Not the ER Show

That we go to the ER expecting to wait a long time has become part of the culture of medicine.  It's almost a cliché.  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.  And that's a problem if your health is on the line. 

This week:  a bit of what we call 'ER-avoidance'.  I visit 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 helps me get inside the heads of these ambivalent patients.  And, we have reaction to Generation Rx, our town hall earlier this month about the epidemic of prescription painkiller abuse. 

Click on the audio link below to listen now or download the podcast.  And tune in Saturday December 17 at 11:30 am (noon NT) and again on Monday December 19 at 11:30 am (3:30 pm NT) on CBC Radio One.

You've got a sore belly, or the beginnings of what you think is the flu.  You leave a nice warm bed in the middle of the night to come to emerg.  You register.  The triage nurse does a bunch of blood tests.  You take a seat in the waiting room.  And wait and wait and wait to be seen by the doctor.

'Should I Stay or Should I Go?' by The Clash could be their theme song. Most stay no matter how long it takes to get seen. But some don't.

In ER medicine, we call them patients who "left without being seen." Studies have shown that depending on the hospital, the time of day, and other factors, between one and twenty percent of patients leave the ER without waiting to see the doctor and find out what ails them. One particular study from Ontario caught my eye.  It concluded that the highest rates of patients who leave can be found in the busiest ERs and in hospitals where patients are seen by residents.  More people leave during the midnight shift than at any other time. The same study found the patients most likely to leave are between the ages of fifteen and thirty-five. 

Patients who leave without being seen are more patient  than you might imagine.  The Ontario study I was talking about before found that on average, people wait one hundred and three minutes before deciding to leave.  At my ER and others, we've brought in nurse practitioners and physician assistants so there are more people to see you.  The lesson for patients is to wait it out.  But the lesson for people like me is to shorten the wait. 

There are patients who leave the ER because they can't stand the wait.  Imagine if they could avoid the trip in the first place. That was something paramedics in Halifax wanted dearly.  Too many patients and not enough hospital beds in that city led to clogged ERs and medics who waited - sometimes as long as an entire 12-hour shift - to hand over patients to ER staff. Since last Spring, they've tested out a pilot program at fifteen nursing homes in Halifax.  Specially trained paramedics see and treat seniors at the nursing home, sewing up cuts, treating dehydration by giving intravenous fluids, saving the senior and the system a needless trip to the ER. Recently, I paid a visit to Halifax to meet Darrel Bardua, a senior paramedic with the program.

According to data presented in the Canadian Medical Association Journal article linked above, in the pilot program, ninety-eight of one hundred and thirty-five seniors in long term care facilities were spared a trip to the ER. The program in Halifax has been so successful it's moved beyond nursing home residents.  Now, paramedics visit patients in police custody and have plans to do the same for people who live in shelters, and patients who attend Halifax's mobile street health van.

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