Welcome to the Third World

Editorials / Commentaries

CJEM 2000;2(1):6

4pm. The start of my evening shift. I tour the department, noting that all 18 stretchers and the trauma room are full - mostly with admitted patients! The waiting room is jammed with people who have been there for hours, and ambulance stretchers and paramedics line the hallway.

"Someone important is going to have to die," a paramedic mutters as I pass.

"Important people don’t lie in hallways," I reply.

I grab a chart from the triage desk. The patient is a 50-year-old with "diabetes and weakness" who arrived at noon. I find him in a wheelchair and take him to the only available spot - our cast room stretcher. He tells me his hepatitis is worsening and his diabetes is out of control. His quality of life is deteriorating and he’s becoming progressively weaker. A hepatologist has prescribed interferon and ribavirin, but he can’t afford to buy them. His plan today is to admit himself for appropriate treatment. I spend half an hour explaining that I can’t admit him. He’s not sick enough yet.

I grab another waiting room chart. The patient, who is on home peritoneal dialysis, has abdominal pain and fever. She’s been waiting for hours, with peritonitis. I call the renal resident but the renal unit can’t take her. The resident says he’ll start treatment in the ED as soon as she gets a stretcher, which won’t be any time soon. I apologize to the patient for the care she’s receiving, then leave her propped in her chair in the waiting room.

An ambulance stretcher rolls in carrying a middle-aged woman with ulcerative colitis. She has abdominal pain and vomiting, she’s just passed 2 cups of blood, and her skin is a shocking white colour that scares everyone. She gets a spot in the hallway. There’s nowhere else to examine her, so I pull the sheet down just enough to palpate her abdomen, which is benign. The charge nurse tells me no beds are coming open; she’ll be in the hall for a while.

The next chart I grab is that of a 42-year-old with right-sided weakness (an anterior cerebral infarct, I later discover). She’s been in the waiting room for hours - very impressive, I reflect, in this era of thrombolysis for stroke. Am I in British Columbia or Bogota, Colombia?

I take a call from a physician in a small northern community. He has a patient with pancreatitis who is deteriorating and needs transfer. I explain that we can’t care for the patients we have and that his patient wouldn’t get past our ambulance bay. He says he’ll look elsewhere.

Just then the triage nurse hands me a chart to sign. It’s from a patient with chest pain who left without being seen, and I am the "most responsible" physician. My new role, it seems, is to be the qualified person in the ED - the fall guy - when the inevitable medical disaster happens.

The next patient is an ill-looking elderly man, 3 weeks post-gastrectomy for cancer. He’s lost 30 pounds since the surgery and now he’s vomiting everything. I suspect he has a gastric outlet obstruction, but it’s hard to tell with him sitting in a wheelchair. Then there’s a man with metastatic cancer who has increasing back pain and right leg weakness. After ensuring he has no new sacral findings, I try to convince him to go home, promising to arrange outpatient neurological follow-up and a lumbar CT. But he refuses to leave, and I’m not about to have security throw him out. One more stretcher that won’t be opening up.

At 11 o’clock I see an 84-year-old who developed a febrile illness and ended up on the floor, too weak to get up. The paramedics got her here, but we had no beds so she waited hours to be seen - with pneumonia and an oxygen saturation of 91%. I order some Tylenol, 2 litres of fluid, and IV cefuroxime. An hour later, I have her on her feet doing a road test to see if there’s any way she can go home. She can’t.

The doctor from up north calls back, saying he’s tried 5 other hospitals and no one can accept his patient. I discuss it with my EP colleague and we decide that we can’t either. The doc should try Alberta - or maybe Seattle. I feel like a piece of shit for turning him down.

Recently I participated in a focus group discussing the role of glycoprotein inhibitors for unstable angina. I’ve pondered the value of tPA for stroke and debated the merits of new thrombolytics for myocardial infarction. But at the moment, in this system, these issues are absurd. What I need are stretchers to examine patients on and beds to admit them to. I think back to the US county hospital I trained in, where medically indigent patients had better access to care than my patients do here. But maybe I expect too much. I guess I should feel fortunate to work in a health care system that is "second to none."

Recent graduates may not believe it, but there was a time when emergency medicine was a great job - when all you had to worry about was diagnosis and treatment. Patients arrived with a problem, were triaged to a bed, had an expedient work-up, and received the treatment they needed. If they required admission, it was possible to admit them (although, on rare occasions, they stayed in the ED for an hour or two until their bed was ready). I’ve always thought of emergency physicians as the ultimate doctors and EM as the ultimate career, but I’m not so sure any more.

At 02:30, after tying up my loose ends, I head for home, frustrated enough to punch someone out - preferably a politician. On the way out I wave to a medical student. She must think emergency medicine is some kind of bizarre, depressing field. But maybe if we promoted it as "third world medicine. . ."