Not the ER Mailbag

I've worked in the ER for nearly thirty years.  There have been lots of efforts to shorten the wait. Still, it bugs many of you enough to be a major factor in your decision to go or not to go to the ER and - if you actually get there - your decision to stay.  Last week on White Coat Black Art, we did a show about what we call 'ER-avoidance'.  I visited Halifax to check out a pilot project that has paramedics helping frail seniors avoid a trip to the ER by making house calls to local nursing homes. 

There are patients who avoid ER in the first place.  Then again, there are patients who put the effort and time into going but leave the ER before the doctor sees them.   Veteran ER physician and White Coat, Black art contributor Dr. Bruce Campana talked about patients who "leave without being seen".  After that, we heard from you.

As I discussed with fellow ER colleague Dr. Bruce Campana, one of the major reasons why patients leave without being seen is that they are made to wait too long.  One of the reasons for that is the speed with which people like me are able to "move the meat", a crude expression we use to talk about pushing patients through the system.

Campana talked about the need to restrain intoxicated patients with potentially serious ailments who - in his opinion - aren't able to understand the consequences of leaving due to their intoxicated state. 

That prompted Norman Sim of Victoria, B.C. to send this email: "In your broadcast of December 17th I think you and Dr. Campana misrepresented the role of nurses in preventing intoxicated patients or other patients with altered levels of cognition from leaving the ER AMA. In my province depriving ER patients of their ability to make decisions, including the decision to leave the ER, requires a physician's order under a mental health statute. Frequently physicians in my ER saddle nurses with the unreasonable responsibility of preventing an uncooperative patient from leaving without first issuing the requisite statutory order. Our security service will not restrain a patient without such an order, why would you suggest nurses should? Step up to the plate Drs. Goldman and Campana. If you want patients restrained from leaving because you think their ability to make decisions may be impaired, issue the necessary order else do not expect nurses to expose themselves to the legal liability of acting without the protection your order would provide."

Graham sent this email:  "What our system doesn't recognise is that there's a strong relationship between wait time and utilisation.  My experience in this field come from modelling computer systems where the conventional wisdom at the time was that performance of storage subsystems deteriorates suddenly when utilisation rises above roughly seventy per cent capacity.  This is not to say that we should solve the problem by having emergency staff working at that capacity. They should spend all of their time doing important work; the key is to divide this work into their urgent work, presumably dealing with waiting patients and not-so-urgent tasks while important, do not need to be done right now. The key is to find the right numbers and the work to fill the not-urgent part."

Susan Eck of Toronto sent this email:  "The most important thing I learned from your book is that an emergency doctor can see on average only between two and five patients per hour.  I've asked several people since what they thought and the answers range from twelve to twenty-five per hour.  Now that I know what really to expect I have become a lot more patient. Please let others know too."

Doug Peterman of Stratford, Ontario writes:  "I just listened to your piece on ER wait times with interest, and wanted to add this wrinkle to the discussion:  Our GP went out of business without warning and without notifying us.  We only discovered this when the pharmacy refused to renew our prescriptions.  His departure also meant we were no longer supported by the health network clinic in town.  There are no drop-in clinics in town.  There is a doctor shortage in Stratford, so it hasn't been easy finding a new GP -- we finally found one in a town forty-five minutes away by care.  In the period without a doctor, I was aghast to find that our only option for getting prescriptions renewed in Stratford was to go to the ER and convince the ER doctor to help us.  I know we have a doctor shortage, but this seems an insane waste of ER resources as well as everyone's time.  Thanks for reading -- love your show!"

Mary Cooper of Surrey, B.C. sent this email:  "As the show pointed out,  people leave ERs early for many reasons.  I don't know if the fact that they leave because they are sick was mentioned.  When you feel sick, the last place you want to be is in an ER for any length of time. It is the most uncomfortable, disturbing place for a sick person to be and every minute of extended time is tortuous. Sitting in a room full of people in severe pain and/or expressing very negative feelings can only be tolerated for so long before one must leave in order to decrease one's own level of discomfort.  People go home to get away from a scenario that after a short time becomes an additional cause of their discomfort.  Also, people leave because of the parking fees.  Sure it may be said that if you own a car the parking cost shouldn't be a problem but not so.  At a rate of four dollars per hour or more, sitting in a room for hours becomes prohibitive.  These days, many people who own cars are just paying for the expenses to operate it out of necessity but are not walking around with extra cash for parking. It is a burden on the sick and a great inconvenience as well.  Spending an amount such as twenty-four dollars to park in order to sit in an ER for the hours it takes to wait for medical attention is too onerous.  Personally, the only time that I have avoided the negative experiences in ER have been when an ambulance had to be called to deal with my situation and to get me to a hospital.  On those occasions I was treated immediately."

Michael Taylor of Ottawa sent these comments:  "The general public doesn't understand the reasons for wait times. They sort of rationally understand that the extra-sick people should be seen ahead of them, that that must be what is going on to explain why they are waiting so long.  They don't actually see the ambulances come in and don't see paramedic crews doing CPR.  They have no insight into the arguments emerg docs have, every day, to get the required tests in a timely fashion (especially on evenings, nights and weekends), to convince a specialist to see an emerg patient before rounding on the recovering patients upstairs."

"They often don't really understand that, done in an expeditious manner, blood tests, an ECG and maybe an x-ray, along with the doc's careful consideration of the acquired facts can easily take the better part of 2 hours. And that's always after having waited to see the doc. You should explain the waits for tests, the wait caused by having to call in a technician to do an ultrasound at 11 pm. People think that there's a radiologist just waiting for their case to show up. There's also the wait for a bed, that's delayed by the wait for discharges, the wait for long-term care beds. The wait for home care, the wait for organizing palliative care. It's far more complex than than the average person realizes."

"Among the "Left Without Being Seen" patients there is definitely a risk that some take home a disastrous outcome, but the vast majority are probably making a good decision, deciding to treat themselves and/or see a practitioner in a different care setting in a more tolerable context."

"We all have similar stories: people who've been told that same morning that they have a cold, don't believe their doc and queue up in the evening to wait several hours to see the emerg doc and be told the same thing (this is common). I've once met a man who was sent in by his GP for us to remove one stitch from his finger.  It's all important. In the trenches, we continue to deal with increasing demands on our time and resources, from the people who come in, to the Ministries who feel we should do more. We do it, of course and we all still love what we do."

We heard from budding health professionals too.  Monica Aikman of Regina sent this reflective email on her experience as the mother of a child she worried about enough to take her to the ER.  She writes:  "What an excellent show today (as always)! As a student nurse, I'm starting to witness the challenges of working in overcrowded departments.  I feel for the staff, dealing with long hours and often challenging patients."

"But today I'm writing you as a parent.  One day last year, my toddler had a course of antibiotics and after the first dose, broke out in a head-to-toe rash with a fever.  He had reacted before, so there was a chance it was an allergic reaction.  We called the Telehealth, and then our Pediatrician and both recommended taking him to the ER, and so off we went."

"After six hours, we had still not seen a doctor. Our child was inconsolable.  Blisters had formed in his mouth, his fever was elevated and he wouldn't drink water, and hadn't for hours.  Since it was now deep into the night, we were all miserable and exhausted, and cramped in one of six packed, tiny makeshift, curtained exam rooms.  The elderly lady in the curtain over kept demanding the RN to "shut that damn baby up!"  We approached the RN ourselves many, many times and begged her to give us some pediatric acetaminophen, just to help him at least sleep through the long wait.  She refused.  I know she can't give meds without orders, but it seems like if she had advocated for us, the entire exam area would have benefited."

"We finally gave up.  It was just too much.  My feeling was that  my own minimal student nursing skills were  better than nothing and at least at home I could medicate and monitor him myself and then call 9-1-1 if things got worse.  To be safe, I didn't give him any further doses of antibiotic.  Any doctor hearing this is probably thinking, "blisters in the mouth?  Not allergic, probably just viral."   I figured the same thing thanks to Dr. Google.  And I am guessing it was an uncomfortable situation more than it was a serious situation."

"But the problem is that, I will likely hesitate before I bother with the ER again.  And as we all know, in some conditions, delay can be dangerous. I would have been happy not to take up ER time.  I know how valuable it is and I don't want to be that parent who clogs it up with a simple pediatric malady.  Any doctor could have made the diagnosis upon examination.  But here in Regina, it seems there isn't any choice."

As usual, thank you so much for sharing your thoughts with us.

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