This is Part 1 of a three-part TVO.org series on emergency health care in Ontario. Look for Part 2 on Thursday.
On July 2, my four-year-old son tripped on an awkward step near our cottage. He was in acute pain and tucked his left arm protectively against his body. A few hours later, while undressing him, I noticed that his collarbone looked completely wrong. My sister-in-law is a doctor, and when I showed her photos, she told me to take him to a hospital emergency room.
Those of you who’ve read my recent National Post essay know what happened next. We arrived at Ross Memorial Hospital, in Lindsay — the nearest to the cottage — where an electronic display warned of a two-hour wait in the ER. But a sudden and unpredictable surge of patients, including several with critical, life-threatening conditions, overwhelmed the small hospital.
We left, having not received any meaningful care, after a six-hour wait. My wife took our son to the next-nearest hospital, in Peterborough, where he was quickly admitted and found to have broken his collarbone.
As I noted in the Post, I’m not a reflexive basher of Canadian health care. A few months ago, my son received absolutely terrific medical care at Toronto’s Hospital for Sick Children, when a viral infection (ultimately minor) presented symptoms suggestive of bacterial meningitis, which can kill in hours. His recent injury, though triaged as “urgent,” was not life- or limb-threatening. My son therefore landed in the awkward part of the triage spectrum — sick or injured enough to need a hospital but not quite sick or injured enough to be in actual danger.
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It’s not my intention here to further restate what I’ve already explored, in ample detail, in the Post. But my recent experience, as well as the research I did after it, raised questions I couldn’t answer at the time. Over the next three days, I’ll be addressing some of those issues in a series of articles for TVO.org, asking various professionals with direct exposure to hospital ER departments what’s working in our system, what’s not, and what, if anything, we can do to improve it.
Because it’s a problem. An Ontario government website publishes data on ER visits, data that tracks wait times (classed by emergency severity). The most recent numbers, current to May of this year, showed that wait times had generally been stable over the preceding 12 months: the provincewide average was 1.6 hours, measured from arrival to first assessment by a physician. That average, though, includes patients whose condition is so obviously critical that they’re assessed immediately upon arrival. Most patients end up waiting much longer.
Perhaps a more realistic assessment of how long most patients are actually waiting for non-critical care can be found in a 2017 report by Health Quality Ontario. It indicates that, between 2010 and 2017, almost 90 per cent of patients who were not urgently ill and did not require hospitalization were sent home within four hours of arriving at an ER. That’s good, on the face of it — but the report also notes that an aging population is placing increasing demands on the system. Visits by patients aged 65 and up increased 29 per cent between 2010 and 2017, and the emergencies bringing the average patient to the ER became more severe. Presumably, the situation will only have gotten worse in the two years since the report was published. Ontario ranks near the bottom of per capita health-care spending and is dead last in hospital beds per 1,000 residents.
The problem is real, and the coming demographic changes will make it worse. So what can we do about it?
I began my research by talking with someone from a group that’s part of the ER experience but often overlooked: paramedics.
Paramedics are not, per se, part of the emergency department. In fact, they are completely distinct from it — I’ll explain that in a minute. But understanding the role of the paramedic is an essential part of understanding the challenges facing our emergency rooms. Because while you’re sitting in the waiting room, wondering what’s taking so long, ER beds are also filling up, out of your sight, with patients who’ve arrived by ambulance. (This was a big part of my son’s recent experience at Ross Memorial; the hospital explained to me that a series of ambulances, some carrying patients in life-threatening condition, had arrived while we’d been waiting.)
So how does it work, from a paramedic’s perspective?
An old friend of mine — who’ll remain anonymous, as they were not authorized to speak to the media — is a paramedic in the Greater Toronto Area. I asked for a very basic explanation of what happens when someone calls 911.
Paramedics in the ambulances typically don’t make real-time decisions about where to take patients, I was told. The dispatch centres — which turn 911 calls into orders for deployed ambulances — stay in touch with the local hospitals. Most of the time, ambulances ferry patients to whatever hospital serves the local area. These areas can be very geographically confined in densely populated urban areas but vast in rural ones. When a hospital becomes overloaded with patients, it can communicate that to the dispatch centres, and ambulances can be routed to less overwhelmed ERs.
There are exceptions, of course, my friend explained. Sometimes a patient is so obviously critical that the paramedics rush them to the nearest hospital because any delay could be fatal. In other situations, an ambulance crew might bypass a closer hospital to take a non-critical patient to a hospital better able to offer specialized care of some kind (a children’s hospital, for instance, or a trauma centre). But, in general, ambulances will ferry patients to the hospital serving that area, unless that hospital has declared it’s at capacity for anything other than urgently critical emergencies.
There was something else I was curious about. One of the known problems facing Ontario’s emergency wards is a high volume of patients who don’t really need to be there. They could, at least in theory, be served by a family doctor, a walk-in clinic, or an urgent-care centre (urgent-care centres are specifically intended to handle patients who genuinely do urgently need medical attention — for a broken bone, a wound that needs stitches, a mild burn, etc. — but won’t need hospitalization). I asked my friend two related questions: What happens when it’s clear to a paramedic that the patient requesting an ambulance doesn’t require care at an emergency room? And how often does that happen?
My friend laughed ruefully. “Somewhere between 10 and 20 per cent of my patients actually needed an ambulance ride to a hospital,” was the answer. There is some margin of error, of course — when in doubt, sometimes it really is better to call for help. But no matter how obviously frivolous the request, paramedics simply cannot refuse to transport someone to an ER if they ask to be taken.
In fact, my friend explained, the opposite is more often a problem — a patient who the paramedics feel really should go to hospital doesn’t want to. If the issue is one of mental health, police can be called and then arrest the person under the Mental Health Act so that they can receive care. But, a lot of the time, the problem is simple stubbornness. My friend explained that paramedics do a lot of begging and negotiating and appealing to common sense. But they can’t make someone go. “It sucks,” my friend said. “If we don’t take someone who ends up dying, there are liability issues. But we can’t kidnap someone against their will.”
I asked next what happens when a patient is taken to hospital. The answer: almost the same thing that happens when a patient arrives on their own. A triage nurse will meet the ambulance, receive a report on the patient’s condition, and assess that patient’s needs. The nurse then slots the patient into priority sequence along with everyone already waiting inside the ER. Contrary to popular belief, my paramedic friend explained, arriving via ambulance does not automatically confer any immediate priority.
There is an important difference, though. I mentioned above that a paramedic, though an essential part of our health care, isn’t actually part of ER care. Once an ambulance loads a patient, the paramedic crew becomes responsible for that patient’s care, and they remain solely responsible for that patient until they are admitted by the ER. Non-urgent patients then wait on stretchers under the watchful gaze of well-trained paramedics, who are legally compelled to remain with them no matter how long it takes. Paramedic crews, and their valuable ambulances, can sit idle for many hours.
This is, to put it mildly, not a particularly good use of scarce resources.
In any event, eventually — in seconds or hours — the patient will be admitted into the emergency room, my friend explained. At that point, the paramedic is relieved of their obligation. After they write a report on that assignment, the ambulance is cleaned, and it becomes available for deployment again. One non-urgent patient can wipe out almost an entire 12-hour shift.
I asked my friend what could be improved — what would make our ERs more effective and make better use of resources. “We can always use more of everything,” they said. “But, realistically, the problem is people who don’t need an ambulance or an ER calling us anyway. And I don’t know how we fix that.”
I’m not sure we can. This means that, in the end, it’s always going to come down to what happens inside the emergency room. And that’s where we’ll pick up tomorrow.