Over the last two days, TVO.org has taken a look inside Ontario emergency rooms, asking paramedics and nurses about their ER experiences. Last week, when discussing the idea for this series with my editor, we talked about whose perspectives we should cover. I’d already written a long essay for the National Post, and we didn’t want to duplicate it. We agreed to break this complicated topic down into three big pieces — how patients arrive at hospitals (paramedics), what happens next (nurses), and how it wraps up (doctors).
The first two pieces came together pretty much as planned. But a funny thing happened when I started working on the third one: I began to realize that maybe the next story wasn’t about doctors, per se. Maybe it was about the system itself. Because a lot of the time, a patient’s experience in a hospital doesn’t wrap up with the doctor at all. Leaving the emergency room often means simply exiting one struggling part of our health-care system and entering another.
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I wanted to open with that because, in some ways, rather than concluding this series, this third and final article will be setting up a future one. When I spoke with paramedics, nurses, and doctors, one theme came up again and again — the problems with backlogged and overloaded emergency rooms don’t begin there, and the challenges don’t end there. If you’ll indulge me in a medical pun: jammed ERs are a symptom, not the sickness itself.
But before we begin to examine the bigger issues, let’s first address what this article was originally intended to study and what still needs to be explored — the role of the doctor in an emergency room.
Though a doctor’s work is complicated, their job is simple to explain: diagnose a patient and provide the appropriate treatment. Several doctors I talked to for this project said that part of what makes the emergency ward so unpredictable an environment is the incredible variety of problems that can arise. One doctor who served for years in an ER said that every case fits into one of four general categories. The first is easy to diagnose and easy to treat — a broken bone or a bad cut. The second is easy to diagnose but hard to treat — an immediately obvious life-threatening injury requiring major intervention. The third is hard to diagnose but easy to treat once diagnosed — a medication conflict, for instance, or a previously unknown allergy.
The last, of course, is the hardest: difficult to diagnose, difficult to treat.
For a doctor, life in the emergency department is a constant shuffling between these cases. One doctor, who spoke with me on condition of anonymity (his hospital had not authorized him to speak to media), said that in the case of the first category — easily diagnosed and treated — he may need to spend only 15 minutes with a patient. That patient may have waited hours for those 15 minutes, but once the doctor is able to attend to them, they can be treated and discharged rapidly. The third category — hard to diagnose but easy to treat — may also require only about 15 minutes (or so) of direct, hands-on care and communication from a physician. The rest of the doctor’s work with that patient would be what the ER doctor called “indirect care” — conducting research, ordering tests, analyzing results, and, if warranted, consulting with other doctors who have more relevant expertise.
How long treating a patient in the second or fourth category will take is, of course, impossible to predict.
This doctor, who works in a large hospital in a major Ontario city, estimated that roughly half to two-thirds of his shift is spent on indirect care (although he stressed that it really can vary by the day). Patients in an ER may wonder where the doctor has gone, not realizing that that doctor is still actively involved in their case. The doctor may be reading results from diagnostic tests, ordering more, or consulting with colleagues. It’s an invisible part of care but an essential one. As discussed in Part 2 of this series, while this is happening, nurses are overseeing the patient.
I asked the doctor the same question I’ve asked during all my interviews: What would make the job easier? What would make emergency rooms better for patients? He gave a very thoughtful answer, one that echoed a point raised by a Toronto-area ER nurse I interviewed in Part 2. “I don’t want anyone waiting in an ER,” the doctor said. “It’s not good for them; it’s not good for us. We want people moving through the ER as fast as possible. In a best-case scenario, they get the care they need and go home. If they’re too sick or hurt for that, we have to admit them and get them a hospital bed in the proper ward. We also need that to be as fast as possible.”
But most of the problems, the doctor stressed, are not really confined to the ER. He was not saying this to duck responsibility. He agreed that there are always ways to speed certain processes up in every individual case. On some days, for instance, a diagnostic lab doing blood work may be overworked and fall behind. Or an X-Ray machine may go offline, slowing down results. Minutes or even hours can be lost waiting for a consultation call to be returned. One patient with a critical injury can consume so many resources that other patients simply have to wait.
Finding ways to eliminate such delays would improve the experience for patients. But, as the nurse I spoke to in Part 2 explained, perfection isn’t really attainable. She explained that an emergency room needs enough of these four things in order to function optimally: nurses to oversee patients, lab technicians and equipment to run tests, doctors to treat patients, and beds to receive those patients who need admission. Some days, she said, you have all four of those things at once. Most days, you’ll have three of them — but you can’t predict what the missing piece will be in advance. On bad days, you may have only one or two of the four key ingredients. Those are the days that make the news.
Fair enough — that’s a doctor and a nurse, from different hospitals in different cities, generally agreeing on this point. But they also agreed on the broader systemic problem I alluded to above: ERs are jammed with patients because too many people are coming to them, and there’s nowhere else to send them.
This is an aspect of the systemic failure I mentioned above. In Part 1, a paramedic in the Greater Toronto Area told TVO.org that as many as 80 per cent of the patients calling for ambulances don’t need emergency care. In Part 2, all three nurses I spoke to agreed that many of the patients in ERs didn’t need emergency care but simply medical care, period — care that could be provided by a family doctor or a walk-in clinic. There is always a grey area, they agreed. Sometimes, when in doubt, you’re better off calling for help. And they recognize that not everyone has a family doctor and not every community has a walk-in clinic or urgent-care centre providing around-the-clock coverage.
But if we could direct everyone away from an ER who doesn’t need to be there, there would be no problems with wait times.
How to do that is a fantastically complicated problem, the ER doctor explained. It’s not really an achievable goal: 100 per cent diversion of non-emergency cases would require that the entire population be properly educated not just in the basics of medicine, but also in how the system itself works — how family doctors, walk-in clinics, urgent-care centres, and ERs complement one other. That’s not realistic. There are also funding incentives, he noted, that encourage family doctors to refer patients they can’t see to an ER instead of to a walk-in clinic. These incentives make financial sense for the family doctor but cost the system as a whole more money.
The problem, the doctor explained, is that if you can’t reduce the intake, the only way to avoid delays is to increase the outflow of patients from an ER. That would mean more of everything, at tremendous cost, and would also require political will and consistent funding. It takes at least six years to train an ER doctor and four years to train a nurse. If Ontario stepped up with billions for more personnel and equipment tomorrow, the results wouldn’t really be felt until a full election cycle later. That’s a hard sell for any political party, he observed.
But there is one other critical issue that the doctors and nurses all agreed on. Even if every patient who came to an ER were seen absolutely instantaneously, some would need admission into the hospital for further monitoring and care.
But our hospitals are chronically overloaded. In fact, as this series was being produced, Health Minister Christine Elliott acknowledged that the government’s plan to end “hallway medicine” was running well behind schedule: each day, our hospitals are providing care to roughly 1,000 more patients than they’re designed to handle. These patients fill hallways, chapels, and meeting areas as well as our ER wards — patients admitted to a hospital via its emergency room continue to occupy beds, and the attention of nurses and ER doctors, until they’re moved to another part of the hospital.
That can take days. And it’s a massive roadblock that will continue to guarantee that our ERs remain backlogged and prone to buckling under patient surges until the broader systemic issues are addressed.
But that’s a topic for later. Sadly, the problem isn’t going anywhere.