Ask Paddy Mark about a typical day in the ER, and the chief of staff at British Columbia's Nanaimo Regional General Hospital compares the country's emergency rooms with canaries in a coal mine: she thinks ERs have become an early-warning system for the entire health care system.
The Nanaimo General is a relatively small hospital, with 229 acute care beds serving 250 000 people on the east coast of Vancouver Island, but its emergency room is facing the same critical short-falls as ERs in Canada's large cities. Its most recent crisis stemmed from a lack of hospital beds that resulted in patients being lined up on gurneys, waiting to be admitted. "People ran in clutching a child who had been run over, and there was nowhere to put this child down for examination," says Mark. FIGURE
Although ERs across the country were feeling stressed in January after flu season arrived with a vengeance, Mark says ERs in smaller centres face unique problems. Without other hospitals to divert patients to during a crisis, community hospitals like the one in Nanaimo are forced to evacuate patients when there's a crunch. "Two weeks ago we airlifted a patient from Duncan - a sister hospital with 150 beds - to Seattle because there were no respirators on the Lower Mainland." The BC government will foot the bill.
Multiply the crowding by a factor of 10 and you arrive at the Vancouver General, the second largest hospital in Canada, with more than 75 000 patients admitted in 1999. Its emergency room made national news before Christmas when a doctor decided to examine and treat patients in the waiting room or where they lay on stretchers in the hallway. There were simply no beds. "I reached my level of tolerance," said Dr. David Harrison, who took histories and blood on the spot.
Similar dramas were played out in emergency rooms in Quebec. As predictable as the weather forecast, logjams in emergency departments were chronicled in the press, with daily graphs detailing how many patients were waiting in each ER. Just before Christmas, 80 patients were competing for 34 stretchers at Montreal's Maisonneuve-Rosemont Hospital. A 725-bed facility serving half a million people, its emergency room is one of busiest in Montreal. Of the 46 patients waiting in the corridors, 12 had been there for more than 24 hours. "A lack of manpower is the biggest problem," says Dr. Pierre Masson, the director of professional services, who had reduced the number of nurses for staff holidays. "The system is particularly clogged today because of a shortage in nursing, but that's not the real issue. The emergency room is the doorway and security net for the entire health network. If there's a problem anywhere in the system, it shows up in the ER."
The new year did not bring much respite, despite promises from the Quebec government of an $8-million infusion. On Jan. 4, emergency rooms at the Maisonneuve-Rosemont and the Montreal General Hospitals - the 2 busiest in the city - each reported they had more than 40 patients waiting to be seen, with some walk-in patients waiting more than 48 hours.
"These are serious cases: pneumonia, respiratory and heart problems, abdominal pain," said Chantal Beauregard, a spokesperson for the Montreal General. Space was at a premium and the scene was one of controlled mayhem. Ambulance technicians were posted alongside their wheeled charges, occupying waiting-room corners and the few feet surrounding the nursing stations. Patients lay on stretchers in the waiting room and lined the corridors, but everyone had been seen by a triage nurse, the sicker patients had been treated by attending staff and isolated moments allowed for some small kindnesses from nurses.
"There are not many beds in the city because of hospital closures and there are not many at the Montreal General because of budget cutbacks," explained Dr. Robert Primavesi, the head of emergency medicine, who estimated that the hospital lost 24 beds last year. He noted that even if beds are available, "we often don't function at maximum capacity because of nursing shortages."
Anne Thomas, the hospital's assistant nurse manager, agrees. "We did a survey today. There were 9 nurses and there were supposed to be 15 [according to standards]. I find it more frustrating than stressful. You're changing bedpans for patients in the corridor, and you go home feeling that you haven't given them the care that you wanted to."
Primavesi said other factors are in play, such as beds closed for infection control. "If a VRE [vancomycin-resistant enterococcus] patient comes up in a 4-bed room, all 4 patients have to be isolated and can't be transferred." Then there are patients who arrive with an acute illness but can't be sent back to their living situation. The CLSC's (Quebec's community health clinics), which usually arrange home care, were closed for the holidays or maintaining only skeleton staff levels, as were private clinics. People with acute respiratory problems and flu found hospital emergency rooms the only place to go.
"A lot of people would prefer to speak to their own doctors, but these places have been closed. That's why we have to bear the brunt," says Beauregard.
So, whether the hospital was big or small, urban or rural, or on the East or West Coast, at the turn of the century emergency rooms became health care's fulcrum, trying to balance a decreased number of beds and staff on one side with increased flu-related patient flow and a vulnerable, aging population on the other. In January, it was clear which side was carrying more weight.
Primavesi said all of this took a toll on ER staff, some of whom worked 15 consecutive shifts. Nurses were calling in sick at the rate of 5 a day. "Can you imagine the stress, the trauma and difficulty that this situation produces for the ER staff and their families?" asked Mark, implying that the warning signs - that ailing canary in the mine - are obvious.
"Doctors and nurses are caught in a double bind. They know they can make a difference, but they can't do things as quickly as they should be done and it eats away at them.
"Every winter the noose gets tighter."