Non-urgent cases jammed my ER in Baghdad in 1990 and we have it in Canada today. But there are solutions

Dr. Jabir JassamSeptember 1990, Baghdad, Iraq: It was my first ER shift in my first rotation in my first residency. A young newly graduated resident, backed up by a second-year resident who was more experienced in the ER than me, so we were only two doctors in my very first night. The shift was from midnight to 8 a.m.My first case was a suicidal girl who ingested 20 pills of her mother's Eltroxin 50 mcg at once after a family conflict. She was conscious and able to answer all my questions; however, the incident has happened 24 hours before so I expected things to get ugly in the upcoming few hours or so.After a gastric lavage (which probably was too late) and I.V. fluid , I opened my book but I didn’t find what I was looking for, back then there was no UpTodDate or Google, I then realized I had to singlehandedly manage this case. Dr. Jassam in 1990.There was no place to call or to get help, back there and then. You are the doctor; you have to know everything and to fix everything. “I don’t know” wasn’t an option.It was 1:30 a.m. and my backup resident was busy with a chest bullet injury and trying to resuscitate his unstable patient.I thought, well, let me deal with this as a case of thyroid storm. While I was collecting my thoughts, another patient arrived with a cough, a second with headache, a third with a UTI, all while my colleague was still trying to insert a chest tube into his patient.It seems that I was stuck—newly graduated resident alone in the desert, thirsty with no water around, so to speak. The internist on call didn’t respond to my telephone call (there was no cell phone or pager).Why am I getting so many non-urgent cases, I wondered. I'd thought as it was an emergency department that I would see only emergency cases.Suicidal patientI hooked the suicidal patient to a monitor and noticed her heart rate was very high. It was a thyroid storm then, I thought, so I decided to give her I.V. beta blocker. It was the first injection in my life and it was an I.V. beta blocker! Yes, I was bold but not anymore.I remember I didn’t find atropine injection just in case the beta blocker caused heart block or severe bradycardia. Yes, I thought about all of that, and no adrenaline injection either—my country was under siege back then in 1990.While I was monitoring my patient, I saw many non-urgent cases, but I had to come back every few minutes to monitor and observe the suicidal girl. Then there was no qualified nurse who could do that for us.Finally, my first night was over and at the end of my shift I handed over the cases to the next resident with the presence of the internist, who praised me for handling the suicidal girl and for giving her beta blocker, as it was not easy for a first-night resident to make such a huge decision.Next day, there was a meeting and the chairman asked about the ER and if there was any issues. I raised my hand and said: "I thought the ER is for emergency cases only but I have seen at least 20 cases that were simple and could be treated in outpatient clinics."He replied that it is an inveterate problem and we can’t stop people from visiting the ER.I said these non-emergent cases can delay us and prevent us from focusing on serious cases."You are not the first one who has complained. All new residents complain and then they get used to it and you will too," he replied quickly, and asked if there was any thing else. The meeting continued to discuss other things; I sucked up my complaint.Next shiftMy next shift in the ER was two days later, running 8 a.m. to 4 p.m., and the problem was was even worse. I saw tonsillitis, ear infections, cough and many more simple non-urgent cases.There is something wrong here and it needs to be fixed, I whispered to myself.At the next meeting, I raised my hand again and said the same thing, and added there is something wrong and it needs to be fixed.The chairman looked at me unhappily and condescendingly said, "You want to fix a 60-year-old problem and you just started your career a week ago." Then he laughed; so did other attendees.I replied: "Why not. I might have a suggestion."He smirked. "What is your suggestion?""We can set up an outpatient clinic in the hospital. Any case goes directly to that clinic unless it is a stab or bullet injury or chest pain etc.. We see those patients, filter them and either send them home or to the ER so the doctors can focus on real emergencies," I said.He replied in an irritated tone that we would discuss it later.I continued raising my hand at each meeting I attended and talking about the same thing, and every time I raised my hand I could see the annoyance and irritation on the majority of attendees faces.I completed my rotation in that hospital, which was located in a low socioeconomic area, and started another rotation at a different hospital that didn’t have an ER.Eight months later I went back for a personal visit to that first hospital. I entered through the ER door and noticed the ER was empty. I asked the resident on duty what was going on and if they had closed the ER. She replied not really but they opened two outpatient clinics inside the hospital; they see patients first and redirect them, and the ER now sees the real emergency cases only.I smiled and went out to see those outpatient clinics. I could see people lining up in front of these clinics, security in the middle to stop people from fighting or crossing over to go directly to the ER, as they hadn’t separated the two departments yet.I honestly didn’t care who got credit for the idea that sparked the blaze; all I cared about was that it worked and it saved money, resources, time and, more importantly, the emergency department became a real emergency department.In Canada2007 Ottawa: It was my second residency in my life and history repeated itself: I was on duty in the ER and still seeing a lot of cold, cough, depression, diarrhea and so on. The waiting time was six to eight hours.I hope the Ontario ministry of health reads this article related to our struggles with ER waiting times.I am sure the outpatient idea can work here, too, will save time, resources and money—more than the money the ministry is hoping to save from cutting the income of poor, exhausted, close to burned out primary healthcare providers.The outpatient shifts can be rotated between all city doctors and can be integrated in the residency program so residents can take turns too.I am still whispering. . . .Dr. Jabir Jassam is a family physician who works at Health Treasure Medical Center in Ottawa.Opinions expressed in this article are those of the writers, and do not necessarily reflect those of CanadianHealthcareNetwork.ca or its parent company.

Non-urgent cases jammed my ER in Baghdad in 1990 and we have it in Canada today. But there are solutions

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