Paracelsus' poison

On Spending the Night in the Emergency Ward (and Myths and Realities of the ED)

A couple of weeks ago Amanda Blair wrote, in the light of of the problems with the South Australian Health Budget, that she could provide savings by being the “Door Bitch” at Emergency Departments and keeping out people she saw as being time wasters who weren’t sick enough to justify emergency admission.

At the time I thought to myself “well, you better be able to tell the difference between meningitis and flu” before moving on to other things.

And then I became one of the people she would like to keep on the other side of the velvet rope.

It all started, ironically enough, on the day I had seen my GP for a check up (which I passed with flying colours), by the evening, I felt as if I had a bit of a flu coming on, no respiratory symptoms but muscle acheness you get just before. Near midnight I woke up in pain, the right side of my chest and back hurting terribly.

After taking ibuprofen and waiting, I eventually dug out some old Panadene Forte as the pain was just not going away. My Beloved Life Partner, who had been woken up by me stomping about digging out pain killers and walking around because the pain was so intense I could lie down, asked me if I wanted an ambulance.

“No” said I heroically, “the pain will go away in a while”. Half an hour later it felt like I was being stabbed in the kidneys with rusty sissors, the sort of pain I imagined passing a kidney stone felt like, and I heroically begged for an ambulance.

The ambulance guys arrived and did lots of technical things, ran an ECG, and decided to take me to emergency at the Queen Elizabeth Hospital, there I was bundled onto a trolley, ECG’d again, X-rayed, had urinalysis and muttered over seriously.

In the end they could find no reason for the pain, suggested it might be something like a pulled muscle (despite me lifting nothing heavier than a pencil that day), gave me strong pain killers and sent me home at 5:00 am.

The last thing I think I remember was them saying very seriously “ if it gets worse, come back”. But that could have been an hallucination due to almost 20 hours lack of sleep and oxycodone.

Well it didn’t, midday the next I was back fronting up to the triage nurse at QEH, asking them to take me back as the pain was worse and spreading.

This was the “Door Bitch” moment, where Amanda Blair would have sent me packing, not letting me cross the velvet rope. After all, my discharge letter said “musculoskeletal pain”, hardly an emergency.

But they took me, put me in line, took more blood samples (where I heroically fainted), did more scans…

…and discovered the blood clots on my lungs.

So on the evening of my Beloved Life Partners birthday, instead of enjoying a meal in a nice restaurant we shared a ham and chutney sandwich as I lay on a trolley in ER, waiting to be admitted to the hospital.

My emergency was a real emergency, requiring hospital admission, but it was a complicated and subtle emergency, and difficult to pick up.

And this is part of the problem, many serious problems can look like more ordinary things, like early meningitis and the flu. If your kid is sick with something that could be flu or could be meningitis what parent is NOT going to take their child to ER? Do you want to be the person in front of the rope, make a decision that might (rarely to be true, but just might), lead to the death of a child?

The seriousness of missing a diagnosis of meningitis or heart attack or stroke or many other things that could look like much less dangerous conditions means that we err on the side of caution.

Also, it’s the reason we have triage nurses, trained professionals who sort people out according to the seriousness of their conditions.

Now my story is just an anecdote, and the plural of anecdote is not data, neither is Amanda Blair’s tale of someone going to emergency for bits of apple stuck between their teeth (a true story, but completely unrepresentative of what goes on most of the time). The real data is that most people go for actual emergencies, and most of the rest go for reasons that worry them a lot (like kids with what looks like colds and flu) which could be very, very bad if mundane explanations are not eliminated quickly.

The reasons for clogging up emergency wards in Australia has been researched (this comprehensive review from 2009 covers all of Australia). And people turning up with non-emergency related conditions actually play a very minor role. Ms Blair raises GP hotlines as something people should be using, but they don’t work.

The biggest issue in “clogging” of ER’s is the availability of hospital beds (see also here), so that people on trolleys in ER can moved out and resources used seeing new arrivals, rather than monitoring people waiting for beds. In my case, it took around 10 hours before a bed became available (I know, anecdote, not data).

And it will become worse, as people put off going to the GP because of the GP co payment (championed by people who didn’t even know how many times people actually go to GPs) and will end up in emergency with worse, more expensive to treat conditions.

Making people pay for attendance at emergency departments will result in poorer health outcomes and health costs that will be even worse (it is as if the proposers do not understand the meaning of preventative medicine).

Because people in general do not have the medical knowledge to distinguish between a mild self limiting illness and the early stages of a similar, serious, potentially lethal disease, we should not be turning them away.

We don’t need “Door Bitches” on emergency ward doors, we need adequate resources so that people can move from ER to the wards quickly.

(My fulsome thanks and those of my family to the Ambos, the QEH ER doctors, nurses and other staff, the QEH main hospital doctors, nurses, pharmacists, diagnostic staff and other ward staff. You put up with my bad jokes and general, smart arsedness, treated me seriously and set me on the road to recovery).