Case 7: Seniors on Stretchers

[Triage Note: Family concerned about lesion on face. Seen by MD at nursing home and prescribed creams – patient rubs it off. The family wants swabs and assessment.]

It’s early evening in the middle of spring.  I’ve been in the department less than an hour and I’ve seen an asthmatic boy rushed over from school, and two middle-aged women with chest pain. The tracking board tells me that the next person to be seen is in ‘EMS Hall 2’. He’s eighty-eight and it’s been thirty-four minutes since he arrived in the department – via ambulance.

Our E.R. is divided into four main zones. The Acute Zone has 18 beds, each enclosed within a bay, and each equipped with cardiac monitors, oxygen, and suction. If a patient presents with an emergent condition – chest pain, shortness of breath, sepsis – they will have priority for these rooms. Three of these beds are Resuscitation beds – saved for those who may need immediate, life-saving intervention.

The majority of our patients are seen in a rapid assessment area called Yellow Zone. Patients are brought onto examination tables, examined, and tests are ordered if indicated. Patients then wait in chairs for re-assessment. The third zone is called “Subacute” –  twelve beds for patients who cannot wait in chairs, but who do not require continuous cardiac or respiratory monitoring.

Finally, Fast-track is where patients who have minor problems and injuries go: lumps, bumps, lacerations, wound checks, follow-up blood tests.

Last week, an article in the Globe and Mail titled “Seniors on stretchers: a health care disgrace” made rounds on social media. The piece is written by Andre Picard, in response to Quebec’s Health and Welfare commissioner’s recent report on the evolution of emergency care in the province. “It makes for chilling reading,” Mr. Picard says, “especially if you have a loved one like a frail elderly parent.”

Picard notes that long E.R. waits are not the fault of the ER, but “due to problems upstream and downstream. We stick them in hallways,” Picard says, “behind curtains, or in transformed broom closets…with little or no access to meals, toilets, or privacy. They are most often alone.”

‘EMS Hall 2’ is not a room. It’s a spot beside a wall in a busy hallway. The words “Hall 2” are scrawled in black ink on an eight-by-ten page taped taped above a stretcher.

The lines on Edward Bell’s face show each and every one of his eighty-eight years. He is withered and frail, pale skin hanging off bones like an over-sized wet shirt. I approach him slowly, noting the words “unpredictable/aggressive” on his chart. There is pureed slop on his clothing. He scratches his head, then picks at the large, fungus-like mass that’s overtaking his right temple.

“Mr Bell? How are you doing?”

He notices me, then looks away. I slip into gloves and gently palpate the tumor. He swats my hand, and then goes for my stethoscope.

I take a seat and review his chart. Mr Bell is from a nursing home. He has severe dementia and chronic back pain. He cannot walk, wears a diaper, and cannot feed himself. His family doctor has tried many topical remedies for this lesion – steroids, anti-bacterials, anti-fungals. These creams, however, will only reduce irritation and infection; The doctor knows –  just as I know – that this is cancer, and a tube of ointment will not make it go away. The lesion has been growing slowly for three years, and I can see frustration in the family doctor’s transfer note.  The patient’s family has not wished treatment to this point. However, on this Wednesday night, they’ve changed their minds, and now it’s an emergency. They want it excised. They want it treated. They want it gone. They’ve demanded treatment. Immediately. Call an ambulance. He needs to go to the Emergency Room. Now.

The number listed as next-of-kin is Mr. Bell’s son. I call him from my cell phone. There’s no answer. I look at Mr. Bell. There’s almost nothing for me to do. I make a referral to a plastic surgeon and I let a nurse know that Mr. Bell can go back to his nursing home.

Early in his piece, Mr. Picard describes the two types of patients in the E.R: Those who are able to move about (ambulatory), and those who are non-ambulatory. He leaves out a crucial subset: Those who can move about, but should not: those with chest pain, those in respiratory distress, those with severe infection, those with unstable fractures. For these patients, a stretcher or bed isn’t simply a matter comfort; it’s a crucial component of treatment. And these patients must take priority.

Had Mr. Bell been struggling for air, or had his confusion begun suddenly hours earlier, he would have been rushed to a monitored bed. His E.R. treatment, however, consisted of paperwork only. A call to 9-1-1, a pick-up by skilled paramedics, a trip by ambulance, a nursing assessment, and a doctor’s examination – all for routine paperwork.  I was in the E.R. on the day I read Mr. Picard’s article. All four EMS hall beds were occupied when I arrived. I made note of the patients there: A 92 year old from a nursing home who missed a chair while trying to sit, scraping her knee on the way down. Family was informed and she was sent to the E.R. based on their wishes; An 83 year-old diabetic who was visited by a community-care nurse, and sent in be because she wasn’t sure how to check her sugars. She wants badly to go home and is waiting for an ambulance to give her a lift;  A 92 year old from a retirement home who called 9-1-1 because of abdominal pain – the pain had resolved during the ride over; A 70 year old with chronic emphysema on home oxygen – he was short of breath, received a treatment in the ambulance, and was now back to baseline.

Mr. Picard asserts that seniors left in the hall is due to an “engineering issue,” and Mr. Salois, Quebec’s health and welfare minister says policy-makers should be compelled to act. Perhaps there is  truth to this. However, a quick look around the E.R suggests that the public – those with a “loved one like a frail elderly parent” – can make a difference as well. If a parent is called about a sick child at school, the parent will rush over and decide whether or not to visit a doctor. Fifty years later, however, when the same child is called by the nursing home about an elderly parent, a common knee-jerk response is “send them to the hospital.” While not all families act this way, this practice is a significant contributor to the Seniors on Stretchers problem.

Earlier this week, I had the pleasure of looking after an 86 year old who had been recently discharged from hospital after a stroke. She was improving at home, where she still lived on her own, but suffered a small set-back, with some nausea and vomiting. She was smiling, well-hydrated, and comfortable – sipping water on a stretcher in EMS Hall. She wasn’t sick enough for an acute bed, and didn’t mind waiting for admission to a hospital bed. I didn’t need to call her family, because her son was right there, chatting with her, helping her pass time, as they enjoyed each others company.

Mr. Bell was lucky. He only waited five hours on hall stretcher before he was picked up – once again by ambulance – and taken back to his nursing home. Many patients lay on stretchers for much longer, especially once midnight hits, and paramedic crews are occupied with transporting the sick.

Several months later, Mr. Bell was taken by his son to the plastic surgeon. After a lengthy discussion and considerable thought, Mr. Bell’s son was still unsure of whether or not he wanted the lesion removed.

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