'I don't think I'll last': How Canada's emergency room crisis could be killing thousands
Sid Shniad
'I don't think I'll last': How Canada's emergency room crisis could be killing thousands
As many as 15,000 Canadians may be dying unnecessarily every year because of hospital crowding, according to one estimate
Sharon Kirkey
Patients left in the hallway due to an at capacity emergency room at the Humber River Hospital in Toronto in January 2022. PHOTO BY NATHAN DENETTE /The Canadian PressArticle content
It wasn’t how the emergency doctors ranked each statement — from “never” to “every day” — in the burnout inventory that alarmed Dr. Kerstin de Wit and her research team.
It was the doctors’ responses, in a final, optional, open-ended question: “Is there anything you would like to tell us about your experiences?”
“This is awful. Worst in 20 years. With no light; just darkness,” one remarked.
“The environment is drowning me slowly, and it’s increasingly difficult to come up for air,” another responded. “After 23 years in the ED, I don’t think I’ll last another year.
“I’m done.”
The survey found levels of emotional exhaustion and depersonalization — a lack of ability to feel empathy for others, an emotional distancing and numbness that comes from feeling at the end of your rope — have increased among emergency doctors since COVID hit, and the consequences for patients could be disastrous.
The environment is drowning me slowly
“The most striking thing was how uniform the voice was,” said de Wit, a professor in emergency medicine and research director for the department of emergency medicine at Queen’s University in Kingston.
“It wasn’t that we had a balance of good and bad things. Ninety-eight per cent of comments were about negative experiences, or feeling really desperate,” she said.
“It was a real gut punch.”
The study looked at Canadian emergency doctor burnout rates in December 2020, and then burnout rates reported by the same doctors in the fall of 2022, when emergency rooms were slammed with simultaneous tidal waves of respiratory syncytial virus and COVID when kids returned to school.
“Viruses and COVID just went crazy,” de Wit said. Exhausted doctors and nurses worked extra and longer shifts. Families faced miserable wait times. Horror stories were reported of people left to languish for days on stretchers, or dying while waiting to be moved to a bed upstairs.
Today, emergency rooms are still filled with sick people waiting to be moved to the wards. In Ontario, the average wait time in May was 18.8 hours. Fewer than a third were moved to a bed within the government’s eight-hour target. Emergency departments are reporting record levels of “boarding,” a dehumanizing practice of holding patients in hallways or makeshift spaces after they’ve been admitted because there are no open beds upstairs. In Nova Scotia, emergency department deaths hit a six-year high last year, CTV reported, increasing to 666 deaths in 2023, from 558 the previous year.
Some are waiting hours with as-yet undiagnosed heart attack or strokes, conditions that need time-sensitive treatments like drugs to bust clots and restore blood flow to brains, “obscured from view amidst the chaos,” according to a Canadian Association of Emergency Physicians task force.
According to a report published in the Canadian Journal of Emergency Medicine, if recently published analyses of weekly deaths attributable to emergency overcrowding in the United Kingdom hold true in Canada — and there’s no reason they shouldn’t, given Canada’s crowding statistics are even worse than Britain’s — an estimated 8,000 to 15,000 Canadians are dying each year as a result of hospital overcrowding.
It is remarkable that this excess death rate is rarely discussed in Canada
“It is remarkable that this excess death rate is rarely discussed in Canada,” emergency physicians James Worrall and Paul Atkinson wrote.
“Physicians, politicians and the media often describe hospital crowding and prolonged wait times for ED patients as an inconvenience, but not a killer.”
Last August, a 73-year-old woman died of an aneurysm in an emergency bathroom in Joliette, Que., after waiting 17 hours without seeing a doctor, Le Journal de Montréal reported. The death, the result of a diagnostic error in triaging the woman, was “very unfortunate,” Quebec Health Minister Christian Dubé said when responding to opposition questions in the legislature in March.
Ontario’s patient ombudsman received more than 4,300 complaints in 2022/23, 33 per cent more than the previous year and the highest number since opening in 2016. Hospitals accounted for half the complaints. Among those related to emergency care, “of greatest concern is a growing number of complaints that serious health conditions were not recognized or treated, resulting in patients leaving to seek treatment elsewhere or serious consequences, including patient deaths.”
Reports included a woman waiting in emergency while having a miscarriage and nearly passing out in the bathroom while actively bleeding. In another case a patient who’d been taken to emergency several times over the course of a week with shortness of breath and chest heaviness was examined and sent home each time, only to be found dead less than 24 hours after the last visit to the emergency.
But pressure on emergency staff has been unrelenting, the patient ombudsman noted, a legacy, those on the frontlines say, of bed and staffing shortages compounded by COVID and made worse over the last three years by the family doctor crisis, delays to see specialists, uncoordinated, fragmented hospital processes and older patients with more complex needs. Emergency doctors are examining people on chairs or in waiting rooms. Hallway medicine is the norm. Some people are being treated in storage closets. Emergency doctors are increasingly having to tell someone, “You have cancer” because of months-long waits they’d faced for tests for suspicious symptoms, like sudden and puzzling weight loss or a mass that can be felt. Emergency rooms have become the “dumping ground” for the brunt of the system’s failures, doctors told de Wit’s team.
“The most prevalent theme is that the health care system is broken,” the researchers wrote in Annals of Emergency Medicine. “They feel it’s going to take decades to recover,” de Wit said.
The surveyed doctors described “horrible” and “unsafe” working conditions, moral injury, pessimism and feeling powerless. In 2022, 59 per cent reported high emotional exhaustion, up from 41 per cent two years earlier; 64 per cent had high depersonalization scores, up from 53 per cent.
It’s going to take decades to recover
With depersonalization, doctors can appear aloof and unsympathetic. “Patients can pick up on that very easily, and it’s upsetting,” de Wit said. A lack of sensitivity and caring were among the most frequent complaints about emergency experiences in Ontario last year. In most cases of high depersonalization, “I think people are just struggling to keep their head above water,” de Wit said.
And the river is rising. “I’m so tired of people talking about burnout,” one surveyed doctor said. “What I am feeling isn’t burnout. It’s moral injury. No amount of ‘self care’ is going to get my patient to OR on time today when they need it, or a bed to be in…. It’s (about) being handicapped and unable to provide patients the level of care I am trained to provide and that patients need and deserve.”
“Physician burnout is a huge patient safety risk,” de Wit said. It increases the risk of medical mistakes — errors in medication, misdiagnoses and rash decision-making. Burnout is like a physical illness, she said. “You’re not performing at your best; you don’t feel well.” It also risks further depleting the workforce, because, in addition to good nurses, Canada is losing good doctors, she said, “like, really good people who’ve dedicated their careers to emergency medicine who’ve decided they no longer want to do this.” The median age of the doctors surveyed was 42, with roughly equal numbers of men and women.
There are thousands of emergency doctors across Canada. There’s no way of knowing if the 381 doctors who responded to the survey in 2022 are representative of everyone working in the field.
But de Wit fears that, “as a profession, we’ve become casualties.”
It’s a complex problem with no simple fix. Hospitals have more patients than beds, and there aren’t enough family doctors anywhere near the numbers our population needs, de Wit said. A lack of long-term care beds and home care — all put back pressure on emergency.
In life- or limb-threatening emergencies, “we clear people out of our resuscitation rooms,” de Wit said. But the person moved out is now in the hallway. Other potential dangers occur when people are triaged appropriately to the waiting room, but then have a 12-hour wait. If things change and there’s nobody to advocate for them, or their deteriorating condition goes unrecognized, “that becomes a more serious problem.”
Doctors said it’s often just one Band-Aid solution after another, like adding more hallway spaces, or “over-capacity protocols,” instead of figuring out how to address the crisis in the long-term.
“If the emergency system collapses or becomes non-functional, it’s a threat to the entire health of Canadians,” de Wit said. “We’re the one main portal of entry to the hospital. If we’re not getting it right in the emergency department, if we’re not able to do the job of diagnosing and treating and triaging, patients are going to suffer enormously.”