Front Burner - Canada’s emergency rooms are in crisis

Episode Date: July 6, 2022

Health-care workers are calling attention to a crisis unfolding in Canadian emergency rooms. Staff shortages and a lack of hospital beds are causing long waits, shortened operating hours and even temporary ER closures across the country. Meanwhile, workers say more patients are coming in for problems neglected during the pandemic. Patients' stories are dramatic. Two weeks ago in Red Deer, Alta., a woman with abdominal pain said she waited six hours to get an ultrasound, and was told to find her own way to another hospital to have her appendix removed. In May and June in St. John's, the wife of a man with Alzheimer's says he waited 20 nights in emergency before getting a hospital bed. Today, a conversation with a veteran emergency physician about the new and long-standing factors stretching Canadian ERs to the limit. Dr. Brian Goldman is the host of CBC's White Coat Black Art and the author of The Power of Teamwork.

In the Dragon's Den, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization, empowering Canada's entrepreneurs through angel investment and industry connections. This is a CBC Podcast. Hi, I'm Jamie Poisson. When it was the worst, it was 10 out of 10. I was laying on the bathroom floor crying very, very, very, very bad, like worst pain in my life. 21-year-old Olivia Armstrong started getting these abdominal pains two weeks

ago today. And after this intense flare-up at 4 a.m. a few days later, she went to the Red Deer Regional Hospital Center in Alberta. Olivia says there was only a couple of other people waiting in the emergency room. But she told my colleague, Julia Wong, she had to wait for six hours to get an ultrasound. At about noon, the doctor had come and told me it's appendicitis and you need to go in for surgery today. But we have no doctors or surgeons here to do it for you. Appendicitis can be really urgent. If the appendix ruptures, it can cause internal infection and even be life-threatening. So the staff looked for another hospital that could do the procedure.

And at about 1.30, she says they told her this. You need to go to Camrose for your surgery. But we can't take you there. There's no transportation. So you have to find your own way pretty much. Wow, is basically what I thought. Instead of an ambulance, her mother drove her an hour and a half to Camrose. The ride was tense. I hope it doesn't burst on the drive.

What if it does? My mom wouldn't know what to do. Olivia says she got the surgery to remove her appendix at about 7 p.m. and her story is one of a growing list of examples of Canadian health care slowing to a crawl. In May and June in Newfoundland, the wife of a man with Alzheimer's says he spent 20 nights in emergency waiting for a hospital bed. Ontario has record wait times for emergency patients to get admitted to hospital. And because of staff shortages, Quebec is partially closing six emergency rooms this summer, while several ERs in Ontario and rural BC have temporarily done the same already.

So today, after years of talk about protecting our hospitals through the worst of the pandemic, a look at the long-standing reasons our emergency rooms are still in crisis now. Dr. Brian Goldman is with me to help explain. He's a veteran ER physician, the host of CBC's White Coat Black Art, and the author of The Power of Teamwork, a book about how a collective approach can improve emergency medicine. Hi, Dr. Goldman. It's always a pleasure to have you on. Thank you so much for making the time. And Jamie, it is always a pleasure speaking with you. Good. Well, you are one of my favorites. As an emergency physician, I'm hoping you can give me a sense of the stakes here. So why are ballooning wait times in the ER dangerous for Canadians?

Because, you know, there's an expectation that the emergency department is this infinitely expandable resource that can take care of every patient with every problem. What we're finding, what we're seeing with emergency departments under stress is that they can't. That's something that we're seeing, especially in rural and remote smaller emergency departments, but we're also seeing it in big cities where, you know, because we don't have enough beds, and we don't have enough nursing staff, and other allied staff. And as a result, you know, that means that patients in the emergency department who come in with a certain illness and a certain level of illness might get sicker, smoldering along while they wait to be seen to get blood

work, to get the CT scans that they need to get seen by the emergency doctor or the nurse practitioner to be seen by a consultant. Whenever you have that, you have a recipe for disaster. And all of us who work in the emergency department dread the idea that a patient who comes in, who's fairly stable, becomes unstable in the waiting room while waiting to be seen by us. And sadly, sometimes they have a cardiac arrest. And when they do, it's not optimal to try to resuscitate somebody when you know in your heart that if you had gotten to them sooner, seen them sooner, that that might not have happened. Yeah, yeah. What does it say to you that some ERs have actually been

temporarily closing, like that it's gotten to this point? Well, sadly, it says to me that there's no surprise. I'm not surprised by that at all, because the issues that are affecting those rural and remote emergency departments, and they're all across Canada, they're, you know, in parts of Manitoba, Alberta, you know, rural BC, rural Ontario, the Maritimes, Quebec. It's everywhere. This hospital in Perth, Ontario, was forced to shut down its ER Saturday morning. Staffing was already tight, and then a COVID-19 outbreak hit. Closures in Manitoba have already resulted in at least one death. The most recent critical incident report from the province shows a patient died en route

after the emergency department they presented at was closed. Felicia Holden and her 8-year-old son Jackson were attending events on the waterfront in Pugwash, Nova Scotia when the incident occurred. They called 911, but help was slow to arrive. We had waited down at the waterfront for about a half hour, 40 minutes, I would say. And then we took him up to the hospital ourselves. They have been dealing with the kinds of problems that, you know, people like me who work in urban emergency departments

are just starting to see right now. And the difference between us and them is that if we have a complement of 30 nurses and we're short 10 or 12 nurses, we can kind of, through a bit of jiggery-pokery, we can kind of make it work. Think about the emergency department that sees 19 or 20 or 22,000 patients a year that has two nurses on duty. And now one of them has to transfer, has to accompany a patient who's being transferred to a larger center.

That happens not infrequently. So now you have to bring in another nurse to replace that person, or you've only got one nurse on duty who's looking after whoever is there. And suppose 10 patients show up, 15 patients show up and need to be seen. So you're going to have one nurse looking after 10, 15, 20, I've heard even 30 patients. Well, that's physically impossible. So at some point, the hospital has to make the wise decision that we can't keep operating. Why has there been such a run on nurses and nursing shortage, even with lower levels of COVID? They are leaving the profession in droves.

Even before the pandemic pandemic a national survey found 60 percent of nurses plan to leave their jobs within a year due to poor working conditions and exhaustion during the pandemic if you look let's start by looking at the at the shortfall from one province to the next thing they may be 100 200 800 a thousand nurses short acute care nurses short of what they want. In other words, there are that many vacancies. There was a time during the spring, Jamie, when I was saying goodbye to a nurse that I'd worked with for one, two, five, 10 years, almost every shift. So it's happening everywhere. If you want to, like, I'm not speaking for nurses. They are fully capable

of speaking for themselves. Here's what they tell me me they tell me that they feel unappreciated or underappreciated underpaid in some provinces there have been bills like bill 124 and i don't want to make this an ontario specific conversation you know where they have capped the salary increases uh for nurses and and that has been regarded as utterly offensive because it comes at a time when they feel doubly unappreciated. Younger nurses have told me that they steer clear of those smaller, underserviced hospitals in rural and remote parts of Canada because they don't want to graduate and then jump in as the only nurse on duty in the resuscitation room in a place where they not infrequently see patients

who come from two car collisions and they have major trauma resuscitations. They want to work alongside someone who can train them up, mentor them. And so they tend to steer clear of those kinds of emergency departments where they're actually needed the most. And let's not forget the working conditions themselves. You have nurses who are being forced to work day after day after day. And particularly in those smaller emergency departments, they have to pull in over time. They may be asked to do it three, four.

And when they get to a fifth day they just want to go home and no they have to work a few extra hours then so when we say you know burnout's a word but they're living it and you know some of my emergency physician colleagues particularly who work in those smaller emergency departments are living it and when they say they're burned out it's two years past the point when they should have been declared burned out. I've also been hearing about the lack of inpatient hospital beds causing problems for the ER, so sort of like a downstream effect. And what's going on? What's

going on with that? So a couple of things are going on, Jamie. First, we have fewer beds per capita, you know, population than a lot of other countries, a lot of other developed nations. In addition to that, we lack long term care beds, nursing home beds. So what happens is that a patient gets admitted to hospital. And for, you know for various reasons, they're often frail seniors, they may have dementia, a decision is made, agreed to by the family that that person cannot go home. So they need to be placed in a long-term care facility. And even under the most emergency conditions, they will wait for many weeks and sometimes many, many months to get a bed. As long as they occupy that bed, that means that bed cannot be used to admit more patients from the

emergency department. So what happens is that as those beds fill up in hospital, you have patients who are admitted to the emergency department on stretchers waiting to be transferred to beds who have to wait longer and longer and longer. And you have people in the waiting room who can't be brought into those stretchers because those stretchers are occupied by patients who are supposed to be admitted to those beds that are occupied by people who are bound for long-term care facilities. This is a longstanding problem. Oh man, it's incredible that the cascading effects here. Okay, so we've got staffing problems, bed problems. Are there more patients coming in right now or or or no?

Yeah, there are more patients coming in. You know, certainly our volumes and, you know, I think the volumes in many emergency departments were way down during some of the the major peaks of COVID. during some of the major peaks of COVID. But we knew that smoldering along were patients with cancer, heart failure, and many, many other diseases, disability brought on by severe osteoarthritis, pneumonias, and other conditions. And what we have seen is volumes coming back with a vengeance.

Like, well, the hospital wards are often at 120, 130% capacity, even more depending on the hospital. We're seeing many more patients and they tend to be sicker. They tend to have problems that have frankly been neglected during the pandemic, not their fault. Often they had difficulty getting in to either see their family doctor or they themselves felt that I'm not going to bother the family doctor, you know, because COVID or either because I'm afraid of getting COVID or

because my problems can't be worse than the next person's. Maybe that community spiritedness, it was a factor as well. I'm not slagging anybody here, but there's no question today that we actually saw a drop up, you know drop up until a few months ago, we saw a decrease in the number of patients coming in with cancer. And it's not because the incidence of cancer dropped, it's because they weren't showing up. Now they're showing up. And instead of having stage two cancer, they've got stage four cancer, which means that their

treatment options are limited, but their need for care is often greater. They often need palliative care, more intensive forms of treatment. It's not just cancer. We're seeing it all across the board, a lot more patients and a lot sicker patients so that we have to spend a lot more time per patient taking care of them. It's not quickly see them and discharge them, not by any means. and discharge them, not by any means. Hi, it's Ramit Sethi here. You may have seen my money show on Netflix. empowering Canada's entrepreneurs through angel investment and industry connections. know their own household income. That's not a typo. 50%. That's because money is confusing. In my new book and podcast, Money for Couples, I help you and your partner create a financial vision together. To listen to this podcast, just search for Money for Couples. You know, obviously there are some very acute contemporary reasons why we're seeing this right now.

But also, I know on White Coat Black Art recently, you dug up audio from like your third ever episode from 15 years ago. And parts of it sounded eerily familiar to the conversation that we're having today. There were two triage nurses in Calgary complaining about ER wait times. It is the worst feeling in the world to know that you have somebody in the waiting room who is sick and you want to bring them in and you have absolutely nowhere to do that. I am terrified. I am terrified for these people because I'm afraid someone's going to die on me. You spoke with an ER physician at Vancouver General. Give me enough doctors. Give me enough staff that I can see these people and at least reduce their danger of having an arrest out in a chair in the waiting room, which is not an ideal resuscitation environment.

Has that happened? Yes. Oh, yes. Of course it's happened. It's happened. And so this is years before the pandemic. Why has Canada had this perennial problem with ER wait times? is that Canada tends to plan its health care to the best case scenario.

By that, I mean to the lowest volume, the least amount of crisis conditions. And the thing about emergency care, emergency medicine, is that it is oasis, nice times followed by tsunami. And you never know when the tsunami is going to hit. It could be a bus crash, heaven forbid. In the United States, it could be a shooting. We haven't seen as much of that in Canada and I hope we don't. Or it could be a natural disaster, a flood.

It can be, or wildfires seen in Alberta and in British Columbia. And so when you don't plan for the tsunami of patients and the tsunami hits, you're swamped. And by the time the tsunami hits, it's too late to plan. And we saw that with lived with have COVID. So, you know, to me, I think the biggest reason is that we don't plan for the worst and we don't pour the resources that we need into maintaining enough coverage during the worst times. I mean, there's other factors. I don't think there's enough planning that goes into figuring out what kind of healthcare workers and professionals we need in the right place at the right time. You know, there are other countries that have experimented more with

allied healthcare workers of different kinds who could fulfill some of the duties of the people that we traditionally think of as frontline healthcare workers, nurses and physicians. You know, we are an example of that, like, sure, having paramedics, you know, paramedics have been called the Swiss Army knives of healthcare. They are incredibly skilled at first response, you know, they're great with procedures great with IVs. There are community paramedics who are providing palliative care. They're great with procedures, great with IVs. There are community paramedics who are providing palliative care. So can they work in the emergency department? Yeah, yeah. There are hospitals that are experimenting with that. We've heard of that in Atlantic Canada. We've heard of that in parts of Ontario and other provinces as well. Personal support workers. We're starting to actually see personal support workers who provide care,

workers. We're starting to actually see personal support workers who provide care, delegated care from what a nurse would provide without giving medications or doing procedures, giving IM injections, which would be the purview of the nurse. But having that would relieve the nurse of some of those duties and allow them to concentrate on duties that are closer to the top of their scope of practice, admittedly under very trying circumstances. Talking about solutions here, advocates for private health care have essentially said privately owned businesses are waiting in the wings here to help where public care has failed. And so can we expect this crisis to lead to a bigger role for private health care in Canada? Well, and I'll say that I'm sure they are waiting in the wings.

And I am a supporter of publicly funded health care services for the very simple reason that, you know, the studies that I've looked at suggest that having a single payer in a publicly funded model is more efficient. You'll get more bang for your buck than if you have a smattering of private for profit providers, each with slightly different clientele.

They might focus on different aspects of the healthcare system, that you're going to have a much more efficient system and you're going to deliver better care to more people for less money in a publicly funded model, if it's adequately funded, of course, it has to be adequately funded. So is there a risk right now? The doomsayers, you know, the conspiracy theorists believe that the system right now in Canada, the publicly funded system in some provinces is being starved of the cash it needs to provide the service that feel that the only solution is to step out of it and pay, you know, whatever that premium would be $10,000 a year, whatever $5,000 a year to, to have a, you know, private for profit parallel system, which of course would violate the Canada

Health Act. And then, you know, there have been cases that have gotten all the way to the Supreme Court of Canada. And I'm sure there'll be more that have come to the conclusion that if you can't deliver this kind of care to this patient within what would widely be regarded as a reasonable period of time, then you're violating your own terms of the Canada Health Act and you're leaving open the door for private for profit health care. You know, I hope we don't get to that point. I don't see it as a great opportunity, but I can say that Canada has some of the lowest levels of care compared to other organization for economic cooperation and development, OECD countries, when it comes to the supply of nurses, supply of physicians. But that's been a longstanding issue. And I think it's up to voters to decide what kind of health care system they want.

And it's curious to me that we pass through elections. For instance, there was an election in the province of Ontario. And I can hardly remember when health care was cited as any kind of an issue. And now we have this crisis occurring, just weeks after, like a month, barely a month after the provincial government was basically reelected. And at a time when people are screaming crisis, and nobody was screaming crisis five weeks ago, six weeks ago. Yeah, I mean, I was gonna, this is what I was gonna ask you about, Yeah, I mean, I was going to, this is what I was going to ask you about. Why do you think it care is the number one preoccupation on their minds. And my comment about that is, yeah, sure, when you or a loved one are on a gurney in the emergency department.

in the emergency department. And when you aren't, then just as, you know, people don't remember the pain that they felt when their fractured hip was fixed, or the chest pain that they felt when they had their heart attack long after, you know, and well, they shouldn't, you know, I don't think it's, I wouldn't wish that on anybody that they would actually remember how bad the pain felt. We, you know, that's. But when the experience recedes in the rearview mirror, we often tend to forget how important an issue this is. And, you know, frankly, I think in our health care system, the voice of the patient has not been heard enough. You know, certainly on our show and others who've started to see it, there certainly is much more interest and demand by patients that their voices be heard, particularly the ones who have recently had experience in the healthcare system, who've been in that hallway, or the loved one of someone who's been in that hallway in the

emergency department, that they have a voice, that they be able to say something about how things should run. Because, you know, there's wonderful things about health care. There's a lot of administrative, you know, snafus and encumbrances that just make it really, really difficult to operate smoothly. to operate smoothly, you know, it's easier to transfer large sums of money in the banking system, you know, than it is to transfer records to or, you know, for a family doctor to find out the care that their patient received in another province a month ago. And, you know, and there are all kinds of reasons for that. But I think the patient perspective in telling us what we're doing well and what we're not doing well and in honest terms could be nothing but helpful to making the health care system

run better. All right. Dr. Goldman, thank you for this. You're welcome. All right, so before we go today, a major legal win for sexual assault accusers at criminal trials. Last Thursday, the Supreme Court of Canada upheld protections for their private records in court. The so-called Gomeshi amendments were introduced in part because of the sexual assault trial of former CBC host Jean Gomeschi. That hearing saw the defense introduce private messages to discredit the accusers.

The new rules say those private records must be deemed admissible at a hearing where the accuser can be present with a lawyer. The Supreme Court's 6-3 ruling says the law is constitutional, noting the right to a fair trial does not guarantee the most advantageous trial possible from the accused perspective. That's all for today. I'm Jamie Poisson. Thanks so much for listening. We'll talk to you tomorrow.