historically that’s not the way they’ve done it, but in emerg we’re doing a lot of things that historically we weren’t doing.”
“We lost a lot of our good, experienced nurses a few years ago. It’s really hard on them. Sometimes I wonder why they stick around. One of our nurses came back after six months. She said she missed the camaraderie and the team work. Despite it all, we have good people and we work closely as a team. That’s the fun part.”
The saving grace is the people I work with. I love them. On bad days it gets me through.
Do you worry about what young doctors are learning in emergency departments like this?
“Yes. I worry that they will think that it’s the norm to have patients complaining. The lack of a real apology is the norm now too. I worry that they won’t have empathy for patients; won’t realize that the lack of privacy in a hallway is poor quality care.”
“I saw an older patient who had a bad gastro. Her stretcher was in the hallway and she couldn’t make it to the bathroom. Because of that, the hallway was a mess. She said, ‘You know what dear, I think I will just go home. This is inhuman.’ And she left. I felt terrible. How would you feel if she was your grandma? What do residents learn when they see that?”
“Sometimes it feels as though we function in silos within the hospital. Patients admitted to services but held in ER are “emerg patients” right up until they get to the floor. In reality, they are all of our patients. We all need to be held to account.”
“We unveiled a widely agreed upon protocol last year to try to make sure that no one stayed in emerg more than 24 hours. The idea was to share the load of admitted patients without a bed among all services. There was supposed to be a meeting every day if that wasn’t adhered to. As far as I know there hasn’t been one meeting, and our stats are actually worse now. I felt guilty that it gave my colleagues a faint glimmer of hope when morale had been low, and I felt responsible when nothing happened.”
“A daily diet of overcrowded conditions wears on everyone after a while, and we see first-hand the effect it has on patients.”
You were involved in an initiative that did succeed in changing the way women who were sexually assaulted are cared for.
“In the days before we had a sexual assault program, a lot of attention was drawn to the women because the police brought them to the emergency department and often stayed for quite a while. It takes a long time to collect the evidence that is needed. There are probably over 20 steps to follow and multiple forms to fill in. You have to be careful with each step because it’s evidence collection. We would be in the middle of using the rape kit and we’d get called away if a critically ill patient came in. I felt bad for the women.”
I got involved with establishing a program where the women get a quick medical clearance in the ED and are then met by a sexual assault trained nurse who is on call. She takes them to a private room right away, where they can have the full assessment and psychological support without interruption.
“It’s much more humane. I was very happy when we got that under way. That was very rewarding.”
Overall, are you hopeful or pessimistic?
“I’m afraid I’m pessimistic right now because the ultimate solutions are political ones. That is a difficult thing for me to say because I’m an optimist at heart. But, like others, I have been battling this for quite a while and I don’t see the long-term solutions coming.”
“The problems we see today with overcrowded emergency departments are a result of poor planning for an expanding population and shifting demographics, none of which is a surprise to us. In Ontario they’ve cut the number of hospital beds by almost half since 1990 despite a population growth of 36 percent. No wonder we’re in trouble now. I am fed up with dealing with it. It’s the one thing that makes me ask if I want to do this anymore. That’s hard to face because I still like the medicine and the people.”
“I called an administrator down once. I have been doing this a long time, so we have to be in dire straights before I say we really need help because of overcrowding. He came down and said, ‘What do you expect? It’s an emergency department.’ I said,‘Yeah, but it’s not a mash unit, and that’s what it feels like right now.’ To be told that, as a seasoned clinician, is demoralizing.”
“I have tried to humanize my presentations to administrators with patient stories rather than just statistics and logic. I have gotten tearful telling patient stories, and I hate to get emotional in a meeting. But it’s still not effective. This might be a bad analogy, but it’s like starving kids in Africa. We all listen with great empathy yet most do nothing. I feel that many who are in a position to effect change know but they aren’t doing anything effective to keep emergency departments properly functional. At the end of the day, we all need access to emergency departments that can fulfill their function – to be a safe and reliable haven for serious, acute illness.”