Emergency Departments in Crisis — Dr. Fraser Mackay and David Leary

Avis Favaro
Across Canada, emergency rooms are under extreme pressure. And people waiting for care, like this woman, are very distressed.

Unidentified patient
The amount of patients that were in this hallway or in this situation was overwhelming.

Avis Favaro
Data is showing that emergency visits are now back up to over 15 million a year, with longer waits for care and for beds. It’s leaving emergency departments overflowing, says this doctor.

Unidentified doctor
We have to see patients in these unconventional spaces, like waiting rooms, like driveways, like closets, that patients don’t expect, and they certainly deserve better.

Avis Favaro
On today’s episode, a closer look at this national ER crisis with 2 people right on the front lines. One is B.C. paramedic, David Leary.

David Leary
You see a lot of patients on stretchers waiting to be put into a hospital bed, waiting to be triaged. It’s quite concerning and it’s quite stressful.

Avis Favaro
And we’ll talk to New Brunswick emergency physician Fraser Mackay, on the distress of seeing more patients, many without family doctors, who need care.

Dr. Fraser Mackay
We cannot say “no.” We cannot refuse a patient. We don’t close our doors and we just keep sucking it up. And that leads to the burnout, and that leads to less staffing, and that leads to closures.

Avis Favaro
Hello and welcome to the Canadian Health Information Podcast. We call it the CHIP for short. I’m Avis Favaro, the host of this conversation.

A note, the opinions expressed here don’t necessarily reflect those of the Canadian Institute for Health Information, but it is an open discussion. And this one is about emergency care, the last line of defence when we’re injured or seriously ill, a safety net that some believe is breaking down.
Joining us now from Surrey, B.C., is veteran paramedic David Leary. Hello, David.

David Leary
Hello. Thank you for having me.

Avis Favaro
Great. So you are with the Ambulance Paramedics of B.C. You’ve been a veteran for 25 years?

David Leary
Yeah. I’m coming up to 25 years now. Correct.

Avis Favaro
You’ve seen it all. How many times a week would you end up in a hospital ER with a patient?

David Leary
Well, paramedics typically here work 4 days on and 4 days off. So for their 4-day block, they’re probably doing anywhere from 8 to 12 calls in a shift. And the majority of those calls, they’re transporting to the hospital. So they could be at the hospital 40 times in their 4-day work week.

Avis Favaro
So you get a good bird’s-eye view of what’s going on at that entry point of the health system.

David Leary
Absolutely, 100%. I mean, it doesn’t get any closer than that, than transporting patients right into the emergency department. And we live and breathe that every shift and every day.

Avis Favaro
So how would you describe the change that you’ve seen at that entry point over the 25 years you’ve been a paramedic?

David Leary
Well, I mean, our call volumes increased significantly over those years. There’s also an increase in hospital ERs, people just attending emergency rooms in general. So they’re being overwhelmed with the amount of patients that go to the hospital seeking treatment. So it puts a huge strain on the system within the hospital and the emergency departments, which then reflects back onto the ambulance service and puts a huge strain on us.

Avis Favaro
Take us on a walk. You’re bringing in a patient on a stretcher. You go through the sliding doors. What do you see more of now when you walk in?

David Leary
Congestion. Congestion. A lot of congestion. A lot of crews waiting to be accepted into the health care system, into the hospital. You see a lot of patients on stretchers waiting to be put into a hospital bed.
It’s quite concerning and it’s quite stressful for paramedics. It’s quite stressful for the patients, again, and it’s very stressful for the hospital staff. There’s a lot of pressure on everybody to be able to help move the patients through the system in an appropriate and timely fashion.

Avis Favaro
Have you ever seen patients in unusual spots? Unconventional spots, I think they call them.

David Leary
Every day you see patients in the hallways, at the back hallways. You see them inside the emergency department placed around the nursing stations in hospital beds. So they’re not actually in rooms.
And when they’re being treated and assessed and cared for in hallways and out in the open, they don’t have that dignity and the proper care, the proper privacy and confidentiality, that you would expect to have.

Avis Favaro
We hear that everyone — physicians, front-line workers, the nurses — are all working really hard. What do you see?

David Leary
We know that they’re stressed. We talk to them. We can see it. But I will say this, is that they are professionals, and they conduct themselves as so when they’re caring for and treating patients within the department.
And as paramedics, in our profession, we have nothing but praise for the staff that work within the emergency departments here in B.C., and in Metro Vancouver specifically, where I work. But it’s a tough task for them to do under the working conditions that they have, so.

Avis Favaro
There’s a word that’s used called “offloading.” David, can you explain that to us?

David Leary
So, yeah. When a paramedic crew or ambulance crew arrives at the hospital, they start to proceed through registering the patient, and then they have to be triaged. And then if there’s any special assessments that they need prior to being placed in an area within the hospital, or they have to be assigned to a bed, if they can’t have that done in a timely fashion, then that’s called, like, an “offload delay” or a “hospital delay” for the ambulance crew or paramedic crew. And we’re basically being held within the emergency department to care for that patient until they can be accepted within the hospital system.

Avis Favaro
How long should that take, that transfer?

David Leary
It should be like a 30-minute to 45-minute type of timeline to when you arrive at an emergency department to go through the process of registering, and then being triaged, and then being placed into a hospital bed.

Avis Favaro
But what’s happening now?

David Leary
Depending on what the staffing is like within the hospital, we can be waiting for an hour, 2 hours. I mean, I’ve seen times up to 5 hours waiting for a placement into a bed.

Avis Favaro
What happens when a hospital is so busy that the paramedics can’t offload?

David Leary
The obvious situation is that they’re not available to respond to other calls for emergencies or transfers or care, which — that can have adverse effects on patients that are out in the public or in the field, as we call it, waiting for an ambulance, for if they’re injured or sick, and they need to be transported to the hospital or need the care of paramedics. It delays the care that they receive.
And it also — the patients that we do, are sitting on offload delays with or hospital delays, we can only provide so much in when it comes to diagnostics or care for what they need at that moment, and what they need is a higher level of care, which the hospital provides. When it gets delayed that could result in them being held in the health care system longer than they should have been, meaning that their condition has worsened in that time because they potentially were not [receiving] the care that they need.

Avis Favaro
What you’ve described is not that seamless, nice flow from emergency services through to the actual hospital. And it’ll help people understand, it’s not just anecdotes that patients have; this is what professionals see too.

David Leary
For us, we see it every day. We know how the system works within the hospitals. But to a patient who may or may not have ever been into an emergency department before, I think about looking through their eyes, and they must look at it and be — they’re already stressed and they’re sick, injured, not well — and it must look very chaotic to them, and must add a lot to the stress of their situation already because they don’t know exactly what’s happening within that department. And it probably looks very chaotic to them.
But for us, like I said, we do know that the staff work very, very hard and we want to acknowledge that we know that they’re doing their best in difficult times and difficult situations, so.

Avis Favaro
Well, I want to thank you, Dave. Thank you very much for your observations and for helping people understand the perspective from the paramedic front line.

David Leary
Well, thank you very much for having me. And the Ambulance Paramedics of British Columbia and the Paramedic Association of Canada thanks you for inviting us on the show.

Avis Favaro
Now for a look at what it’s like to work inside those overflowing emergency units, we go to Saint John, New Brunswick. Dr. Fraser Mackay is an ER physician and also a member of the Canadian Association of Emergency Physicians, or CAEP. Thanks for joining the podcast.

Dr. Fraser Mackay
Thank you very much for having me on.

Avis Favaro
And I understand that as soon as we’re done recording, you’re going to be running across the street to start working your shift in the ER.

Dr. Fraser Mackay
Absolutely.

Avis Favaro
What do you expect when you walk in the doorway there?

Dr. Fraser Mackay
That’s the fun thing about emerg, you never know what to expect. But definitely, as an emerg physician walking into work these days, we notoriously avoid the waiting room because we know making eye contact with patients can set up an interesting vibe because the wait times are so consistently prolonged.

Avis Favaro
When you don’t look at them, what is it that you don’t want to say or signify?

Dr. Fraser Mackay
It’s more that I want to start my shift with an open mind, without any preset expectations, without the concerns; without that automatic, “oh no, I’m starting at the bottom of a big pile.” I just want to go in fresh, start with my first patient and not have that weight of the waiting room on me.

Avis Favaro
Does it weigh on you?

Dr. Fraser Mackay
It does. The reality is, in a busy department, you’re juggling somewhere between 3 and 8 patients at any given moment as a physician. And the frustration that the patients feel when I come in to see them, usually it’s not too bad of an experience. If they have to vent a little bit, they’re a little bit frustrated, they’re a little bit upset — that’s understandable. And that’s not the problem. It’s more the awareness that we don’t know what we’re missing in the waiting room. We know that patients are leaving the departments without being seen.

Avis Favaro
If you had to describe overall the state of emergency medicine right now in Canada with 1 word, what would it be?

Dr. Fraser Mackay
Tenuous.

Avis Favaro
Why that word?

Dr. Fraser Mackay
The emergency departments across the country are functioning well above capacity, and the staff go above and beyond as default, and have been for a long time. That really came out in the pandemic. At first, the numbers of people dropped off to near 0 for a short period of time in the emergency departments, and we’re now above pre-pandemic levels, but the staffing has never recovered. The system has never recovered. So all of our limits are being exceeded on a regular basis.
So the emergency system and the emergency department, it’s often viewed as front-line care. The problem is we’re now not only the start of the line, we’re also — we’ve become the end of the line for care as well. The rest of the system is revealing its lack of capacity.
And I don’t like to use the word “system” because, to be clear, I do not believe there is a health care system. They are a series of siloed locations and services. And more often than not, each service in each system has its own internal struggle that it’s trying to manage, and this creates a self-protective effect.
The fact is we’re all doing our best, but there is a very distinct lack of leadership and lack of vision overall for health care.

Avis Favaro
Hmm. Okay. Let’s break it down. How long have you practised for? I know you were a paramedic beforehand.

Dr. Fraser Mackay
Yeah. I was a paramedic for a long time and I worked in many places all across Canada. And so I’ve been practising independently just for 5 years now. So I trained in family medicine and then wound up certifying in emergency medicine.

Avis Favaro
And so what have you seen over the last 5 years in terms of what you meet in the ER?

Dr. Fraser Mackay
The acuity overall, on average, is, I think, creeping up a bit in terms of the frequency of patients that are sicker than you might expect. It’s well-known that there’s more and more elderly patients that have increasingly complex problems and have not been managed optimally because of lack of access.
Although the overall numbers are creeping up in the emergency department and the wait times are creeping up — well not creeping up, they’re skyrocketing, to be blunt — but also the acuity is increasing. And that’s across the board. I work in an urban location as well as several rural locations. And we’re seeing it in the rural locations as well, which is, again, indicative overall of the problem with the health care system.

Avis Favaro
So these are sicker patients and more patients.

Dr. Fraser Mackay
Yes. We were looking back in a region where I work at just a year ago, looking at our notes from previous meetings with leadership about how many admitted patients we had in our emergency department and the impact that that was having on the wait times, and our numbers have doubled since then. And a year ago we were saying, “This is unbelievable. This has never been this bad. We cannot allow this to continue.” And it has just steadily gotten worse. And this is a pretty consistent story across the country.

Avis Favaro
Okay. Where are these patients being kept in your emergency?

Dr. Fraser Mackay
In all of our beds. In our acute beds. We have patients in my department right now that have been admitted to the internal medicine unit, which is sort of 1 step down from an ICU, that have been in our department for 48 hours, for 72 hours in the bed that I’m supposed to be able to come and see the 80-year-old lady with acute onset of chest pain this morning. And that patient is still in the waiting room because I don’t have a bed to assess my patient in.

Avis Favaro
Yeah. There are stories of people waiting days to get admitted. I spoke to 1 woman who needed emergency gallbladder surgery. She waited 48 hours in the hallway of a Toronto hospital before she could get admitted, before she could get the surgery. So why is the wait so long?

Dr. Fraser Mackay
Getting someone admitted is the first step. You need an accepting physician and an accepting service. So that in itself, if your hospital is full, that can be a challenge because there’s going to be that push and shove — who has capacity to accept this patient?
But then on paper, if a patient gets accepted by a given service, yes, we agree this patient needs to be admitted under our service, we don’t have a bed. So that patient is going to stay in your emergency department.
It’s the wrong care in the wrong place at the wrong time. And there is ample evidence that patients lingering in the emergency department — especially when they’re admitted — negative outcomes, increased morbidity and increased mortality come from this, and the data backs this up. We know this.
And because there are so many patients upstairs in the hospital on the unit that can’t get discharged. Why can’t they get discharged? Because it’s not safe to discharge them and there’s no place to discharge them to.
So you see this rapidly mushrooms into a far greater problem that is not based in emergency care. But the emergency department is the only place — we never close. We cannot say “no.” We cannot refuse a patient. We don’t close our doors and we just keep sucking it up. And that leads to the burnout, and that leads to less staffing, and that leads to closures, and that — So if you close a department in a small town, that sick patient now goes to the next city over where that department’s already overloaded, and then they sit in that waiting room for 15 hours, and there we are in the cycle.
And this cycle has been spiralling and spiralling and spiralling for years, to the point now that it’s just obvious people are dying because of this.

Avis Favaro
This must be frustrating. How do you feel watching this unfold?

Dr. Fraser Mackay
This is an ironic response. I feel a little bit energized that things are so bad that we are in a position now to make change happen because everyone knows how bad it is. People are dying publicly because of a failure of our overall provincial and national systems to adapt to the current situation.

Avis Favaro
I heard of the physicians in Surrey, B.C., sending a letter to people: don’t come to our ER because we may not be able to help you. You’ve even had some provinces send out suggestions to people, don’t come to the ER unless you absolutely have to. The message seems to be that, if you reduce the stress on the emergency system, it’ll be okay.

Dr. Fraser Mackay
So I will challenge you back on that. People declare their own emergencies. And if a given politician, or administrator, or whoever wants to put out a message that you should not come to the emergency department, then that person needs to provide an alternative of care for them.
The other major problem, as I see it, sort of the philosophical problem, the very nature of emergency medicine is you have to be prepared for unexpected problems. You’ve got to be able to take that disaster like that. There’s no time to wait. We’ve lost that. There’s this view that if there’s an empty bed, it should be filled.
And that flies in the face of the fundamental principle of the emergency department. We should never be at 100% capacity. And virtually all departments are regularly exceeding that capacity. So we have no capacity to absorb a bad situation. If there’s a bus crash, if there’s a new pandemic and all of a sudden overnight 50 people come in severely ill, people will die because of that, because we don’t have the capacity for that.

Avis Favaro
I understand that a lot of the patients that are in the hospital in the hospital beds that need to be moved out are often older patients who need alternative level of care, either long-term care or home care, or something like that. Does it indicate that somehow hospitals have become de facto nursing homes?

Dr. Fraser Mackay
Yes and yes. It’s probably, in my opinion, the single biggest problem is the number of admitted patients that are waiting for safe discharge to an appropriate place. And there are more and more patients that don’t have either the home support that they need or that need a higher level of care. And I would say that is probably glaringly the main driver of hospital beds being full.
In addition to the fact that Canada has a deplorably low hospital bed–to-population ratio, which has continued to decline despite an increasing population. So there’s that as well.

Avis Favaro
So I’m going to make you king of health care in Canada, king of emergency medicine. Tell me the top 3, 4 things that you would do as soon as possible to clear this up so that patients can be seen quickly enough, the right people get the right care in the right place.

Dr. Fraser Mackay
The top 3 things.

Avis Favaro
You can make it 4, you can make it 5. But what would it take?

Dr. Fraser Mackay
In short, as we just said, greatly expanded access to higher levels of care outside of the hospital. So nursing homes and supported care and in-home care. That would be 1.
Number 2 would be a significant increase in the number of nurses and physicians trained for specific jobs. For example, family medicine and emergency medicine, which are the 2 major problems in the country right now.
And thirdly, an intentionally designed, integrated health care system. Now that sounds like a real simple concept. Doesn’t it? But there is no health care system. I want to be clear on that. There’s this perception that there is, but there really isn’t. And until that changes, we will not be able to deal with the inevitable problems of a growing and aging and complex population and their health needs.

Avis Favaro
What does that third one mean? What does a harmonized health system mean to you? What would that mean fixing?

Dr. Fraser Mackay
It means we need political courage. So the Canadian Association of Emergency Physicians has created this task force called EM:POWER, which is basically the future of emergency care in Canada. But it’s really much more than emergency care. It’s integrated care.
We’ve been calling for quite a long time for a national forum on health care. It hasn’t happened. So we’re going to host it. We’re going to start funding it to get everyone together to agree on the problems, to agree on the directions to start creating a system that is actually integrated, that actually is using evidence and data, such as CIHI has reams of, and use that data to start long-term planning.
It’s — let’s agree on the questions, let’s agree on the problems and let’s design an accountability framework for this at a provincial and a national level, because there really isn’t any accountability in health care. And until that happens, we’re going to keep stuck in this 4-year political cycle of meaningless promises, small, tiny changes that don’t seem to be having any positive benefit as we’re seeing in the current state of things.

Avis Favaro
Because people think, oh, it’s the ER. It’s emergency medicine is breaking down.

Dr. Fraser Mackay
Yes. There are problems in emergency medicine, primarily because the job has become so hard that we have a staffing problem. But the main problems, once again, the 30 admitted patients in my department, that’s not an emerg problem. We have done everything we can for them. We’re doing more than we should be doing for them, more than we’re trained to do for them.
And that is beyond the ken of the emergency department. That has to be upstream. There have to be beds in the hospital. Patients have to be able to be discharged from the hospital. There are many locations where, if it’s Friday at 5 in the afternoon, you can’t be discharged until Monday because the system of discharging patients is a Monday to Friday, 9 to 5 kind of job.
These concepts are so anachronous. They’re so outdated. There’s no excuse for it. But there is nobody at the wheel.

Avis Favaro
Every province has said that it’s tackling this. The federal government has put out an extra fund for emergency medicine. Do you see any signs at all that there’s attention being paid to the problem?

Dr. Fraser Mackay
I see lots of great initiatives on a very small scale all over the place. But these are small. These are temporary. These are Band-Aids. This is not large-scale system development.
So I’m not attacking anybody. Because there is, as I say, I don’t believe there’s a health care system; ergo, there is no one to attack. And I’m not even, I’m not blaming individual politicians or political parties because there is no system for us to actively fine tune and support. That’s the problem.

Avis Favaro
What is your hope?

Dr. Fraser Mackay
My hope is that the national forum is a success in that we get enough players across the country in the same place at the same time. And I’m hoping people leave with some recognition that we do have the capacity to deal with these problems, if we work together, if there is agreement, if there is political engagement and courage that, yeah, this is not an insurmountable problem.

Avis Favaro
That’s what you’re hoping to do. Okay. What’s your greatest fear?

Dr. Fraser Mackay
More of the same. My greatest fear is that 5 years from now, I’ll think I can’t do this anymore because it hasn’t gotten better, it’s gotten worse. And I need to take care of myself, take care of my family. It’s funny, I actually got a little bit emotional, which is okay. But, yeah. That fear that this problem could be fixed. We can make things better. I would really hate to think that we gave up.

Avis Favaro
What was that emotion that you touched?

Dr. Fraser Mackay
That I’ve been close to thinking that I couldn’t do it. And I know what that feels like, and I would never blame anyone for walking away.

Avis Favaro
You felt sadness.

Dr. Fraser Mackay
I’ve been overwhelmed. Completely overwhelmed. I know what that feels like. I’ve got a great support structure. I’ve got a great life. I’ve got a great job. And even so, I’ve been overwhelmed.

Avis Favaro
Well, I know you have to start your shift on that note. I want to thank you for your candour and thank you for your thoughts. At least it’ll give Canadians some idea of what to look for. So we’ll know it’s working if we start seeing some of the things you’ve discussed.

Dr. Fraser Mackay
Hopefully.

Avis Favaro
Yeah. Okay. Thank you again, Dr. Mackay, and have a good shift.

Dr. Fraser Mackay
Thank you.

Avis Favaro
Studies show that longer waits in ER lead to worse outcomes and a higher risk of death. There’s much more data on the state of emergency care. Go to the Canadian Institute for Health Information website, cihi.ca. That’s C-I-H-I dot C-A. And we’d like to hear from you if you’ve been impacted.
Thank you for taking time to listen.
Our executive producer is Jonathan Kuehlein. Our production assistant, Heather Balmain. And a shout-out to Alya Niang, the host of our French show.
And please subscribe to the CHIP wherever you get your podcasts.
I’m Avis Favaro. Talk to you next time.