Karen Graham is an assistant professor at Queen’s University and has been an emergency-room doctor for 29 years.Seema Marwaha
When I first started [as an emergency physician] 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. Such as 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 patient, "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 as if 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.
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.
Karen Graham is an assistant professor at Queen's University and has been an emergency-room doctor for 29 years.
This story, as told to Andreas Laupacis, first appeared in Healthy Debate, an online publication guided by health care professionals and patients that covers health policy and evidence-based medicine in Canada.