The Health Care Crisis III: Emergency Rooms

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Jordan Heath-Rawlings If you have heard about this via newspaper headlines or news clips, then congratulations. But that means that you don’t fully understand. Just how bad things are in Canada’s emergency rooms. Nurses, doctors, personal support workers, et cetera, have been asking for better investments in our public healthcare system. What is happening in emergency rooms across the country now is worse than during the depth of the repeated covid waves. Overworked, burnt out and understaffed. That’s the situation. Nurses across Canada continue to fe in the workplace. We’re on the Brinks of collapse and we need an action plan and uh, we need it now. It’s one thing to hear these stories on the news all jumbled up together, hand, however you get them, but just imagine. If you or a loved one was walking into that situation or more accurately waiting on a stretcher in an ambulance outside of that situation, hoping that they will eventually take you into that situation, you’re already worried. You know something’s wrong, but you also know that in the current crisis, Unless you are actively dying, you’re gonna be waiting and waiting and waiting. The crisis in Canadian emergency rooms did not happen overnight. It is not entirely the result of the pandemic. It began a long time ago and it’s been accelerated by everything that’s happened the past couple of years. But we are approaching. A tipping point. The question is how much more this system can take. We are already seeing er closures, scale backs, and incredible wait times. Now when these things happen in other parts of the medical system, like doctor’s offices or walk-in clinics, things take longer When these things happen in emergency rooms, people. So what happens next? Are we gonna fix this or just let it break and break until we are left with bodies and burnt out doctors and not much else? I’m Jordan Heath-Rawlings. This is The Big Story. Dr. Kashif Pirzada is an emergency room physician in Toronto. He has an up close and personal view of this crisis. Hello, Dr. Pirzada.

Dr. Kashif Pirzada Thank you so much for allowing me to join you.

Jordan You must be very busy right now. I’d like to start, maybe if you could just describe what it’s like to work in an emergency room right now, on a daily basis, we’re hearing a lot of stories that they are at the breaking point. What does that actually look like on the ground?

Dr. Kashif Pirzada So you’ll walk into a shift and you’ll see rows of ambulances trying to offload their patients on one shift. Uh, it was about 20 of them. That means there’s no room to receive these patients inside the emergency department. You go in to start your shift and you find out there’s no actual patients to see because there’s no beds to see anybody. And the only place that’s actually moving is a bunch of areas with chairs where you move very frail and elderly people in and out of chairs to examine them and see them. And so what you have is a situation where you have total gridlock in a lot of hospitals, even at this point, which is not traditionally a very busy time for us.

Jordan When you say there’s no beds to see them, you mean cuz those beds are taken up by other people who need to be moved into a bed in the hospital or elsewhere, but you don’t have that either?

Dr. Kashif Pirzada Pretty much. So you have on average, like let’s say we have 30 beds at one hospital, 25, 28, even all 30 of them will be occupied by patients waiting to be admitted. Upstairs people. And then every time you bring someone in who’s not very well, they become another patient who needs to be admitted as well. So it’s an endless, endless stream, uh, backing up into a big, uh, dam that’s blocking everything. In the early days of the pandemic, we talked about this. As a result of Covid itself, you know, we had so many cases and we had no vaccines and people needed to get to the hospital and that was what was crushing the system.

Jordan Is this covid patients that you’re seeing? Is it people with regular, I shouldn’t say regular, but you know, the things that would typically send them to the emergency room? What is it?

Dr. Kashif Pirzada It’s kind of a combination. So covid, it’s not a disease that kills like one in five. Like it started with at the start of the pandemic when we were. We locked down, we waited for the vaccines to come. It’s become something that’s about equivalent to heart disease and, um, cancer in terms of mortality risks. So in the last, you know, year, we’ve added this whole new disease, this new disease that you know, is new to the medical world, new to everyone. , but it kills as many people and disables as many people as cancer and heart disease if you look at the mortality numbers. So that’s a huge burden that’s been placed on the system, which was already strained at the beginning. And now you have, you know, let’s say an elderly person gets covid, they lose their function to live alone, uh, faster recovering from an infection like that, they become unable to walk, unable to feed themselves. Aging process is accelerated in those people. Um, small children who, who catch covid and all the other viruses that are circulating, they need to be hospitalized more frequently than before. So we have a lot of kids getting hospitalized now from daycare or school exposures, but not necessarily always from Covid, but just from all the other things that are circulating as well. So it’s kind of, um, It’s a big new burden that’s been added to the system. It’s not the only thing, but it’s made everything, you know, 30, 40% worse.

Jordan What are the other things? So we have more patients than you would typically have, at least before the pandemic, even if they’re not presenting with just classic, serious covid. What else? Is it people who’ve left the profession? Is it doctors who are absent because of covid? Like it’s, It sounds like you’re describing a multifaceted problem.

Dr. Kashif Pirzada Oh, definitely. This is. There’s always someone getting sick and needing backup. You know, before the pandemic, we have a backup system where we have someone ready to come in to cover for a sick call. We used it maybe once a month. Now we use it almost every day because either, uh, the hospital’s overwhelmed, we need an extra hand, or we or someone is sick or someone’s, uh, family member is sick with covid. They’re even reducing the amount of time you need to stay at home. But basically, they’re saying if you don’t have symptoms and you have a negative rapid test, you can come into work as long as you wear a, a good mask. So our, um, sort of isolation stuff is, is, is decreasing with time. But you know, that person takes off their masks to have a, a lunch break or something. They could infect other staff members and it keeps on going from there. So you have people getting sick, is one thing. People leaving the profession is definitely another thing. Um, a lot of us, uh, a lot of departments in the city can’t fill all their nursing and, uh, hospital, uh, doctor shifts. So you have people who’ve basically burned out and have moved on to other careers. So those are, those are huge factors.

Jordan What kinds of things do you do on a daily basis in the emergency room now that you wouldn’t have done before, just to get by, You know, how do you, uh, slap on the duct tape, I guess, to keep the car rolling?

Dr. Kashif Pirzada So, one thing, uh, we do, we stay in, we stay longer to try to see as many people as we can. It’s hard to leave your colleagues in the lurch like that. So we’re all asked to stay a bit longer to help out. That’s one thing where we’re all being asked to pick up extra work as well, but that, that is gonna end up burning more of us out faster. You only have so much to do. People are, I think some hospitals are trying to throw money around to nurses and doctors to work more shifts. Um, I don’t know if that’s gonna work. It’s kind of a fixed supply of people right now. The other thing is, um, you know, going back to some of the. Side effects of covid. We have to do a lot more scans on people to catch things like blood clots, which we’re seeing a lot more. So that’s another added stress. So we have to order. A young person can’t feel their left arm, you know, before you could say, you know, maybe it’s a pinch nerve in their neck. Now you have to make sure that it’s not a stroke because we are seeing stroke in young people a lot more than before we invited you on, because we did want a doctor who could tell us about this, you know, on the ground level in terms of what you’re seeing every day.

Jordan But I know. You probably also talk to your colleagues, uh, in ERs across the province and across the country. How common is an er, like what you’ve just described to us in yours?

Dr. Kashif Pirzada Oh, I think, I think it’s fairly common talking to colleagues. Um, we all, pretty much all of us work at, at one or, or two sites is typical. And we share information with each other about, you know, how bad is it, you know, kind of with the, the, the subtext that maybe I could move over to your place if it’s better . Uh, but nowhere, nowhere is better. Everywhere has, has the same stresses and the, the same kind of overwhelming, um, burden that, um, that is being faced across the system. And I think it’s like that all over, all over North America. So there’s no, uh, place that’s really unaffected by. Does the public get that? Now, I, I ask that in a way, you know, we ran some clips in the intro to this show about the reporting that’s been done on, you know, uh, hallway medicine and ambulances waiting and, you know, the, the tagline that our system is at the brink of claps, which is why we’re examining this.

Jordan Do people understand that? Just what that means until they actually need the ER and they have to show up and see what’s happening.

Dr. Kashif Pirzada That’s the thing. I don’t think people understand until they actually see it for themselves when they’re sitting on an a. Stretcher for like 10 hours in one of our hallways, uh, until they experience that, like after a car accident, they’re basically shuffled off to sit in a hard wooden chair in a, in a waiting room surrounded by hundreds of people waiting to be seen. Like, I don’t think people appreciate how bad it’s gotten unless they see it for themselves. And I hope you know that you’re listeners don’t have to use our services, but if they do, obviously come, we’ll find a way to take care of you. But really, really pay attention to the healthcare workers who are telling you that it’s not where it should be right now.

Jordan When an emergency room is at the breaking point, the way you described, who is the most impacted? I mean, I assume that you know, patients who arrive obviously at risk of death get triaged and get seen. But what about somebody who just, you know, who shows up with a condition, they don’t know what it is, it’s causing them intense pain? Like who bears the brunt of the overcrowd?

Dr. Kashif Pirzada I think it’s, um, it’s kind of shared equally, but I think the brunt will be faced by people who are, um, you know, most vulnerable, who can’t really advocate for themselves. So those could be, you know, seniors who aren’t so tech savvy, who didn’t know that they should have gotten, like, you know, the flu vaccine or the, or the updated covid vaccine, let’s say. They, they’ll come in very sick eventually when they do get sick. The other folk are, um, people who stay at home too long with symptoms that should get checked out and miss an important diagnosis. And that’s what I’m afraid of is that if you, you know, people are facing, you know, 10, 12 hour waits, uh, in, in a lot of cases, especially in high demand times like evenings and weekends, they will not show up for a problem that they should get checked out. So that, that’s really what I’m afraid of.

Jordan Are you seeing that now from problems people might have had during the pandemic when they didn’t have as much contact with the medical system?

Dr. Kashif Pirzada Like I, we heard about this, uh, during the waves of Covid when lots of things were shut down. That people would not get early warning signs for things like cancer or heart disease checked out, and that we would be seeing a crush of these people after the pandemic when the symptoms had worsened. I, I wouldn’t say it’s a crush, like we are picking up a lot of things. It’s hard for me to tell because I see 20, 30 patients a shift. I can’t see a whole system at once, but Right. I’ve diagnosed, you know, more diabetes, a lot of cancer. A lot of, a lot of things that, um, you know, pre pandemic I wouldn’t have seen as frequently. So I think there’s definitely a factor. It’s hard to say. I don’t have access to the, the full numbers on that, but it feels like there’s a lot more of this happening.

Jordan One of the things that we covered, uh, in the first two episodes of this week is the lack of nurses and the lack of family physicians, and what our guests described to us was, A system that would compensate for those lacks by driving more people who otherwise would be fine. You know, talking to a family doctor to the ERs and kind of exacerbate the overload you’re seeing there. Is that something you’ve seen?

Dr. Kashif Pirzada Oh, a hundred percent. Like we are taking on almost a family medicine role for a lot of patients that we see because we can expedite a lot of things that can’t be done in the community for some reason. Like we can get same day, you can get your scan or your blood test done. A lot of patients will wait for that because they’re not getting or not don’t have access to that. Um, I think, you know, the solution to that is to open up more centers, like what we could provide, maybe not ERs like, uh, where you’re not dealing with life threatening problems, but kind of, and the Ooma, the Ontario Medical Association has mentioned this as one of their ideas is that open up these kinds of urgent care clinics that people don’t have. Family doctors, people who have complex needs, who need, like, you know, minor surgery can come. Um, and, um, and get treatment outside of, um, a family medicine system that’s really over strained right now. You mentioned at the beginning of our conversation that, you know, we weren’t starting from a good place even before this happened.

Jordan Why weren’t we, How come our emergency rooms were so close to the breaking point before we were even hit with a pandemic?

Dr. Kashif Pirzada I think a lot of, you know, I kind of deferred maintenance, you’d call it. Uh, just negligence. I think there was no incentive, um, in a system like ours to really plan for the future. We knew that, um, the boomers were aging, that there would be a huge demand on services. Even now, even before, even if there was no pandemic, we’d still have a lot of strain. We knew, um, from flu seasons before that the systems always brought to the breaking point in, uh, January, February, when flu as it is at its peak. But we never really planned or changed anything. So it’s really on us and on our leaders. That, uh, that we didn’t plan ahead for something like this.

Jordan I wanna talk about two kinds of solutions. The first would be immediate, and then we can talk about long term, you know, what would make a difference to your ER and other ERs in the, in the similar situations like tomorrow. You know, would millions of dollars in cash even help right now or is the problem bigger than that?.

Dr. Kashif Pirzada No, I think it would help in the long term, but now, like especially going into fall and winter, I think the biggest difference would be to really get people to uptake, uh, the flu shot and, uh, the updated covid shot that could reduce a lot of hospital visits. And I think, you know, governments need to get that message that, um, Covid 19 is, uh, don’t pretend it’s gone. Um, respect it. Work around it, mitigate it, but don’t pretend it’s gone. And be honest with the public about that. You know, this is a movie that doesn’t have a clear and happy ending, but it’s more like, you know, The Simpsons, which is limping on forever and ever . It’s uh, you know, therapies will keep getting better, you know, vaccines, antivirals. Um, I think, you know, they should have an appetite to bring back, um, you know, some public health measures if things get outta control as the winter goes on. So that’s, that’s the number one thing I think that will help right now. Number two, um, really open up to foreign trained workers. There’s a lot of underemployed, foreign expertise, the nurses and physicians that they could really bring in quickly. I work with some of them that were struggling through exams and trying to get placements. We could mobilize these people very quickly and put them to work. Uh, number three, you know, urgent care centers, like not everyone. Full on emergency care. Like they don’t need to be put on ventilators. They don’t need the kind of life saving equipment we have in hospitals. Really, you know, urgent care clinics everywhere can take the load off of family medicine clinics can take a lot of that burden off, Give a home to the, I think 10% of, Canadians who don’t have family physicians. Um, the other thing is like, um, uh, nursing home care and palliative care services, like it’s overloaded. It’s part of the backlog in our hospitals. They really need to plan for this because, People are getting more disabled and can’t be cared for at home, and they need a place to go.

Jordan First of all, I wanna just thank you for actually articulating something that we can do. A lot of the conversations we’ve had, uh, so far have been like, well, we need government to do this. We need somebody to step in, we need, et cetera, et cetera. But just getting your dang shots, um, we’ll make a difference.

Dr. Kashif Pirzada I think so. Like, um, Australia had a pretty rough flu season on top of their covid like, uh, flu. I’ve, I had it 15 years ago. I’ll never, ever forget. And I line up like a good boy for my shots every year. Yeah. And I’m never, I never wanna get that again.

Jordan What can we do in the long term? I know that. You know the situation that you’ve described, it must make it really hard to recruit young medical students to go into this line of work when all they see or hear is just how awful it is. Just how many extra hours you’re working and you have no space to put anybody. How do we increase our capacity to recruit young medical students to work as emergency room, doctors?

Dr. Kashif Pirzada I think overall we can be safe to think, like I work with a lot of pre-medical students and I, I mentor them and, you know, try, write reference letters for them. There’s a lot of people that really answer the calling and want to help and serve. I don’t think we’ll ever, ever have a shortage of that, but we can make it easier for them to work and make it safe for them to work and show them that the public is interested in maintaining a system in which, um, we can treat people effectively. And not give up, basically. So I think, I think we’ll always have people, but we have to make it easier for them to stay in this, in this fight, basically.

Jordan How do we do that?

Dr. Kashif Pirzada So I think respect, respect them and their, um, expertise and, but also protect them. Right now hospitals have, um, great ventilation that happened after sar. So you remember SARs one, you know, in 2003?

Jordan Yes.

Dr. Kashif Pirzada Every, um, hospital Ontario was upgraded, uh, ventilation wise after that. And when Covid came along, um, along with masking, almost nobody will get sick as working in a hospital now in Ontario. I can’t say the same for other provinces. They’ll get sick maybe from kids coming home from school or maybe, uh, from other workplaces, but from hospitals. It’s very rare to happen. And that’s what we did to protect workers. So extend that attitude to all workers. You know, we want you to work in a system that works. We don’t want you to, uh, be despair over your patients by having to make horrible decisions, um, that, you know, don’t improve them. So keep the system well resourced. I think that’s the best way to do it. Is there a. We can or should overhaul the emergency room system to make it more efficient and more able to handle. Occasional, hopefully not constant searches in capacity. You know, there’s always a tortured debate about private involvement in our system, but I think when you have a centrally planned system, like most health systems in Canada, it’s really hard to come up with innovative ideas and, and empower people who have innovative ideas. Like, but I look at countries like, like Israel, which has like kind of like imagine your province had like four competing ministries. Trying to outdo each other and compete for quality and, and price, but they’re all public, right? That’s, that’s one way we could do it, in which you have people coming up with solutions. It’s really hard to plan and, and know everything from the top down, but maybe stuff on the ground from teams working on their own can come up with stuff. So that’s one way. Like you don’t want private involvement where you have like this crony capitalism where people are skimming money. For like the American private system, but you wanna have a system where you have new ideas that can get implemented right now. Like, it’s almost like going to some meetings at, at uh, where at some of the places I work, it’s like, bang your head against the wall. It’s a lot of circling back and let’s put a pin in that. And that kind of talk like, it doesn’t, it doesn’t, doesn’t go anywhere. So I’ve, I’ve, I’ve stopped going to any of those meetings. It’s just frustrating because no one listens and there’s improvement, but it is very slow to happen. But I think if there was some more competition or some more, uh, outlet for innovation, there might be a better way to do it.

Jordan I’m gonna ask a bit of a third rail question, and we’re almost done here. Is there a role for privatization in any of the things you’ve described?

Dr. Kashif Pirzada You know, one of the things you mentioned was people showing up at the ER as kind of a catchall for when they need access to service. Quickly, like a blood test or something like that. Is there a role in your mind for private clinics in that system? I think you could, as long as they’re is accessible and they, um, you know, serve all of the public, you know, most clinics run by in, you know, if you go to a walking clinic, they’re all private rerun by, you know, the staff that work in them. If you, as long as you maintain access, but you can do, you know, private delivery, that’s already what we have. But you could extend the role of it and have these services compete with each other, uh, and to provide better care for everybody. And it has to be all of the systems that in the we in the western world that have. Private options are heavily regulated to maintain access. So that would, that would be the caveat. You can do it and it can provide better service, but it has to be accessible and very heavily regulated.

Jordan Last question then. What will you be watching for over the next several months? And I mean this in two ways. Uh, first like, what will you be watching to, to see if we’re in more trouble or not? And second, are you hopeful about anything that might come out? , what we’ve dealt with this summer and maybe Canadians finally learning just how fragile their system is. I hope, um, that we don’t learn a harsh lesson this, this winter. I hope that we don’t see a huge rise in cases that overwhelms our system, but I, I can’t see why we wouldn’t. Like there’s, everything’s pointing to some kind of surge coming in the winter. New variants coming our. You know, flu coming back to bite us. I hope, Um, we act faster than, than we did last time, like bringing back some measures. And then hopefully we’ll learn a lesson on how to plan and how to deal with these challenges that are facing us. Um, you know, it’s, it’s, um, you know, we’ve been through seven waves of c Um, we should have learned more by now. Maybe we’ll have to learn again. I don’t know. I hope it doesn’t happen. I really do. I hope all the vaccines that we’ve gotten, I hope, you know, most people have gotten sick at least once or twice. I hope that provides something, but I can’t, The scientific reason scientifically, it’s hard to imagine why this thing won’t stop.

Jordan Very unscientifically, I’m just gonna cross my fingers.

Dr. Kashif Pirzada Me too. Both my heads.

Dr. Kashif Pirzada Thank you, Dr. Pirzada.

Dr. Kashif Pirzada Thank you so much,

Dr. Kashif Pirzada

Jordan Dr. Kashif Pirzada an emergency room doctor working in Toronto. That was The Big Story, part three of our examination of the healthcare crisis. You can find the previous two episodes. At the Big Story podcast.ca or of course, wherever you get podcasts, you can follow us on Twitter at the Big story fpn. You can email us hello at the big story podcast.ca, and you can call and leave a voicemail, four one six nine three five. 5 9, 3 5 We’re available wherever you get podcasts. And via smart speaker, just tell it to play the Big Story podcast. Thanks for listening. I’m Jordan Heath Rowlings. We’ll talk tomorrow.