Introduction by Croakey: Emergency Department clinicians have described how the system is failing both patients and those working in it, in a series of articles published recently at Croakey.
Australasian College for Emergency Medicine president Dr Simon Judkins kicked off the series with this article, prompting this on-the-ground response from a clinician, to which Judkins replied with further accounts of a system in crisis.
Now, another ED clinician adds to the discussion with an impassioned call for colleagues to partner with consumers to drive transformative health system re-design.
Clinicians and consumers should stand together in refusing to accept long waits, deteriorating facilities, under-staffing, over-crowding, systematic under-funding of primary care, and increasing fragmentation and privatisation of health services, the clinician says.
I also work in an Emergency Department. A big, busy public one – surrounded by suburban sprawl. I’ve been working in Emergency Departments across Australia for over 20 years and I’ve felt the pressure build – more patients, less time, more scrutiny, less space, more paperwork, less humanity.
And even though my colleagues and I feel like frogs in a boiling pot, it’s patients I’m really worried about. Because patients are the reason I get out of bed and go to work each day.
I read Dr Simon Judkins’ recent article for Croakey with a sense of relief, almost euphoria. “Yes!”, I thought. “The moment has finally arrived.” I had been wondering just what it would take for Emergency clinicians to stand up and say “enough is enough”.
The system has been held together with Band-Aaids and goodwill for years. But I also felt sad. Does the article by Judkins signal that my caring, talented, hard-working and resilient colleagues in Emergency medicine are starting to give up?
The response by an anonymous clinician to the question put by Judkins, “Are you okay?”, describing a series of near-misses on night shift, really resonates with me. As does Judkins’ subsequent response, “An Open Letter to a System in Crisis”.
I thank my colleagues for their courage and honesty. I desperately hope that this organic series on the theme “Emergency Departments are not okay”, is the start of a ground-swell towards genuine system reform. I add my words to keep the momentum going.
But this is not really about me and my colleagues. It’s about our patients.
Judkins’ tweet about a 25 year-old woman, stuck in the Emergency Department for hours, while inpatient teams squabbled over her admission, tells a story that plays out in Emergency Departments across Australia every day.
A growing body of evidence demonstrates that prolonged stays in the Emergency Department increase morbidity and mortality – read Geelhoed and de Klerk’s article about the impact of the four-hour rule in Perth or explore the Australasian College for Emergency Medicine’s page about access block if you want to learn more.
I extend a deep and sincere apology to the patient referenced in Judkins’ tweet and to all the others like her. This is not good enough and does not reflect the care that clinicians working in Emergency Departments want to provide.
I apologise to the patient with a prolonged seizure that I had to inject with midazolam, on the waiting room floor, because there were no treatment spaces available inside the Emergency Department.
I apologise to the patient with severe back pain, eventually diagnosed with aortic dissection, who was treated in a chair in the triage area until he was taken to theatre for surgical repair. I wanted to give you intravenous analgesia, but policy says “no”.
I apologise, as a clinician and a parent, to the septic child, resuscitated while an intoxicated man shouted obscenities from the adjacent cubicle. I apologise to your mum and dad too, and your brother. That must have been terrifying for you all. Not for me, I’m used to it.
I apologise to the patient with vaginal bleeding – a nurse from a neighbouring hospital. I’m sorry that we were not able to provide you with a bed, let alone an en-suite toilet, or a private space to grieve for your lost pregnancy.
I’m sorry that you felt the need to apologise to me for wiping up your own blood from the corridor floor. I really hope there is not a next time, but if there is, please scream and shout: “This is not okay!”
The canary’s warning
This is not really about Emergency Departments either. It’s about a fundamentally broken health system. Emergency Departments are the canary in the coal-mine.
I apologise to the frail elderly patient, nearly dead on an ambulance stretcher, sent in for assessment after a minor fall in the middle of the night – the Emergency Department is not the best place for you.
It’s safer for you to be cared for in your nursing home, but the system, tangled up in inter-jurisdictional red-tape, hasn’t worked out how to provide you with humane, patient-centred care in familiar surroundings just yet.
I apologise to the patient referred to Emergency with abnormal kidney function tests. Your GP did the right thing, trying and trying again to get you an appointment with a specialist.
But you’re on the pension and no appointments were available for months. The outpatient clinic closed years ago. You don’t really belong here in the Emergency Department, but we’ll do our best to look after you anyway.
I apologise to the teenager, overwhelmed by family violence, who took an overdose, then waited 21 hours for a definitive admission plan. Only to discover there were no adolescent psychiatry beds available across the entire state. I apologise for the harm we caused you with our security guards and sedatives.
I would act-out too, if I was surrounded by the bright lights, noise and chaos of the Emergency Department for nearly three days, not knowing what would happen next, feeling scared and alone, with nothing to do.
I wanted to spend time with you, listen to you and show you that some adults can be trusted. It breaks my heart to be unable to provide you with the trauma-informed care you need.
I wish the system had been able to reach out and support you before you hit the crisis that landed you in the Emergency Department.
I keep wondering when our patients will revolt. Increasing episodes of aggression and violence in my workplace suggest they are at boiling point but are struggling to find a meaningful channel for their outrage.
Build a movement for change
If Emergency Departments were a new cancer drug, or a cutting-edge surgical device, or a super-specialised clinical unit needing government funding, patients would have marched on Parliament by now, possibly calling for a Royal Commission.
But Emergency Departments have a broad scope – we treat symptoms of all varieties, at all hours of the day, across all age groups – so we belong to everyone and to no-one.
We struggle to generate a coherent and consistent consumer voice.
Emergency clinicians need to actively partner with consumers to drive transformative health system re-design. We’re in the same boat. We’re not okay.
We don’t accept long waits and deteriorating facilities. We don’t accept under-staffing and over-crowding. We don’t accept systematic under-funding of primary care. We don’t accept increasing fragmentation and privatisation of health services. And no! We’re not going to sell bloody raffle tickets to fund-raise for essential clinical equipment.
Emergency Departments are about all of us – clinicians, patients and our communities. We are the system and we can change it.
Together, we need to start holding decision-makers accountable for the undignified and inadequate care they force us to provide.
• The Emergency Department clinician who wrote this article asked not to be identified.